We found no evidence of a beneficial effect of fibrinolysis in patients with cardiac arrest and pulseless electrical activity of unknown or presumed cardiovascular cause. Our study had limited statistical power, and it remains unknown whether there is a small treatment effect or whether selected subgroups may benefit.

Objective: To determine whether naloxone administered IV to out-of-hospital patients with suspected opioid overdose would have a more rapid therapeutic onset than naloxone given subcutaneously (SQ). Methods: A prospective, sequential, observational cohort study of 196 consecutive patients with suspected opioid overdose was conducted in an urban out-of-hospital setting, comparing time intervals from arrival at the patient's side to development of a respiratory rate 2 1 0 breathdmin, and durations of bag-valve-mask ventilation. Subjects received either naloxone 0.4 mg IV (n = 74) or naloxone 0.8 mg SQ (n = 122). for respiratory depression of < l o breathdmin. Results: Mean interval from crew arrival to respiratory rate 2 1 0 breathdmin was 9.3 2 4.2 min for the IV group vs 9.6 & 4.58 min for the SQ group (95% CI of the difference -1.55. 1.00). Mean duration of bagvalve-mask ventilation was 8.1 & 6.0 min for the IV group vs 9.1 _+ 4.8 min for the SQ group. Cost of materials for administering naloxone 0.4 mg IV was $12.30/patient, compared with $10.7O/patient for naloxone 0.8 mg SQ. Conclusion: There was no clinical difference in the time interval to respiratory rate 2 10 breathdmin between naloxone 0.8 mg SQ and naloxone 0.4 mg IV for the out-of-hospital management of patients with suspected opioid overdose. The slower rate of absorption via the SQ route was offset by the delay in establishing an IV.

Abstract. Objective: To develop a clinical prediction rule to identify patients who can be safely discharged one hour after the administration of naloxone for presumed opioid overdose. Methods: Patients who received naloxone for known or presumed opioid overdose were formally evaluated one hour later for multiple potential predictor variables. Patients were classified into two groups: those with adverse events within 24 hours and those without. Using classification and regression tree methodology, a decision rule was developed to predict safe discharge. Results: Clinical findings from 573 patients allowed us to develop a clinical prediction rule with a sensitivity of 99% (95% CI = 96% to 100%) and a specificity of 40% (95% CI = 36% to 45%). Patients with presumed opioid overdose can be safely discharged one hour after naloxone administration if they: 1) can mobilize as usual; 2) have oxygen saturation on room air of >92%; 3) have a respiratory rate >10 breaths/min and <20 breaths/min; 4) have a temperature of >35.0ЊC and <37.5ЊC; 5) have a heart rate >50 beats/min and <100 beats/min; and 6) have a Glasgow Coma Scale score of 15. Conclusions: This prediction rule for safe early discharge of patients with presumed opioid overdose performs well in this derivation set but requires validation followed by confirmation of safe implementation.

Objective:We assessed the self-reported theoretical and practical preparedness training of Canadian emergency medical services (EMS) providers in chemical, biological, radiological and nuclear (CBRN) events. Methods: We designed an online survey to address the theoretical and practical CBRN training level of prehospital providers. Emergency medical services staff in British Columbia and Ontario were invited to participate. Results: Of the 1028 respondents, 75% were male, and the largest demographic groups were front-line personnel with more than 15 years of experience. Only 63% of respondents indicated they had received either theoretical or practical training to work in a contaminated environment, leaving 37% who indicated they had received neither type of training. Of those that had received any training, 61% indicated they had received "hands-on" or practical training and 82% indicated they had received some training in identification of a possibly contaminated scene. Only 42% had received training for symptoms of nerve agents, 37% had received training for symptoms of blister agents and 46% had received training for symptoms of asphyxiants. Thirty-two percent had received training for the treatment of patients exposed to nerve agents, and 30% had received training for the treatment of patients exposed to blister agents. Only 31% of all respondents had received training for detecting radiation. Conclusion: CBRN events involve unique hazards and require specific education and training for EMS providers. A large proportion of Canadian EMS providers report not having received the training to identify and work in contaminated environments. RÉSUMÉObjectif : Nous avons évalué le degré de préparation théorique et pratique autodéclarée par le personnel des services médicaux d'urgence au Canada en cas de menaces chimiques, biologiques, radiologiques et nucléaires (CBRN). Méthodes : Nous avons conçu un questionnaire administré en ligne pour mesurer le degré de préparation théorique et pratique du personnel des services préhospitaliers en cas de menaces CBRN. Le personnel des services médicaux d'urgence de la Colombie-Britannique et de l'Ontario a été invité à y répondre. Résultats : Parmi les 1028 répondants, 75 % étaient de sexe masculin et les groupes démographiques les plus volumineux se composaient de personnel de première ligne cumulant plus de 15 années d'expérience. Soixante-trois pour cent seulement des répondants ont mentionné avoir reçu une formation théorique ou pratique pour travailler dans un milieu contaminé, les 37 % restants ayant signalé n'avoir reçu ni l'une ni l'autre. Parmi ceux qui avaient reçu un type de formation, 61 % ont indiqué avoir reçu une formation pratique ou concrète et 82 % ont indiqué avoir reçu un type de formation pour la reconnaissance d'une zone potentiellement contaminée. Seulement 42 % avaient reçu une formation relative aux symptômes occasionnés par les agents neurotoxiques, 37 %, pour les symptômes occasionnés par les agents vésicants, et 46 %, pour les symptômes occasionnés pa...

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Introduction: Patients with suspected opioid overdose frequently require naloxone treatment. Despite recommendations to observe such patients for 4 to 24 hours after naloxone, earlier discharge is becoming more common. This prospective, observational study of patients with presumed opioid overdose examines the safety of early disposition decisions and the accuracy of outcome prediction by physicians 1 hour after the administration of naloxone. Methods: The study was carried out at St. Paul’s Hospital, an inner city teaching centre that cares for most of the injection drug users in Vancouver, BC. Patients were formally assessed 1 hour after receiving naloxone for presumed opioid overdose. Demographics, medical history and physical examination were documented on specific data forms, and physicians recorded their comfort with early discharge. Patients were followed up, and those who required a critical intervention or suffered a pre-defined adverse event (AE) within 24 hours of their 1-hour assessment were identified. Results: Of 573 patients, 48% were discharged in less than 2 hours, 23% in 2–4 hours and 29% in &gt;4 hours. 94 patients who were held in the emergency department (ED) or admitted required a critical intervention, including supplemental oxygen for hypoxia (74), repeat naloxone (52), antibiotics administered intravenously (IV) (14), assisted ventilations (13), fluid bolus for hypotension (12), charcoal for associated life-threatening overdose (6), IV inotropic agents (2), antiarrhythmics for sustained tachycardia &gt;130 beats/min (1), and administration of bicarbonate for arterial [HCO3] &lt;5 or venous CO2 &lt;5 (1). Physicians predicted adverse events with 94% sensitivity and 59% specificity. No discharged patients suffered a serious AE within 24 hours of ED discharge. Conclusions: Emergency physicians can clinically identify patients at risk of deterioration after naloxone reversal of suspected opioid overdose. Prolonged observation or hospital admission is not usually required. Selective early discharge of patients with presumed opioid overdose is feasible and appears safe. A clinical prediction rule may be useful in identifying patients eligible for early discharge.

The proposed framework and objectives are suitable for training medical students, family medicine trainees, community physicians, EM residents, and EMS fellows in Canada. The authors hope this article will serve as a guideline for residency and fellowship directors to develop their EMS training programs in a consistent manner, promote formal training for physicians involved in EMS, and help define the specific knowledge and expertise required of physicians who provide EMS medical direction in Canada.

Providing prehospital care poses unique risks. Paramedics are essentially the only medical personnel who are routinely at the scene of violent episodes, and they are more likely to be assaulted than are other prehospital personnel. In addition to individual acts of violence, emergency medical services (EMS) providers now need to cope with tactical violence, defined as the deployment of extreme violence in a non-random fashion to achieve tactical or strategic goals. This study reviewed two topics; the readiness of EMS crews for violence in their environment and the impact of violence on the EMS crew member. This latter also evaluated the access and effectiveness of emotional support available to caregivers exposed to violent episodes.The results of the survey indicate a significant lack of preparedness for situations involving tactical violence. A total of 89% of respondents either had never had such training or had been trained more than one year ago. Thirty-six percent of respondents had never engaged in a field exercise with other responding agencies, and 4.5% of respondents were not aware of who would be in charge in such an event. In addition, this study indicates that EMS crews are exposed to events with significant emotional impacts without access to appropriate training and adequate support.