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Study objective-The first hour after the onset of out-of-hospital traumatic injury is referred to as the "golden hour," yet the relationship between time and outcome remains unclear. We evaluate the association between emergency medical services (EMS) intervals and mortality among trauma patients with field-based physiologic abnormality.Methods-This was a secondary analysis of an out-of-hospital, prospective cohort registry of adult (aged ≥15 years) trauma patients transported by 146 EMS agencies to 51 Level I and II trauma hospitals in 10 sites across North America from December 1, 2005, through March 31, 2007. Inclusion criteria were systolic blood pressure less than or equal to 90 mm Hg, respiratory rate less than 10 or greater than 29 breaths/min, Glasgow Coma Scale score less than or equal to 12, or advanced airway intervention. The outcome was inhospital mortality. We evaluated EMS intervals (activation, response, on-scene, transport, and total time) with logistic regression and 2-step instrumental variable models, adjusted for field-based confounders.Results-There were 3,656 trauma patients available for analysis, of whom 806 (22.0%) died. In multivariable analyses, there was no significant association between time and mortality for any EMS interval: activation (odds ratio [OR] 1.00; 95% confidence interval [CI] 0.95 to 1.05), response (OR 1.00; 95% CI 9.97 to 1.04), on-scene (OR 1.00; 95% CI 0.99 to 1.01), transport (OR 1.00; 95% CI 0.98 to 1.01), or total EMS time (OR 1.00; 95% CI 0.99 to 1.01). Subgroup and instrumental variable analyses did not qualitatively change these findings. Conclusion-In this NorthAmerican sample, there was no association between EMS intervals and mortality among injured patients with physiologic abnormality in the field.

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Background and Objective-Cardiopulmonary Resuscitation (CPR) with adequate chest compression depth appears to improve first shock success in cardiac arrest. We evaluate the effect of simplification of chest compression instructions on compression depth in dispatcher-assisted CPR protocol.Methods-Data from two randomized, double-blinded, controlled trials with identical methodology were combined to obtain 332 records for this analysis. Subjects were randomized to either modified Medical Priority Dispatch System (MPDS) v11.2 protocol or a new simplified protocol. The main difference between the protocols was the instruction to "push as hard as you can" in the simplified protocol, compared to "push down firmly 2 inches (5cm)" in MPDS. Data were recorded via a Laerdal® ResusciAnne® SkillReporter™ manikin. Primary outcome measures included: chest compression depth, proportion of compressions without error, with adequate depth and with total release.Results-Instructions to "push as hard as you can", compared to "push down firmly 2 inches (5cm)", resulted in improved chest compression depth (36.4 vs 29.7 mm, p<0.0001), and improved median proportion of chest compressions done to the correct depth (32% vs <1%, p<0.0001). No significant difference in median proportion of compressions with total release (100% for both) and average compression rate (99.7 vs 97.5 per min, p<0.56) was found.Conclusions-Modifying dispatcher-assisted CPR instructions by changing "push down firmly 2 inches (5cm)" to "push as hard as you can" achieved improvement in chest compression depth at no cost to total release or average chest compression rate.

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