The EMSB Digital Research Library

The Digital Research Library is a searchable, indexed, moderated database of research and literature pertinent to prehospital and emergency medicine. Its mission is to collect empirical studies that provide meaningful information on prehospital treatment, transport, and other operations that comprise EMS service, with a focus on the United States and similar practice environments.

All papers are reviewed by our editorial staff and meta-information is extracted into a table. The table can be searched globally, or sorted (alphabetically or numerically) by any category; in combination this should allow astute users to drill down on desired material. (For example, if interested in large studies addressing spinal immobilization, one might search for “immobilization” and then sort the results in descending order of study size.) The index is updated regularly with older material or newly-published studies, and should be considered a continual work in progress.

Information in the DRL itself aims to be concise, informative, and objective. Further analysis and commentary can be found on the DRL blog, Lit Whisperers.

Go here for more information on using the library



To view newly added material, search for the triple asterisk (***)

[1-14-14] 8 new additions: 3 Cardiac Arrest, 5 misc. (including Trauma, Hematology, Electrocardiography, Patient Assessment, and Respiratory)

[5-13-13] 12 new additions: 6 Cardiac Arrest, 2 Spinal Immobilization, 4 misc. (all Fluid Resuscitation)

[4-18-13] 12 new additions: 6 Cardiac Arrest, 1 Spinal Immobilization, 5 misc. (3 Patient Assessment, 2 Physiology)

[4-9-13] 9 new additions: 9 Cardiac Arrest

[4-2-13] 10 new additions: 5 Cardiac Arrest, 3 Ambulance Operations, 1 Spinal Immobilization, 1 Fluid Resuscitation

[3-26-13] 9 new additions: 3 Cardiac Arrest, 6 Spinal Immobilization


Subject Shelves

All papers are initially labeled with a primary topic (e.g. Spinal Immobilization, Cardiac Arrest, etc.) and listed in the miscellaneous index below. Once a particular subject category becomes sufficiently large, however, it is removed from the general index and organized into a separate, subject-specific “shelf.” Click an image to visit its subject shelf.


Spinal Immobilization

Cardiac Arrest

Cardiac Arrest


Miscellaneous Index

Patient Assessment Accuracy of the ATLS guidelines for predicting systolic BP using palpated pulses.Deakin CD, Low JL.2000Prospective observational study20Patients with hypovolemic shock had their pulses checked by a blinded observer and compared to the reading from their arterial blood pressure monitor.Although loss of pulses followed the order classically described by ATLS, the numbers commonly quoted would consistently and significantly over estimate the patient's blood pressure.3
Respiratory Breathing lessons: basics of oxygen therapyPruitt WC, Jacobs M2003Review article0Reviews some of the basic information regarding the advantages, disadvantages, and differences between various common modalities of supplemental oxygen administration.Nice introductory article for O2 administration options besides "12-15 LPM via non-rebreather."2
Respiratory Delivered oxygen concentrations using low-flow and high-flow nasal cannulasWettstein RB, Shelledy DC, Peters JI2005Prospective comparative trial, non-blinded10Patients were administered O2 at various flow-rates (1-15 LPM) via nasal cannula, and their FiO2 was measured at the level of the uvula.Open-mouth breathing results in a higher FiO2 than closed-mouth breathing when a nasal-cannula is being used.3
Respiratory Unrecognized severe postoperative hypercapnia: a case of apneic oxygenationAyas N, Bergstrom LR, Schwab TR, Narr BJ1998Case report1A patient was left intubated on 100% O2 but not ventilated. The inadequacy of her ventilations was not recognized and she received multi-medical therapies to correct her pCO2 of >200 mmHg, with further deterioration until ventilatory assistance was administered.Pulse oximetry is not a measure of the adequacy of ventilation, especially when the patient is receiving supplemental oxygen therapy.
Fluid Resuscitation Fluid Resuscitation: Past, Present, and the FutureSantry HP, Alam HB2010Review article0Reviews the historical development of, and scientific basis for, fluid resuscitation in the haemorrhaging trauma patient. Summarizes clinical and laboratory study data on common resuscitation fluids and their effect on physiology and patient outcomes.While there is no strong evidence in favour of any particular modality, the article favours L-isomer Lactated Ringers, permissive hypotension, a systematised approach to blood product administration and further investigation into immunomodulation.4
Fluid Resuscitation Immediate versus Delayed Fluid Resuscitation for Hypotensive Patients with Penetrating Torso InjuriesBickell WH, Wall MJ Jr., Pepe PE, Martin RR, Ginger VF, Allen MK, and Mattox KL1994Prospective, quasi-randomised controlled trial.598Compared immediate and delayed fluid resuscitation in 598 adults with penetrating torso injuries who presented with a prehospital systolic blood pressure ≤ 90 mm Hg.203/289 (70%) patients in the delayed fluid group survived and were discharged from the hospital, as compared with 193/309 (62%) patients who received immediate fluid resuscitation (P = 0.04). There was also a non-significant reduction in postoperative complications and duration of hospitalisation in the delayed fluid group.5
Fluid Resuscitation A randomised controlled trial of prehospital intravenous fluid replacement therapy in serious trauma.Turner J, Nicholl J, Webber L, Cox H, Dixon S, Yates D.2000Prospective, randomised controlled trial.1309Trauma patients randomised prehospitally to receive either immediate fluid or delayed fluid resuscitation.There was no evidence of any difference in mortality rates or composite outcomes between any subgroups, or between protocols within any subgroup.5
Fluid Resuscitation Hypotensive Resuscitation during Active Hemorrhage: Impact on In-Hospital MortalityDutton RP, Mackenzie CF, Scalea TM.2002Prospective, randomised controlled trial.110Compared a target SBP > 100 mm Hg to a target SBP of 70 mm Hg. Fluid therapy was titrated to either endpoint until definitive hemostasis was achieved. In-hospital mortality, injury severity, and probability of survival were determined for each patient.Titration of initial fluid therapy to a lower than normal SBP during active hemorrhage did not affect mortality in this study.4
Fluid Resuscitation Mortality after Fluid Bolus in African Children with Severe Infection.Maitland K, Kiguli S, Opoka RO, Engoru C, Olupot-Olupot P, Akech SO, Nyeko R, Mtove G, Reyburn H, Lang T, Brent B, Evans JA, Tibenderana JK, Crawley J, Russell EC, Levin M, Babiker AG, Gibb DM; FEAST Trial Group.2011Prospective trial, randomized control, single-blinded, multi-site3170In austere Sub-Saharan Africa, pediatric patients <12 with sepsis signs were enrolled. In addition to standard supportive care, one randomly-assigned group received rapid infusion of at least one saline bolus (20ml/kg), one received at least one 5% albumin bolus (20ml/kg), and one received no bolus. Outcomes compared.Bolus with either saline or albumin increased mortality by 3.3%, and death or neuro sequelae at 4 weeks by 4%; however, there was no significant difference between saline vs. albumin. No subgroup benefitted. Pulmonary edema or increased ICP was rare.3
Ambulance Operations Response time effectiveness: comparison of response time and survival in an urban emergency medical services system.Blackwell TH, Kaufman JS.2002Retrospective cohort study, single-site5424Chart review of consecutive patients in a single ALS EMS system. Stratified all emergency responses into 1-minute intervals by duration from 911 call until EMS arrival on scene, and compared outcomes between groups. (All first responders carried defibrillators.)Mean response for survivors was 6.97 minutes vs. 7.06 for non-survivors (10s difference, insignificant). Average mortality for all responses was 1.31%, yet responses 5 mins had more (1.58% mortality); beyond 5 mins survival was flat. Experts felt that ~5.6% of non-survivors might have benefitted from faster response.3
Ambulance Operations Is ambulance transport time with lights and siren faster than that without?Hunt RC, Brown LH, Cabinum ES, Whitley TW, Prasad NH, Owens CF Jr, Mayo CE Jr.1995Prospective cohort study, experimental control, single-site50Observers rode along with paramedic units on emergent transports (<8 miles, urban environment), using a stopwatch to time the interval from scene departure to ED arrival. A paramedic later timed the identical route driving with the flow of traffic at the same time of day. Travel times were compared.Emergent transport with lights and sirens was an average of 43.5 seconds faster than non-emergent travel. The range was from 5m11s faster to 2m49s slower; 76% were faster.3
Ambulance Operations Eight minutes or less: does the ambulance response time guideline impact trauma patient outcome?Pons PT, Markovchick VJ.2002Retrospective cohort study, single-site3490Chart review of trauma patients transported by an ALS service over two years to a single trauma center. Compared outcomes between patients with response time (from EMS notification to scene arrival) 8 minutes.Response time had no significant impact on outcomes in most subgroups; however, survival was significantly higher (not lower) for Injury Severity Scores (ISS) above 25 in the >8 minute group. No explanation is forthcoming.4
Patient Assessment Clinical characteristics of patients with acute pulmonary embolism.Stein PD, Saltzman HA, Weg JG.1991Retrospective secondary analysis of a prospective cohort1226Secondary analysis of the cohort studied in PIOPED I was performed, looking for factors associated with the presence of PE.No significant difference was found between those positive and negative for PE. Among the 383 patients with acute PE the most frequent symptoms were dyspnea in 78%, pleuriticpain in 59% and cough in 43%. The most frequent signs of PE were tachypnea (respiratory rate > 19 /min) in 73%, rales in 55%, and tachycardia (heart rate > 100 beats/min) in 30%.2
Patient Assessment Clinical characteristics of patients with acute pulmonary embolism: data from PIOPED II.Stein PD, Beemath A, Matta F, Weg JG, Yusen RD, Hales CA, Hull RD, Leeper KV Jr, Sostman HD, Tapson VF, Buckley JD, Gottschalk A, Goodman LR, Wakefied TW, Woodard PK.2007Retrospective secondary analysis of a prospective cohort824Secondary analysis of the cohort studied in PIOPED II was performed, looking for factors associated with the presence of PE.In patients with PE, dyspnea during rest or exertion was present in 79%, orthopnea was present in 36%, pleuritic pain in 47%, cough in 43%, calf or thigh pain in 42%, tachypnea in 57%, tachycardia in 26%, and circulatory collapse in 8%.3
Patient Assessment Clinical characteristics of patients with acute pulmonary embolism stratified according to their presenting syndromes.Stein PD, Henry JW.1997Retrospective secondary analysis of a prospective cohort119Secondary analysis of the cohort studied in PIOPED I was performed, looking for clinical presentations associated with the presence of PE.65% of confirmed PE's presented with the syndrome of pulmonary hemorrhage or infarction characterized by pleuritic pain or hemoptysis. The syndrome of isolated dyspnea occurred in 22%. Circulatory collapse among patients who survived long enough for diagnostic evaluation was observed in only 8%.2
Physiology ABC of Oxygen: Oxygen transport -- 1. Basic principlesTreacher DF, Leach RM.1998Review article0A brief overview of the basic principles involved in oxygen delivery.Provides a concise intermediate-level overview of the physiology of oxygen transport. A couple of statements are a bit outdated, but many of the concepts are timeless.3
Physiology ABC of Oxygen: Oxygen transport -- 2. Tissue hypoxiaTreacher DF, Leach RM.1998Review article0A brief overview of the principles involved in oxygen delivery and the role hypoxia plays in the body.Another concise overview of oxygen transport, this time slightly more advanced and focused on the topic of hypoxia.4
Fluid Resuscitation The Preventive Treatment of Wound ShockCannon WB, Fraser J, Cowell EM1918Review article0A discussion of haemorrhagic shock (then referred to as 'wound shock') in relation to fluid administration based on experience gained in WWI.One of the earlier papers discussing IV fluid therapy in haemorrhagic shock. Perhaps more importantly, this paper is the first to suggest the potential for harm secondary to raising a patient's blood pressure prior to definitive surigical control of the haemorrhage. While not specifically mentioned, this paper is often cited as being the thematic origin of permissive hypotension.2
Fluid Resuscitation The coagulopathy of trauma: a review of mechanisms.Hess JR, Brohi K, Dutton RP, Hauser CJ, Holcomb JB, Kluger Y, Mackway-Jones K, Parr MJ, Rizoli SB, Yukioka T, Hoyt DB, Bouillon B.2008Review article0Articles addressing the causes and consequences of trauma-associated coagulopathy were identified and reviewed.Provides an overview and discussion of Acute Coagulopathy of Trauma-Shock as a disease process; its pathophysiology; contributing factors, particularly fluid resuscitation, hypothermia and acidaemia; as well as potential therapies.3
Fluid Resuscitation Fluid resuscitation strategies: a systematic review of animal trials.Mapstone J, Roberts I, Evans P.2003Systematic review0Animal RCT data on fluid resuscitation in uncontrolled haemorrhage was reviewed. Outcome measure was mortality at the end of the scheduled follow-up period of the trial.Of the 44 models of haemorrhage comparing fluid vs no fluid resuscitation, there were varrying results depending largely on the particular model of haemorrhage. Authors conclude that fluid resuscitation appears to be beneficial in severe haemorrhage but may be detrimental in less severe injury. In the 9 articles on the topic showed significant improvements in survival with the application of permissive hypotension.4
Fluid Resuscitation Timing and volume of fluid administration for patients with bleedingKwan I, Bunn F, Roberts I.2009Systematic review0A through literature search conducted as part of a Cochrane review revealed nine randomised trials relating to fluid resuscitation in haemorrhagic shock and were divided into two categories: delayed vs immediate resuscitation and small vs large volume resuscitation.Authors found no evidence from the nine included randomised controlled trials for or against early or larger volume of intravenous fluid administration in uncontrolled haemorrhage. They concluded that there is continuing uncertainty about the best fluid administration strategy in bleeding trauma patients.5
Trauma *** Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trialCRASH-2 Collaborators2010Double-blind, randomized controlled trail202011Prospective, double-blind, randomized controlled trial undertaken in 40 countries at 274 hospitals varying from low to high income. Randomisation was balanced by centre, with an allocation sequence based on a block size of eight, generated with a computer random number generator. Both participants and study staff (site investigators and trial coordinating centre staff) were masked to treatment allocation. Primary measured outcome was death in hospital within 4 weeks of injury.Statistically significant reduction in all-cause mortality (14.5% vs 16%) and death due to bleeding (4.9% vs 5.7%) in treatment group. Risk of traumatic exsanguination reduced by 30% if given with 3 hours of injury. No adverse effects. Can be given empirically. May delay hematoma expansion in isolated TBI, but further study warranted (CRASH-3).5
Hematology *** Management of Severe HyperkalemiaWeisburg2008Review Article0This article reviews and analyzes literature relevant to the pathophysiology and management of severe hyperkalemia. Methods include search of MEDLINE, and bibliographic search of current textbooks and journal articles.The efficacy, pitfalls, and risks of the agents available for use at each step in the sequence are critically reviewed.3
Electrocardiography *** ST-segment depression and T-wave inversion: Classification, differential diagnosis, and caveatsHanna E, Glancy D2011Review Article0Review of how to distinguish the various causes of ST-segment depression and T-wave inversionN/A3
Patient Assessment *** The Utility of Gestures in Patients with Chest DiscomfortMarcus GM, Cohen J, Varosy PD, Vessey J, Rose E, Massie BM, Chatterjee K, Waters D2007Prospective cohort study, single-site202Adult patients presenting to a large ED with chest pain were enrolled, and noted whether they referred to their pain using a closed fist (Levine's sign), open palm, pointing finger, or clutching their arm, as well as the diameter of the indicated area. Gesture was compared against eventual diagnosis of coronary ischemia using angiography (occlusion >70%), troponin, or stress test.Sensitivity/specificity for MI was: Levine's 6%/87%; palm 32%/64%; arm 18%/83%. Pointing was 5%/98% for indicating a non-ischemic cause. Larger areas of pain corresponded directly with lower probability of ischemic etiology.3
Respiratory *** Comparison of Bag-Valve-Mask Hand-Sealing Techniques in a Simulated ModelOtten D, Liao MM, Wolken R, Douglas IS, Mishra R, Kao A, Barrett W, Drasler E, Byyny RL, Haukoos JS.2013Prospective cross-over trial, convenience sample52Assorted clinicians performed BVM ventilation on a mannequin using a one-handed (EC) technique, two-handed (double EC), and two-handed thumbs-down. Tidal volume was held constant by ventilator, and ventilated volume was measured at the test lung.The median successful ventilated volume was 31% for one-handed EC, and 85% for both two-handed techniques. Volume was much higher in men than women using the one-handed (but not two-handed) technique. Experienced providers were not more successful with the one-handed technique.4


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