92 SUBJECTIVE EVALUATION OF PREHOSPITAL LMA USE BY EMER-GENCY MEDICAL TECHNICIANS AND PARAMEDICS SalvatoreSilvestri, George A. Ralls, Andrew Van Horn, Amy Senn,Orange County EMS

Objective: To assess the subjective evaluation of emergencymedical technician (EMT) and paramedic (PM) use of thelaryngeal mask airway (LMA) in prehospital patients. Thestudy was conducted in order to identify areas whereimprovements can be made to facilitate the use of this device.Methods: A cross-sectional survey was conducted of EMTand PM who had placed at least one LMA in the field. Thissurvey used a quantifiable scale (1–10) to evaluate theprovider’s subjective assessment of LMA use in the pre-hospital setting. Providers were asked to rate the LMA forease of insertion, timing of insertion, effectiveness of ventila-tion, ease of cuff inflation, stability in stationary and movingpatients, ability to generate end-tidal CO2 readings, and skillretention. Information on the providers’ level of training andnumber of years at this level was gathered, as well as theirtraining experience with the LMA. Results: Of the 705surveys completed, 58 EMTs and 127 PMs were identified tohave used the LMA in prehospital patients. The mean (6SD)number of years at respective practice levels was 8.22 (66.5).Initial training was accomplished via operating room (8.6%)or mannequin (91%) LMA placement simulations. The meannumber of actual field placements (6SD) was 1.9 (61.3) perEMT or PM surveyed. The median responses are as follows(median followed by 25th–75th quartiles): Ease of insertion =7 (5–9), timing of insertion = 7 (5–8), effectiveness ofventilation = 6 (4–8), ease of cuff inflation = 8 (6–9), stabilityin stationary patient = 7 (5–8), stability during CPR = 6 (4–8),stability when moving from scene to unit = 5 (3–7), stabilityduring transport = 5.5 (4–7), stability during transfer fromunit to ED = 6 (4–7), Ability to generate CO2 reading = 6 (4–8),skill retention = 7 (6–9). Conclusion: EMTs and PMssubjectively rate the LMA higher in the area of insertionprocedure and use in stationary patients. Lower subjectivescores were seen when EMT/PM rated the use of the LMA inpatients during movement and transport.

94 THE INDEX OF RESPIRATORY DISTRESS: A CLINICAL DECISION

RULE TO ASSIST OUT-OF-HOSPITAL PROVIDERS IN CARING FOR OLDER

PATIENTS IN RESPIRATORY DISTRESS Susan E. Shapiro, OregonHealth & Science University

Objective: The purpose of this project was to begin de-veloping a clinical decision rule (CDR) for evaluatingrespiratory distress (RD) in older out-of-hospital (OOH)patients. Specifically, the study aimed to: 1) determine theappropriate items, scaling, and scoring of the instrument and2) assess the instrument’s reliability and validity. Methods:The investigator developed a definition of RD, then reviewedthe medical, nursing, and out-of-hospital literature to de-termine the clinical signs that have been described asindicating various levels of severity of respiratory distress.This list was reduced to seven signs using a Delphitechnique to obtain input from six experts in out-of-hospitalcare. Results: Data on the seven predictors were abstractedfrom the OOH medical records of 124 cases of RD patients50 years of age and older. Severity was determined fromreview of the emergency department (ED) record matched tothe OOH event. A binary logistic regression was done,with "severe distress" as the outcome of interest. Accessorymuscle use, abnormal respiratory effort, and the inability tospeak full sentences were identified as the three bestpredictors of severe respiratory distress in older OOHpatients. However, these results were difficult to interpretprimarily due to a relatively small sample size and problemsencountered in coding the predictor variables. Conclusion:Despite the numerous limitations cited, the results of thisstudy demonstrate the possibility of determining severe RDfrom clinical signs currently being assessed by OOHproviders. This suggests that with further work, it will bepossible to develop an Index of respiratory distress that canassist OOH providers in caring for older patients in re-spiratory distress.

112 PREHOSPITAL EMERGENCY CARE JANUARY / MARCH 2004 VOLUME 8 / NUMBER 1

93 THE EFFICACY OF ADDING IPRATROPIUM BROMIDE TO ALBU-

TEROL FOR THE PREHOSPITAL TREATMENT OF REACTIVE AIRWAYS

DISEASE Gary M. Vilke, Christopher Wiesner, Daniel P.Davis, Theodore C. Chan, University of California San DiegoMedical Center

Objective: Ipratropium bromide has demonstrated efficacywhen added to albuterol for the treatment of reactive airwaysdisease. Its prehospital use has not been explored. Methods:A ‘‘before-and-after’’ design was used. Prehospital and EDmedical records were examined retrospectively 6 monthsbefore and 6 months after institution of a new protocol, whichallowed the addition of ipratropium bromide to all nebulizedtreatments with albuterol. Primary outcome measures in-

cluded: changes in vital signs (HR, resp rate, SaO2), clinicalimprovement as assessed by paramedics, and admissionrates. Results: A total of 371 patients were included (n = 192albuterol alone, n = 179 ipratropium/albuterol). There wereno statistically significant differences between groups withregard to the change in HR, respiratory rate, or SaO2. Inaddition, there were no differences in the proportion ofpatients with clinical improvement or deterioration asassessed by paramedics. There were no statistically signifi-cant differences in the admission rate from the ED except inthe subgroup of patients using an MDI at the time of illness.Of note, more than one-third (133/371) of patients wereultimately determined to have a diagnosis other than RAD,the majority of whom were diagnosed with cardiac disease.Conclusions: The addition of ipratropium bromide toalbuterol for the prehospital treatment of reactive airwaysdisease does not appear to result in clinical outcomeimprovements. A substantial number of patients enrolled inthe study were diagnosed with cardiac disease.