Global Emergency Medical Registry

11/14/2025

KETAMINE AS A DISSOCIATIVE AGENT IN NON-INVASIVE VENTILATION (NIV)v– Michael Christie

https://www.gemr.org/blog/34/ketamine-as-a-dissociative-agent-in-non-invasive-ventilation-niv/

In recent years, ketamine has been recognized as a notable dissociative agent in the context of non-invasive ventilation (NIV), particularly for patients facing respiratory distress. Its unique pharmacological profile, which includes effective analgesic and sedative properties, renders it beneficial for patients in need of mechanical support or those at risk for intubation due to inadequate respiratory function. Studies highlight ketamine's role in reducing ventilator-induced dyssynchrony (VPD), which can be especially problematic in patients with acute respiratory distress syndrome (ARDS) (Wyler et al., 2023).

As a versatile anesthetic, ketamine not only deepens sedation but also serves as a valuable adjunct in analgo-sedation protocols, particularly minimizing the use of opioids and benzodiazepines (Wyler et al., 2023; Verma et al., 2019). The bronchodilator effects of ketamine further support its use in patients with respiratory compromise, including those suffering from severe asthma exacerbations (Shlamovitz & Hawthorne, 2011). Experimental and clinical evidence suggests that ketamine can relax bronchial smooth muscle, thereby improving ventilation parameters such as PaO2 and mean airway pressure, which are critical in NIV settings (Shlamovitz & Hawthorne, 2011). Moreover, its sedative efficacy can help facilitate the patient-ventilator interface during NIV, making it an attractive option in cases of decompensated chronic obstructive pulmonary disease (COPD) and acute heart failure (Verma et al., 2019; Bradshaw et al., 2019).

A study demonstrated that continuous ketamine infusion can effectively reduce the consumption of other sedatives while ensuring adequate sedation in critically ill patients (Buchheit et al., 2017). Furthermore, its use has been documented alongside dexmedetomidine, maximizing sedation while minimizing respiratory depression, a common concern in patients with compromised pulmonary function (Riccardi et al., 2023). The sedative doses typically range from low to moderate, which helps in achieving desired outcomes without the associated risks tied to traditional sedatives like benzodiazepines, which have significant side effects including delirium and prolonged mechanical ventilation (Haliloğlu, 2022).

Nevertheless, the risk of cholestatic liver injury associated with prolonged ketamine infusion in critically ill COVID-19 patients raises concerns about its long-term usage (Wendel‐Garcia et al., 2022). Despite these apprehensions, ketamine's application in acute settings—especially as a temporizing measure to avoid mechanical ventilation—continues to show promise (Shlamovitz & Hawthorne, 2011; Verma et al., 2019; . Clinical observations and trials emphasize that ketamine supports patient comfort during NIV and enhances overall tolerance, leading to better outcomes in respiratory management (Ghazaly et al., 2024; Verma et al., 2019; Bradshaw et al., 2019).

In conclusion, ketamine's multifaceted role as a dissociative anesthetic in non-invasive ventilation is evidenced by its analgesic, bronchodilatory, and sedative properties, making it an essential tool in critical care medicine for various patient populations. A thoughtful balance between its advantages and potential adverse effects is crucial for optimizing patient outcomes in respiratory emergencies.

REFERENCES:
Bradshaw, P., Droege, C., Carter, K., Harger, N., & Mueller, E. (2019). Continuous infusion ketamine for adjunctive analgosedation in mechanically ventilated, critically ill patients. Pharmacotherapy the Journal of Human Pharmacology and Drug Therapy, 39(3), 288-296.
https://doi.org/10.1002/phar.2223
Buchheit, J., Yeh, D., Eikermann, M., & Lin, H. (2017). Impact of low-dose ketamine on the usage of continuous opioid infusion for the treatment of pain in adult mechanically ventilated patients in surgical intensive care units. Journal of Intensive Care Medicine, 34(8), 646-651.
https://doi.org/10.1177/0885066617706907
Ghazaly, H., Elansary, M., Mahmoud, A., Hasanen, M., & Hassan, M. (2024). Dexmedetomidine versus ketamine in improving tolerance to noninvasive ventilation after blunt chest trauma: a randomized, double-blinded, placebo-controlled trial. Journal of Anaesthesiology Clinical Pharmacology, 40(4), 619-625.
https://doi.org/10.4103/joacp.joacp_145_23
Haliloğlu, M. (2022). Continuous infusion of ketamine for adjunctive analgosedation in mechanically ventilated patients with chronic obstructive pulmonary disease. Eurasian Journal of Pulmonology.
https://doi.org/10.14744/ejp.2022.3005
Riccardi, A., Serra, S., Iaco, F., Fabbri, A., Shiffer, D., & Voza, A. (2023). Uncovering the benefits of the ketamine–dexmedetomidine combination for procedural sedation during the italian covid-19 pandemic. Journal of Clinical Medicine, 12(9), 3124.
https://doi.org/10.3390/jcm12093124
Shlamovitz, G. and Hawthorne, T. (2011). Intravenous ketamine in a dissociating dose as a temporizing measure to avoid mechanical ventilation in adult patient with severe asthma exacerbation. Journal of Emergency Medicine, 41(5), 492-494.
https://doi.org/10.1016/j.jemermed.2008.03.035
Verma, A., Snehy, A., Vishen, A., Sheikh, W., Haldar, M., & Jaiswal, S. (2019). Ketamine use allows noninvasive ventilation in distressed patients with acute decompensated heart failure. Indian Journal of Critical Care Medicine, 23(4), 191-192.
https://doi.org/10.5005/jp-journals-10071-23153
Wendel‐Garcia, P., Erlebach, R., Hofmaenner, D., Camen, G., Schuepbach, R., Jüngst, C., … & David, S. (2022). Long-term ketamine infusion-induced cholestatic liver injury in covid-19-associated acute respiratory distress syndrome. Critical Care, 26(1).
https://doi.org/10.1186/s13054-022-04019-8
Wyler, D., Torjman, M., Leong, R., Baram, M., Denk, W., Long, S., … & Schwenk, E. (2023). Observational study of the effect of ketamine infusions on sedation depth, inflammation, and clinical outcomes in mechanically ventilated patients with sars-cov-2. Anaesthesia and Intensive Care, 52(2), 105-112.
https://doi.org/10.1177/0310057x231201184

In recent years, ketamine has been recognized as a notable dissociative agent in the context of non-invasive ventilation (NIV), particularly for patients facing respiratory distress. Its unique pharmacological profile, which includes effective analgesic and sedative properties, renders it beneficial...

11/01/2025

INSTRUCTOR LED SIMULATION IS VITAL FOR IMPROVED OUTCOMES IN RESUSCITATION TRAINING – Michael Christie

https://www.gemr.org/blog/33/instructor-led-simulation-is-vital-for-improved-outcomes-in-resuscitation-training/

The effectiveness of instructor-led simulation in resuscitation training is well documented and supported by a growing body of evidence demonstrating significant improvements in both knowledge and skill retention among healthcare providers.

Simulations provide a realistic environment that fosters the practice of critical skills in a controlled setting, allowing for repeated exposure to emergencies that are rarely encountered in everyday clinical practice. This aligns with findings from Mccoy et al., who assert that simulation training yields better adherence to American Heart Association (AHA) guidelines among medical students learning cardiopulmonary resuscitation (CPR) compared to standard training methods (McCoy et al., 2018).

Furthermore, studies indicate that the integration of simulation training significantly enhances the competencies of healthcare professionals delivering critical care. For example, Ouseph et al. emphasize that simulation training is considered a cornerstone for educating medical professionals in resuscitation techniques, as recognized by the AHA (Ouseph et al., 2015). This sentiment is echoed by Sawyer et al., who conclude that simulation-based education is not only effective in enhancing immediate performance but also critical for long-term retention of procedural knowledge and skills in neonatal resuscitation (Sawyer et al., 2016).

Moreover, the application of high-fidelity simulations has been shown to markedly improve performance in resuscitation tasks, as indicated by the systematic review conducted by Huang et al., which highlights the positive impact of such training on neonatal resuscitation outcomes (Huang et al., 2019). In a similar vein, Garvey and Dempsey point to the reduction in mortality rates through simulation programs in both developed and developing countries, demonstrating the effectiveness of these training methods (Garvey & Dempsey, 2020).

The benefits of simulation extend beyond individual skill enhancement; they also foster team dynamics crucial during resuscitation scenarios. Research by Farhadi et al. shows that team-based simulation training enhances collaborative skills among healthcare teams, facilitating more effective resuscitation efforts (Farhadi et al., 2023). Such collaborative approaches, as Palmer et al. note, ensure that nursing activities align with the timing and coordination required in high-stakes environments, thereby supporting the premise that simulation training is vital for improving clinical outcomes in neonatal resuscitation (Palmer et al., 2019).

In summary, instructor-led simulation training serves as a critical method for advancing resuscitation training. The consensus in literature reinforces its role in optimizing both individual competencies and team performance, which collectively lead to improved patient outcomes. It is imperative that institutions continue to incorporate simulation into their training curricula to sustain and advance the quality of healthcare delivery.

REFERENCES:
Farhadi, R., Azandehi, B., Amuei, F., Ahmadi, M., Zazoly, A., & Ghorbani, A. (2023). Enhancing residents’ neonatal resuscitation competency through team-based simulation training: an intervention educational study. BMC Medical Education, 23(1).
https://doi.org/10.1186/s12909-023-04704-4
Garvey, A. and Dempsey, E. (2020). Simulation in neonatal resuscitation. Frontiers in Pediatrics, 8.
https://doi.org/10.3389/fped.2020.00059
Huang, J., Tang, Y., Tang, J., Shi, J., Wang, H., Xiong, T., … & Mu, D. (2019). Educational efficacy of high-fidelity simulation in neonatal resuscitation training: a systematic review and meta-analysis. BMC Medical Education, 19(1).
https://doi.org/10.1186/s12909-019-1763-z
McCoy, E., Rahman, A., Rendon, J., Anderson, C., Langdorf, M., Lotfipour, S., … & Chakravarthy, B. (2018). Randomized controlled trial of simulation vs. standard training for teaching medical students high-quality cardiopulmonary resuscitation. Western Journal of Emergency Medicine, 20(1), 15-22.
https://doi.org/10.5811/westjem.2018.11.39040
Ouseph, B., Mohidin, S., Tabsh, L., & Al‐Hebshi, A. (2015). Nurses' resuscitation performance: study on the effectiveness of training and support at a teaching hospital in ksa. International Journal of Cardiovascular and Cerebrovascular Disease, 3(4), 21-27.
https://doi.org/10.13189/ijccd.2015.030401
Palmer, E., Labant, A., Edwards, T., & Boothby, J. (2019). A collaborative partnership for improving newborn safety: using simulation for neonatal resuscitation training. The Journal of Continuing Education in Nursing, 50(7), 319-324.
https://doi.org/10.3928/00220124-20190612-07
Sawyer, T., Ades, A., Ernst, K., & Colby, C. (2016). Simulation and the neonatal resuscitation program 7th edition curriculum. Neoreviews, 17(8), e447-e453.
https://doi.org/10.1542/neo.17-8-e447

10/18/2025

RECOMMENDATIONS FOR THE MANAGEMENT OF SYNCOPE
– Michael Christie

https://www.gemr.org/blog/32/recommendations-for-the-management-of-syncope/

In 2025, advancements in the management and treatment of syncope will be crucial, continuing to evolve based on both clinical findings and updated guidelines. A holistic approach is necessary, considering various forms of syncope, including reflex, arrhythmic, and orthostatic causes, while emphasizing risk stratification, lifestyle modifications, and patient education.

The treatment of reflex syncope, such as vasovagal syncope, remains fundamentally directed towards avoidance of known triggers and enhancements in fluid and salt intake. Studies have shown that educating patients about their condition, along with prescribed interventions that include physical counter-pressure maneuvers and tilt training, can effectively prevent syncopal events and improve quality of life (Ahmadi et al., 2024; (Wen et al., 2020; Loughlin et al., 2020). Increased salt intake has been recognized as an important recommendation in several clinical management protocols, contributing to blood volume expansion and thus aiding symptom management (Wen et al., 2020; Loughlin et al., 2020).

In cases of high-risk syncope, particularly with significant cardiac etiology, an expedited evaluation is critical. The European Society of Cardiology (ESC) emphasizes that individuals exhibiting alarming clinical features should undergo an early intensive assessment, typically in specialized syncope units or observation units (Reed et al., 2023; (Ghariq et al., 2023; . Current guidelines further recommend that patients with unexplained syncope or those presenting with dangerous arrhythmic profiles should be monitored closely and may require the fitting of implantable cardioverter-defibrillators (ICDs) (Shabbir et al., 2022; Francisco‐Pascual et al., 2023). For patients with cardioinhibitory syncope caused by vagal mechanisms, pacing strategies, including the use of leadless devices, can provide effective management solutions (Brieger et al., 2024; Francisco‐Pascual et al., 2023).

Educational initiatives are vital for improving adherence to syncope management guidelines, as highlighted by studies focusing on enhancing healthcare providers' understanding of syncope diagnostics (Ghariq et al., 2023; Ghariq et al., 2021). Incorporating multidisciplinary approaches and standardized clinical pathways is essential to ensure appropriate care, reducing unnecessary testing and hospitalizations, which burden the healthcare system and compromise patient experience (Amin et al., 2021).

Furthermore, there is a growing interest in technological advancements, particularly artificial intelligence, that can enhance diagnostic accuracy and streamline syncope management workflows. AI tools are being explored to refine clinical decision-making processes, which may prove integral as the field advances (Amin et al., 2021; Johnston, 2025).

In essence, the recommended strategies for syncope management center on thorough diagnostic evaluations, tailored treatment plans based on syncope types, increased patient involvement through education, and the integration of innovative technologies to support clinical practices.

REFERENCES:
Ahmadi, A., Sabri, M., Navabi, Z., Dehghan, B., Taheri, M., & Mahdavi, C. (2024). The impact of self-care recommendations with and without tilt-training on quality of life in children and adolescents with vasovagal syncope: a randomized clinical trial. Iranian Journal of Nursing and Midwifery Research, 29(3), 358-367.
https://doi.org/10.4103/ijnmr.ijnmr_137_23
Amin, S., Gupta, V., Du, G., McMullen, C., Sirrine, M., Williams, M., … & Li, J. (2021). Developing and demonstrating the viability and availability of the multilevel implementation strategy for syncope optimal care through engagement (mission) syncope app: evidence-based clinical decision support tool. Journal of Medical Internet Research, 23(11), e25192.
https://doi.org/10.2196/25192
Brieger, D., Tofler, G., & Chia, K. (2024). Use of a leadless pacemaker in the management of swallow syncope: a case report. Pacing and Clinical Electrophysiology, 47(8), 1061-1064.
https://doi.org/10.1111/pace.14923
Francisco‐Pascual, J., Jordán, P., Silva, J., & Rivas-Gándara, N. (2023). Arrhythmic syncope: from diagnosis to management. World Journal of Cardiology, 15(4), 119-141.
https://doi.org/10.4330/wjc.v15.i4.119
Ghariq, M., Bodegom‐Vos, L., Brignole, M., Peeters, S., Groot, B., Kaal, E., … & Thijs, R. (2021). Factors facilitating and hindering the implementation of the european society of cardiology syncope guidelines at the emergency department: a nationwide qualitative study. International Journal of Cardiology, 333, 167-173.
https://doi.org/10.1016/j.ijcard.2021.02.067
Ghariq, M., Hout, W., Dekkers, O., Bootsma, M., Groot, B., Groothuis, J., … & Fokke, C. (2023). Diagnostic and societal impact of implementing the syncope guidelines of the european society of cardiology (synergy study). BMC Medicine, 21(1).
https://doi.org/10.1186/s12916-023-03056-6
Johnston, S. (2025). The hope and the hype of artificial intelligence for syncope management. European Heart Journal - Digital Health, 6(5), 1046-1054.
https://doi.org/10.1093/ehjdh/ztaf061
Loughlin, E., Judge, C., Gorey, S., Costello, M., Murphy, R., Waters, R., … & Canavan, M. (2020). Increased salt intake for orthostatic intolerance syndromes: a systematic review and meta-analysis. The American Journal of Medicine, 133(12), 1471-1478.e4.
https://doi.org/10.1016/j.amjmed.2020.05.028
Reed, M., Karuranga, S., Kearns, D., Alawiye, S., Clarke, B., Möckel, M., … & Laribi, S. (2023). Management of syncope in the emergency department: a european prospective cohort study (seed). European Journal of Emergency Medicine, 31(2), 136-146.
https://doi.org/10.1097/mej.0000000000001101
Shabbir, M., Shaukat, M., Ehtesham, M., Murawski, S., Singh, S., & Alimohammad, R. (2022). Bifascicular block in unexplained syncope is underrecognized and under-evaluated: a single-center audit of esc guidelines adherence. Plos One, 17(2), e0263727.
https://doi.org/10.1371/journal.pone.0263727
Wen, C., Wang, S., Zou, R., Wang, Y., Tan, C., Xu, Y., … & Wang, C. (2020). Duration of treatment with oral rehydration salts for vasovagal syncope in children and adolescents. The Turkish Journal of Pediatrics, 62(5), 820-825.
https://doi.org/10.24953/turkjped.2020.05.014

10/04/2025

Current recommendations on the assessment of acute coronary syndrome patients – Michael Christie

https://www.gemr.org/blog/31/most-frequent-causes-for-adult-patient-mortality-in-moderate-sedation-dental-anesthesia/

Current recommendations for the assessment and treatment of acute coronary syndromes (ACS) focus on a multifaceted, evidence-based approach that builds on prior guidelines while integrating advancements in pharmacotherapy and diagnostic techniques. ACS encompasses conditions such as unstable angina and myocardial infarction (both ST-elevation and non-ST-elevation), necessitating prompt identification and management to optimize patient outcomes.

Initial assessment should prioritize a comprehensive clinical evaluation, utilizing clinical decision tools such as the HEART score (https://www.heartscore.nl/), which aids in stratifying risk among patients presenting with chest pain (Wang et al., 2024)Babu et al., 2023). The integration of these tools, alongside traditional metrics such as electrocardiogram (ECG) findings and troponin levels, forms the cornerstone of early risk stratification, helping to rule in or rule out ACS (Damani & Roongsritong, 2025). The use of computed tomography coronary angiography is also highlighted as a valuable tool in selected cases to assist in diagnosis (Wang et al., 2024).

Pharmacological management remains pivotal in the treatment of ACS, particularly regarding antiplatelet therapy. Current guidelines recommend dual antiplatelet therapy (DAPT) combining aspirin with a P2Y12 inhibitor, such as clopidogrel, for at least 12 months following percutaneous coronary intervention (PCI) to reduce the risk of recurrent thrombotic events (Cheng et al., 2025). Emerging evidence suggests modifications in antiplatelet regimens may be warranted depending on individual patient characteristics and the presence of specific complications such as spontaneous coronary artery dissection (SCAD) (Park et al., 2024; Ilić et al., 2023).

A particular emphasis has been placed on tailoring treatment strategies according to the demographic and clinical profile of patients, particularly older adults, who may present unique challenges due to comorbidities and frailty (Damluji et al., 2023). The recommendations advocate for an individual approach to therapy, factoring in the complexities of polypharmacy and the need for careful monitoring of potential adverse effects (Damluji et al., 2023).

Furthermore, the guidelines encourage healthcare providers to optimize adherence to evidence-based therapies through comprehensive patient education and awareness of secondary prevention measures. These include lifestyle modifications, the management of comorbid conditions, and engagement in cardiac rehabilitation programs, which have been shown to improve clinical outcomes significantly (Gebremichael et al., 2024).

As part of evolving care strategies, attention to socioeconomic factors and barriers to accessing care is increasingly recognized as crucial in the management of ACS. The American Heart Association recommends that healthcare systems work to address disparities in treatment and outcomes across different patient populations (Sarrafzadegan et al., 2024).

In conclusion, current recommendations emphasize a holistic and personalized approach to the assessment and management of ACS, incorporating the latest evidence in pharmacotherapy, technology, and patient-centered care practices to enhance outcomes for individuals at risk of or suffering from acute coronary syndromes.

References:
Ahmadi, A., Sabri, M., Navabi, Z., Dehghan, B., Taheri, M., & Mahdavi, C. (2024). The impact of self-care recommendations with and without tilt-training on quality of life in children and adolescents with vasovagal syncope: a randomized clinical trial. Iranian Journal of Nursing and Midwifery Research, 29(3), 358-367.
https://doi.org/10.4103/ijnmr.ijnmr_137_23
Amin, S., Gupta, V., Du, G., McMullen, C., Sirrine, M., Williams, M., … & Li, J. (2021). Developing and demonstrating the viability and availability of the multilevel implementation strategy for syncope optimal care through engagement (mission) syncope app: evidence-based clinical decision support tool. Journal of Medical Internet Research, 23(11), e25192.
https://doi.org/10.2196/25192
Babu, M., Parimala, L., & Barathi, K. (2023). Assess the risk level of acute coronary syndrome (acs) among patients with chest pain in emergency department. CM, (26), 696-700.
https://doi.org/10.18137/cardiometry.2023.26.696700
Brieger, D., Tofler, G., & Chia, K. (2024). Use of a leadless pacemaker in the management of swallow syncope: a case report. Pacing and Clinical Electrophysiology, 47(8), 1061-1064.
https://doi.org/10.1111/pace.14923
Cheng, B., Xiang-hai, K., Chen, J., He, Q., Zhou, M., & Deng, A. (2025). Assessing the efficacy and safety of low dose clopidogrel in chinese acs patients undergoing pci: a retrospective study. Medicine, 104(22), e42551.
https://doi.org/10.1097/md.0000000000042551
Damani, D. and Roongsritong, C. (2025). Zero coronary artery calcification: a promising value in acute chest pain evaluation. Cureus.
https://doi.org/10.7759/cureus.78365
Damluji, A., Forman, D., Wang, T., Chikwe, J., Kunadian, V., Rich, M., … & Alexander, K. (2023). Management of acute coronary syndrome in the older adult population: a scientific statement from the american heart association. Circulation, 147(3).
https://doi.org/10.1161/cir.0000000000001112
Francisco‐Pascual, J., Jordán, P., Silva, J., & Rivas-Gándara, N. (2023). Arrhythmic syncope: from diagnosis to management. World Journal of Cardiology, 15(4), 119-141.
https://doi.org/10.4330/wjc.v15.i4.119
Gebremichael, L., Beleigoli, A., Foote, J., Bulamu, N., Ramos, J., Suebkinorn, O., … & Clark, R. (2024). missed opportunity: a clinical data linkage study of guideline‐directed medical therapy and clinical outcomes of patients discharged with acute coronary syndrome who attended cardiac rehabilitation programs. Journal of Pharmacy Practice and Research, 54(4), 314-322.
https://doi.org/10.1002/jppr.1923
Ghariq, M., Bodegom‐Vos, L., Brignole, M., Peeters, S., Groot, B., Kaal, E., … & Thijs, R. (2021). Factors facilitating and hindering the implementation of the european society of cardiology syncope guidelines at the emergency department: a nationwide qualitative study. International Journal of Cardiology, 333, 167-173.
https://doi.org/10.1016/j.ijcard.2021.02.067
Ghariq, M., Hout, W., Dekkers, O., Bootsma, M., Groot, B., Groothuis, J., … & Fokke, C. (2023). Diagnostic and societal impact of implementing the syncope guidelines of the european society of cardiology (synergy study). BMC Medicine, 21(1).
https://doi.org/10.1186/s12916-023-03056-6
Ilić, I., Radunović, A., Timčić, S., Odanović, N., Radoicic, D., Dukuljev, N., … & Apostolović, S. (2023). Drugs for spontaneous coronary dissection: a few untrusted options. Frontiers in Cardiovascular Medicine, 10.
https://doi.org/10.3389/fcvm.2023.1275725
Johnston, S. (2025). The hope and the hype of artificial intelligence for syncope management. European Heart Journal - Digital Health, 6(5), 1046-1054.
https://doi.org/10.1093/ehjdh/ztaf061
Loughlin, E., Judge, C., Gorey, S., Costello, M., Murphy, R., Waters, R., … & Canavan, M. (2020). Increased salt intake for orthostatic intolerance syndromes: a systematic review and meta-analysis. The American Journal of Medicine, 133(12), 1471-1478.e4.
https://doi.org/10.1016/j.amjmed.2020.05.028
Park, H., Cho, L., Fendrikova-Mahlay, N., Chaudhury, P., & Cameron, S. (2024). Antiplatelet therapy following spontaneous coronary artery dissection: systemic review..
https://doi.org/10.1101/2024.09.03.24312989
Reed, M., Karuranga, S., Kearns, D., Alawiye, S., Clarke, B., Möckel, M., … & Laribi, S. (2023). Management of syncope in the emergency department: a european prospective cohort study (seed). European Journal of Emergency Medicine, 31(2), 136-146.
https://doi.org/10.1097/mej.0000000000001101
Sarrafzadegan, N., Bagherikholenjani, F., Shahidi, S., Ghasemi, G., Shirvani, E., Rajati, F., … & Abdi, A. (2024). Development of the first iranian clinical practice guidelines for the diagnosis, treatment, and secondary prevention of acute coronary syndrome. Journal of Research in Medical Sciences, 29(1).
https://doi.org/10.4103/jrms.jrms_851_23
Shabbir, M., Shaukat, M., Ehtesham, M., Murawski, S., Singh, S., & Alimohammad, R. (2022). Bifascicular block in unexplained syncope is underrecognized and under-evaluated: a single-center audit of esc guidelines adherence. Plos One, 17(2), e0263727.
https://doi.org/10.1371/journal.pone.0263727
Wang, K., Taggart, C., McDermott, M., O’Brien, R., Oatey, K., Keating, L., … & Gray, A. (2024). Clinical decision aids and computed tomography coronary angiography in patients with suspected acute coronary syndrome. Emergency Medicine Journal, 41(8), 488-494.
https://doi.org/10.1136/emermed-2024-213904
Wen, C., Wang, S., Zou, R., Wang, Y., Tan, C., Xu, Y., … & Wang, C. (2020). Duration of treatment with oral rehydration salts for vasovagal syncope in children and adolescents. The Turkish Journal of Pediatrics, 62(5), 820-825.
https://doi.org/10.24953/turkjped.2020.05.014

The primary causes of mortality related to moderate sedation in adult dental patients largely stem from respiratory complications, bradycardia, inadequate monitoring practices, variations in sedation methods, and patient-specific factors including anxiety levels and overall health.

08/14/2025

USE OF ADVANCED PARAMEDICS IN HOSPITAL CRITICAL CARE AREAS – Michael Christie
https://www.gemr.org/blog/30/use-of-advanced-paramedics-in-hospital-critical-care-areas/

The use of advanced paramedics (APs) in hospital critical care areas is an evolving aspect of healthcare delivery, enhancing the capacity and effectiveness of medical response in high-acuity environments. Their expanded roles have been increasingly recognized as necessary due to various challenges facing emergency services, particularly the escalating demand for timely patient care and the pressures on medical institutions to optimize patient outcomes. Advanced paramedics’ involvement in critical care not only addresses the immediate medical needs of patients but also alleviates some of the burdens from emergency departments (EDs), enabling a more streamlined healthcare system.

A significant aspect of advanced paramedics' impact on critical care settings is their ability to undertake more complex medical interventions. Australian MICA (Mobile Intensive Care Ambulance) paramedics, for example, are trained in critical care protocols similar to those of hospital-based teams, allowing them to manage severe injuries effectively while on-site or during patient transport (Vopelius‐Feldt et al., 2013). They can administer advanced airway management, including life-saving procedures like intubation and chest tube thoracostomy, both of which have shown efficacy comparable to hospital settings in terms of complication rates (Vopelius‐Feldt & Benger, 2014). This capability empowers APs to provide pre-hospital critical care that can stabilize patients before they reach a hospital, potentially increasing survival rates from critical conditions such as cardiac arrests (Vopelius‐Feldt et al., 2015).

Moreover, the integration of advanced paramedics within rural and urban healthcare frameworks significantly diversifies their skill sets, allowing them to engage in both acute care and preventative health. Studies indicate that advanced paramedics can operate under standardized protocols to treat, stabilize, and refer patients without the immediate need for a physician’s oversight, which is particularly beneficial in rural settings where physician access may be limited (Feerick et al., 2022; , Power et al., 2019). This adaptability reflects an increasing recognition of their role in bridging the gap between emergency response and ongoing patient management, contributing to a reduction in hospital overcrowding by managing cases directly at the community level (Barry et al., 2022).

The application of curriculum enhancements for paramedics has also led to this role expansion. Current training programs have begun to include competencies in critical decision-making processes and interdisciplinary collaboration with other healthcare professionals (Campbell et al., 2012). Advanced paramedics employed in hospital settings often liaise directly with emergency nurses, ensuring smoother transitions of care for patients classified as low acuity. In fact, the use of APs to handle these less complex cases has demonstrated a reduction in the length of hospital stays, directly improving patient flow and operational efficiency within emergency departments (Campbell et al., 2012).

As the healthcare landscape continues to shift, there remains an imperative to understand the nuances of AP integration into hospital systems. Concerns have been raised regarding the long-term sustainability of relying on advanced paramedics to alleviate workforce strains within emergency services, particularly amidst the stresses associated with high-pressure environments in the healthcare sector (Stenner et al., 2021). Burnout and job dissatisfaction are notable issues that can affect paramedics, contributing to workforce turnover that complicates the goal of establishing consistently high-level care Power et al., 2019). Thus, while advanced paramedics bring invaluable skills to critical care, there is a need for systemic support to address the underlying challenges of recruitment and retention in this field.

The development of triage and treatment protocols, such as the "treat and discharge" framework in Ireland, underscores the potential of advanced paramedics to redefine patient management pathways. These protocols empower them to operate autonomously in various clinical scenarios, improving efficiency without compromising the quality of care provided to patients (Feerick et al., 2022; , Power et al., 2019). This paradigm shift aligns with international trends recognizing the effective functioning of APs in emergency medical services, where their training equips them with specialized knowledge applicable across diverse medical scenarios (Campbell et al., 2012).

Further empirical evidence pertaining to advanced paramedics’ roles in critical care indicates that they significantly enhance patient access to necessary medical interventions. They find themselves at the forefront of managing patients with complex health profiles who might typically overwhelm emergency departments. The practical involvement of APs ensures that interventions can be initiated promptly, where traditional hierarchies might result in delays (Campbell, 2017). Evidence also suggests that advanced paramedics possess a sophisticated understanding of geriatric assessments, preparing them to effectively address the unique needs of older patients (Goldstein et al., 2015).

Challenges faced by APs are manifold, including the pressing need for ongoing training to maintain high standards of practice. Given the broad scope of skills they must master, advanced paramedics require continuous professional development opportunities that reflect evolving healthcare practices (Jensen et al., 2013; , Brown, 2017). This aspect integrates the need for additional support systems within hospitals where these paramedics function, ensuring they can fulfill their roles competently and confidently.

In conclusion, the integration of advanced paramedics into hospital critical care areas represents a pivotal evolution in healthcare delivery, responding to the needs of an increasingly complex patient population. Their ability to leverage advanced skills effectively not only enhances patient outcomes in acute scenarios but also contributes to the overall efficiency of healthcare systems. As healthcare continues to evolve, embracing the role of advanced paramedics within critical care will be fundamental for improving service delivery and addressing the ongoing challenges facing emergency medical services.

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This ‘day-in-the-life’ article is the author's first-person account of his experiences as a paramedic working in an inner-city GP practice, while training to be an advanced clinical practitioner. The author aims to illustrate the range and complexity of the role of paramedics based in primary ca...