Peter Antevy MD

Abstract
Objectives: Resuscitation in the Head Up position improves outcomes in animals treated with active compression decompression cardiopulmonary resuscitation and an impedance threshold device (ACD + ITD CPR). We assessed impact of time to deployment of an automated Head Up position (AHUP) based bundle of care after out-of-hospital cardiac arrest on return of spontaneous circulation (ROSC).
Methods: Observational data were analyzed from a patient registry. Patients received treatment… Show more

Abstract
Objectives: Resuscitation in the Head Up position improves outcomes in animals treated with active compression decompression cardiopulmonary resuscitation and an impedance threshold device (ACD + ITD CPR). We assessed impact of time to deployment of an automated Head Up position (AHUP) based bundle of care after out-of-hospital cardiac arrest on return of spontaneous circulation (ROSC).
Methods: Observational data were analyzed from a patient registry. Patients received treatment with 1) ACD + and/or automated CPR 2) an ITD and 3) an AHUP device. Probability of ROSC (ROSCprob) from the 9-1-1 call to AHUP device placement was assessed with a restricted cubic spline model and linear regression.
Results: Of 11 sites, 6 recorded the interval from 9-1-1 to AHUP device (n = 227). ROSCprob for all rhythms was 34%(77/227). Median age (range) was 66 years (19-101) and 68% men. The ROSCprob for shockable rhythms was 47%(18/38). Minutes from 9-1-1 to AHUP device (median, range) varied between sites: 1) 6.4(4,15), 2) 8.0(5,19), 3) 9.9(4, 12), 4) 14.1(6, 36), 5) 15.9(6, 34), 6) 19.0(8, 38),(p = 0.0001). ROSCprob also varied; 1) 55.1%(16/29), 2) 60%(3/5), 3) 50%(3/6), 4) 22.7%(17/75), 5) 26.4%(9/34), and 6) 37.1%(29/78), (p = 0.019). For all rhythms between 4 and 12 min (n = 85), ROSCprob declined 5.6% for every minute elapsed (p = 0.024). For shockable rhythms, between 6 and 15 min (n = 23), ROSCprob declined 9.0% for every minute elapsed (p = 0.006).
Conclusions: Faster time to deployment of an AHUP based bundle of care is associated with higher incidence of ROSC. This must be considered when evaluating and implementing this bundle. Show less

When the death of a child comes without warning, the shock and disbelief can be overwhelming for their parents, family and friends. In such cases, there is no opportunity to prepare, to say good-bye, to resolve any misunderstandings, tell them you love them or to prevent what happened. It is traumatic and it shatters the assumptions of what we believe the world should be and causes us to search for answers to questions that cannot be answered.

A child’s death is a loss that affects a… Show more

When the death of a child comes without warning, the shock and disbelief can be overwhelming for their parents, family and friends. In such cases, there is no opportunity to prepare, to say good-bye, to resolve any misunderstandings, tell them you love them or to prevent what happened. It is traumatic and it shatters the assumptions of what we believe the world should be and causes us to search for answers to questions that cannot be answered.

A child’s death is a loss that affects a very large number of people. All are affected—fathers, mothers, brothers, sisters, grandparents, extended family as well as the community at large.
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Following acute stroke onset, time elapsed for EMS response and transport is relatively short compared to the lengthy intervals elapsing between symptom onset and 9-1-1 system activation, regardless of demographics. Exploration of innovative strategies to improve public education regarding stroke symptoms and immediate 9-1-1 system activation are strongly recommended.

Only time will tell if the EHR can adopt a level of humanity that puts the patient back in the center, breaks free from its silos, and allows clinicians to give their patients more of a human touch.

Objectives: Combined with devices that enhance venous return out of the brain and into the thorax, preclinical outcomes are improved significantly using a synergistic bundled approach involving mild elevation of the head and chest during cardiopulmonary resuscitation. The objective here was to confirm clinical safety/feasibility of this bundled approach including use of mechanical cardiopulmonary resuscitation provided at a head-up angle. Measurements and Main Results: No problems were observed… Show more

Objectives: Combined with devices that enhance venous return out of the brain and into the thorax, preclinical outcomes are improved significantly using a synergistic bundled approach involving mild elevation of the head and chest during cardiopulmonary resuscitation. The objective here was to confirm clinical safety/feasibility of this bundled approach including use of mechanical cardiopulmonary resuscitation provided at a head-up angle. Measurements and Main Results: No problems were observed with head-up/torso-up positioning (n = 1,489), but resuscitation rates rose significantly during the transition period (April to June 2015) with an ensuing sustained doubling of those rates over the next 2 years (mean, 34.22%; range, 29.76-39.42%; n = 1,356 vs 17.87%; range, 14.81-20.13%, for 806 patients treated prior to the transition; p < 0.0001). Outcomes improved across all subgroups. Response intervals, clinical presentations and indications for attempting resuscitation remained unchanged. Resuscitation rates in 2015-2017 remained proportional to neurologically intact survival (similar to 35-40%) wherever tracked. Conclusions: The head-up/torso-up cardiopulmonary resuscitation bundle was feasible and associated with an immediate, steady rise in resuscitation rates during implementation followed by a sustained doubling of the number of out-of-hospital cardiac arrest patients being resuscitated. These findings make a compelling case that this bundled technique will improve out-of-hospital cardiac arrest outcomes significantly in other clinical evaluations. Show less

Easy problems have easy answers – complex problems require complex answers. However, in pediatrics, we’ve taken an easy problem and made it unnecessarily complicated. Pediatric resuscitation isn’t that complex (BVM – compressions – Epi), yet over the last 3 decades we’ve been convinced otherwise. Why? Many have focused on one thing – getting the child’s weight. We’ve been convinced that a single tool or widget will get us through a difficult pediatric call. It’s time to change this… Show more

Easy problems have easy answers – complex problems require complex answers. However, in pediatrics, we’ve taken an easy problem and made it unnecessarily complicated. Pediatric resuscitation isn’t that complex (BVM – compressions – Epi), yet over the last 3 decades we’ve been convinced otherwise. Why? Many have focused on one thing – getting the child’s weight. We’ve been convinced that a single tool or widget will get us through a difficult pediatric call. It’s time to change this mentality.

As a pediatric emergency physician for 17 years, and EMS medical director for the last 7, I have seen both sides of the story and have much greater clarity and insight into something that has eluded us for some time. There is one thing that is undeniably true, yet is contrary to popular belief – success in pediatric arrest relies highly on efforts prior to arrival on scene. This includes the efforts of bystanders, the 9-1-1 call-takers, and those of EMS professionals. Some of these ideas are contrarian, yet we now have data to back them up. Here are 10-steps your agency can take to improve pediatric out-of-hospital cardiac survival in your community. Show less

Race/ethnic differences were observed in the time from stroke onset to hospital arrival among EMSTARS patients, driven by differences in time from onset to 911 call. Culturally-tailored intervention programs are needed to educate the public, especially black communities, about stroke symptoms and the importance of immediate 911 activation.

This month's cover story of EMSWorld (EMS - EMT - Paramedic - Emergency Medical Services) Magazine details the mobile integrated health program started 18 months ago in Broward and Miami-Dade Counties. The program uses highly skilled paramedics to bring the ER to the patient's home and video conference with their physician. Thus far they have seen over 1400 acutely ill Medicare patients and have kept 84% of them at home.

Proud to collaborate with such a talented group of individuals.

Abstract

Introduction: Sprawling and multi-ethnic with extremes of age / socioeconomics, Palm Beach County (PBC), FL (pop. 1.4 mill) has still realized short term survival rates (hospital admission) akin to nationwide data for out of hospital cardiac arrest (OOHCA). Then, in early 2015, a new medical direction/training team at PBC Fire Rescue (PBCFR) re-focused on nontraditional protocols including flow oriented CPR methods and head/torso up positioning. The purpose of this analysis was… Show more

Abstract

Introduction: Sprawling and multi-ethnic with extremes of age / socioeconomics, Palm Beach County (PBC), FL (pop. 1.4 mill) has still realized short term survival rates (hospital admission) akin to nationwide data for out of hospital cardiac arrest (OOHCA). Then, in early 2015, a new medical direction/training team at PBC Fire Rescue (PBCFR) re-focused on nontraditional protocols including flow oriented CPR methods and head/torso up positioning. The purpose of this analysis was to evaluate how these nontraditional tactics would affect outcomes.

Methods: All OOHCA cases (all rhythms) in PBC were followed over 2 years (2014-15). In 2015, PBCFR crews were trained to: 1) ensure proper use of mechanical CPR (Lucas©); 2) apply O2 but defer ventilation 6 mins; 3) apply impedance threshold devices; 4) raise the backboard 30o (head/torso up position). With neuro-intact hospital discharge data not available before 2015, short term survival was used for consistent comparisons. Quarterly reports were run to identify any periodic variations or incremental effects during protocol transition (late Quarter 1 / early Quarter 2, 2015).

Results: Among 1,304 consecutive OOHCA cases in 2014-15, survival rates (Fig 1) were fairly constant in 2014 (17.4% mean, range 15-20%) but rose steadily during the transition with an ensuing sustained doubling of survival (36.0%; range 35-37%). Outcome improved across subgroups while response intervals, indications for initiating CPR and bystander CPR rates were unchanged. Regionally in 2015, hospital admission rates were found to remain proportional to neuro-intact discharge.

Conclusions: Though using historically-controlled data that did not examine the relative influence of each non-traditional CPR method, the immediate, steady rise in resuscitation rates seen in the transition phase (which endured) still makes a strong case that re-searching novel approaches can help EMS further improve OOHCA outcomes, even in large, complex settings. Show less

If the general public can be given sanction to take action to stop life-threatening bleeding by providing access to tourniquets and other bleeding-control equipment, many lives can be saved. The town of Davie was recognized as one of the leading municipalities in the country that has already added severe-bleeding kits to community AEDs.

Abstract*

Background: Pediatric Advanced Life Support guidelines set forth by the American Heart Association recommends use of a length-based resuscitation tape (LBT) by healthcare providers. Pediatric medication errors in the pre-hospital setting have been studied by numerous investigators, occur frequently and are potentially fatal. This study seeks to compare pediatric drug dosages from large and small EMS agencies to those listed on the Broselow LBT and determine discordance… Show more

Abstract*

Background: Pediatric Advanced Life Support guidelines set forth by the American Heart Association recommends use of a length-based resuscitation tape (LBT) by healthcare providers. Pediatric medication errors in the pre-hospital setting have been studied by numerous investigators, occur frequently and are potentially fatal. This study seeks to compare pediatric drug dosages from large and small EMS agencies to those listed on the Broselow LBT and determine discordance rates.

Methods: We first sought to determine the percentage of medications on the Broselow LBT found at incongruent dosages compared to the EMS protocols. We then determined the total number of medications from each EMS protocol that were not present on the Broselow LBT. For each EMS agency, the sum of incongruent medications and missing medications was divided by the total number of medications to determine the overall discordance rate for each EMS agency. Finally, we calculated the frequency of each of the medications in each EMS protocol that were missing from the Broselow LBT, as well as those that were listed at incongruent doses.

Results: Thirty-eight EMS protocols were reviewed. Of medications listed in both the Broselow LBT and EMS protocol, 10% were listed at a dose at least 30% greater than that recommended by the EMS protocol. On average, 38% of EMS protocol medications were not listed on the Broselow LBT. This calculated to a total average medication discordance rate of 49% (Range 32-63%,SD 8%). Further analysis revealed that five medications represented 62% of the missing medications: Epinephrine 1:1000 IM, Ondansetron, Diphenhydramine, Morphine, and Albuterol. Three medications accounted for 84% of the incongruent dosages: Midazolam, Fentanyl, and Diazepam.

Conclusion: A significant discrepancy exists between the pediatric drug dosages found in 38 EMS protocols and those listed on the Broselow Length-Based Tape.
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The Society of Neurointerventional Surgery has introduced a new term to define stroke patients who have a similar acute vascular emergency. Emergent large vessel occlusion (ELVO) was coined in order to signal the healthcare community that stroke is an acute vascular emergency.6 With that, the primary goals for acute ischemic stroke diagnosis and management have changed. This article discusses the recent stroke publications and how they will revolutionize treatment of patients both in the field… Show more

The Society of Neurointerventional Surgery has introduced a new term to define stroke patients who have a similar acute vascular emergency. Emergent large vessel occlusion (ELVO) was coined in order to signal the healthcare community that stroke is an acute vascular emergency.6 With that, the primary goals for acute ischemic stroke diagnosis and management have changed. This article discusses the recent stroke publications and how they will revolutionize treatment of patients both in the field and in the hospital. Show less

Patient satisfaction can sometimes feel like a burden to the health care provider, especially when the situation, based on the circumstances, is negative from the outset. It turns out, however, that making someone “happy” during a time of pain and suffering is complex, yet not as negative as it would appear on the surface.

A major emphasis must be placed on public awareness of pediatric stroke. The AHA must include pediatric stroke in the same campaign as for adults. Physicians and sub-specialists must educate parents of at-risk children about the signs and symptoms of pediatric stroke. EMS personnel need to keep pediatric stroke high on their list of potential problems, specifically in high-risk children and also in those who present with classic stroke symptoms. The concept that “kids don’t get strokes” should… Show more

A major emphasis must be placed on public awareness of pediatric stroke. The AHA must include pediatric stroke in the same campaign as for adults. Physicians and sub-specialists must educate parents of at-risk children about the signs and symptoms of pediatric stroke. EMS personnel need to keep pediatric stroke high on their list of potential problems, specifically in high-risk children and also in those who present with classic stroke symptoms. The concept that “kids don’t get strokes” should be revised to “kids absolutely get strokes,” and did I mention that kids are just little adults? Show less

Pediatric arrest patients deserve the same opportunity to walk out of the hospital and to that end we must mandate on-scene resuscitation for at least two minutes (one round of CPR) before moving off scene. Proficient and confident teams will remain on scene until ROSC is achieved, similar to the expectation in the adult scenario, while others may consider staying on scene within the confines of the ambulance. While this may be a culture change that will be difficult to obtain, consideration of… Show more

Pediatric arrest patients deserve the same opportunity to walk out of the hospital and to that end we must mandate on-scene resuscitation for at least two minutes (one round of CPR) before moving off scene. Proficient and confident teams will remain on scene until ROSC is achieved, similar to the expectation in the adult scenario, while others may consider staying on scene within the confines of the ambulance. While this may be a culture change that will be difficult to obtain, consideration of age-based resuscitation will facilitate the transition. Attention to outcomes must be the number one priority and department champions on every level are required for such a change to occur. Show less

Study Objectives: The 2010 Pediatric Advanced Life Support (PALS) guidelines state that length-based tapes (LBT) are more accurate than age-based methods in the prediction of body weight (Class IIa, LOE C). A novel hybrid pediatric age and length-based weight estimation method (Handtevy) has been described to significantly improve accuracy in a pre-hospital pediatric simulation trial compared to the Broselow system. The primary objective of this study was to validate the correlation between… Show more

Study Objectives: The 2010 Pediatric Advanced Life Support (PALS) guidelines state that length-based tapes (LBT) are more accurate than age-based methods in the prediction of body weight (Class IIa, LOE C). A novel hybrid pediatric age and length-based weight estimation method (Handtevy) has been described to significantly improve accuracy in a pre-hospital pediatric simulation trial compared to the Broselow system. The primary objective of this study was to validate the correlation between predicted weights using the Handtevy age-based system and published pediatric normal weights. The secondary objective was to compare the predictive validity of the Handtevy LBT to the Broselow LBT.

Results: Rater agreement between the Handtevy age-based system and measured NHANES weights shows a significant prediction, with 71% of the variance accounted for in the model. A Bland-Altman plot demonstrates only 5.5% percent of the measurements outside of the limits of agreement (95% CI, -25.67 to 24.12). In a comparison of the two length based tapes, paired t-tests demonstrate that the Handtevy LBT is more accurate 62% of the time. Both length based techniques become less accurate as a subject’s weight increases. To compare the Handtevy age-based system to the Broselow LBT, pairwise comparisons were used to compare the percentage difference between predicted and actual weights for each BMI category. The Handtevy age-based system performed statistically better (p < 0.05) for underweight, normal weight, and obese children. No difference was found for overweight children.

Conclusion: Predicted weights from the Handtevy age-based weight estimation method accurately predict pediatric normal weights. A comparison of two length-based tapes demonstrates increased accuracy of the Handtevy LBT over the Broselow LBT. The Handtevy age-based system outperforms the Broselow LBT for underweight, normal weight, and obese children. Show less

The difficulty in treating critically ill children is pervasive. The key to success in a pediatric resuscitation relies on access to tools and knowledge of reliable algorithms, but also the psychology of the provider.

The Handtevy System uses a unique “hybrid” approach that addresses the psychological hurdles pre-hospital providers encounter during low volume-high stress pediatric calls.

Nail bed injuries and fingertip avulsions occur frequently and may have significant associated functional or cosmetic morbidity. These injuries are commonly treated in an outpatient setting. Nail bed lacerations require careful repair and measures to preserve the nail folds and germinal matrix. Complete fingertip avulsions require debridement, cleansing, and local wound care.

The repair of nail bed lacerations and fingertip avulsions are reviewed here. The management of subungual… Show more

Nail bed injuries and fingertip avulsions occur frequently and may have significant associated functional or cosmetic morbidity. These injuries are commonly treated in an outpatient setting. Nail bed lacerations require careful repair and measures to preserve the nail folds and germinal matrix. Complete fingertip avulsions require debridement, cleansing, and local wound care.

The repair of nail bed lacerations and fingertip avulsions are reviewed here. The management of subungual hematoma is discussed separately. Show less

Abstract

Background: Digital anesthesia in the pediatric population has traditionally been accomplished using a ring block that requires multiple injections. A modified transthecal digital nerve block is a single-injection technique of the midproximal phalanx that has been shown to be technically simple and highly effective in adults.

Objective: To describe the success rate of the modified transthecal digital nerve block in children.

Results: Between November 2003 and March… Show more

Abstract

Background: Digital anesthesia in the pediatric population has traditionally been accomplished using a ring block that requires multiple injections. A modified transthecal digital nerve block is a single-injection technique of the midproximal phalanx that has been shown to be technically simple and highly effective in adults.

Objective: To describe the success rate of the modified transthecal digital nerve block in children.

Results: Between November 2003 and March 2004, 48 patients (50 digits) requiring digital anesthesia were enrolled into the study. The mean age of patients was 8.3 years (median, 7.6 years; range, 0.7-17.5 years). Twenty-four (50%) were boys and 30 whites (62.5%). Overall, the transthecal digital nerve block technique was successful in 47 (94%) of the 50 digits (95% confidence interval [CI], 83%-98%), including 37 (97%) of 38 fingers (95% CI, 85%-99%) and 10 (83%) of 12 thumbs (95% CI, 54%-96%). Forty-seven (94%) of the 50 digits had a recorded pain score of 0 five minutes after injection. Mean (SD) procedure time was 113 (24.8) seconds, and mean (SD) anesthetic volume was 2.13 (0.61) mL. No adverse events were reported.

Conclusions: The single-injection modified transthecal digital nerve block is a safe and effective method for digital anesthesia in children. These data confirm the applicability of transthecal digital nerve block for children with finger and thumb injuries that require minor surgical procedures. Show less

A book chapter on the management of finger injuries in children