Mary Knotts

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Scholarly Contributions

Journals/Publications

• Gaither, J. B., French, R., Knotts, M., Lerman, M., Harrell, A. J., McIntosh, S., Rice, A. D., Cole, R., Gilmore, S., Hindman, D. E., Edwards, C., Nguyn, H. N., Truxillo, M., West, J., Yeoh, A., David, T., Shirazi, F. M., Wilson, B. Z., Debevec, J. T., , Schertz, M., et al. (2025).

  Consensus Guideline for the Care of Patients in the Prehospital and Aerospace Settings with Exposures to Hydrazine and Hydrazine Derivatives

  . Prehospital Emergency Care, Epub ahead of print, 1-9. doi:10.1080/10903127.2024.2442097
• Vandergrift, L. A., Rice, A. D., Primeau, K., Gaither, J. B., Munn, R. D., Hannan, P. L., Knotts, M. C., Hollen, A., Stevens, B., Lara, J., & Glenn, M. (2025). Precipitated Withdrawal Induced by Prehospital Naloxone Administration. Prehospital Emergency Care, 29(Issue 4). doi:10.1080/10903127.2024.2449505
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  Objectives: Buprenorphine is becoming a key component of prehospital management of opioid use disorder. It is unclear how many prehospital patients might be eligible for buprenorphine induction, as traditional induction requires that patients first have some degree of opioid withdrawal. The primary aim of this study was to quantify how many patients developed precipitated withdrawal after receiving prehospital naloxone for suspected overdose, as they could be candidates for prehospital buprenorphine. The secondary objective was to identify associated factors contributing to precipitated withdrawal, including dose of naloxone administered, and identify rate of subsequent transport. Methods: A retrospective cohort study reviewing electronic patient care reports (ePCRs) from March 2019 to April 2023 in a single Emergency Medical Services (EMS) system was performed. Cases were included if naloxone was administered during the prehospital interval and excluded if the patient was in cardiac arrest upon arrival and died on scene. Precipitated opioid withdrawal was defined using reliably available ePCR data points measured by the Clinical Opiate Withdrawal Scale: administration of an antiemetic or sedative, persistent tachycardia, or new tachycardia after naloxone. Descriptive statistics were calculated to quantify the incidence of precipitated withdrawal. Risk ratios were calculated to identify variables associated with outcomes of interest. A subgroup analysis was performed examining patients explicitly diagnosed with an overdose by EMS. Results: During the study period, 4561 individuals were given naloxone, and 2124 (46.2%) met our proxy criteria for precipitated withdrawal. Patients who received multiple doses of naloxone were more likely to meet our precipitated withdrawal definition versus those who received a single dose (RR 1.2, 95% CI 1.12–1.28). Patients who experienced precipitated withdrawal were more likely to accept transportation than those who did not experience withdrawal (RR 1.08 95% CI 1.04–1.12). Persistent tachycardia (80.3%) was the most common criterion met for our definition of precipitated withdrawal. Conclusions: Almost half of patients who received a dose of prehospital naloxone for suspected overdose met our proxy criteria for precipitated withdrawal. Patients who met our precipitated withdrawal definition were more likely to have received greater doses of naloxone and were more likely to accept transport to an emergency department.
• Rice, A., Hannan, P., Kamara, M., Gaither, J., Blust, R., Chikani, V., Castro-Marin, F., Bradley, G., Bobrow, B., Munn, R., Knotts, M., & Lara, J. (2024). Use of Long Spinal Board Post-Application of Protocol for Spinal Motion Restriction for Spinal Cord Injury. Western Journal of Emergency Medicine, 25(5). doi:10.5811/westjem.18342
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  Introduction: Historically, prehospital care of trauma patients has included nearly universal use of a cervical collar (C-collar) and long spine board (LSB). Due to recent evidence demonstrating harm in using LSBs, implementation of new spinal motion restriction (SMR) protocols in the prehospital setting should reduce LSB use, even among patients with spinal cord injury. Our goal in this study was to evaluate the rates of and reasons for LSB use in high-risk patients—those with hospital-diagnosed spinal cord injury (SCI)—after statewide implementation of SMR protocols. Methods: Applying data from a state emergency medical services (EMS) registry to a state hospital discharge database, we identified cases in which a participating EMS agency provided care for a patient later diagnosed in the hospital with a SCI. Cases were then retrospectively reviewed to determine the prevalence of both LSB and C-collar use before and after agency adoption of a SMR protocol. We reviewed cases with LSB use after SMR protocol implementation to determine the motivations driving continued LSB use. We used simple descriptive statistics, odds ratios (OR) with 95% confidence intervals (CI) to describe the results. Results: We identified 52 EMS agencies in the state of Arizona with 417,979 encounters. There were 225 patients with SCI, of whom 74 were excluded. The LSBs were used in 52 pre-SMR (81%) and 49 post-SMR (56%) cases. The odds of LSB use after SMR protocol implementation was 70% lower than it had been before implementation (OR 0.297, 95% CI 0.139–0.643; P = 0.002). Use of a C-collar after SMR implementation was not significantly changed (OR 0.51, 95% CI 0.23–1.143; P = 0.10). In the 49 cases of LSB use after agency SMR implementation, the most common reasons for LSB placement were ease of lifting (63%), placement by non-transporting agency (18%), and extrication (16.3%). High suspicion of SCI was determined as the primary or secondary reason for not removing LSB after assessment in 63% of those with LSB placement, followed by multiple transfers required (20%), and critical illness (10%). Conclusion: Implementation of selective spinal motion restriction protocols was associated with a statistically significant decrease in the utilization of long spine boards among prehospital patients with acute traumatic spinal cord injury.
• Martin, T., Chung, A., Knotts, M., Panknin, T., & Hannan, P. (2022). Postcoital cyst rupture presenting as peritonitis and hemorrhagic shock: A case report. Case Reports in Women's Health, 34. doi:10.1016/j.crwh.2022.e00402
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  Introduction: This report presents an unusual case of severe post-coital abdominal pain and signs of hemorrhagic shock requiring admission to a surgical intensive care unit (SICU) and emergent laparoscopy. This case was unique given the timing and progression of the patient's symptoms, as well as her age, surgical history, and symptomatic progression. Here we document the notable characteristics and treatment of this patient. Case presentation: The patient presented to a local emergency department with signs progressive peritonitis and shock after an episode of non-traumatic intercourse. Her initial computed tomography (CT) scan showed signs of free fluid in the abdomen around the bladder and liver with no definitive source of bleed. She developed worsening shock with severe pain. She was then emergently transferred to a tertiary care center for evaluation by gynecology service and for general trauma surgery evaluation. She was further stabilized in the emergency department, and then admitted to the surgical critical care service. Following additional imaging, she received exploratory surgery with gynecology to control a hemorrhagic ruptured cyst. She remained stable and was discharged the next day. Conclusion: This case demonstrated a complication of an often-benign diagnosis, revealing the potential danger of underestimating this chief complaint, as well as the importance of understanding how minimal trauma can lead to cyst rupture.
• Moses Mhayamaguru, K., Gaither, J., French, R., Christopher, N., Waters, K., Jado, I., Rice, A., Beskind, D., Knotts, M., Ronnebaum, J., Smith, J., & Walter, F. (2021). Availability and use of medications by prehospital providers trained to manage medical complications of patients in hazardous materials incidents. American journal of disaster medicine, 16(3). doi:10.5055/ajdm.2021.0404
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  INTRODUCTION: Little is known about prehospital availability and use of medications to treat patients from hazardous materials (hazmat) medical emergencies. The aim of this study was to identify the availability and frequency of use of medications for patients in hazmat incidents by paramedics with advanced training to care for these patients. METHODS: A prospectively validated survey was distributed to United States paramedics with advanced training in the medical management of patients from hazmat incidents who successfully completed a 16-hour Advanced Hazmat Life Support (AHLS) Provider Course from 1999 to 2017. The survey questioned hazmat medication availability, storage, and frequency of use. Hazmat medications were considered to have been used if administered anytime within the past 5 years. For analyses, medications were grouped into those with hazmat indications only and those with multiple indications. RESULTS: The survey email was opened by 911 course participants and 784 of these completed the survey (86.1 percent). Of these 784 respondents, 279 (35.6 percent) reported carrying dedicated hazmat medication kits, ie, tox-boxes, and 505 (64.4 percent) did not carry tox-boxes. For those medications specifically for hazmat use, hydroxocobalamin was most commonly available, either within or not within a dedicated tox-box. Of the 784 respondents, 313 (39.9 percent) reported carrying hydroxocobalamin and 69 (8.8 percent) reported administering it within the past 5 years. For medications with multiple indications, availability and use varied: for example, of the 784 respondents, albuterol was available to 699 (89.2 percent) and used by 572 (73.0 percent), while calcium gluconate was available to 247 (31.5 percent) and used by 80 (10.2 percent) within the last 5 years. CONCLUSION: Paramedics with advanced training in the medical management of patients in hazmat incidents reported limited availability and use of medications to treat patients in hazmat incidents.

Presentations

• Gaither, J. B., Anderson, C., Stevens, B., Rice, A., Spaite, D. W., Fisher, T., Knotts, M., Munn, R., Hannan, P., & Hunt, T. (2025, Sept).

  Impact of an Advance Life Support First Response on Patients with Primary Impression of Chest Pain

  . American College of Emergency Physicians Research Forum. Salt Lake City, UT: American College of Emergency Physicians.

Poster Presentations

• Gaither, J. B., Rice, A., Munn, R., Liu, J., Knotts, M., Ng, V., Bethel, A., Camarillo, R., Shihab, S., DeMers, D., & Hannan, P. (2024, January).

  MCI Triage Accuracy Among Resident Physicians

  . Annual Scientific Assembly of the National Association of EMS Physicians. Austin, Texas.
• Knotts, M., Gaither, J. B., Hannan, P., Munn, R., Hollen, A., Haley, J., Brian, K., Shawn, T., & Rice, A. (2024, January). A Liberal Shocking Strategy Distorts Utstein Survival Calculation for Out of Hospital Cardiac Arrests. NAEMSP Annual Conference. Austin, TX.
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  The Menegazzi Scientific Sessions: Research Abstracts for the 2024 National Association of EMS Physicians Annual Meeting. (2023). Prehospital Emergency Care, 28(sup1), S1–S111. https://doi.org/10.1080/10903127.2023.2273890
• Knotts, M., Rice, A., Wise, J. N., Dolana, B., Joshua, C., Doty, B., Hannan, P., Munn, R., Lerman, M., & Gaither, J. B. (2024, January). Comparison of Direct Laryngoscopy and Video Laryngoscopy on Difficult Airway Mannequins in the Prehospital Setting. NAEMSP Annual Conference. Austin, TX.
  More info

  The Menegazzi Scientific Sessions: Research Abstracts for the 2024 National Association of EMS Physicians Annual Meeting. (2023). Prehospital Emergency Care, 28(sup1), S1–S111. https://doi.org/10.1080/10903127.2023.2273890