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A pinboard by
Matt Holland

This board is owned by Matt Holland, LKS ASE, Librarian. Contact Matt.Holland@nwas.nhs.uk.

PINBOARD SUMMARY

Hosts recent articles from research based journals. Pinboard started in September 2016.

Coverage

This board collates published research on the prehospital and paramedic Practice.

Audience

The board is aimed at those working in Ambulance Services and Prehospital Care. Anyone can look.

Updates

The board is updated regularly. Somewhere between daily and weekly depending on the volume of publication.

Who is responsible

This board is maintained and run by Matt Holland, Librarian LKS ASE Matt.Holland@nwas.nhs.uk.

More about LKS ASE

Check the LKS ASE website to find out more about us. Follow us on Twitter, our Twitter handle is @NWASLibrary.

1476 ITEMS PINNED

[Successful prehospital emergency thoracotomy after blunt thoracic trauma : Case report and lessons learned].

Abstract: The European Resuscitation Council guidelines for resuscitation in patients with traumatic cardiac arrest recommend the immediate treatment of all reversible causes, if necessary even prior to continuous chest compression. In the case of cardiac tamponade immediate emergency thoracotomy should also be considered. The authors report the case of a 23-year-old male patient with multiple injuries including blunt thoracic trauma, which caused a witnessed cardiac arrest. He successfully underwent prehospital emergency resuscitative thoracotomy. The lessons learned from this case on internal and external quality measures are discussed in detail. After 60 min of technical rescue, extensive trauma life support including intubation, chest decompression and bleeding control was carried out. The cardiovascular insufficiency progressively deteriorated and under the suspicion of a cardiac tamponade a prehospital emergency thoracotomy was carried out. After successful resuscitative thoracotomy and return of spontaneous circulation (ROSC) the patient was airlifted to the next level 1 trauma center for damage control surgery (DCS). The patient could be discharged 59 days after the accident and now 2 years later is living a normal life without neurological or cardiopulmonary limitations. Airway management, chest decompression including resuscitative thoracotomy, fluid resuscitation and blood products were the key components to ensure that the patient achieved ROSC. Advanced Trauma Life Support® as well as structural prerequisites made these measures and good results for the patient possible.

Pub.: 07 Jun '18, Pinned: 18 Jun '18

Effect of Detection Time Interval for Out-of-Hospital Cardiac Arrest on Outcomes in Dispatcher-Assisted Cardiopulmonary Resuscitation: A Nationwide Observational Study.

Abstract: The association between the detection time interval (DTI) from the call for ambulance to the detection of out-of-hospital cardiac arrest (OHCA) by the dispatcher and the neurological outcome in dispatcher-assisted cardiopulmonary resuscitation (DA-CPR) is unclear. Adults who sustained OHCA with cardiac etiology received DA-CPR between 2013 and 2016 were analyzed. The main predictor was DTI defined as the time interval from the beginning of the emergency call to identification of OHCA by the dispatcher. The primary outcomes were the good cerebral performance category (CPC) 1 or 2. Multivariable logistic regression analysis was performed to calculate the adjusted odds ratio (AOR) and 95% confidence interval (CI) for outcomes, adjusting for potential confounders, by the 10- and 30-seconds DTI delay and three DTI groups; Short (0-90 seconds), Middle (91-180 seconds), and Long (181-1,200 seconds) groups. Interaction analysis for DTI and urbanization level (megacity with 10 million or more population in urban region, metropolis with 1 to 5 million population in urban region, and Rural province with less than 2 million population in urban, suburban, and rural region) was performed to compare the effect size of DTI group according to urbanization level. Of 116374 adults with an OHCA, 11833 were finally analyzed. Overall, the number (%) of survival to discharge was 1380 (11.4%), and the good CPC was 945 (8.0%). For good cerebral performance category, the AOR (95% CIs) for good CPC was 0.99 (0.98-1.00) by 10-seconds DTI delay and 0.97 (0.95-0.99) by 30-seconds DTI delay. The AORs (95% CIs) for good CPC were 0.84 (0.71-1.00) for the Middle and 0.79 (0.66-0.96) for the Long DTI groups compared with Short DTI. The AORs (95% Cl) for good CPC compared with Short DTI group were 0.93 (0.68-1.27) by Middle DTI and 0.84 (0.59-1.20) by Long DTI in megacity, 0.60 (0.44-0.81) by Middle DTI and 0.60 (0.44-0.82) by Long DTI in metropolis, and 0.43 (0.31-0.60) by Middle DTI and 0.38 (0.26-0.56) by Long DTI in Rural province, respectively. A longer DTI in DA-CPR showed significantly lower good neurological recovery in adult patients with witnessed OHCA. A 30 second delay in DTI was associated with a 3% decrease of a good CPC score (can abbreviate CPC since it was abbreviated earlier. The DTI effect on good CPC was significant in metropolis and Rural province while not in megacity region. Copyright © 2018. Published by Elsevier B.V.

Pub.: 07 Jun '18, Pinned: 18 Jun '18

Does the prehospital National Early Warning Score predict the short-term mortality of unselected emergency patients?

Abstract: The prehospital research field has focused on studying patient survival in cardiac arrest, as well as acute coronary syndrome, stroke, and trauma. There is little known about the overall short-term mortality and its predictability in unselected prehospital patients. This study examines whether a prehospital National Early Warning Score (NEWS) predicts 1-day and 30-day mortalities.Data from all emergency medical service (EMS) situations were coupled to the mortality data obtained from the Causes of Death Registry during a six-month period in Northern Finland. NEWS values were calculated from first clinical parameters obtained on the scene and patients were categorized to the low, medium and high-risk groups accordingly. Sensitivities, specificities, positive predictive values (PPVs), negative predictive values (NPVs), and likelihood ratios (PLRs and NLRs) were calculated for 1-day and 30-day mortalities at the cut-off risks.A total of 12,426 EMS calls were included in the study. The overall 1-day and 30-day mortalities were 1.5 and 4.3%, respectively. The 1-day mortality rate for NEWS values ≤12 was lower than 7% and for values ≥13 higher than 20%. The high-risk NEWS group had sensitivities for 1-day and 30-day mortalities 0.801 (CI 0.74–0.86) and 0.42 (CI 0.38–0.47), respectively.In prehospital environment, the high risk NEWS category was associated with 1-day mortality well above that of the medium and low risk NEWS categories. This effect was not as noticeable for 30-day mortality. The prehospital NEWS may be useful tool for recognising patients at early risk of death, allowing earlier interventions and responds to these patients.

Pub.: 07 Jun '18, Pinned: 18 Jun '18

Comparison of the performance of battery-operated fluid warmers.

Abstract: Warming intravenous fluids is essential to prevent hypothermia in patients with trauma, especially when large volumes are administered. Prehospital and transport settings require fluid warmers to be small, energy efficient and independent of external power supply. We compared the warming properties and resistance to flow of currently available battery-operated fluid warmers. Fluid warming was evaluated at 50, 100 and 200 mL/min at a constant input temperature of 20°C and 10°C using a cardiopulmonary bypass roller pump and cooler. Output temperature was continuously recorded. Performance of fluid warmers varied with flows and input temperatures. At an input temperature of 20°C and flow of 50 mL/min, the Buddy Lite, enFlow, Thermal Angel and Warrior warmed 3.4, 2.4, 1 and 3.6 L to over 35°C, respectively. However, at an input temperature of 10°C and flow of 200 mL/min, the Buddy Lite failed to warm, the enFlow warmed 3.3 L to 25.7°C, the Thermal Angel warmed 1.5 L to 20.9°C and the Warrior warmed 3.4 L to 34.4°C (p<0.0001). We found significant differences between the fluid warmers: the use of the Buddy Lite should be limited to moderate input temperature and low flow rates. The use of the Thermal Angel is limited to low volumes due to battery capacity and low output temperature at extreme conditions. The Warrior provides the best warming performance at high infusion rates, as well as low input temperatures, and was able to warm the largest volumes in these conditions. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Pub.: 09 Jun '18, Pinned: 18 Jun '18

Closure simulation for reduction of emergency patient diversion: a discrete agent-based simulation approach to minimizing ambulance diversion.

Abstract: The city of Munich uses web-based information system IVENA to promote exchange of information regarding hospital offerings and closures between the integrated dispatch center and hospitals to support coordination of the emergency medical services. Hospital crowding resulting in closures and thus prolonged transportation time poses a major problem. An innovative discrete agent model simulates the effects of novel policies to reduce closure times and avoid crowding. For this analysis, between 2013 and 2017, IVENA data consisting of injury/disease, condition, age, estimated arrival time and assigned hospital or hospital-closure statistics as well as underlying reasons were examined. Two simulation experiments with three policy variations are performed to gain insights on the influence of diversion policies onto the outcome variables. A total of 530,000+ patients were assigned via the IVENA system and 200,000+ closures were requested during this time period. Some hospital units request a closure on more than 50% of days. The majority of hospital closures are not triggered by the absolute number of patient arrivals, but by a sudden increase within a short time period. Four of the simulations yielded a specific potential for shortening of overall closure time in comparison to the current status quo. Effective solutions against crowding require common policies to limit closure status periods based on quantitative thresholds. A new policy in combination with a quantitative arrival sensor system may reduce closing hours and optimize patient flow.

Pub.: 10 Jun '18, Pinned: 18 Jun '18

The Aftermath of the Kuwait Mosque Bombing: A retrospective cohort analysis and lessons learned.

Abstract: The occurrence of terrorist attacks are still recurrent incidents plaguing the middle east region. However, Kuwait has been mostly spared from these attacks over the years. Therefore, when the bombing of the mosque in 2015 happened, it shocked a country that is not prepared for such disasters. Our aim was to present the incident that occurred on that day and on the lessons learned from it. A collaborative effort among the hospitals in Kuwait examined the details and outcomes of the initial response to the bombing. The centers reported their retrospective data, which was analyzed to determine prehospital and intra-hospital management and assess the medical response to the terrorist bombing. A total of 239 victims were involved in the explosion, of which 18 were pronounced dead on site. 147 (67%) were transferred to the hospital for care 22 min after the explosion occurred. The injuries seen were not localized to one region of the body, but afflicted various organ systems. 86 patients were admitted to the hospital, for which five required urgent surgical intervention. Total mortality (on-site and in-hospital) reported after the bombing was 11.2%. Rapid response after a mass casualty is of utmost importance for the adequate management of the victims of such tragedies, and could ensure excellent outcomes if performed precisely. However, many lessons can be learned from this shocking event, especially that it exposed the gaps currently present in our disaster plan systems and the importance of looking into addressing them. Copyright © 2018 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.

Pub.: 11 Jun '18, Pinned: 18 Jun '18

Ambulance staff and end-of-life hospital admissions: A qualitative interview study.

Abstract: Hospital admissions for end-of-life patients, particularly those who die shortly after being admitted, are recognised to be an international policy problem. How patients come to be transferred to hospital for care, and the central role of decisions made by ambulance staff in facilitating transfer, are under-explored. To understand the role of ambulance staff in the admission to hospital of patients close to the end of life. Qualitative interviews, using particular patient cases as a basis for discussion, analysed thematically. Ambulance staff ( n = 6) and other healthcare staff (total staff n = 30), involved in the transfer of patients (the case-patients) aged more than 65 years to a large English hospital who died within 3 days of admission with either cancer, chronic obstructive pulmonary disease or dementia. Ambulance interviewees were broadly positive about enabling people to die at home, provided they could be sure that they would not benefit from treatment available in hospital. Barriers for non-conveyance included difficulties arranging care particularly out-of-hours, limited available patient information and service emphasis on emergency care. Ambulance interviewees fulfilled an important role in the admission of end-of-life patients to hospital, frequently having to decide whether to leave a patient at home or to instigate transfer to hospital. Their difficulty in facilitating non-hospital care at the end of life challenges the negative view of near end-of-life hospital admissions as failures. Hospital provision was sought for dying patients in need of care which was inaccessible in the community.

Pub.: 12 Jun '18, Pinned: 18 Jun '18

Intubation Success after Introduction of a Quality Assurance Program Using Video Laryngoscopy

Abstract: Publication date: Available online 7 June 2018 Source:Air Medical Journal Author(s): Amir Louka, Christopher Stevenson, Gregory Jones, Jeffrey Ferguson Objective The deployment of video laryngoscopy devices that include recording capability presents a new and unique opportunity for medical directors to review prehospital patient encounters. We sought to evaluate the effect of introducing a video laryngoscope and video quality assurance program to an air medical program on measures of intubation success including overall success, first-pass success, success within 2 attempts, and the total number of attempts. Methods This was a retrospective review of data collected on intubations by nurses and paramedics of the Virginia State Police Med-Flight 1 air medical program. Results After introduction of the video laryngoscope and quality assurance program, the overall intubation success improved to 100% but did not reach statistical significance (95% confidence interval [CI], −4.40 to 12.57; P = .25). First-pass success improved from 76.19% to 92.86% (CI, 1.14-33.14; P = .02), whereas the average attempts declined from 1.31 to 1.09 per patient encounter (CI, −.41 to −.03; P = .02). Success within 2 attempts was 92.86% before the intervention and 98.21% after (CI, 4.25-17.82; P = .19). Conclusion Video laryngoscopy and a robust means for medical director oversight are important components of a high-performance airway management program and demonstrably improve intubation first-pass success.

Pub.: 10 Jun '18, Pinned: 18 Jun '18

Psychometric Analysis of a Survey on Patient Safety Culture-Based Tool for Emergency Medical Services.

Abstract: Evaluating organizational safety culture is critical for high-stress, high-risk professions such as prehospital emergency medical services (EMS). The aim of the study was to evaluate the psychometric properties of a safety culture instrument for EMS, based on the Agency for Healthcare Research and Quality's widely used Surveys on Patient Safety Culture (SOPS). The final EMS-adapted instrument consisted of 37 items covering 11 safety culture domains including 10 domains from existing SOPS instruments and one new domain for communication while en route to an emergency call. The analysis sample included 23,029 nationally certified EMS providers. Domain structure was evaluated on two separate halves of the data set through confirmatory factor analysis using a polychoric correlation matrix for ordinal data. The reliability and validity of each domain were evaluated using Cronbach α and Pearson correlation coefficients. The confirmatory factor analysis supported the 11-domain model. All items loaded above the 0.4 threshold (range = 0.508-0.984). Three composite domains exhibited factor variance below the 0.5 threshold: staffing (0.32), communication about incidents (0.26), and handoffs (0.26). Floor and ceiling effects were not detected. Inter-item consistency exceeded 0.6 for all subscales (α = 0.65-0.88). Predictive validity was supported as all domain composites were correlated with the outcome variables of overall safety rating (r = 0.44-0.72) and frequency of event reporting (r = 0.31-0.48). Overall, the EMS-adapted tool demonstrated adequate psychometric properties consistent with those of existing SOPS instruments. Additional research is needed to evaluate the instrument's performance at the agency level and its correlation with safety outcomes in the prehospital setting.

Pub.: 13 Jun '18, Pinned: 18 Jun '18

High acuity rural transport: findings from a qualitative investigation.

Abstract: The High Acuity Response Team (HART) was introduced in British Columbia (BC), Canada, to fill a gap in transport for rural patients that was previously being met by nurses and physicians leaving their communities to escort patients in need of critical care. The HART team consists of a critical care registered nurse (CCRN) and registered respiratory therapist (RRT) and attends acute care patients in rural sites by either stabilizing them in their community or transporting them. HART services are deployed in partnership with provincial ambulance services, which provide vehicles and coordination of all requests in the province for patient transport. This article presents the qualitative findings from a research evaluation of the efficacy of the HART model, including staffing and inter-organizational functioning. Open-ended qualitative research interviewing was done with key stakeholders from 21 sites. Research participants included HART CCRNs, RRTs, administrative leads, as well as local emergency department (ED) physicians and nurses. Thematic analysis was done of the transcripts. A total of 107 interviews in 21 study sites were completed. Participants described characteristics of the model, perceptions of efficacy and areas for improvement. Rural sites reported a decrease in physician- and nurse-accompanied transports for high-acuity patients due to the HART team, but also noted challenges in delayed deployment, sometimes leading to adverse patient outcomes. The salient issues for the HART model were grounded in a somewhat artificial distinction between pre-hospital and interfacility transport for rural patients, which leads to a lack of service coordination and potentially avoidable delays. A beneficial systems change would be to move towards dedicated integration of high-acuity transport services into hospital organizational structures and community health services in rural areas.

Pub.: 13 Jun '18, Pinned: 18 Jun '18

Prehospital Notification Procedure Improves Stroke Outcome by Shortening Onset to Needle Time in Chinese Urban Area.

Abstract: Intravenous thrombolysis (IVT) with recombinant tissue plasminogen activator (rt-PA) can improve clinical outcome in eligible patients with acute ischemic stroke (AIS). However, its efficacy is strongly time-dependent. This study was aimed to examine whether prehospital notification by emergency medical service (EMS) providers could reduce onset to needle time (ONT) and improve neurological outcome in AIS patients who received IVT. We prospectively collected the consecutive clinical and time data of AIS patients who received IVT during one year after the initiation of prehospital notification procedure (PNP). Patients were divided into three groups, including patients that transferred by EMS with and without PNP and other means of transportation (non-EMS). We then compared the effect of EMS with PNP and EMS use only on ONT, and the subsequent neurological outcome. Good outcome was defined as modified Rankin Scale score of 0-2 at 3-months. In 182 patients included in this study, 77 (42.3%) patients were transferred by EMS, of whom 41 (53.2%) patients entered PNP. Compared with non-EMS group, EMS without PNP group greatly shortened the onset to door time (ODT), but EMS with PNP group showed both a significantly shorter DNT (41.3 ± 10.7 min vs 51.9±23.8 min, t=2.583, p=0.012) and ODT (133.2 ± 90.2 min vs 174.8 ± 105.1 min, t=2.228, p=0.027) than non-EMS group. Multivariate analysis showed that the use of EMS with PNP (OR=2.613, p=0.036), but not EMS (OR=1.865, p=0.103), was independently associated with good outcome after adjusting for age and baseline NIHSS score. When adding ONT into the regression model, ONT (OR=0.994, p=0.001), but not EMS with PNP (OR=1.785, p=0.236), was independently associated with good outcome. EMS with PNP, rather than EMS only, improved stroke outcome by shortening ONT. PNP could be a feasible strategy for better stroke care in Chinese urban area.

Pub.: 14 Jun '18, Pinned: 18 Jun '18

Accuracy of Prehospital Care Providers in Determining Total Body Surface Area Burned in Severe Pediatric Thermal Injury.

Abstract: Accurate measurement of total body surface area (TBSA) burned is a key factor in the care of pediatric patients with burn, especially those with large thermal injuries. There is a paucity of data on the accuracy of these measurements by prehospital, nonburn center, and emergency department (ED) providers, which can have drastic implications for patient management and outcomes. We sought to determine the accuracy of these estimates for large pediatric burns. A retrospective chart review was conducted of patients with TBSA ≥10% admitted to an American Burn Association (ABA)-verified pediatric burn center from 2007 to 2015. Final TBSA was determined by pediatric burn surgeons and compared with prehospital emergency medical service providers, outside hospital physicians for transferred patients, and burn center ED physicians. Statistical significance was determined using a paired t-test with P < 0.05. A total of 139 patients ≤18 years of age met inclusion criteria, with an average TBSA of 18.9 ± 1.1%, weight 23.7 ± 1.6 kg and age of 5.4 ± 0.41 years. When compared in a pairwise fashion to the TBSA values determined by pediatric burn surgeons, estimates of TBSA were higher by: prehospital emergency medical service providers, 40.0% (n = 67, P < 0.0001); outside hospital physicians, 18.7% (n = 46, P = 0.0009), and burn center ED physicians, 7.2% (n = 120, P = 0.0117). TBSA burn estimates for pediatric patients by prehospital, nonburn center, and ED providers are significantly higher than those recorded by burn surgeons at an ABA-verified pediatric burn center. These inaccuracies in TBSA measurement may have profound clinical implications.

Pub.: 15 Jun '18, Pinned: 18 Jun '18

Overuse of Air Ambulance Services at a Regional Burn Center.

Abstract: Air ambulances rapidly transport burn patients to regional centers, expediting treatment. However, limited guidelines on transport introduce the risk for inappropriate triage and overuse. Given the additional costs of air vs ground transport, evaluation of transportation use is prudent. A retrospective review of all burn patients transported by helicopter to a single burn center from May 2013 to January 2016 was performed. Data gathered included patient demographics, transfer origin, burn characteristics, and inpatient hospital stay. The primary outcome was appropriate triage based on literature-derived severity criteria. Secondary outcomes included independent predictors of emergent treatments and the cost of overuse. Sixty-eight patients were examined, of which 66% met air ambulance criteria. Inappropriately triaged patients sustained smaller burns (% TBSA 4.8 vs 25.3, P < .001), had fewer flame burns (48 vs 82%, P = .007), had decreased lengths of stay (mean days 8.2 vs 21.2, P = .002), underwent fewer inpatient surgeries (mean 0.69 vs 2.57, P = .006), received no emergent procedures (0 vs 56%, P < .001), and suffered no deaths (0 vs 9%, P < .001). Independent predictors of emergent procedures included transport for airway concern (odds ratio = 45.29, confidence interval = 2.49-825.21, P = .010) and % TBSA (odds ratio = 1.13, confidence interval = 1.02-1.27, P = .019). If the 23 inappropriately triaged patients had been transported by ground, a cost savings of $106,370 could have been realized using 2016 California Medicare reimbursements (per-patient savings of $4624). While appropriate in most circumstances, the cost of air ambulances should be weighed in light of their utility, as a significant proportion of patients did not benefit from air transport.

Pub.: 15 Jun '18, Pinned: 18 Jun '18

Different defibrillation strategies in survivors after out-of-hospital cardiac arrest.

Abstract: In the last decade, there has been a rapid increase in the dissemination of automated external defibrillators (AEDs) for prehospital defibrillation of out-of-hospital cardiac arrest patients. The aim of this study was to study the association between different defibrillation strategies on survival rates over time in Copenhagen, Stockholm, Western Sweden and Amsterdam, and the hypothesis was that non-EMS defibrillation increased over time and was associated with increased survival. We performed a retrospective analysis of four prospectively collected cohorts of out-of-hospital cardiac arrest patients between 2008 and 2013. Emergency medical service (EMS)-witnessed arrests were excluded. A total of 22 453 out-of-hospital cardiac arrest patients with known survival status were identified, of whom 2957 (13%) survived at least 30 days postresuscitation. Of all survivors with a known defibrillation status, 2289 (81%) were defibrillated, 1349 (59%) were defibrillated by EMS, 454 (20%) were defibrillated by a first responder AED and 429 (19%) were defibrillated by an onsite AED and 57 (2%) were unknown. The percentage of survivors defibrillated by first responder AEDs (from 13% in 2008 to 26% in 2013, p<0.001 for trend) and onsite AEDs (from 14% in 2008 to 30% in 2013, p<0.001 for trend) increased. The increased use of these non-EMS AEDs was associated with the increase in survival rate of patients with a shockable initial rhythm. Survivors of out-of-hospital cardiac arrest are increasingly defibrillated by non-EMS AEDs. This increase is primarily due to a large increase in the use of onsite AEDs as well as an increase in first-responder defibrillation over time. Non-EMS defibrillation accounted for at least part of the increase in survival rate of patients with a shockable initial rhythm. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Pub.: 16 Jun '18, Pinned: 18 Jun '18

Improvised first aid techniques for terrorist attacks.

Abstract: Terrorist acts occur every day around the world. Healthcare professionals are often present as bystander survivors in these situations, with none of the equipment or infrastructure they rely on in their day-to-day practice. Within several countries there has been a move to disseminate the actions to take in the event of such attacks: in the UK, , and in the USA, This paper outlines how a very basic medical knowledge combined with everyday high-street items can render highly effective first aid and save lives. We discuss and summarise modern improvised techniques. These include the <C> ABCDE approach of treating catastrophic haemorrhage before airway management, bringing together improvised techniques from the military and wilderness medicine. We explain how improvised tourniquets, wound dressings, splinting and traction devices can be fabricated using items from the high street: nappies, tampons, cling film, duct tape and tablecloths. Cervical spine immobilisation is a labour-intensive protocol that is often practised defensively. With little evidence to support the routine use of triple immobilisation, this should be replaced with a common sense dynamic approach such as the Montana neck brace. Acid or alkali attacks are also examined with simple pragmatic advice. Analgesia is discussed in the context of a prehospital setting. Pharmacy-obtained oral morphine and diclofenac suppositories can be used to treat moderate pain without relying on equipment for intravenous/intraosseous infusion in prolonged hold situations. The differentiation between concealment and cover is summarised: scene safety remains paramount. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Pub.: 17 Jun '18, Pinned: 18 Jun '18

Static Rope Evacuation by Helicopter Emergency Medical Services in Rescue Operations in Southeast Norway.

Abstract: Physician-staffed helicopter emergency medical services (HEMS) in Norway are an adjunct to existing search and rescue services. Our aims were to study the epidemiological, operational, and medical aspects of HEMS daylight static rope operations performed in the southeastern part of the country and to examine several quality dimensions that are characteristic of this service. We reviewed the static rope operations performed at 3 HEMS bases during a 3-y period and applied a set of quality indicators designed for physician-staffed emergency medical services to evaluate the quality of care. Data are presented as medians with quartiles, except National Advisory Committee for Aeronautics (NACA) scores, which are presented as mean (SD). Fifty-nine static rope operations were identified, involving 60 patients. Median (quartiles) age was 43 (27-55) y. Median (quartiles) take-off time was 9 (5-13) min. Trauma-related injuries were found in 48 patients. The main conditions were lower limb injuries, found in 32 patients. Ten patients experienced medical conditions. Mean (SD) NACA score was 3.3 (1.3). A potential or actual life-threatening diagnosis (NACA score: 4-6) was reported among 15 patients. The main interventions were intravenous lines (19 patients), analgesics (17), and oxygen treatment (14). Four patients were intubated, and 1 thoracostomy was performed. Static rope operations are rarely performed. The quality indicators suggest that the service is safe, available, and equitable. Its main benefit seems to be evacuation and the maintenance of readiness before rapid transport of the physician to the scene or the patient to the hospital. Copyright © 2018 The Authors. Published by Elsevier Inc. All rights reserved.

Pub.: 18 Jun '18, Pinned: 18 Jun '18

The ACUTE (Ambulance CPAP: Use, Treatment effect and economics) feasibility study: a pilot randomised controlled trial of prehospital CPAP for acute respiratory failure

Abstract: Acute respiratory failure (ARF) is a common and life-threatening medical emergency. Standard prehospital management involves controlled oxygen therapy and disease-specific ancillary treatments. Continuous positive airway pressure (CPAP) is a potentially beneficial alternative treatment that could be delivered by emergency medical services. However, it is uncertain whether this treatment could work effectively in United Kingdom National Health Service (NHS) ambulance services and if it represents value for money.An individual patient randomised controlled external pilot trial will be conducted comparing prehospital CPAP to standard oxygen therapy for ARF. Adults presenting to ambulance service clinicians will be eligible if they have respiratory distress with peripheral oxygen saturation below British Thoracic Society (BTS) target levels, despite titrated supplemental oxygen. Enrolled patients will be allocated (1:1 simple randomisation) to prehospital CPAP (O_two system) or standard oxygen therapy using identical sealed boxes. Feasibility outcomes will include incidence of recruited eligible patients, number of erroneously recruited patients and proportion of cases adhering to allocation schedule and treatment, followed up at 30 days and with complete data collection. Effectiveness outcomes will comprise survival at 30 days (definitive trial primary end point), endotracheal intubation, admission to critical care, length of hospital stay, visual analogue scale (VAS) dyspnoea score, EQ-5D-5L and health care resource use at 30 days. The cost-effectiveness of CPAP, and of conducting a definitive trial, will be evaluated by updating an existing economic model. The trial aims to recruit 120 patients over 12 months from four regional ambulance hubs within the West Midlands Ambulance Service (WMAS). This sample size will allow estimation of feasibility outcomes with a precision of < 5%. Feasibility and effectiveness outcomes will be reported descriptively for the whole trial population, and each trial arm, together with their 95% confidence intervals.This study will determine if it is feasible, acceptable and cost-effective to undertake a full-scale trial comparing CPAP and standard oxygen treatment, delivered by ambulance service clinicians for ARF. This will inform NHS practice and prevent inappropriate prehospital CPAP adoption on the basis of limited evidence and at a potentially substantial cost.ISRCTN12048261. Registered on 30 August 2017. http://www.isrctn.com/ISRCTN12048261

Pub.: 18 Jun '18, Pinned: 18 Jun '18

Influence of Entrapment on Prehospital Management and the Hospital Course in Polytrauma Patients: A Retrospective Analysis in Air Rescue.

Abstract: Entrapment is a challenging and crucial factor in the prehospital setting. Few studies have addressed whether entrapment has an influence on on-scene treatment or on the following hospital course. Here we aimed to investigate the influence of entrapment on prehospital management and on the hospital course of polytrauma patients. We performed a retrospective analysis of consecutive patients with an Injury Severity Score ≥16 and aged 16-65 years that were admitted between 2005 and 2013 to a Level I trauma center. Two groups were built: entrapped (E) and nonentrapped patients (nE). These groups were evaluated for multiple prehospital and clinical parameters, including on-scene time, prehospital interventions, and posttraumatic complications. There were 310 patients (n = 194 no entrapment [Group nE], n = 116 with entrapment [Group E]) enrolled. The on-scene time was significantly longer in Group E than Group nE. Moreover, this group received a significantly higher volume of colloidal solution. Regarding the Injury Severity Score and Abbreviated Injury Scale (AIS), there were no significant differences between the groups, except for the AIS, which was significantly increased in Group E. The overall hospital stay and the initial theater time were significantly longer in Group E than Group nE. No significant differences were present for the occurrence of systemic inflammatory response syndrome, multiple organ dysfunction syndrome, and acute respiratory distress syndrome, nor for Acute Physiology and Chronic Health Evaluation II and estimated and final mortality. In polytraumatized patients, entrapment has a minor influence on the outcome and treatment in the prehospital and hospital setting when using physician-based air rescue. However, entrapped patients are prone to sustain more severe trauma to the extremities. Copyright © 2018 Elsevier Inc. All rights reserved.

Pub.: 24 Apr '18, Pinned: 29 Apr '18

Quantitative Approach Based on Wearable Inertial Sensors to Assess and Identify Motion and Errors in Techniques Used during Training of Transfers of Simulated c-Spine-Injured Patients.

Abstract: Patients with suspected spinal cord injuries undergo numerous transfers throughout treatment and care. Effective c-spine stabilization is crucial to minimize the impacts of the suspected injury. Healthcare professionals are trained to perform those transfers using simulation; however, the feedback on the manoeuvre is subjective. This paper proposes a quantitative approach to measure the efficacy of the c-spine stabilization and provide objective feedback during training. . 3D wearable motion sensors are positioned on a simulated patient to capture the motion of the head and trunk during a training scenario. Spatial and temporal indicators associated with the motion can then be derived from the signals. The approach was developed and tested on data obtained from 21 paramedics performing the log-roll, a transfer technique commonly performed during prehospital and hospital care. . In this scenario, 55% of the c-spine motion could be explained by the difficulty of rescuers to maintain head and trunk alignment during the rotation part of the log-roll and their difficulty to initiate specific phases of the motion synchronously. . The proposed quantitative approach has the potential to be used for personalized feedback during training sessions and could even be embedded into simulation mannequins to provide an innovative training solution.

Pub.: 26 Apr '18, Pinned: 29 Apr '18

Effects of Emergency Medical Services Times on Traffic Injury Severity: A Random-Effects Ordered Probit Approach.

Abstract: Emergency Medical Services (EMS) play a vital role in the post-crash effort to reduce fatalities by providing first aid treatment and transportation to medical facilities. This study aims to analyze the time required for crash reporting and EMS arrival in fatal traffic crashes and to explore the effects of EMS time on the traffic injury severity. The time required for EMS reporting, arrival, and transport to hospital were calculated by location type and roadway functional classification using 2016 FARS (Fatality Analysis Reporting System) data. Subsequently, an ordered probit model was developed to identify contributing factors for the injury severity considering the EMS time. The average time for the crash-reporting durations is 5.38 minutes, the reporting-scene arrival interval is 10.52 minutes, and the scene-hospital interval is 34.72 minutes. The average crash-reporting and reporting-scene arrival intervals were the longest on conventional roads in rural areas and the shortest on conventional roads in urban areas. The average scene-hospital interval was longest in conventional rural areas and the shortest on freeways/expressways in urban areas. The developed random-effects ordered probit model shows that prolonged reporting-scene arrival and scene-hospital intervals result in more severe injuries. The result also presents that crash type, violation, age, location, lighting condition, and alcohol/drug involvement have significant effects on the injury severity. The key findings from this study indicate that EMS times differ according to the urban/rural location and road functional classification, and that reporting-scene arrival and scene-hospital intervals have significant effects on the injury severity along with various factors. It is expected that the findings from this study can be used to develop effective and practical strategic plans to minimize EMS reporting, arrival time, and transport to hospital and, therefore, decrease the traffic injury severity.

Pub.: 26 Apr '18, Pinned: 29 Apr '18

Prehospital Intubation and Outcome in Traumatic Brain Injury-Assessing Intervention Efficacy in a Modern Trauma Cohort.

Abstract: Prehospital intubation in traumatic brain injury (TBI) focuses on limiting the effects of secondary insults such as hypoxia, but no indisputable evidence has been presented that it is beneficial for outcome. The aim of this study was to explore the characteristics of patients who undergo prehospital intubation and, in turn, if these parameters affect outcome. Patients ≥15 years admitted to the Department of Neurosurgery, Stockholm, Sweden with TBI from 2008 through 2014 were included. Data were extracted from prehospital and hospital charts, including prospectively collected Glasgow Outcome Score (GOS) after 12 months. Univariate and multivariable logistic regression models were employed to examine parameters independently correlated to prehospital intubation and outcome. A total of 458 patients were included ( = 178 unconscious, among them,  = 61 intubated). Multivariable analyses indicated that high energy trauma, prehospital hypotension, pupil unresponsiveness, mode of transportation, and distance to the hospital were independently correlated with intubation, and among them, only pupil responsiveness was independently associated with outcome. Prehospital intubation did not add independent information in a step-up model versus GOS ( = 0.154). Prehospital reports revealed that hypoxia was not the primary cause of prehospital intubation, and that the procedure did not improve oxygen saturation during transport, while an increasing distance from the hospital increased the intubation frequency. In this modern trauma cohort, prehospital intubation was not independently associated with outcome; however, hypoxia was not a common reason for prehospital intubation. Prospective trials to assess efficacy of prehospital airway intubation will be difficult due to logistical and ethical considerations.

Pub.: 26 Apr '18, Pinned: 29 Apr '18

Early Hospital Discharge After Helicopter Transport of Pediatric Trauma Patients: Analysis of Rates of Over and Undertriage.

Abstract: Helicopter air ambulance (HAA) of pediatric trauma patients is a life-saving intervention. Triage remains a challenge for both scene transport and interhospital transfer of injured children. We aimed to understand whether overtriage or undertriage was a feature of scene or interhospital transfer and how in or out of state transfers affected these rates. Children (<18 years) who underwent trauma activation at a level I trauma center between 2011 and 2013 were identified and reviewed. Patients transported by HAA were compared with those transported by ground ambulance (GA). Of 399 pediatric patients (median age, 10.4 years; range, 0.1-17 years; 264 male [66%]), 71 (18%) were transported by HAA. Seventy-two percent of HAA patients went to the intensive care unit or the operating room from the trauma bay or suffered in-hospital mortality (vs 42% GA, P < 0.001). More patients were overtriaged (HAA with injury severity score [ISS] of <15) from interhospital transfers than from the scene (25% vs 3%, P = 0.002). Undertriage (GA with ISS >15) was acceptable at 5% from the scene and 14% from interhospital transfers (P = 0.08). Overtriage of patients with ISS less than 15 to HAA was significantly lower from in-state hospitals (22%) than out-of-state hospitals (45%) (P = 0.02). Undertriage of patients with ISS greater than 15 to GA was also lower from in-state hospitals (20%) versus out-of-state hospitals (38%) (P = 0.03). Triage of pediatric trauma patients to HAA remains difficult. There remains potential for improvement, particularly as regards interhospital HAA overtriage, but well developed transfer protocols (such in-state protocols) may help.

Pub.: 27 Apr '18, Pinned: 29 Apr '18