Category Archives: PHARM

Prehospital and Retrieval Medicine

Helicopter use in rural trauma

171 rural Australian HEMS missions were retrospectively analysed. Some of the data contrast starkly with the more limelight-occupying urban services: average time from dispatch to scene was 48 minutes, average scene time was 50 mins, and average total distance flown was 160 nautical miles (297 km!) – the longest reported in the literature. There was no difference in injury severity between physician-staffed and paramedic-staffed missions, and no difference in mortality. When transport times for distances less than 50km from the hospital were compared, road responses were significantly faster than helicopter dispatch, whereas helicopter use created significant time savings at distances over 100km. The authors suggest that in the absence of special circumstances, a helicopter response within 100 km from base does not improve time to definitive care. They also recommend caution in mandating physician staffing of HEMS, particularly in environments with a limited pool of critical care doctors.
Helicopter use in rural trauma
Emerg Med Australas. 2008 Dec;20(6):494-9

Failed prehospital intubation attempts and pneumonitis

A review of 1954 out-of-hospital tracheal intubation (ETI) attempts by EMS crews revealed 444 (22.7%) patients experienced one or more ETI errors, including tube misplacement or dislodgement in 61 (3%), multiple ETI attempts in 62 (3%) and failed ETI in 359 (15%). Pneumonitis was associated with failed ETI (n=20, 19%; univariable OR 2.54; 95% CI 1.24-5.25). The authors conclude that out-of-hospital ETI errors are not associated with mortality, but failed out-of-hospital ETI increases the odds of pneumonitis.

Nurse-delivered prehospital CPAP

A nurse-based pre-hospital care system in Holland describes its experience with pre-hospital CPAP for acute cardiogenic pulmonary oedema. It appears that the simple Boussignac apparatus is straightforward to apply in the ambulance environment. Arguments about lack of outcome studies aside, if it’s necessary to undertake an interhospital transfer of a patient established on CPAP then this might be a relatively straightforward means of doing so.

Prehospital intubation of children

A prospective observational study of paediatric patients requiring pre-hospital intubation attended by a helicopter medical team (HMT) included 95 children with a GCS of 3-4. Fifty-four received bag-mask support by EMS paramedics until the HMT arrived and intubated them (survival 63%), and 41 were intubated by EMS paramedics. Of these, ‘correction of tube/ventilation’ was required in 37% and the survival was 5%. The authors conclude that bag-mask support should be the technique of choice by EMS paramedics, as the rate of complications of tracheal intubation in this patient group is unacceptably high. Hard to comment as I only have access to the abstract but one wonders if the EMS-intubation group were sicker patients requiring more aggressive early control of airway and breathing.