Category Archives: PHARM

Prehospital and Retrieval Medicine

All Updates, Kids, PHARM, Resus

Infant CPR: two thumbs even when alone

Infant CPR guidelines recommend two-finger chest compressions with a lone rescuer and two-thumb with two rescuers. Two-thumb provides better chest compression but is perceived to be associated with increased ventilation hands-off time. A manikin study revealed more effective compressions with the two-thumb technique with only four fewer compressions per minute compared with two-fingers.

Two-thumb technique is superior to two-finger technique during lone rescuer infant manikin CPR
Resuscitation. 2010 Jun;81(6):712-7

All Updates, PHARM

Surviving avalanche burial


Avalanche burial has a high mortality and yet in some cases there have been some amazing saves despite prolonged cardiac arrest. An international working group undertook a systematic review to examine 4 critical prognostic factors for burial victims in cardiac arrest. You have a better chance of surviving a prolonged burial if you have a patent airway and a pocket of air (even a very small one), are hypothermic, and preferably not hyperkalaemic.
Prognostic factors in avalanche resuscitation: A systematic review
Resuscitation. 2010 Jun;81(6):645-52

All Updates, PHARM, Resus, Trauma

Pre-hospital RSI

Physicians from HEMS London document their experience of 400 pre-hospital rapid sequence induction / intubations. Their data are consistent with the experience of other similar services and with the emergency airway management literature in general:

  • Failure to intubate is rare
  • Removing cricoid pressure often improves the view
  • A BURP manoeuvre can improve the view and facilitate intubation, but bimanual laryngoscopy / external laryngeal manipulation is better
  • Having an SOP optimises first-pass success rate

Cricoid pressure and laryngeal manipulation in 402 pre-hospital emergency anaesthetics: Essential safety measure or a hindrance to rapid safe intubation?
Resuscitation 2010(81):810–816

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Poor pre-hospital intubation success

A Scottish study of 628 pre-hospital intubation attempts in cardiac arrest patients records the rate of successful intubations, oesophageal intubations, and endobronchial intubations. Prehospital tracheal intubation was associated with decreased rates of survival to admission. This study has the limitations of a retrospective series but indirectly provides some further muscle to the supraglottic airway lobby.
Field intubation of cardiac arrest patients: a dying art?
Emerg Med J. 2010 Apr;27(4):321-3

Acute Med, All Updates, PHARM, Resus

Oxygen in AMI – no benefit, possible harm

A Cochrane review examined the evidence from randomised controlled trials to establish whether routine use of inhaled oxygen in acute myocardial infarction (AMI) improves patient-centred outcomes, the primary outcomes being death, pain and complications.

Three trials involving 387 patients were included and 14 deaths occurred. The pooled relative risk (RR) of death was 2.88 (95% CI 0.88 to 9.39) in an intention-to-treat analysis and 3.03 (95% CI 0.93 to 9.83) in patients with confirmed AMI. While suggestive of harm, the small number of deaths recorded meant that this could be a chance occurrence. Pain was measured by analgesic use. The pooled RR for the use of analgesics was 0.97 (95% CI 0.78 to 1.20).
There is therefore no conclusive evidence from randomised controlled trials to support the routine use of inhaled oxygen in patients with acute AMI. A definitive randomised controlled trial is required.
Oxygen therapy for acute myocardial infarction
Cochrane Review

All Updates, PHARM, Resus, Trauma

Traumatic Aortic Injury

Two recent papers expand our knowledge of blunt traumatic aortic injury.
UK crash data identified risk factors for low impact blunt traumatic aortic rupture, or ‘LIBTAR’ (crashes at relatively low speed): age >60, lateral impacts and being seated on the side that is struck are predictive of LIBTAR. This study should raise our index of suspicion of aortic injury in low-impact scenarios since low-impact collisions account for two thirds of fatal aortic injuries.
Low-impact scenarios may account for two-thirds of blunt traumatic aortic rupture
Emerg Med J. 2010 May;27(5):341-4

Data from the Victorian State Trauma Registry showed pre-hospital mortality from traumatic thoracic aortic transection was approximately 88.0%, whereas patients who survive to reach hospital have a much lower hospital mortality (33.3%, and once patients who arrived in extremis were removed hospital mortality was reduced to 5.9%). Repair was performed in 46 patients, with 22 receiving initial endovascular repair and 24 receiving initial open repair. Mortality rates following surgery were 9.1% and 16.7%, respectively.

The majority of patients arriving at hospital (57.1%) had an ISS of over 40 highlighting that these patients are unlikely to have only one serious injury and are likely to be more seriously injured than the normal trauma population. An ISS greater than 40 was a main predictor of mortality before repair.

Aortic transection: demographics, treatment and outcomes in Victoria, Australia
Emerg Med J. 2010 May;27(5):368-71

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Junior pre-hospital doctors spend a bit longer on scene

More junior pre-hospital doctors took longer on scene than their senior colleagues according to a German study, although patient clinical factors were the main determinant of scene time. The majority of cases were non-trauma presentations
Duration of mission time in prehospital emergency medicine: effects of emergency severity and physicians level of education
Emerg Med J 2010;27:398-403

All Updates, Kids, PHARM

Guideline improved pre-hospital RSI in kids


French physicians provide pre-hospital critical care in medical teams of regional SAMU (service d’aide me ́dicale urgente). A national guideline was introduced in France to guide the management of traumatic brain injury (TBI), which included airway management. A study was conducted which examined the practice of paediatric pre-hospital intubation in TBI in comatose children both before and after the introduction of the guideline.
After the guideline there were more pre-hospital intubations, with more standardised approach to rapid sequence induction(RSI). There were fewer complications and a 100% intubation success rate. Despite an increase in portable capnography use, PaCO2 was measured outside the recommended range of 35– 40 mmHg (3.5-4.5 kPa) in 70% of the cases upon arrival.
Emergency tracheal intubation of severely head-injured children: Changing daily practice after implementation of national guidelines
Pediatr Crit Care Med. 2010 May 13. [Epub ahead of print]

All Updates, ICU, Kids, PHARM

Paediatric Retrieval – what's the rush?

The Children’s Acute Transport Service (CATS) in the UK performed 2106 interfacility transports between April 2006 and March 2008. The stabilisation time averaged just over 2 hrs. Stabilisation time was prolonged by the number of major interventions required to stabilise the patient before transfer and differed significantly between various diagnostic groups. The length of time spent by the retrieval team outside the intensive care environment had no independent effect on subsequent patient mortality.

They have shown that stabilisation time can be influenced by a number of patient- and transport team-related factors, and that time spent undertaking intensive care interventions early in the course of patient illness at the referring hospital does not increase patient mortality. In the authors’ words: ‘the “scoop and run” model can be safely abandoned in favor of early goal-directed management during interhospital transport for intensive care.‘
There’s NO rush guys!
Effect of patient- and team-related factors on stabilization time during pediatric intensive care transport
Pediatr Crit Care Med. 2010 May 6

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Pre-hospital intubation experience and outcomes

Hospitals and medical personnel performing high volumes of procedures demonstrate better patient outcomes and fewer adverse events. The relationship between rescuer experience and patient survival for out-of-hospital endotracheal intubation is unknown.
An American study analysing 3 statewide databases with 26,000 records aimed to determine the association between endotracheal intubation experience and patient survival.
In-the-field intubators were EMS paramedics, nurses, and physicians, although paramedics performed more than 94% of out-of-hospital tracheal intubations. Although all air medical rescuers may use neuromuscular- blockade-assisted (rapid sequence) tracheal intubation, select ground EMS units are allowed to use tracheal intubation facilitated by sedatives only; the rest are done ‘cold’.

Patients in cardiac arrest and medical nonarrest experienced increased odds of survival when intubated by rescuers with high procedural experience. In trauma patients, survival was not associated with rescuer experience.
The odds of survival for air medical trauma patients were almost twice that of other patients, which may be related to the use of neuromuscular- blocking agents by air medical crews, or due to more specialised critical care training. The authors suggest that rescuers should perform at least 4 to 12 annual tracheal intubations.
Out-of-Hospital Endotracheal Intubation Experience and Patient Outcomes
Ann Emerg Med. 2010 Jun;55(6):527-537