Tag Archives: pre-hospital

All Updates, PHARM, Resus, Trauma

Prehospital thoracostomy tube misplacement

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An interesting study from Germany examined prehospital thoracostomy tube (TT) placement by physicians working in the field. Of 69 patients who received them, 67 underwent prehospital intubation. 88 TT were placed in the 69 patients.
There were 19/88 (22%) radiologic chest tube misplacements (defined as too far in the chest, twisted, or bent). The position of 10/88 (11%) chest tubes had to be corrected. None of the patients with a TT had a “not-decompressed” pneumothorax or a chest tube placed below the diaphragm or into a solid organ.
Roughly half were placed in the ‘Monaldi’ position (the second or third intercostal space in the midclavicular line)…..

Monaldi position

 
 
 
 
 
 
 
 
 
…..and half in the Bülau position (fourth or fifth intercostal space in the midaxillary line).
Bülau position

 
 
 
 
 
 
 
 
 
There was no difference in the misplacement rates between the two positions although interestingly helicopter doctors (as opposed to ground response) more often opted for the Monaldi position.
It is not possible to tell from the results whether the TT insertion was indicated in all cases. Also, it would be interesting to know whether TT insertion preceded or followed tracheal intubation. While it is heartening that these physicians do not routinely rely on needle decompression, I cannot fathom while simple open thoracostomy was not used, avoiding the risk of tube misplacement and saving time.
See this post for a more thorough review of open thoracostomy and the limitations of needle decompression.


Objectives. To evaluate the frequency of use, placement site, success and misplacement rates, and need for intervention for tube thoracostomies (TTs), and the complications with endotracheal intubation associated with TT in the prehospital setting.

Methods. We performed a five-year, retrospective study using the records of 1,065 patients who were admitted to the trauma emergency room at a university hospital and who had received chest radiographs or computed tomography (CT) scans within 30 minutes after admission.

Results. Seven percent of all patients received a TT (5% unilateral, 2% bilateral). Ninety-seven percent of all patients with a TT were endotracheally intubated. The success rate for correctly placed chest tubes was 78%. Twenty-two percent of the chest tubes were misplaced (i.e., too far in the chest, twisted, or bent); half of those had to be corrected, with one needing to be replaced. There were no statistical differences in the frequency of Monaldi or Bülau positions, or the frequency of left or right chest TT. In addition, the two positions did not differ in misplacement rates or the need for intervention. Helicopter emergency medical services physicians used the Monaldi position significantly more frequently than the Bülau position. In-hospital physicians performing interhospital transfer used the Bülau position significantly more frequently, whereas ground emergency medical physicians had a more balanced relationship between the two positions. Tube thoracostomy had no influence on endotracheal tube misplacement rates, and vice versa.

Conclusion. Tube thoracostomy positioning mostly depends on the discretion of the physician on scene. The Monaldi and Bülau positions do not differ in misplacement or complication rates.

Incidence And Outcome Of Tube Thoracostomy Positioning In Trauma Patients
Prehosp Emerg Care. 2011 Oct 3. [Epub ahead of print]

Acute Med, All Updates, PHARM, Resus, Ultrasound

Prehospital echo predicts arrest outcome

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In hospital, the detection of cardiac standstill with ultrasound predicts a fatal outcome from cardiac arrest with a high degree of accuracy. A similar finding has been made in the prehospital setting. Interestingly, it was a better predictor than other commonly recognised factors associated with outcome: the presence of asystole, down time, bystander CPR, or end-tidal CO2 levels.


Introduction. The prognostic value of emergency echocardiography (EE) in the management of cardiac arrest patients has previously been studied in an in-hospital setting. These studies mainly included patients who underwent cardiopulmonary resuscitation (CPR) by emergency medicine technicians at the scene and who arrived at the emergency department (ED) still in a state of cardiac arrest. In most European countries, cardiac arrest patients are normally treated by physician-staffed emergency medical services (EMS) teams on scene. Transportation to the ED while undergoing CPR is uncommon. Objective. To evaluate the ability of EE to predict outcome in cardiac arrest patients when it is performed by ultrasound-inexperienced emergency physicians on scene.

Methods. We performed a prospective, observational study of nonconsecutive, nontrauma, adult cardiac arrest patients who were treated by physician-staffed urban EMS teams on scene. Participating emergency physicians (EPs) received a two-hour course in EE during CPR. After initial procedures were accomplished, EE was performed during a rhythm and pulse check. A single subxiphoid, four-chamber view was required for study enrollment. We defined sonographic evidence of cardiac kinetic activity as any detected motion of the myocardium, ranging from visible ventricular fibrillation to coordinated ventricular contractions. The CPR had to be continued for at least 15 minutes after the initial echocardiography. No clinical decisions were made based on the results of EE.

Results. Forty-two patients were enrolled in the study. The heart could be visualized successfully in all patients. Five (11.9%) patients survived to hospital admission. Of the 32 patients who had cardiac standstill on initial EE, only one (3.1%) survived to hospital admission, whereas four out of 10 (40%) patients with cardiac movement on initial EE survived to hospital admission (p = 0.008). Neither asystole on initial electrocardiogram nor peak capnography value, age, bystander CPR, or downtime was a significant predictor of survival. Only cardiac movement was associated with survival, and cardiac standstill at any time during CPR resulted in a positive predictive value of 97.1% for death at the scene.

Conclusion. Our results support the idea of focused echocardiography as an additional criterion in the evaluation of outcome in CPR patients and demonstrate its feasibility in the prehospital setting.

Cardiac Movement Identified on Prehospital Echocardiography Predicts Outcome
Prehosp Emerg Care. 2012 Jan 11. [Epub ahead of print]

All Updates, PHARM, Resus, Trauma

Training in prehospital and retrieval medicine

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I’ve been too busy to blog literature updates for a couple of weeks since I and my colleagues have been flat out running a two week training course in prehospital and retrieval medicine.
Our Helicopter Emergency Medical Service physicians and paramedics care for a wide range of adult and paediatric trauma and critical care patients in some challenging environments. We therefore need to provide a fairly comprehensive induction course for new recruits.
The new guys did us proud. They just need to stay this awesome.

All Updates, Resus, Trauma

Prehospital fluids for head injury – keep it simple

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Just in case you thought you might be missing some recent gem on what we should be giving patients with traumatic brain injury in the field: a team from Melbourne has reviewed the literature and concluded isotonic crystalloids (Ringer’s or Saline) are as good as anything else.


The early management of patients who have sustained traumatic brain injury is aimed at preventing secondary brain injury through avoidance of cerebral hypoxia and hypoperfusion. Especially in hypotensive patients, it has been postulated that hypertonic crystalloids and colloids might support mean arterial pressure more effectively by expanding intravascular volume without causing problematic cerebral oedema. We conducted a systematic review to investigate if hypertonic saline or colloids result in better outcomes than isotonic crystalloid solutions, as well as to determine the safety of minimal volume resuscitation, or delayed versus immediate fluid resuscitation during prehospital care for patients with traumatic brain injury. We identified nine randomized controlled trials and one cohort study examined the effects of hypertonic solutions (with or without colloid added) for prehospital fluid resuscitation. None has reported better survival and functional outcomes over the use of isotonic crystalloids. The only trial of restrictive resuscitation strategies was underpowered to demonstrate its safety compared with aggressive early fluid resuscitation in head injured patients, and maintenance of cerebral perfusion remains the top priority.

Review article: Prehospital fluid management in traumatic brain injury
Emerg Med Australas. 2011 Dec;23(6):665-76

All Updates, PHARM, Resus, Trauma

Make space for pre-hospital intubation

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“Control your environment – don’t let it control you” is a reliable adage for pre-hospital providers, and its adherence can assist in in-hospital resuscitation too. Commanding control of ones space is a skill demonstrated by more seasoned paramedics compared with novices and the requirement, where possible, for 360 degrees of access around a patient is included in some Standard Operating Procedures for pre-hospital rapid sequence intubation.

Brett Rosen MD controlling space in the field

Evidence for this approach is now further supported by a study demonstrating that limited surrounding space on scene was a significant risk factor for difficult pre-hospital intubation by European EMS physicians.
Other predisposing factors for difficult prehospital intubation included obesity and a short neck.


OBJECTIVES:For experienced personnel endotracheal intubation (ETI) is the gold standard to secure the airway in prehospital emergency medicine. Nevertheless, substantial procedural difficulties have been reported with a significant potential to compromise patients’ outcomes. Systematic evaluation of ETI in paramedic operated emergency medical systems (EMS) and in a mixed physician/anaesthetic nurse EMS showed divergent results. In our study we systematically assessed factors associated with difficult ETI in an EMS exclusively operating with physicians.

METHODS:Over a 1-year period we prospectively collected data on the specific conditions of all ETIs of two physician staffed EMS vehicles. Difficult ETI was defined by more than 3 attempts or a difficult visualisation of the larynx (Cormack and Lehane grade 3, or worse). For each patient ETI conditions, biophysical characteristics and factors of the surrounding scene were assessed. Additionally, physicians were asked whether they had expected difficult ETI in advance.

RESULTS:Out of 3979 treated patients 305 (7.7%) received ETI. For 276 patients complete data sets were available. The incidence of difficult ETI was 13.0%. In 4 cases (1.4%) ETI was impossible, but no patient was unable to be ventilated sufficiently. Predicting conditions for difficult intubation were limited surrounding space on scene (p<0.01), short neck (p<0.01), obesity (p<0.01), face and neck injuries (p<0.01), mouth opening<3cm (p<0.01) and known ankylosing spondylitis (p<0.01). ETI on the floor or with C-spine immobilisation in situ were of no significant influence. The incidence of unexpected difficult ETI was 5.0%.
CONCLUSIONS: In a physician staffed EMS difficult prehospital ETI occurred in 13% of cases. Predisposing factors were limited surrounding space on scene and certain biophysical conditions of the patient (short neck, obesity, face and neck injuries, and anatomical restrictions). Unexpected difficult ETI occurred in 5% of the cases.

Difficult prehospital endotracheal intubation – predisposing factors in a physician based EMS
Resuscitation. 2011 Dec;82(12):1519-24

All Updates, PHARM

American airway management in the field

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I often wonder why my US colleagues are so vehemently opposed to out-of-hospital tracheal intubation. This paper provides a clue. I would love it if any EMS providers out there could comment, as I find these results staggering.
The authors comment that the data set “contains data on over 4.3 million EMS events from 16 states (Alabama, Colorado, Florida, Hawaii, Iowa, Maine, Minnesota, Missouri, North Carolina, North Dakota, Nebraska, New Hampshire, New Jersey, New Mexico, Nevada, and Oklahoma) for the one-year period January 1, 2008–December 31, 2008. These states were the first to participate in the NEMSIS project. There are no estimates of the numbers of EMS agencies or EMS responses that are not included in NEMSIS. Hawaii, New Jersey, New Mexico and Oklahoma provided only partial data for the study period because of their implementation of NEMSIS during 2008.”

OBJECTIVE: Prior studies describe airway management by single EMS agencies, regions or states. We sought to characterize out-of-hospital airway management interventions, outcomes and complications across the United States.
 
METHODS: Using the 2008 National Emergency Medical Services Information System (NEMSIS) Public-Release Data Set containing data from 16 states, we identified patients receiving advanced airway management, including endotracheal intubation (ETI), alternate airways (Combitube, Laryngeal Mask Airway (LMA), King LT, Esophageal-Obturator Airway (EOA)), and cricothyroidotomy (needle and open). We examined airway management success and complications in the full cohort and in key subsets (cardiac arrest, non-arrest medical, non-arrest injury, children <10 and 10-19 years, rapid-sequence intubation (RSI), population setting and US census region). We analyzed the data using descriptive statistics.
RESULTS: Among 4,383,768 EMS activations, there were 10,356 ETI, 2246 alternate airways, and 88 cricothyroidotomies. ETI success rates were: overall 6482/8418 (77.0%; 95% CI: 76.1-77.9%), cardiac arrest 3494/4482 (78.0%), non-arrest medical 616/846 (72.8%), non-arrest injury 417/505 (82.6%), children <10 years 295/397 (74.3%), children 10-19 years 228/289 (78.9%), adult 5829/7552 (77.2%), and rapid-sequence intubation 289/355 (81.4%). ETI success was success was lowest in the South US census region. Alternate airway success was 1564/1794 (87.2%). Major complications included: bleeding 84 (7.0 per 1000 interventions), vomiting 80 (6.7 per 1000) and esophageal intubation 12 (1.0 per 1000).
CONCLUSIONS: In this study characterizing out-of-hospital airway management across the United States, we observed low out-of-hospital ETI success rates. These data may guide national efforts to improve the quality of out-of-hospital airway management.

Out-of-hospital airway management in the United States
Resuscitation. 2011 Apr;82(4):378-85

All Updates, PHARM, Resus

Pre-hospital therapeutic hypothermia

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A Czech study demonstrated effective pre-hospital therapeutic cooling of post-cardiac arrest patients using fairly modest amounts of intravenous saline at 4°C: the administration of 12.6 ± 6.4 mL/kg (1,032 ± 546 mL) of 4°C normal saline led to a tympanic temperature decrease of 1.4 ± 0.8°C (from 36.2 ± 1.5 to 34.7 ± 1.4°C; P < 0.001) in 42.8 ± 19.6 minutes. No ice packs were applied.

Before other emergency medical services adopt this, it should be noted that all these patients were managed in the field by emergency physicians who administered sedatives and neuromuscular blockers. It’s a European thing.
Pre-hospital cooling of patients following cardiac arrest is effective using even low volumes of cold saline
Critical Care 2010, 14:R231 Full text

All Updates, PHARM, Resus, Trauma

Helicopters and trauma: systematic review

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In the midst of reconfiguring its trauma systems, the United Kingdom’s National Health Service needed to evaluate the cost effectiveness of helicopter emergency medical services (HEMS). A systematic literature review was undertaken of all population-based studies evaluating the impact on mortality of helicopter transfer of trauma patients from the scene of injury. The authors also attempted to analyse whether it is the helicopter as a transport platform or the standard of the emergency medical service that accounts for any differences seen.
A search of the literature revealed 23 eligible studies. 14 of these studies demonstrated a significant improvement in trauma patient mortality when transported by helicopter from the scene. 5 of the 23 studies were of level II evidence with the remainder being of level III evidence.

Only one eligible study assessed HEMS in the UK. The other papers reported data from the USA, Italy, Australia, the Netherlands, Germany and South Africa.
The majority of studies show a mortality benefit with HEMS: fourteen studies reported results that demonstrated a significant mortality rate improvement with HEMS, four reported data that did not reach significance and five did not report whether results reached significance.
The authors suggest this variation may be a result of any of the following factors, and provide a thorough discussion of the literature pertaining to each of them:

  1. Transport of a physician to the scene
  2. Transport of advanced airway skills to the scene
  3. Transporting a team experienced in managing trauma patients
  4. Triage to the definitive treatment facility

The full text of the review is available at the link below.
Is it the H or the EMS in HEMS that has an impact on trauma patient mortality? A systematic review of the evidence
EMJ 2010;27(9):692-701 (Free Full Text)

All Updates, PHARM, Resus, Trauma

Open thoracostomy

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Not a new paper to cite here, just a collection of resources that refer to open thoracostomy in trauma.
A longstanding practice by some European and Australasian HEMS physicians, open thoracostomy is essentially a chest tube procedure without the actual intercostal catheter: the surgical incision is made, blunt dissection is performed, and the pleura penetrated. The wound is then left open.
This is a rapid way of decompressing a tension pneumothorax in a critically injured trauma patient who is intubated. The positive pressure ventilation prevents the thoracostomy wound from acting as an open, ‘sucking’, chest wound.
In many pre-hospital services this is the preferred approach to pleural decompression in an intubated patient, and also forms part of the approach to resuscitation in traumatic cardiac arrest.
Some principles to consider are:

  • A tube and drainage system are not necessary for the drainage of air, but should be used if there is signficant haemothorax
  • The tissues may re-appose during transport so physiological deterioration should prompt a re-fingering of the thoracostomy to re-establish the drainage tract and allow air to escape
  • Standard intravenous cannula devices may be shorter than the distance from chest wall to pleural space in many adults, adding to the inadequacy of needle decompression
  • Signs of tension pneumothorax are rarely if ever as obvious as the textbooks suggest – unexplained shock or hypoxaemia in a patient with actual or probably thoracic trauma should prompt consideration of pleural decompression even in the absence of obvious clinical signs of pneumothorax – subtle evidence only may exist, such as palpable subcutaneous emphysema
  • This should only be done in intubated patients undergoing positive pressure ventilation!

This video shows the procedure, done by a relative beginner; a slightly larger incision with more assertive dissection would make it faster and more effective

Not yet heard Scott Weingart’s excellent podcast on traumatic arrest, which includes open, or ‘finger’, thoracostomy? You can find it here
Thoracostomy references

Simple Thoracostomy Avoids Chest Drain Insertion in Prehospital Trauma
J Trauma 1996 39(2):373-374
Simple thoracostomy in prehospital trauma management is safe and effective: a 2-year experience by helicopter emergency medical crews
European Journal of Emergency Medicine 2006, 13:276–280
Prehospital thoracostomy
European Journal of Emergency Medicine 2008, 15:283–285
Chest decompression during the resuscitation of patients in prehospital traumatic cardiac arrest
Emerg. Med. J. 2009;26;738-740
Life-saving or life-threatening? Prehospital thoracostomy for thoracic trauma
Emerg Med J 2007;24:305–306
Pre-Hospital and In-Hospital Thoracostomy: Indications and Complications
Ann R Coll Surg Engl. 2008 January; 90(1): 54–57
Needle decompression is inadequate:
Needle Thoracostomy in the Treatment of a Tension Pneumothorax in Trauma Patients: What Size Needle?
J Trauma. 2008;64:111–114
Pre-hospital management of patients with severe thoracic injury
Injury 1995 26(9):581-5

All Updates, PHARM, Trauma

Pre-hospital iv and increased mortality

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The US media seem to be making a big thing of a recent article published ahead of print which demonstrates an association between increased mortality from trauma and the insertion of an intravenous line with or without the administration of fluid.
This was a retrospective cohort study of over 770 000 patients from the National Trauma Data Bank. Approximately half (49.3%) received ‘prehospital IV’, which could mean fluids, or could just mean insertion of an intravenous cannula: ‘we could not definitively differentiate IV fluid administration versus IV catheter placement alone‘.
Unadjusted mortality was significantly higher in patients in the prehospital IV group, although the abstract inaccurately reports this to be ‘in patients receiving prehospital IV fluids‘ (4.8% vs. 4.5%, P < 0.001).
Multivariable logistic regression was used to examine the relationship between prehospital IV and mortality in the 311,071 patients with complete data. After adjustment, prehospital IV patients had significantly higher mortality than those without a prehospital IV. The odds ratio of death associated with prehospital IV placement was 1.11 (95% CI 1.06–1.17). When Dead-On-Arival patients were excluded from the group as a whole, the association persisted (OR 1.17, 95% CI 1.11–1.23).

Hey you're killing me here!

On subgroup analyses, the association between IV placement and excess mortality was maintained in nearly all patient subsets; the effect was more exaggerated in penetrating trauma victims.
Media speculation as to the reason for this association abounds, like USA Today‘s ‘those who are given pre-hospital IV fluids are actually 11% more likely to die than those who aren’t, not only because of transport delays but also in part because of the increased risk for bleeding that can accompany a fluid-induced increase in blood pressure‘. However the study did not record any pre-hospital times and could not tell which patients received fluid, let alone what the effect of fluid on blood pressure was.
The authors are open about this and other limitations: ‘The NTDB did not report prehospital transport times or differentiate urban versus rural care. Thus, we could not examine whether excess mortality in patients treated with IVs was directly associated with delays in transport to definitive care. We were also not able to control for transport time within the multiple regression model or perform a stratified analysis by urban versus rural patients. Perhaps this analysis would have identified a subset of patients who may benefit from IV placement‘.
No doubt this will be added to the pile of mainly hypothesis-generating literature quoted by the scoop-and-run brigade whose black-and-white worldview includes paramedics who want to delay proper treatment and a homogeneous trauma population whose lives can only be saved by a trauma surgeon in a hospital. Those who have evolved colour vision find this an interesting, but hardly practice-changing study; caution regarding injudicious fluid administration has been the game plan for many civilian and military pre-hospital providers since early last decade, and it is clear that different patients with different injury patterns, different degrees of physiological derangement, and different distances from the right hospital will continue to have different clinical needs specific to their presentation, some of which are likely to be of benefit if provided in the field, through an intravenous line.
Prehospital Intravenous Fluid Administration is Associated With Higher Mortality in Trauma Patients: A National Trauma Data Bank Analysis
Ann Surg. 2010 Dec 20. [Epub ahead of print]