In a study of over 7500 patients with cardiac arrest transported by EMS in the United States, transport distance was not associated with survival on logistic analysis (OR 1.00; 95% CI 0.99–1.01).
A geospatial assessment of transport distance and survival to discharge in out of
hospital cardiac arrest patients: Implications for resuscitation centers
Resuscitation. 2010 May;81(5):518-23
Tag Archives: pre-hospital
Kids need 'proper' CPR if non-cardiac cause of arrest
The American Heart Association recommends cardiopulmonary resuscitation (CPR) by bystanders with chest compression only for adults who have cardiac arrests, but not for children. These recommendations have new support in a large observational study from Japan examining outcomes in 5170 out-of hospital paediatric arrests over a 3 year period.
For children who had out-of-hospital cardiac arrests from non-cardiac causes, conventional CPR (with rescue breathing) by bystander was associated with improved outcomes compared with compression-only CPR (7·2% [45/624] favourable one month neurological outcome vs 1·6% [6/380]; OR 5·54, 2·52–16·99). In children who had arrests of cardiac causes conventional and compression-only CPR were similarly effective. Infants < 1 year had uniformly poor outcomes.
An editorial points out that this is the largest study that has analysed out-of-hospital cardiac arrest in children, and the overall survival of 9% with only 3% of children having a good neurological outcome, is consistent with previous reports.
Conventional and chest-compression-only cardiopulmonary resuscitation by bystanders for children who have out-of-hospital cardiac arrests: a prospective, nationwide, population-based cohort study
Lancet. 2010 Apr 17 345:1347-54
Battlefield resuscitation
An excellent review of the current British military practice to prevent and treat the acute coagulopathy of trauma shock (ACoTS) describes pathophysiology and treatment options and offers an algorithm for management. Key components of the system (when indicated according to their algorithm) outlined include:
- Pre-hospital damage control shock resuscitation by a forward medical team, consisting of RSI with reduced dose thio or ketamine with suxamethonium or rocuronium, large bore sublclavian access, and early use of warmed blood products
- 1:1:1 packed red cells, fresh frozen plasma, and platelets,
- Cryoprecipitate
- Tranexamic acid
- Recombinant activated factor VII
- Permissive hypotension aiming for a systolic BP of 90 mmHg, using blood products and avoiding vasopressors according to a ‘flow rather than pressure’ philosophy
- Avoiding hypothermia by giving warmed blood products and employing active patient warming methods
- Buffering acidosis using Tris-hydroxymethyl aminomethane (THAM), which may be superior to bicarbonate by not affecting minute ventilation or coagulation, and maintaining its efficacy in hypothermic conditions
- Minimising hypoperfusion with an anaesthetic strategy that provides effective analgesia and vasodilation, using high dose fentanyl and a low concentration volatile agent
- Using fresh whole blood for resistant coagulopathy
Battlefield resuscitation
Curr Opin Crit Care. 2009 Dec;15(6):527-35
Sorting ABCD issues pre-hospital
Prospectively collected data on 727 major trauma patients from a Portugese trauma centre registry enabled the comparison of mortality between three groups of patients with a priori defined life threatening ‘ABCD’ problems: those whose ABCD issues were treated in the field by a pre-hospital emergency physician, those that were treated at another hospital prior to trauma centre transfer, and those whose ABCD issues were first treated on arrival at the trauma centre. The study population included mixed urban and rural trauma.
Patients from the pre-hospital and first hospital groups had 20% and 27% mortality respectively, compared to 38% among those whose life-threatening events were corrected only at the trauma centre.
Patients whose life- threatening events were treated in the pre-hospital environment had lower mortality but at the same time were younger and less severely injured, so a multivariate logistic regression was performed to adjust the odds of death to patient characteristics and trauma severity as well as time from accident to trauma centre. Logistic regression showed that increases in mortality were associated with female gender and older age, penetrating type of trauma, higher anatomic severity (ISS), higher physiological severity (RTS) and having the life-threatening events corrected only at the trauma centre. Logistic regression showed that patients whose life-threatening events were corrected only at the trauma centre had an odds of death 3.3 times greater than those from the pre-hospital group, adjusted for patient and trauma characteristics and time to trauma centre.
Correcting life-threatening events pre- trauma centre (pre-hospital and first hospital) increased the total time from the accident to trauma centre, but long pre-hospital times were not associated with worse outcome.
The importance of pre-trauma centre treatment of life-threatening events on the
mortality of patients transferred with severe trauma
Resuscitation. 2010 Apr;81(4):440-5
Spine immobilisation in penetrating trauma
In a retrospective study of 45,284 penetrating trauma patients, unadjusted mortality was twice as high in the 4.3% of patients who underwent spine immobilisation, compared with those who were not immobilised.
An accompanying editorial comments: ‘The number needed to treat with spine immobilization to potentially benefit one penetrating trauma patient was 1,032. The number needed to harm with spine immobilization to potentially contribute to one death was 66.‘
Spine immobilization in penetrating trauma: more harm than good?
J Trauma. 2010 Jan;68(1):115-20
College of Paramedics stands its ground
Articles in this month’s EMJ demonstrate an interesting conflict within UK pre-hospital care. The Joint Royal Colleges Ambulance Liaison Committee Airway Working Group, heavily represented by anaesthetists, recommend the removal of tracheal intubation from UK paramedic practice. The College of Paramedics reject this recommendation, providing a robust critique of the paper and calling for better evidence before changing current practice. A fascinating read.
A critical reassessment of ambulance service airway management in prehospital care: Joint Royal Colleges Ambulance Liaison Committee Airway Working Group, June 2008
Emerg Med J 2010;27:226-233
Full Text
The College of Paramedics (British Paramedic Association) position paper regarding the Joint Royal Colleges Ambulance Liaison Committee recommendations on paramedic intubation
Emerg Med J 2010;27:167-170
Full Text
Intubation harder on the floor or in an ambulance
An abstract from the The National Association of EMS Physicians® 2010 Scientific Assembly published in a Supplement of Prehospital Emergency Care describes a study comparing cadaveric intubation success rates by paramedics in different positions: on the floor, on an elevated stretcher, and in a simulated ambulance. Despite less experience intubating on an elevated stretcher, the participants had increased first-attempt success in the elevated stretcher position compared with the back of the ambulance and the floor (although in the latter case this lacked statistical significance). Position is everything! In our HEMS service we prefer a lowered stretcher to either on the ground or in the ambulance – it would be nice to see this position studied one day too.
Pre-hospital intubation: patient position does matter
Prehospital Emergency Care 2010;14(Suppl 1):9
Better TBI outcome with HEMS
A retrospective study from Italy compared outcomes of head injured patients cared for by a ground ambulance service (GROUND) with those managed by a HEMS team that included an experienced pre-hospital anaesthetist. Interestingly 73% of the ground group were also attended by a physician, but one ‘with only basic life-support capabilities and no formal training in airways management’. Despite these limited skills a results table shows that 36% of the GROUND group were intubated on scene (compared with 92% of the HEMS group), although without the use of neuromuscular blockers.
The HEMS group consisted of 89 patients and the GROUND group of 105 patients. There were no statistical differences in age, ISS, aISShead, or GCS, although arterial hypotension at arrival at the ER was present in 18% of HEMS patients and in 36% of GROUND patients (P < 0.001).
The overall mortality rate was lower in the HEMS than in the GROUND group (21 vs. 25% , P < 0.05). The survival with or without only minor neurological disabilities was higher in the HEMS than in the GROUND group (54 vs. 44% respectively, P < 0.05); among the survivors, the rate of severe neurological disabilities was lower in the HEMS than in the GROUND group (25 vs. 31%, P < 0.05). The out-of-hospital phase duration was longer in the HEMS group but this group had a faster time to definitive care (neurosurgery or neurocritical care).
Influence of prehospital treatment on the outcome of patients with severe blunt traumatic brain injury: a single-centre study
Eur J Emerg Med. 2009 Dec;16(6):312-7
Ketamine use by paramedics
A poster presentation at the Australasian College of Emergency Medicine’s Annual Scientific Conference in Melbourne in November 2009 reports 100 cases of pre-hospital ketamine use for analgesia by paramedics in New Zealand – reproduced below with permission of the author:
Ketamine is a safe and effective analgesic for pre-hospital paramedic led pain relief
HM Hussey & BC Ellis
Introduction: There have been a number of reports on the use of ketamine by pre-hospital physicians, with many advocating its use as the ideal pre-hospital analgesic and sedative due to its airway and cardiovascular stability. There however is little published on its use by paramedics. This study aims to review its effectiveness and safety when administered pre-hospital by paramedics.
Method: Prospective observational study of 100 consecutive administrations by St Johns ambulance paramedics in 2008–09 using a specifically designed data sheet. Demographic data, adjuvant analgesics used, ketamine dose, pre and post dose pain scores on VNRS and physiological parameters were collected. In addition paramedics and patients completed a satisfaction rating score.
Results: The mean dose of ketamine used was 30.2 mg and the mean improvement in pain was 5.10. Ketamine was used both as a lone agent and with morphine; excellent analgesia was achieved in both groups. The most common reason for use was limb trauma followed by burns and extractions from scene. There were no episodes of hypotension or airway compromise. 15% of patients had an adverse reaction all mild and mostly comprising minor psychotropic effects. The median satisfaction rating for both paramedics and patients was ‘Good’.
Conclusion: These results back the use of Ketamine by St John’s Ambulance paramedics and the authors support its use by other pre-hospital services as a safe and effective analgesic.
Emergency Medicine Australasia 2010;22(S1):A30
Pre-hospital thoracotomy and aortic clamping in blunt trauma
This is one of those ‘wow they really do that!?‘ papers…Patients undergoing thoracotomy and aortic clamping for pre-hospital blunt traumatic arrest either in the field or in the ED were evaluated for the outcome of survival to ICU admission. None of the 81 patients who underwent this intervention survived to discharge.
Field thoracotomy resulted in shorter times from arrival of the emergency medical team to performance of the thoracotomy (19.2 vs 30.7 mins). Patients who arrested in front of the team had a greater ICU admission rate than those who were already in cardiac arrest when the team arrived (70% vs 8%).
One may argue against an intervention that seems to have resulted in no benefit to the patient. However a counterargument might be that an ICU admission allows for better end-of-life management for grieving families, and for the possibility of organ donation.
Interestingly, there were some neurologically intact survivors of emergency thoracotomy for blunt trauma by this service, although they were excluded from the study for either (i) receiving the field thoracotomy before full arrest or (ii) arresting after arrival in the ED.
Role of resuscitative emergency field thoracotomy in the Japanese helicopter emergency medical service system
Resuscitation. 2009 Nov;80(11):1270-4