Pre-hospital Anaesthesia Research Articles

Pre-hospital anaesthesia and assessment of head injured patients presenting to a UK Helicopter Emergency Medical Service with a high Glasgow Coma Scale: a cohort study

ObjectivesPatients who sustain a head injury but maintain a Glasgow Coma Scale (GCS) of 13–15 may still be suffering from a significant brain injury. We aimed to assess the appropriateness...

Best practice advice on pre-hospital emergency anaesthesia & advanced airway management

BackgroundEffective and timely airway management is a priority for sick and injured patients. The benefit and conduct of pre-hospital emergency anaesthesia (PHEA) and advanced airway management remains controversial but there are a proportion of critically ill and injured patients who require urgent advanced airway management prior to hospital arrival. This document provides current best practice advice for the provision of PHEA and advanced airway management.MethodThis best practice advice was developed from EHAC Medical Working Group enforced by pre-hospital critical care experts. The group used a nominal group technique to establish the current best practice for the provision of PHEA and advanced airway management. The group met on three separate occasions to discuss and develop the guideline. All members of the working party were able to access and edit the guideline online.ResultsThis EHAC best practice advice covers all areas of PHEA and advanced airway management and provides up to date evidence of current best practice.ConclusionPHEA and advanced airway management are complex interventions that should be delivered by appropriately trained personnel using a well-rehearsed approach and standardised equipment. Where advanced airway interventions cannot be delivered, careful attention should be given to applying basic airway interventions and ensuring their effectiveness at all times.

Advanced Paramedic Delivered Finger Thoracostomy

<p><strong>Introduction & Aims</strong></p><p>Tension pneumothorax is a potentially fatal but reversible injury encountered in major trauma and traumatic cardiac arrest. Needle decompression has been the standard treatment approach pre hospital in Ireland and internationally. However, concerns exist regarding the effectiveness of this approach due to anatomy and body habitus. We aim to describe the training, introduction and experience of finger thoracostomy by advanced paramedics within a pre hospital service in Ireland.</p><p><strong>Methods</strong></p><p>Finger thoracostomy has been advocated as an alternative pre hospital treatment which is both diagnostic and therapeutic. Paramedic delivered thoracostomy is commonplace in pre hospital critical care services internationally. The MCI Medical Team (as part of Motorsport Rescue Services) is a PHECC-registered multidisciplinary team which provides medical cover at motorcycle road racing events in Ireland. The MCI Medical Team has significant experience of major trauma and routinely performs pre hospital anaesthesia for trauma patients. We introduced a training module on finger thoracostomy, comprising: theory, practical instruction and assessment for advanced paramedic members of the team.</p><p><strong>Results & Conclusions</strong></p><p>Advanced paramedic members of the team we trained to deliver finger thoracostomy in predefined circumstances when operating as part of the MCI medical team. To date, advanced paramedic delivered finger thoracostomy has been utilised on three occasions. Introduction of advanced paramedic delivered thoracostomy is a feasible and effective technique for the treatment of tension pneumothorax within a closely governed system.</p>

Pit Crew Approach to Pre Hospital Trauma Resuscitation

<p><strong>Introduction</strong></p><p>Pre hospital trauma care is often delivered by dual crewed ambulances supported by additional resources as necessary and available. Coordinating resuscitation of a critically injured patient may require multiple simultaneous actions. Equally, a large number of practitioners can hinder patient care if not coordinated.</p><p><strong>Aims</strong></p><p>To describe a multi disciplinary, scaleabe approach to pre hospital trauma care suitable for small and large multi disciplinary teams. Methods The MCI medical team (as part of Motorsport Rescue Services) is a PHECC-registered multidisciplinary team, which provides medical cover at Motorcycle road racing events in Ireland. The MCI medical team has significant experience of major trauma and routinely performs prehospital anaesthesia for trauma patients. We have evolved a pit crew approach to trauma care with pre defined roles and interventions assigned to a five person team, three clinical members, a scribe and a team lead. The approach is both scalable and collapsible, meaning that if multiple patients are present, roles can be merged; if additional clinical input is required, roles can also be supplemented. Each team member carries equipment and medications specific to their role, allowing efficiencies at the patients side.</p><p><strong>Results</strong></p><p>The pit crew approach to pre hospital trauma care has evolved over a decade and is routinely implemented at motorcycle road races in Ireland.</p><p><strong>Conclusions</strong></p><p>The pit crew trauma approach, although applicable to a pre defined five person team in unique circumstances, may also be applicable to ad hoc clinical teams that typically form in the pre hospital arena.</p>

Impact of drug and equipment preparation on pre-hospital emergency Anaesthesia (PHEA) procedural time, error rate and cognitive load

BackgroundWe examined the effect of advanced preparation and organisation of equipment and drugs for Pre-hospital Emergency Anaesthesia (PHEA) and tracheal intubation on procedural time, error rates, and cognitive load.MethodsThis study was a randomised, controlled experiment with a crossover design. Clinical teams (physician and paramedic) from the Emergency Medical Retrieval Service and the Scottish Air Ambulance Division were randomised to perform a standardised pre-hospital clinical simulation using either unprepared (standard practice) or pre-prepared (experimental method) PHEA equipment and drugs. Following a two-week washout period, each team performed the corresponding simulation. The primary outcome was intervention time. Secondary outcomes were safety-related incidents and errors, and degree of cognitive load.ResultsIn total 23 experiments were completed, 12 using experimental method and 11 using standard practice. Time required to perform PHEA using the experimental method was significantly shorter than with standard practice (11,45 versus 20:59) minutes: seconds; p = < 0.001). The experimental method also significantly reduced procedural errors (0 versus 9, p = 0.007) and the cognitive load experienced by the intubator assistant (41.9 versus 68.7 mm, p = 0.006).ConclusionsPre-preparation of PHEA equipment and drugs resulted in safer performance of PHEA and has the potential to reduce on-scene time by up to a third.

Prehospital emergency anaesthesia: an updated survey of UK practice with emphasis on the role of standardisation and checklists

IntroductionPrehospital emergency anaesthesia (PHEA or ‘prehospital rapid sequence intubation’) is a high-risk procedure. Standard operating procedures (SOPs) and checklists within healthcare systems have been demonstrated to reduce human error and...

Prospective pilot study of cerebral near infrared spectroscopy monitoring during pre-hospital anaesthesia.

Near-infrared spectroscopy (NIRS) provides a non-invasive measure of cerebral tissue oxygenation. The literature on application of this method in pre-hospital setting is limited. The aims of this study were to determine the feasibility of cerebral NIRS during pre-hospital anaesthesia and to quantify the changes in front lobe regional oxygen saturation (rSO2) during the pre-hospital phase. NIRS monitoring (Nonin SenSmart X-100) of front lobe regional oxygen saturation (rSO2) was initiated before induction of anaesthesia in 31 adult patients and continued until hospital arrival. The median age of the patients was 55years (IQR [range] 43-63 [20-84]), and 20 (65%) of the patients were male. The indications for pre-hospital anaesthesia were neurological reasons (29%), intoxication (23%), traumatic brain injury (23%) and successful resuscitation from cardiac arrest (16%). The NIRS monitoring was successful in 29 of 31 cases (94%; 95% CI: 78-99). One patient could not be monitored due to poor probe-skin contact, and 1 patient had poor contact with 1 hemisphere. Monitoring was performed for a total of 1335minutes and was successful in both hemispheres 95% (95% CI: 94-96) of the time. The median lowest rSO2 was 8% (IQR [range] 2-13 [0-30]) below baseline, and median peak rSO2 was 7% (IQR [range] 2-11 [0-34]) above the baseline. Changes in rSO2 without accompanying changes in vital signs were observed. NIRS is feasible during pre-hospital anaesthesia and substantial changes were observed in some patients. It provides data beyond the standard monitoring used in the pre-hospital setting.

Paediatric acute care: Highlights from the Paediatric Acute Care-Advanced Paediatric Life Support Conference, Gold Coast, 2017.

The Paediatric Acute Care Conference is an annual conference organised by APLS Australia to advance paediatric acute care topics for clinicians in pre-hospital medicine, EDs, acute paediatrics, intensive care and anaesthesia. The Conference 2017 was held at Surfers Paradise, Queensland. We provide a summary of some of the presentations.

Isolated traumatic brain injury results in significant pre-hospital derangement of cardiovascular physiology

IntroductionMajor trauma can result in both life-threatening haemorrhage and traumatic brain injury (TBI). The pre-hospital management of these conditions, particularly in relation to the cardiovascular system, is very different. TBI can result in cardiovascular instability but the exact incidence remains poorly described. This study explores the incidence of cardiovascular instability in patients undergoing pre-hospital anaesthesia for suspected TBI. MethodsRetrospective case series of all pre-hospital trauma patients attended by Kent, Surrey & Sussex Air Ambulance Trust (United Kingdom) trauma team during the period 1 January 2015–31 December 2016. Patients were included if they showed clinical signs of TBI, underwent pre-hospital anaesthesia and hospital computed tomography scanning subsequently confirmed an isolated TBI. ResultsOut of 121 patients with confirmed isolated TBI, 68 were cardiovascularly stable throughout the pre-anaesthesia phase, whilst 53 (44%) showed signs of instability (HR > 100bpm and/or SBP < 100 mmHg pre-anaesthesia). Hypotension (SBP < 100) with or without tachycardia was present in 14 (12%) patients. 10 (8%) patients with isolated TBI received pre-hospital blood product transfusion. ConclusionIncreased awareness that traumatic brain injury can cause significant derangement to heart rate and blood pressure, even in the absence of major haemorrhage, would allow the pre-hospital clinician to treat cardiovascular instability with the most appropriate means, such as crystalloid and vasopressors, to limit secondary brain injury.

Pre-hospital emergency anaesthesia in awake hypotensive trauma patients: beneficial or detrimental?

The benefits of pre-hospital emergency anaesthesia (PHEA) are controversial. Patients who are hypovolaemic prior to induction of anaesthesia are at risk of severe cardiovascular instability post-induction. This study compared mortality for hypovolaemic trauma patients (without major neurological injury) undergoing PHEA with a patient cohort with similar physiology transported to hospital without PHEA. A retrospective database review was performed to identify patients who were hypotensive on scene [systolic blood pressure (SBP) < 90 mmHg], and GCS 13-15. Patient records were reviewed independently by two pre-hospital clinicians to identify the likelihood of hypovolaemia. Primary outcome measure was mortality defined as death before hospital discharge. Two hundred and thirty-six patients were included; 101 patients underwent PHEA. Fifteen PHEA patients died (14.9%) compared with six non-PHEA patients (4.4%), P = 0.01; unadjusted OR for death was 3.73 (1.30-12.21; P = 0.01). This association remained after adjustment for age, injury mechanism, heart rate and hypovolaemia (adjusted odds ratio 3.07 (1.03-9.14) P = 0.04). Fifty-eight PHEA patients (57.4%) were hypovolaemic prior to induction of anaesthesia, 14 died (24%). Of 43 PHEA patients (42.6%) not meeting hypovolaemia criteria, one died (2%); unadjusted OR for mortality was 13.12 (1.84-578.21). After adjustment for age, injury mechanism and initial heart rate, the odds ratio for mortality remained significant at 9.99 (1.69-58.98); P = 0.01. Our results suggest an association between PHEA and in-hospital mortality in awake hypotensive trauma patients, which is strengthened when hypotension is due to hypovolaemia. If patients are hypovolaemic and awake on scene it might, where possible, be appropriate to delay induction of anaesthesia until hospital arrival.

Hip fracture surgery within 48 hours – a reachable recommendation?

Introduction The usual treatment for all types of hip fracture is surgical. Conservative treatment is rarely indicated in developed countries. It is recognized that treatment decreases morbidity and mortality, controls pain and promotes early mobilization. The complexity of most fragility fracture patients is compound by comorbidities and polypharmacy, and requires a multidisciplinary approach. There exists a vast number of available guidelines that vary in relevance and quality. However, evidence supports that hip fracture surgery within 48 hours of admission is associated with better outcomes. Materials and methods We retrospectively reviewed the cases operated for proximal femoral fracture in 2014, at our institution. We intend to evaluate: age, sex, fracture classification, comorbidities, length of hospital stay and average waiting time for surgery. Results We evaluated 474 patients (average 1.298 per day), with an average age of 71 (23–98). Seventy-seven percent are female and 63% of the fractures are extracapsular. The mean time of hospitalization are 18 days and the mean time of waiting for surgery is greater than 5 days. Only 26% of surgeries were done within 48 hours of admission. Discussion The number of these types of fractures has increased. Timing of surgery is one of the biggest challenges of the health system. It involves the pre-hospital emergency coordination, trauma services, geriatrics, anesthesia and surgical equipment capacity. Conclusion Hip fracture is a real worldwide health issue, which increases with age and occurs principally in women. Ideally, it should perform surgery on the day, or the day after, admission. It is essential to identify and treat correctable comorbidities immediately so that surgery is not delayed. For this reason, their approach should be multidisciplinary, including orthogeriatric and trauma teams.

Paediatric acute care: Highlights from the Paediatric Acute Care-Advanced Paediatric Life Support Conference, Adelaide, 2016.

The Paediatric Acute Care Conference (PACC) is an annual conference organised by Advanced Paediatric Life Support Australia to advance paediatric acute care topics for clinicians in pre-hospital medicine, EDs, acute paediatrics, intensive care and anaesthesia. The PACC 2016 was held at Glenelg, Adelaide, Australia. We provide a summary of some of the presentations.

Haemodynamic changes to a midazolam-fentanyl-rocuronium protocol for pre-hospital anaesthesia following return of spontaneous circulation after cardiac arrest.

Following the return of spontaneous circulation after out-of-hospital cardiac arrest, neurological dysfunction, airway or ventilatory compromise can impede transport to early percutaneous coronary intervention, necessitating pre-hospital or emergency department anaesthesia to facilitate this procedure. There are no published reports of the ideal induction agents in these patients. We sought to describe haemodynamic changes associated with induction of anaesthesia using a midazolam (0.1 mg.kg-1 ), fentanyl (2 μg.kg-1 ) and rocuronium (1 mg.kg-1 ) regimen developed using expert opinion, and adherence to the protocol by our pre-hospital teams. We performed a retrospective review of haemodynamic data recorded during induction of anaesthesia in patients following return of spontaneous circulation, over a 30-month period. We analysed the changes in systolic blood pressure and heart rate using a repeated-measures design, as well as the rate of new hypotension or hypertension. Sixty-four patients had four consecutive measurements for analysis (one pre-induction and three post-induction). Systolic blood pressure at all three post-induction measurements was significantly lower than the pre-induction value. Heart rate did not differ between any time-points. New episodes of hypotension (systolic pressure < 90 mmHg) occurred in four (6%) patients at the first measurement post-induction (95%CI 2-15%) and 10 (16%) at the third measurement (95%CI 8-27%). Three patients (5%; 95%CI 1-13%) had a hypertensive response. The median (IQR[range]) dose of midazolam given at induction was 0.04 (0.03-0.05 [0.01 to 0.10]) mg.kg-1 . Adherence to recommended fentanyl and rocuronium doses was high. Overall, systolic blood pressure was reduced following induction of anaesthesia, and systolic pressures < 90 mmHg occurred more often at measurements made later (up to 9 min) after induction. Changes in heart rate, and new hypertension were uncommon.

AAGBI: Safer pre-hospital anaesthesia 2017: Association of Anaesthetists of Great Britain and Ireland.

SummaryPre‐hospital emergency anaesthesia with oral tracheal intubation is the technique of choice for trauma patients who cannot maintain their airway or achieve adequate ventilation. It should be carried out as soon as safely possible, and performed to the same standards as in‐hospital emergency anaesthesia. It should only be conducted within organisations with comprehensive clinical governance arrangements. Techniques should be straightforward, reproducible, as simple as possible and supported by the use of checklists. Monitoring and equipment should meet in‐hospital anaesthesia standards. Practitioners need to be competent in the provision of in‐hospital emergency anaesthesia and have supervised pre‐hospital experience before carrying out pre‐hospital emergency anaesthesia. Training programmes allowing the safe delivery of pre‐hospital emergency anaesthesia by non‐physicians do not currently exist in the UK. Where pre‐hospital emergency anaesthesia skills are not available, oxygenation and ventilation should be maintained with the use of second‐generation supraglottic airways in patients without airway reflexes, or basic airway manoeuvres and basic airway adjuncts in patients with intact airway reflexes.

Pre-Hospital Anesthesia Handbook, 2nd ed.

Pre-Hospital Anesthesia Handbook, 2nd ed.

Paediatric acute care: Highlights from the PAC-APLS conference, Sydney, 2015.

The Paediatric Acute Care Conference (PACC) is an annual conference organised by Advanced Paediatric Life Support (APLS) Australia to advance paediatric acute care topics for clinicians in pre-hospital medicine, EDs, acute paediatrics, intensive care and anaesthesia. All PACC content is made available free online (https://vimeo.com/aplsaustralia). The PAC conference 2015 was held at Coogee, Sydney. We provide a summary of some of the presentations.

Video laryngoscopy in pre-hospital critical care - a quality improvement study.

BackgroundPre-hospital endotracheal intubation is challenging and repeated endotracheal intubation is associated with increased morbidity and mortality.We investigated whether the introduction of the McGrath MAC video laryngoscope as the primary device for pre-hospital endotracheal intubation could improve first-pass success rate in our anaesthesiologist-staffed pre-hospital critical care services. We also investigated the incidence of failed pre-hospital endotracheal intubation, the use of airway adjuncts and back-up devices and problems encountered using the McGrath MAC video laryngoscope.MethodsProspective quality improvement study collecting data from all adult pre-hospital endotracheal intubation performed by four anaesthesiologist-staffed pre-hospital critical care teams between December 15th 2013 and December 15th 2014.ResultsWe registered data from 273 consecutive patients. When using the McGrath MAC video laryngoscope the overall pre-hospital endotracheal intubation first-pass success rate was 80.8 %. Following rapid sequence intubation (RSI) it was 88.9 %. This was not significantly different from previously reported first-pass success rates in our system (p = 0.27 and p = 0.41). During the last nine months of the study period the overall first-pass success rate was 80.1 (p = 0.47) but the post-RSI first-pass success rate improved to 94.4 % (0.048).The overall pre-hospital endotracheal intubation success rate with the McGrath MAC video laryngoscope was 98.9 % (p = 0.17). Gastric content, blood or secretion in the airway resulted in reduced vision when using the McGrath MAC video laryngoscope.ConclusionIn this study of video laryngoscope implementation in a Scandinavian anaesthesiologist-staffed pre-hospital critical care service, overall pre-hospital endotracheal first pass success rate did not change. The post-RSI first-pass success rate was significantly higher during the last nine months of our 12-month study compared with our results from before introducing McGrath MAC video laryngoscope. The implementation of the Standard Operating Procedure and check list for pre-hospital anaesthesia during the study period may have influenced the first-pass success rate and constitutes a potential confounder.The potential limitations of the McGrath MAC video laryngoscope when there are gastric content, blood and secretions in the airways need to be further investigated before the McGrath MAC video laryngoscope can be recommended as the primary device in all pre-hospital endotracheal intubations.Electronic supplementary materialThe online version of this article (doi:10.1186/s13049-016-0276-6) contains supplementary material, which is available to authorized users.

A review of the Great North Air Ambulance Pre-Hospital Emergency Medicine Crew Course

Journal of Paramedic PracticeVol. 8, No. 4 Career DevelopmentA review of the Great North Air Ambulance Pre-Hospital Emergency Medicine Crew CourseJamie Walsh, Jonathan HowesJamie WalshSearch for more papers by this author, Jonathan HowesSearch for more papers by this authorJamie Walsh; Jonathan HowesPublished Online:5 Apr 2016https://doi.org/10.12968/jpar.2016.8.4.194AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References Chesters A, Keefe N, Mauger J, Lockey D (2013) Prehospital anaesthesia performed in a rural and suburban air ambulance service staffed by a physician and paramedic: a 16-month review of practice. Emerg Med J 31(1): 65–8. doi: https://doi.org/10.1136/emermed-2012-201846 Crossref, Google ScholarCrosskerry P, Cosby K (2009) Patient Safety in Medicine. Lippincott Williams and Wilkins, Philadelphia Google ScholarLeSage P, Dyar J, Evans B (2010) Crew Resource Management: Priniciples and Practice. Jones and Bartlett Publishing, London Google ScholarThe Association of Anaesthetists of Great Britain and Ireland (2009) AAGBI Safety Guidelines: Pre-Hospital Anaesthesia. AAGBI, London Google Scholar FiguresReferencesRelatedDetails 2 April 2016Volume 8Issue 4ISSN (print): 1759-1376ISSN (online): 2041-9457 Metrics History Published online 5 April 2016 Published in print 2 April 2016 Information© MA Healthcare LimitedPDF download

Advanced airway management for pre-hospital trauma patients

The need for timely and appropriate airway management for trauma patients is widely recognised. There are a small number of severely injured patients who cannot be adequately supported with basic airway manoeuvres, and require early advanced airway management. The way in which this care is provided remains highly controversial. Whilst it is clear that effective airway management remains a priority for all patients and poorly performed pre-hospital anaesthesia may be detrimental to patient outcome, debate remains over exactly which patients will benefit from early advanced airway interventions, and how it should be provided. The evidence base is small and inconsistent, with significant heterogeneity in the reported data, making it impossible to draw meaningful conclusions. Current practice is not standardised, and care is delivered by providers of different abilities using a range of equipment and techniques. Standards of care provided during in-hospital practice relating to these issues of provider competence, equipment, and monitoring should be directly translated into delivery of care outside the hospital, but this is not always the case. The aim of this review is to evaluate the current evidence surrounding pre-hospital advanced airway management.

Conducting a safe rapid sequence induction in pre-hospital care

This review article will consider how to conduct a safe rapid sequence induction of anaesthesia in the pre-hospital environment. It considers the potential risks and benefits of doing so, reviews some of the literature surrounding the technique and considers aspects from clinician training to choice of induction agent. It aims to give an overview of this element of pre-hospital emergency anaesthesia.