Prehospital Environment Research Articles

Ketamine in acute phase of severe traumatic brain injury \u201can old drug for new uses?\u201d

Maintaining an adequate level of sedation and analgesia plays a key role in the management of traumatic brain injury (TBI). To date, it is unclear which drug or combination of drugs is most effective in achieving these goals. Ketamine is an agent with attractive pharmacological and pharmacokinetics characteristics. Current evidence shows that ketamine does not increase and may instead decrease intracranial pressure, and its safety profile makes it a reliable tool in the prehospital environment. In this point of view, we discuss different aspects of the use of ketamine in the acute phase of TBI, with its potential benefits and pitfalls.

Pilot randomized trial of pre-hospital advanced therapies for the control of hemorrhage (PATCH) using pelvic binders.

Pelvic fractures represent a small percent of all skeletal injuries but are associated with significant morbidity and mortality secondary to hemodynamic instability from bleeding bone surfaces and disrupted pelvic vasculature. Stabilization of the pelvis prior to arrival at a treatment facility may mitigate the hemodynamic consequences of pelvic ring injuries and improve morbidity and mortality. Whether pelvic compression devices such as pelvic binders or sheets can be safely applied in the prehospital setting has not been well-studied. This study aims to evaluate the safety of applying a pelvic binder to at-risk patients in the field after scalable training and the feasibility of conducting a randomized trial evaluating this practice in the prehospital setting. A pilot study (prospective randomized trial design) was conducted in the pre-hospital environment in an urban area surrounding a level-one trauma center. Pre-hospital emergency medical (EMS) personnel were trained to identify patients at high-risk for pelvic fracture and properly apply a commercial pelvic binder. Adult patients with a high-energy mechanism, suspected pelvic fracture, and "Priority 1" criteria were prospectively identified by paramedics and randomized to pelvic binder placement or usual care. Medical records were reviewed for safety outcomes. Secondary outcomes were parameters of efficacy including interventions needed to control hemorrhage (such as angioembolization and surgical control of bleeding) and mortality. Forty-three patients were randomized to treatment (binder: N=20; nonbinder: N=23). No complications of binder placement were identified. Eight patients (40%) had binders placed correctly at the level of the greater trochanter. Two binders (10%) were placed too proximally and 10 (50%) binders were not visualized on x-ray. Two binder group patients and three nonbinder group patients required angioembolization. None required surgical control of pelvic bleeding. Two nonbinder group patients and one binder group patient were readmitted within 30 days and one nonbinder group patient died within 30 days. Identification of pelvic fractures in the field remains a challenge. However, a scalable training model for appropriate binder placement was successful without secondary injury to patients. The model for conducting prospective, randomized trials in the prehospital setting was successful.

Should ascorbic acid be a primary therapy for sepsis in prehospital settings?

Background: Prehospital emergency medical services (EMS) are believed to be responsible for the initial treatment of 68 000 septic patients annually in the UK, 88% of whom have severely low ascorbic acid levels, which can lead to organ dysfunction, increasing the likelihood of mortality. Objective: This review aims to determine if early therapeutic use of ascorbic acid (vitamin C) could reduce the deterioration of septic patients and therefore overall mortality. Method: A literature review was conducted using the mySearch, PubMed and Cochrane Library databases. Each was systematically searched for human studies that addressed the use of ascorbic acid as a primary method of treatment during varying stages of sepsis and whether it reduced associated mortality. Studies not published in English or that were more the 5 years old at the time were excluded. The quality of evidence in the remaining articles were appraised using the GRADE method and further assessed for quality with an adjusted Downs and Black scoring tool. Results: Nineteen articles were found, three of which met the inclusion criteria. All addressed the use of ascorbic acid as a therapy in the treatment of sepsis; none were conducted in a prehospital setting. Conclusion: Intravenous ascorbic acid appears to be a safe and effective therapy in treating septic patients, with the potential to reduce mortality rates if given prophylactically. However, a series of clinical trials would need to be conducted to measure the extent of any improvement and therefore clinical value in the prehospital environment.

Exploring the clinical debrief: benefits and barriers

Paramedics are regularly exposed to traumatic situations in the prehospital environment, which can profoundly affect their emotional resilience. A debrief is a recognised tool that is used to manage the aftermath of such events. Its aims are to unpick the components of the situation, identify any issues or achievements in clinical care, highlight learning points to improve future practice and safeguard the clinician’s emotional wellbeing. This article explores the benefits of and barriers to debriefing in clinical practice as well as the emerging debate around the potential harm or benefit of single-session debriefing.

Simulation-Based Orientation for Emergency Medicine Residents Participating in EMS Ride-Alongs.

IntroductionEmergency medicine resident physicians are required to complete observational ride-alongs with emergency medical services (EMS) units as part of their curriculum as per the ACGME. We created this curriculum to expose emergency medicine residents to the equipment they will encounter in the prehospital setting, discuss basic EMS operations and the challenges of working in the prehospital environment, and review the limitations that restrict care provided by EMS professionals.MethodsWe created a series of five simulation cases for resident physicians participating in an EMS ride-along rotation. Each case was implemented with three to four residents at a time. A critical action checklist was used to assess participants during the scenarios. Following each simulation, a debriefing was conducted to discuss EMS operations and the impact on providers. At the conclusion of the session, participants completed a course evaluation survey.ResultsThirteen emergency medicine resident physicians took part in this curriculum from October 2020 through January 2021. Results indicated that the participants gained insight into the prehospital environment, felt more prepared to complete their ride-alongs, and were engaged and satisfied with the introduction to EMS program.DiscussionSimulation allowed emergency medicine residents to be exposed to the complex nature of prehospital care and prepared them for their ride-along sessions. The five cases provided significant breadth and depth of potential prehospital care issues, and the residents were able to discuss the medical, policy, and operational challenges presented as part of each case.

The Use of Chest Seals in Treating Sucking Chest Wounds: A Comparison of Existing Evidence and Guideline Recommendations

Sucking chest wounds occur when injuries penetrate the thorax and inhalation results in air entering the pleural cavity. Well documented in the prehospital environment, treatment should be chest seal application to attempt prevention of an expanding pneumothorax. However, a seal might occlude the pathway for the escape of air and lead to a worsening tension pneumothorax.The author conducted a literature search of studies reporting the efficacy of various chest seals for treating sucking chest wounds and the prevention of a tension pneumothorax. Study results were compared to current international guidelines.Included were four studies testing chest seals in a swine model of hemopneumothorax. Vented and unvented chest seals stabilized cardiorespiratory parameters after an open pneumothorax, but only vented chest seals showed more success at preventing a tension pneumothorax. Chest seals with flutter valves seemed to be inferior. An additional study showed that vertical movements and soiled skin were more stressful on the applied chest seals. Eight international guidelines were identified: four focused on the tactical environment, and four appeared to be more civilian-oriented. Only two of the civilian-oriented guidelines did not prefer vented chest seals.Vented chest seals seem to be superior to unvented chest seals, and most international guidelines have updated their recommendations for the use of vented chest seals. However, frequent physical examinations for early signs of a developing or worsening tension pneumothorax are the best medical care.

Cutting-Edge Technology for Rapid Bedside Assessment of Capillary Refill Time for Early Diagnosis and Resuscitation of Sepsis.

Sepsis currently affects over 30 million people globally with a mortality rate of ~30%. Prompt Emergency Department diagnosis and initiation of resuscitation improves outcomes; data has found an 8% increase in mortality for every hour delay in diagnosis. Once sepsis is recognized, the current Surviving Sepsis Guidelines for adult patients mandate the initiation of antibiotics within 3 h of emergency department triage as well as 30 milliliters per kilogram of intravenous fluids. While these are important parameters to follow, many emergency departments fail to meet these goals for a variety of reasons including turnaround on blood tests such as the serum lactate that may be delayed or require expensive laboratory equipment. However, patients routinely have vital signs assessed and measured in triage within 30 min of presentation. This creates a unique opportunity for implementation point for cutting-edge technology to significantly reduce the time to diagnosis of potentially septic patients allowing for earlier initiation of treatment. In addition to the practical and clinical difficulties with early diagnosis of sepsis, recent clinical trials have shown higher morbidity and mortality when septic patients are over-resuscitated. Technology allowing more real time monitoring of a patient's physiologic responses to resuscitation may allow for more individualized care in emergency department and critical care settings. One such measure at the bedside is capillary refill. This has shown favor in the ability to differentiate subsets of patients who may or may not need resuscitation and interpreting blood values more accurately (1, 2). This is a well-recognized measure of distal perfusion that has been correlated to sepsis outcomes. This physical exam finding is performed routinely, however, there is significant variability in the measurement based on who is performing it. Therefore, technology allowing rapid, objective, non-invasive measurement of capillary refill could improve sepsis recognition compared to algorithms that require lab tests included lactate or white blood count. This manuscript will discuss the broad application of capillary refill to resuscitation care and sepsis in particular for adult patients but much can be applied to pediatrics as well. The authors will then introduce a new technology that has been developed through a problem-based innovation approach to allow clinicians rapid assessment of end-organ perfusion at the bedside or emergency department triage and be incorporated into the electronic medical record. Future applications for identifying patient decompensation in the prehospital and home environment will also be discussed. This new technology has 3 significant advantages: [1] the use of reflected light technology for capillary refill assessment to provide deeper tissue penetration with less signal-to-noise ratio than transmitted infrared light, [2] the ability to significantly improve clinical outcomes without large changes to clinical workflow or provider practice, and [3] it can be used by individuals with minimal training and even in low resource settings to increase the utility of this technology. It should be noted that this perspective focuses on the utility of capillary refill for sepsis care, but it could be considered the next standard of care vital sign for assessment of end-organ perfusion. The ultimate goal for this sensor is to integrate it into existing monitors within the healthcare system.

Defining and recognising clinical deterioration in the prehospital setting (PRECLuDE study): a systematic scoping review

<p><strong>Introduction</strong></p><p>Early identification of high-risk patients in the prehospital environment is crucial as it enables early intervention, transportation, and may determine the trajectory of future care. Although early warning systems (EWS) in-hospital are well established, it remains unclear whether adaptations of these systems can simply be extrapolated to prehospital care. This scoping review aims to explore how the current literature defines and recognises clinical deterioration in the prehospital setting.</p><p> </p><p><strong>Methods</strong></p><p>In December 2019, a systematic search of five databases using a combination of terms describing ‘paramedic’, were integrated with terminology relating to ‘recognition’ of ‘clinical deterioration’. Additional reference chaining was also undertaken.</p><p> </p><p><strong>Results</strong></p><p>A total of eight papers met the inclusion criteria. Seven out of eight studies included a definition, however these were primarily ad-hoc and fundamentally formed to support the creation of varying EWS. The prevalence of prehospital clinical deterioration is poorly explored in the literature, with only two studies discussing the frequency deterioration (5.1%). Furthermore, studies reported that paramedics were inadequate at identifying clinical deterioration due to medical aetiology by comparison to trauma. Additionally, a number of articles reported an association between clinician experience and recognition of clinical deterioration. As the topic of prehospital clinical deterioration has rapidly moved to focus on the potential implementation of EWS, with few studies providing fundamental description of the concept and its characteristics, there is no standardised operational definition available in the literature. The development of this definition is crucial to assessing clinical deterioration and improving the efficacy of EWS. Not only could this lead to improving early identification of risk factors, but it can lay the foundations for the development of an effective EWS.</p><p> </p><p><strong>Conclusion</strong></p><p>This review has found that further quality research in this understated space is warranted to increase understanding and early identification of the deteriorating patient, prevent unnecessary harm, and ultimately, improve patient outcomes. </p>

Heating Intravenous Fluid Tubing in an Experimental Setting for Prehospital Hypothermia

ObjectiveHypothermia secondary to environmental exposure is a serious condition. Active external warming measures to treat it may prove challenging in the prehospital setting. We conducted an experimental study to measure the ability of commercially available heating elements to warm intravenous (IV) fluids during infusion. Methods250-milliliter bags of dextrose 10% solution were suspended inside a refrigerator. IV tubing was coiled, and the tubing output was placed inside a thermally insulated cup. The tubing was heated directly with a hand warmer, a meals ready-to-eat heater, or a heating blanket. Fluids were run through the IV line. The temperature of the fluid at the tubing output was measured. The initial and final infusion temperatures for the methods were compared. ResultsThe use of hand warmers, meals ready-to-eat heaters, and heating blankets to warm IV tubing did increase the temperature of the fluids but was ineffective at achieving the desired mean infusion temperature of 35°C to 42°C. ConclusionAlthough the mean temperature increase did not meet the established experimental threshold, further research is needed to determine whether the fluid warming effect of these commercial heating elements used in the prehospital environment is significant enough to limit heat loss while repleting the dextrose of a hypothermic, hypoglycemic patient.

Removal of the Prehospital Tourniquet in the Emergency Department.

Life-threatening hemorrhage from extremity injuries can be effectively controlled in the prehospital environment through direct pressure, wound packing, and the use of tourniquets. Early tourniquet application has been prioritized for rapid control of severe extremity hemorrhage and is a cornerstone of prehospital trauma resuscitation guidelines. Emergency physicians must be knowledgeable regarding the initial assessment and appropriate management of patients who present with a prehospital tourniquet in place. An interdisciplinary group of experts including emergency physicians, trauma surgeons, and tactical and Emergency Medical Services physicians collaborated to develop a stepwise approach to the assessment and removal (discontinuation) of an extremity tourniquet in the emergency department after being placed in the prehospital setting. We have developed a best-practices guideline to serve as a resource to aid the emergency physician in how to safely remove a tourniquet. The guideline contains five steps that include: 1) Determine how long the tourniquet has been in place; 2) Evaluate for contraindications to tourniquet removal; 3) Prepare for tourniquet removal; 4) Release the tourniquet; and 5) Monitor and reassess the patient. These steps outlined will help emergency medicine clinicians appropriately evaluate and manage patients presenting with tourniquets in place. Tourniquet removal should be performed in a systematic manner with plans in place to immediately address complications.

Is weight just a number? The accuracy of UK ambulance paediatric weight guidance - findings from a cross-sectional study.

Background:The weight of children provides the cornerstone of their clinical management, as many drug dosages, equipment sizes, fluid boluses, as well as DC shock energy, are administered on a per kilogram basis. Children who attend hospital are weighed using scales prior to receiving these interventions. This is not possible in the pre-hospital environment. A paucity of evidence exists to support the page for age weight guidance indicated by JRCALC, and it remains unknown if this approach meets the reference standard of 70% of estimations within 10% of actual weight and 95% within 20% of actual weight.Methods:We used a cross-sectional study design and collected data from a convenience sample of children who attended the outpatients department of a major hospital in England between July and September 2019. All children aged between 1 and 11 years who were weighed were eligible for inclusion. Outcomes were to determine if the page for age approach meets the reference standard and to determine any implications for care.Results:341 children were included in this study. Each age group consisted of varying numbers of children. 50.5% (172/341) of the sample were female. Observed weights ranged from 8.28 to 82.70 kg (median 20.60 kg). The mean weight of girls versus boys was 24.69 kg and 23.39 kg respectively (95% CI -4.12–1.32, p = 0.3123). Observed weights were greater than the page for age guidance weight in all age groups, and the accuracy of page for age weight guidance diminished with age. Adrenaline 1:10,000 doses and defibrillation energy levels guided by page for age differ from those guided by weight, but are not deleterious to care.Conclusion:Page for age weight guidance does not meet the reference standard. Most paediatric pre-hospital care is administered by age and not weight. In the absence of an accurate weight, ambulance clinicians should continue to use the page for age system, although the gold standard remains to use an accurate weight measurement. While there are no facilities to weigh children in ambulances, if an accurate weight is available then consideration should be given to using this rather than age.

The diagnostic accuracy of pre-hospital assessment of acute respiratory failure.

Introduction:Acute respiratory failure (ARF) is a common medical emergency. Pre-hospital management includes controlled oxygen therapy, supplemented by specific management options directed at the underlying disease. The aim of the current study was to characterise the accuracy of paramedic diagnostic assessment in acute respiratory failure.Methods:A nested diagnostic accuracy and agreement study comparing pre-hospital clinical impression to the final hospital discharge diagnosis was conducted as part of the ACUTE (Ambulance CPAP: Use, Treatment effect and Economics) trial. Adults with suspected ARF were recruited from the UK West Midlands Ambulance Service. The pre-hospital clinical impression of the recruiting ambulance service clinician was prospectively recorded and compared to the final hospital diagnosis at 30 days. Agreement between pre-hospital and hospital diagnostic assessments was evaluated using raw agreement and Gwets AC1 coefficient.Results:77 participants were included. Chronic obstructive pulmonary disease (32.9%) and lower respiratory tract infection (32.9%) were the most frequently suspected primary pre-hospital diagnoses for ARF, with secondary contributory conditions recorded in 36 patients (46.8%). There was moderate agreement between the primary pre-hospital and hospital diagnoses, with raw agreement of 58.5% and a Gwets AC1 coefficient of 0.56 (95% CI 0.43 to 0.69). In five cases, a non-respiratory final diagnosis was present, including: myocardial infarction, ruptured abdominal aortic aneurysm, liver failure and sepsis.Conclusions:Pre-hospital assessment of ARF is challenging, with limited accuracy compared to the final hospital diagnosis. A syndromic approach, providing general supportive care, rather than a specifically disease-orientated treatment strategy, is likely to be most appropriate for the pre-hospital environment.

Challenges of SARS-CoV-2 and conflicting PPE guidelines

During the coronavirus disease 2019 (COVID-19) pandemic, personal protective equipment (PPE) has become a contentious issue in healthcare settings, no more so than in the prehospital environment. The current severe acute respiratory syndrome 2 virus (SARS-CoV-2) has pathogenic and transmission similarities to previous coronaviruses, severe acute respiratory syndrome (SARS-CoV) and Middle Eastern respiratory syndrome (MERS-CoV). There are differences in global and domestic PPE guidelines concerning SARS-CoV-2.

Not Yet Time to Abandon Cervical Collars in Blunt Trauma

In the evidence-based summary by Serigano et al. (Ref 1.) published in this issue of Academic Emergency Medicine under the Brass Tacks series, the authors critically appraise the evidence for the long-standing practice of prehospital and emergency department cervical spinal motion restriction (SMR) in blunt trauma patients. They highlight the absence of class I data demonstrating a benefit and describe some of the potentially harmful side effects of cervical collars.

Can non-physician advanced retrieval practitioners (ARP) acquire and interpret diagnostic views of the lungs with sufficient quality to aid in the diagnosis of pneumothorax in the pre-hospital and retrieval environment?

BackgroundAs an adjunct to physical examination, ultrasound is a potentially attractive option for diagnosing pneumothoraces in the pre-hospital and retrieval environment – and could confer a benefit to patient safety. However, the published evidence supporting non-physicians use of ultrasound in this setting is limited.AimWe aimed to establish if Advanced Retrieval Practitioners (non-physicians) could acquire ultrasound views of the lungs and interpret them with sufficient quality to diagnose pneumothorax in the pre-hospital and retrieval environment when compared to expert review.MethodThe study consisted of an observational trial from April 2017 to April 2018. Twelve (12) patients bilateral lung ultrasound images (24 images) were randomly selected from 87 patients assessed using Point of Care Ultrasound (POCUS) by three Advanced Retrieval Practitioners in the Pre-hospital and Retrieval environment. Two expert reviewers’ evaluated these images to determine ARPs ability to acquire diagnostic quality images and interpret them correctly. CXR results of patients in whom lung ultrasound was undertaken were recorded as the reference standard investigation.ResultsWithin the 22 images considered adequate by the Advanced Retrieval Practitioners, 19 (86.4%, one-tailed McNemar test p = 0.125) were considered adequate on expert review. Of the 19 images mutually considered as adequate, both the Advanced Retrieval Practitioners and the reviewers identified two pneumothoraces which were subsequently confirmed on chest x-ray (Sensitivity 100% and Specificity 100% in technically adequate images). One pneumothorax was detected on CXR in a patient with inadequate ultrasound images. Advanced Retrieval Practitioners were therefore able to both obtain adequate images and correctly diagnose pneumothorax in the pre-hospital environment with 66.6% sensitivity (95%CI 66.6–100%) and 100% specificity (95%CI 81.0–100%) compared to expert review.ConclusionAdvanced Retrieval Practitioners (non-physicians) can obtain diagnostic views of the lungs of sufficient quality to diagnose the presence, or particularly the absence, of pneumothorax in the pre-hospital and retrieval environment. Although Advanced Retrieval Practitioners were less accurate than the expert reviewers at interpreting the quality of the ultrasound images, the result was not statistically significant, despite the ARPs possibly having been at a methodological disadvantage.

Sub30: Protocol for the Sub30 feasibility study of a pre-hospital Extracorporeal membrane oxygenation (ECMO) capable advanced resuscitation team at achieving blood flow within 30 ​min in patients with refractory out-of-hospital cardiac arrest

BackgroundOut-of-hospital cardiac arrest carries a poor prognosis with survival less than 10% in many patient cohorts. Survival is inversely associated with duration of resuscitation as external chest compressions do not provide sufficient blood flow to prevent irreversible organ damage during a prolonged resuscitation. Extracorporeal membrane oxygenation (ECMO) instituted during cardiac arrest can provide normal physiological blood flows and is termed Extracorporeal Cardio-Pulmonary Resuscitation (ECPR). ECPR may improve survival when used with in-hospital cardiac arrests. This possible survival benefit has not been replicated in trials of out-of-hospital cardiac arrests, possibly because of the additional time it takes to transport the patient to hospital and initiate ECPR. Pre-hospital ECPR may shorten the time between cardiac arrest and physiological blood flows, potentially improving survival. It may also mitigate some of the neurological injury that many survivors suffer. MethodsSub30 is a prospective six patient feasibility study. The primary aim is to test whether it is possible to institute ECPR within 30 ​min of collapse in adult patients with refractory out of hospital cardiac arrest (OHCA). The secondary aims are to gather preliminary data on clinical outcomes, resource utilisation, and health economics associated with rapid ECPR delivery in order to plan any subsequent clinical investigation or clinical service. On study days a dedicated fast-response vehicle with ECPR capability will be tasked to out-of-hospital cardiac arrests in an area of London served by Barts Heart Centre. If patients suffer a cardiac arrest refractory to standard advanced resuscitation and meet eligibility criteria, ECPR will be started in the pre-hospital environment. DiscussionDelivering pre-hospital ECPR within 30 ​min of an out-of-hospital cardiac arrest presents significant ethical, clinical, governance and logistical challenges. Prior to conducting an efficacy study of ECPR the feasibility of timely and safe application must be demonstrated first. Extensive planning, multiple high-fidelity multiagency simulations and a unique collaboration between pre-hospital and in-hospital institutions will allow us to test the feasibility of this intervention in London. The study has been reviewed, refined and endorsed by the International ECMO Network (ECMONet). Trial registrationClinicaltrials. gov NCT03700125, prospectively registered October 9, 2018.

Prehospital clinical signs are a poor predictor of raised intracranial pressure following traumatic brain injury

BackgroundFor the prehospital diagnosis of raised intracranial pressure (ICP), clinicians are reliant on clinical signs such as the Glasgow Coma Score (GCS), pupillary response and/or Cushing’s triad (hypertension, bradycardia and...

Neck injuries – israel defense forces 20 years' experience

BackgroundNeck injuries are an important cause of combat mortality and morbidity. This study's objective was to examine the characteristics and causes of neck injuries among Israel Defense Forces (IDF) and emphasize the best treatment protocols for the advanced life support providers in the prehospital combat environment. MethodsThe IDF Trauma Registry (IDF-TR) includes prehospital data regarding casualties treated by the IDF's medical forces. This study was a retrospective, observational study that included all casualties who were injured between January 2006 and December 2018. ResultsBetween January 2016 and December 2018, 3294 casualties were recorded. During the study period, 1% (41/3,394) of all injury casualties in the registry were isolated neck injuries compared to 94% (3185/3,394) without neck injury. 42% (14/41) percent of the neck casualties were classified as urgent compared to 26% (830/3185, P = 0.09) in the no neck group. The most frequent type of injury mechanism in the neck casualties was penetrating injury (54% 22/41), mostly due to shrapnel (68% 15/22). 60% of neck injured personnel were injured during the 2nd Lebanon War and Operation Protective Edge in high-intensity conflicts. As for life-saving interventions, advanced airway interventions were performed in 12% of neck injured group (5/41) compared to 3% (104/3185, P = 0.02) in the no neck group. We revealed that cricothyroidotomy was performed in almost 10% (4/41) of neck injured casualties compared to only 1% (19/3185, P<0.0001) in no neck casualties. As for damage control resuscitation, neck injury casualties received higher amounts of Fresh Dried Plasma 7% (3/41) Vs. 1% (32/3185, P = 0.02) and Tranexamic acid 15% (6/41) Vs. 4% (124/3185, P = 0.01) compared to non-neck casualties. ConclusionsMilitary neck injuries are a significant cause of substantial disability and result in incompatibility with combat duties in previously healthy soldiers. Prompt medical care, especially urgent hemodynamic and airway management, is paramount in these injuries. Routine use of designated neck protection might lower the number of neck injuries, mitigate their severity, and even decrease mortality. Level of EvidenceLevel III (Retrospective study with up to two negative criteria)

Ultrasound Use in the Prehospital Setting for Trauma: A Systematic Review

Background Trauma is a leading cause of death in the United States. Ultrasound use in the prehospital environment has the potential to change trauma management. Although ultrasound use for prehospital trauma is increasing, the role of this modality is not clearly defined. Objectives We examined the use of prehospital ultrasound (PHUS) for trauma patients and the use by different provider types. Specific factors of interest were if prehospital ultrasound has been shown to improve providers’ ability to recognize conditions that can be managed in the prehospital setting, treat these conditions, change transport destination, or improve overall mortality rates for trauma patients. Methods We searched MEDLINE/PubMed, EBSCOhost, Cochrane Library, and Embase medical literature databases for articles that addressed our outcomes. s and articles were examined and studies that did not specifically evaluate ultrasound in the prehospital setting for trauma and duplicates were eliminated. Studies included in this comprehensive review were assessed for the use of ultrasound in the prehospital setting to aid in the diagnosis, treatment, and transport of trauma patients. We also conducted an analysis of bias in the included articles. Due to the large heterogeneity in the included studies, no meta-analysis could be performed. Results Sixteen studies were identified comprising 3,317 patients. One study evaluated Emergency Medical Services (EMS) professionals as the ultrasound operator while five studies involved mixed practitioners and ten studies involved only physicians. Diagnostic accuracy was similar amongst physicians and mixed practitioners with no studies reporting PHUS accuracy for EMS providers alone. Seven studies evaluated treatment and transport impact of PHUS though the variables measured were inconsistent and results varied by protocol and outcomes measured. There were no studies that evaluated PHUS and its impact on patient mortality. Conclusion Ultrasound use in the prehospital setting for trauma is feasible and demonstrates potential. However, the evidence in the medical literature mainly consists of prospective observational studies of physicians utilizing ultrasound for trauma in a HEMS setting. Further scientific research must be undertaken to firmly establish the role of prehospital ultrasound in trauma management by all types of EMS providers.

Can Education and Enhanced Medical Director Oversight Improve Definitive Airway Control in the Prehospital Environment?

Endotracheal intubation (ETI) is the most definitive technique for airway management. However, supraglottic airway (SGA) may be used when ETI is not feasible. The purpose of this study was to determine the effect of updated field sedation protocols, simulation teaching, robust Quality Assurance/Continuing Quality Improvement (QA/CQI) program, and enhanced emergency medical services (EMSs) medical director oversight on ETI and SGA usage at a Level 1 trauma center. After the transition of EMS directors in May 2016, field sedation protocols were updated, a new QA/CQI was instituted, and multiple teaching and simulation sessions were conducted. A retrospective review of EMS data was conducted on all prehospital airway interventions performed by EMS personnel. Intubations occurring from July 2013 to May 2016 served as controls. Intubations from May 2016 to December 2017 served as the comparison group. Data collected included intubation type/indication, age, and successful or unsuccessful. There were 967 ETI and SGA performed on 84% and 15% of patients, respectively. Success rates were 75% for ETI and 82% for SGA. ETI increased from 83% in the control group to 88% in the study group, and SGA decreased from 16% in the control group to 11% in the study group (P = .029). The success rate for ETI increased by 2% in the study group (P = .539). This study showed that definitive airway control could be positively impacted by incorporating education and medical director oversight into EMS training. ETI increased and SGA decreased after implementation.