Prehospital Environment Research Articles

Are Data Driving Our Ambulances? Liberal Use of Tranexamic Acid in the Prehospital Setting.

Current data on tranexamic acid (TXA) supports early administration for severe hemorrhagic shock. Administration by EMS has been facilitated by developing protocols and standing orders informed by these data. In this study, patterns of TXA use by EMS agencies serving a large level 1 trauma center were examined. We hypothesized that current widespread TXA use often includes administration outside of data-driven indications. The trauma registry at a level 1 trauma center was queried for patients who received TXA. To determine the practice patterns and appropriateness of administration of TXA, patients' physiologic state in the prehospital environment based on EMS records, physiologic state on arrival to hospital, and interventions performed in both settings were examined. Over 20 separately managed EMS systems that administer TXA transport patients to this trauma center, allowing for a broad survey of practices. From 2016 to 2021 1089 patients received TXA, 406 (37.3%) having treatment initiated by EMS services. Of these, the average prehospital systolic blood pressure (SBP) was 108.2mmHg and initial ED SBP was 107.8mmHg. Only 58.4% of these patients received blood transfusion after arrival to this trauma center. Compliance with standard indications was low with only 14.6% of administrations meeting any data-driven SBP indication. Similar levels of compliance were seen across high volume EMS services. Tranexamic acid use has become common in trauma and has been adopted by many EMS systems. These results indicate TXA in the prehospital setting is over-used as administration is not being limited to indications that have shown benefit in prior data.

Trauma-induced coagulopathy: What you need to know.

Trauma-induced coagulopathy (TIC) is a global inflammatory state accompanied by coagulation derangements, acidemia, and hypothermia, which occurs after traumatic injury. It occurs in approximately 25% of severely injured patients, and its incidence is directly related to injury severity. The mechanism of TIC is multifaceted; proposed contributing factors include dysregulation of activated protein C, increased tPA, systemic endothelial activation, decreased fibrinogen, clotting factor consumption, and platelet dysfunction. Effects of TIC include systemic inflammation, coagulation derangements, acidemia, and hypothermia. Trauma-induced coagulopathy may be diagnosed by conventional coagulation tests including platelet count, Clauss assay, international normalized ratio, thrombin time, prothrombin time, and activated partial thromboplastin time; viscoelastic hemostatic assays such as thrombelastography and rotational thrombelastography; or a clinical scoring system known as the Trauma Induced Coagulopathy Clinical Score. Preventing TIC begins in the prehospital phase with early hemorrhage control, blood product resuscitation, and tranexamic acid therapy. Early administration of prothrombin complex concentrate is also being studied in the prehospital environment. The mainstays of TIC treatment include hemorrhage control, blood and component transfusions, and correction of abnormalities such as hypocalcemia, acidosis, and hypothermia. Therapeutic/Care Management; Level III.

Evaluation of a Portable Blood Gas Analyzer for Prehospital Triage in Carbon Monoxide Poisoning: Instrument Validation Study.

Carbon monoxide (CO) poisoning is an important cause of morbidity and mortality worldwide. Symptoms are mostly aspecific, making it hard to identify, and its diagnosis is usually made through blood gas analysis. However, the bulkiness of gas analyzers prevents them from being used at the scene of the incident, thereby leading to the unnecessary transport and admission of many patients. While multiple-wavelength pulse oximeters have been developed to discriminate carboxyhemoglobin (COHb) from oxyhemoglobin, their reliability is debatable, particularly in the hostile prehospital environment. The main objective of this pilot study was to assess whether the Avoximeter 4000, a transportable blood gas analyzer, could be considered for prehospital triage. This was a monocentric, prospective, pilot evaluation study. Blood samples were analyzed sequentially with 2 devices: the Avoximeter 4000 (experimental), which performs direct measurements on blood samples of about 50 µL by analyzing light absorption at 5 different wavelengths; and the ABL827 FLEX (control), which measures COHb levels through an optical system composed of a 128-wavelength spectrophotometer. The blood samples belonged to 2 different cohorts: the first (clinical cohort) was obtained in an emergency department and consisted of 68 samples drawn from patients admitted for reasons other than CO poisoning. These samples were used to determine whether the Avoximeter 4000 could properly exclude the diagnosis. The second (forensic) cohort was derived from the regional forensic center, which provided 12 samples from documented CO poisoning. The mean COHb level in the clinical cohort was 1.7% (SD 1.8%; median 1.2%, IQR 0.7%-1.9%) with the ABL827 FLEX versus 3.5% (SD 2.3%; median 3.1%, IQR 2.2%-4.1%) with the Avoximeter 4000. Therefore, the Avoximeter 4000 overestimated COHb levels by a mean difference of 1.8% (95% CI 1.5%-2.1%). The consistency of COHb readings by the Avoximeter 4000 was excellent, with an intraclass correlation coefficient of 0.97 (95% CI 0.93-0.99) when the same blood sample was analyzed repeatedly. Using prespecified cutoffs (5% in nonsmokers and 10% in smokers), 3 patients (4%) had high COHb levels according to the Avoximeter 4000, while their values were within the normal range according to the ABL827 FLEX. Therefore, the specificity of the Avoximeter 4000 in this cohort was 95.6% (95% CI 87%-98.6%), and the overtriage rate would have been 4.4% (95% CI 1.4%-13%). Regarding the forensic samples, 10 of 12 (83%) samples were positive with both devices, while the 2 remaining samples were negative with both devices. The limited difference in COHb level measurements between the Avoximeter 4000 and the control device, which erred on the side of safety, and the relatively low overtriage rate warrant further exploration of this device as a prehospital triage tool.

Prehospital end-tidal carbon dioxide measurement

The prehospital environment presents numerous challenges regarding the diagnosis and subsequent management of critically ill patients—diagnostic aids are limited; point-of-care testing is almost universally unavailable and senior medical advice can be beyond timely reach. Pulse oximetry provides real-time assessment of peripheral tissue oxygen saturation, but not of ventilation adequacy. The past decade has seen the gradual introduction of end-tidal carbon dioxide monitoring or capnography into routine resuscitation practice following successive national audit reports, coronial reports and subsequent guidance regarding safe airway management. However, capnography alone does not prevent adverse outcomes, particularly if it is not properly interpreted. Capnography is now regarded as essential monitoring whenever airway management or ventilation is required. The increasing availability of capnography in the prehospital setting can provide dynamic, real-time information that can aid assessment and treatment of pathology at the first point of contact and direct onward management. This article reviews the pathophysiology associated with the production, transport and excretion of carbon dioxide and suggests a number of ways in which accurate measurement and interpretation can potentially be a useful diagnostic tool and inform management choices in the prehospital setting.

Prehospital blood transfusion in Brazil: results of the first year of implementation in an emergency medical service

IntroductionHemorrhagic shock is the main cause of death in the prehospital environment, which highlights the need to standardize measures aiming at bleeding control and volume replacement in this environment. In Brazil, the first prehospital packed red blood cell transfusion service started in September 2020, in Bragança Paulista, state of São Paulo. ObjectivesDescribe the trends and characteristics of patients who received prehospital transfusions prior to hospital treatment during the first year of operation. MethodsA retrospective data review was made of all patients who received transfusions from the mobile intensive care unit in Bragança Paulista over one year. ResultsIn this period, 19 patients were transfused. Since activation, the average response time was 20 min. The mean shock indexes before and after blood transfusion were 2.16 and 1.1, respectively. During the course of the 1st year of prehospital transfusions, no blood was wasted and there were no adverse effects. ConclusionIntroduction of the prehospital packed red blood cell transfusion service was successful, with significant improvement in hemodynamic parameters.

Practice Preferences using Resuscitative Endovascular Balloon Occlusion of the Aorta for Traumatic Injury Before and After the 2017 EndoVascular and Hybrid Trauma and Bleeding Management Symposium

Background: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a technique to aid in resuscitative eff orts for hemorrhagic shock. The use of REBOA is not yet commonplace and there is little understanding of real-world practice patterns. The Endovascular and Hybrid Trauma and Bleeding Management Symposium is a large international conference specifically developed to discuss multidisciplinary, endovascular and hybrid approaches to hemorrhage management. We sought to evaluate provider opinions and practice patterns using REBOA for traumatic vascular injury before and after attending this conference. Methods: A detailed survey was completed by a variety of providers before and after the conference. The survey was composed of demographic information, and focused on practice patterns and opinions regarding the implementation of REBOA.Results: We received 186 survey responses (99 pre, 87 post). There was increased perception of feasibility for REBOA in all settings, with the largest increase for pre-hospital and austere military environments (53.5% pre, 67.8% post and 59.6% pre, 73.6% post respectively). While there was no consensus on tolerable occlusion times and indications for utilization, most participants felt that partial REBOA was the most viable technique for prolonging the benefi ts of REBOA, and more participants came to this conclusion after attending the conference (62.2% pre, 81.6% post, p = 0.006). Conclusions: REBOA is an exciting and important advancement in the management of life threatening hemorrhage; however, its implementation has not been codifi ed and there is much variation in practitioners’ understanding of its use. Continued investigation is needed to determine the appropriate indications, methods, and practical limitations of REBOA as a new hemorrhage management paradigm.

Efficacy of in-bed chest compressions depending on provider position during in-hospital cardiac arrest: a controlled manikin study.

In contrast to the pre-hospital environment, patients with in-hospital cardiac arrest are usually lying in a hospital bed. Interestingly, there are no current recommendations for optimal provider positioning. The present study evaluates in bed chest compression quality in different provider positions during in-hospital-cardiac-arrest. Paramedics conducted four resuscitation scenarios: manikin lying on the floor with provider position kneeling next to the manikin (control group), manikin lying in a hospital bed with the provider kneeling astride, kneeling beside or standing next to the manikin. A resuscitation board was not used according to the current guideline recommendations. Quality of resuscitation, compression depth, compression rate and percentage of compressions with complete chest rebound were recorded. Afterwards, the paramedics were asked about subjective efficiency and fatigue. Data were analyzed using Generalized-Linear-Mixed-Models and, in addition, by non-parametric Friedman test. A total of 60 participants were recruited. The total quality of chest compressions was significantly higher in floor-based control position compared to the standing (P<.001) and both kneeling positions (P<.05). Also, the compression depth was significantly more guideline compliant in the control (P<.001) and the kneeling position (P<.05) compared to the standing position. The compression frequency as well as the complete chest wall recoil did not differ significantly. The standing position was rated as more fatiguing than the other positions (p≤0.001), kneeling beside as subjectively more efficient than the standing position (P<0.001). In case of an in-bed resuscitation high quality chest compressions are possible. Kneeling astride or beside the patient should be preferred because these positions demonstrated a good chest compression quality and were more efficient and less exhaustive.

ASSESSMENT OF BYSTANDERS PREPAREDNESS AND KNOWLEDGE IN TRAUMA PATIENT MANAGEMENT: A STUDY IN KAKAMEGA COUNTY, WESTERN KENYA

Objective:The objective of the study was to assess Bystanderscapability to handle trauma patients at the prehospital environment in Kakamega County, Western Kenya. Design:The study utilized a descriptive cross-sectional design. Setting:The study was carried out in four Sub-counties in Kakamega County. Sample:Multistage sampling was used to select a sample of two hundred and fifty-six participants(n = 256) Analysis:Data was analyzed using measures of central tendency and dispersion. Main outcome measures:Demographic characteristics, Level of knowledge, attitude and practice among bystanders towards trauma patients. Results:Most of the participants (44.5%) were between the ages 18-27 years old, majority 74.6% being of male gender. 90% respondents had witnessed injuries with a number of accidents witnessed averaging 1-5 (65%) in a period of 3 months. While 22% responded by taking the victims to the hospital, nearly half of the participants either called the police (29%) or stared at the incident (20%). Majority,(51.2%) lacked confidence in handling persons with obstructed airway, while (46.7%) were abit confident in handling patients with bleeding. 64.8% of the respondents lacked knowledge of contacts for emergency response. Availability of Emergency care equipment and supplies was 20% at Lurambi, with the remaining three sub-counties having lowest at (6.7%). Conclusion:There is inadequate knowledge of trauma care among Bystanders and lack of essential emergency care equipment and supplies in management of trauma patients in the prehospital environment of Kakamega County. Recommendations:The County government through the Ministry of Health to train first responders on Basic First Aid and Cardiopulmonary resuscitation and establish booths where bystanders can access equipment and supplies for trauma care.

Consultation Processes With Helicopter Emergency Medical Service Physicians in Finnish Prehospital Emergency Care: The Paramedics’ Perspective

ObjectiveThe Finnish emergency medical services operates mainly with highly educated paramedic-staffed units. Helicopter emergency medical services (HEMS) physicians alongside other physicians provide consultations to paramedics on the scene without the physician physically participating in the mission. We examined the Finnish paramedics’ views regarding the consultation processes involving HEMS physicians. MethodsThis was a cross-sectional survey study among paramedics (n = 200). Assessments of the performance of HEMS physicians and other physicians in the consultation process were analyzed descriptively. The effect of the physician being expressly part of the HEMS was analyzed with inductive content analysis. ResultsOverall, consultations with the HEMS physician were well received among paramedics, and the HEMS physicians received higher assessments than other physicians. The familiarity with the prehospital environment, limitations, and local possibilities was valued. Expertise is particularly valuable in challenging emergency medical services missions but unnecessary in many nonurgent missions. There is scope for improvement in the attitudes and technical fluency of the consultation processes of HEMS physicians. ConclusionUsing HEMS physicians in prehospital consultations could be recommended. Further studies are still needed to ensure the efficacy and efficiency of the consultation process and explore the integration of video connections into current consultation practices.

Mechanical assessment of proprietary and improvised pelvic binders for use in the prehospital environment

IntroductionPelvic fractures often result from high-energy trauma and are associated with a 10% mortality rate and significant morbidity. Pelvic binders are applied in suspected pelvic injury to stabilise fractured bone,...

First-Aid Hydrogel Wound Dressing with Reliable Hemostatic and Antibacterial Capability for Traumatic Injuries.

First-aid for severe traumatic injuries in the battlefield or pre-hospital environment, especially for skin defects or visceral rupture, remains a substantial medical challenge even in the context of the rapidly evolving modern medical technology. Hydrogel-based biomaterials are highly anticipated for excellent biocompatibility and bio-functional designability. Yet, inadequate mechanical and bio-adhesion properties limit their clinical application. To address these challenges, a kind of multifunctional hydrogel wound dressing is developed with the collective multi-crosslinking advantages of dynamic covalent bonds, metal-catechol chelation, and hydrogen bonds. The mussel-inspired design and zinc oxide-enhanced cohesion strategy collaboratively reinforce the hydrogel's bio-adhesion in bloody or humoral environments. The pH-sensitive coordinate Zn2+ -catechol bond and dynamic Schiff base with reversible breakage and reformation equip the hydrogel dressing with excellent self-healing and on-demand removal properties. In vivo evaluation in a rat ventricular perforation model and Methicillin-resistant Staphylococcus aureus (MRSA)-infected full-thickness skin defect model reveal excellent hemostatic, antibacterial and pro-healing effectiveness of the hydrogel dressing, demonstrating its great potential in dealing with severe bleeding and infected full-thickness skin wounds.

A Study to Assess the Knowledge Regarding Cardiopulmonary Resuscitation Among Staff of Ambulance, Equipped Status of Ambulances, and their Utilization

Introduction Most patients are quickly transferred to the hospitals by ambulances worldwide. Hence, it is imperative that ambulance should be well equipped with all emergency equipment and well-trained staff to provide cardiopulmonary resuscitation (CPR) or basic life support (BLS) to victim in pre-hospital environment, if required. Purpose To assess knowledge regarding CPR of ambulance staff, equipped status of ambulances, and their utilization during CPR or first aid. Methods Total 400 ambulance staff were purposively recruited after obtaining informed written consent. They were interviewed as per validated interview schedule regarding CPR knowledge and utilization of equipment during CPR or first aid. Using an observation checklist for assessment of available equipment for CPR and first aid in the ambulance was checked. Results Mean age of participants was 35.57 ± 7.63 years. All were males. Among them 63.75% were posted in private ambulance, and 73.50% ambulances had solo staff. Most (98.25%) ambulances were equipped with oxygen cylinder and only 3.5% had portable ventilator. Majority (75%) lacked the essential equipment as per AHA/national guidelines. Mean knowledge score of participants was 2.85 ± 4.10 and 62.25% and they had poor knowledge regarding CPR and only 12.25% had good/very good knowledge. Conclusion There is a lack of knowledge regarding CPR among ambulance staff and there is lack of equipped status of ambulances. They were not fully aware regarding the use of equipment, which were available in the ambulance in emergency. So, there is a need to train them about CPR as well utilization of ambulance equipment.

Major approaches on the use of ultrasound at the point-of-care at the pre-hospital level: a systematic review

Introduction: Point-of-Care Ultrasound (POCUS) has been established as an ideal imaging modality when used by clinicians trained in the clinical setting. Thus, sophisticated but relatively inexpensive handheld devices have also contributed to point-of-care ultrasound (POCUS) becoming the norm at the prehospital level. Objective: This study aimed to present, through systematic review, the main considerations about the use of ultrasound at the point of care at the prehospital level. Methods: The present study followed a systematic review model. After the criteria of literary search using MeSH Terms clinical studies were collated and submitted to the eligibility analysis. The search strategy was performed in the PubMed, Embase, Ovid and Cochrane Library, Web Of Science, ScienceDirect Journals (Elsevier), Scopus (Elsevier), and OneFile databases. Results and Conclusion: A total of 156 articles were found. Initially, duplication of articles was excluded. After this process, the abstracts were evaluated and a new exclusion was performed, removing the articles that did not include the theme of this article, resulting in 112 articles. A total of 64 clinical studies were collated and submitted to the eligibility analysis and, after that, 20 studies were selected for the systematic review, dated from 2016 to 2022. On-site ultrasound is spreading through Emergency Medicine, Critical Care, and Prehospital Care. However, there is an underlying inherited conflict with established specialties by conducting comprehensive examinations. Thus, in-service ultrasound in the light of disruptive innovation is a different perspective than ultrasound that had not been academically examined before. Therefore, it can be concluded that ultrasound in the hospital can be implemented in several medical fields for the bedside examination of patients, especially in the prehospital environment. Scientific evidence supports the fact that the addition of ultrasound technology in daily practice (portable ultrasound device), called by some 'future stethoscopes', improves patient care and allows early diagnosis in a hospital setting.

Hypothermia Management, an Evaluation of a Novel Lightweight System.

Introduction:Accidental hypothermia remains an important contributory factor to the mortality of trauma patients in both civilian and military environments. As a component of the ‘lethal triad’ it poses a significant problem in patients at risk of hemorrhage from traumatic injuries. Systems used to mitigate hypothermia in the prehospital environment must strike a balance between weight: size ratio and optimal performance.Method:This study compared three hypothermia mitigation systems; two leading products and the novel Xtract™SR Heatsaver, over a three-day trial period. Seven subjects were placed in a closed system, held at around 0°C, to promote the onset of mild hypothermia. Individuals with a tympanic temperature recording of &lt; or = 35°C were placed into one of the three systems. Recordings of aural temperature and a numerical perceived comfort score were made every 15-20 minutes to assess rate of rewarming and subject’s perceptions of the process. An additional study was carried out by an experienced consultant in military and civilian emergency medicine, on day three of the trial, to determine the ease of clinical assessment of individuals placed inside the Xtract™SR Heatsaver prototype.Results:On all three days, subjects placed in the Xtract™SR Heatsaver recovered from their hypothermic state faster than those placed in the other systems. Clinical assessment could easily be performed on a patient placed in the Xtract™SR Heatsaver system.Conclusion:Results demonstrate that the new Xtract™SR Heatsaver system is superior with regards to reducing heat loss, increasing patient comfort and allowing for clinical assessment. The study also highlights the importance of the use of adjuncts such as heat cell blankets and insulation matts alongside hypothermia mitigation systems deployed in the prehospital environment. Furthermore, data gathered provides scope for future research into nuances surrounding the effects and onset of hypothermia.

A narrative review of prehospital hemorrhagic shock treatment with non-blood product medications.

Hemorrhagic shock remains a leading cause of death in both military and civilian trauma casualties. While standard of care involves blood product administration, maintaining normothermia, and restoring hemostatic function, alternative strategies to treat severe hemorrhage at or near the point of injury are needed. We reviewed adjunct solutions for managing severe hemorrhage in the prehospital environment. We performed a literature review by searching PubMed with a combination of several keywords. Additional pertinent studies were identified by crossreferencing primary articles. Clinical experience of each author was also considered. We identified several promising antishock therapies that can be utilized in the prehospital setting: ethinyl estradiol sulfate (EES), polyethylene glycol 20,000 (PEG20K), C1 esterase inhibitors (e.g. Berinert, Cinryze), cyclosporin A, niacin, bortezomib, rosiglitazone, icatibant, diazoxide, and valproic acid (VPA). Several studies show promising adjunct treatment options in the management of severe prehospital hemorrhage. While some are rarely used, many others are readily available and commonly utilized for other indications. This suggests the potential for future use in resourcelimited settings. Human studies and case reports supporting their use are currently lacking.

A Pre-Hospital Intervention to Alleviate Loneliness and Isolation in Older Adults

Aims The project’s objectives included determining how lonely older folks were in their pre-hospital environment and how much social contact they had. To gauge older individuals’ knowledge of regional programmes to combat isolation and loneliness. Letting elderly folks who could benefit from local services know that they are available. Using pre-hospital efforts to identify and treat patients who are lonely. Methods Thirty (30) patients were recruited whilst on 6 ambulance observer shifts in Berkshire, UK. The ambulance observer shifts took place between January 2023 to February 2023. The patients were asked a simple questionnaire on loneliness and social isolation. At the end of the questionnaire, all patients were offered information leaflets with local services and their contact details that they might find useful to alleviate loneliness and social isolation. Patients were also offered a follow-up telephone call to assess the impact of the intervention or if help was needed with getting in touch with the local services. Results Of the 30 patients interviewed, 15 were male and 15 were female. The youngest patient was 66-years-old and the oldest patient interviewed was 98. The average age was 80.4. Twelve (12) patients (40%) scored 7 and above on the question of ‘How lonely do you feel?’, with 10 being extremely lonely. Fifty percent (50%) of the patients saw their friends or families less than twice a week and 46.6% spoke to their friends and families less than twice a week. Several patients had not had a conversation with friends or family for several weeks, with one response being ‘over 3-months ago’. The vast majority (80%) of patients interviewed did not know that there were charities and local services in place to alleviate loneliness and social isolation. As part of the intervention, patients were offered information leaflets about local services available. These were printed on A4 paper or emailed to the patients if they preferred a digital copy. Conclusion Loneliness and social isolation is an epidemic on the rise amongst older adults, and their effects transcend not only mental wellbeing but physical health as well. Intervening in the pre-hospital setting is pivotal because pre-hospital practitioners are in a unique position to observe and assess patients in their own environment and gather firsth and evidence about the determinants of the patient’s health. The benefits will be multi-fold if we can help patients before they get admitted to hospitals. Apart from the economic benefits of reduced admissions, patients will not be unnecessarily admitted and put at risk of deconditioning or nosocomial infections. Most importantly, these interventions aim to improve the patient’s overall quality of life by enhancing their social connections and reducing loneliness.

Transition from College to Professional Workplace: Lived Experiences of Mid-Level Emergency Care Graduates Working in a Provincial Department of Health in South Africa

This study aimed to obtain empirical data on the lived experiences of emergency care technicians (ECT) during their transition into the emergency medical service work environment. This qualitative (phenomenological) study used focus group discussions with 26 ECT graduates to obtain verbal statements describing their lived experiences when transiting from college to pre-hospital workplace environments. The three dominant emerging themes were workplace readiness and reception, professional confidence, and resistance in the workplace. The experiences reported regarding workplace readiness and reception were largely negative. The majority of the participants shared that the EMS station they were deployed to had not been ready to receive and optimally utilise their skills. In addition, participants stated that their integration into the workplace had been unpleasant, as they experienced a great deal of exclusion and resistance from colleagues. Furthermore, participants described how peer support, positive feedback from patients and co-workers, and the new skills and knowledge acquired during training enhanced their professional confidence. These findings suggest that more needs to be done by stakeholders in emergency care education and practice in South Africa to ensure that the transition of graduate paramedics to the workplace environment is a positive and less stressful experience. The recommendations made in this article could be beneficial in achieving this.

Epidemiological Analysis of the Emergency Vascular Access in Pediatric Trauma Patients: Single-Center Experience of Intravenous, Intraosseous, Central Venous, and Arterial Line Placements

Vascular access in severely injured pediatric trauma patients is associated with time-critical circumstances and low incidences, whereas only scarce literature on procedure performance is available. The purpose of this study was to analyze the performance of different vascular access procedures from the first contact at the scene until three hours after admission. Intubated pediatric trauma patients admitted from the scene to a single Level I trauma center between 2008 and 2019 were analyzed regarding intravenous (IV) and intraosseous (IO) accesses, central venous catheterization (CVC) and arterial line placement. Sixty-five children with a median age of 14 years and median injury severity score of 29 points were included, of which 62 (96.6%) underwent successful prehospital IV or IO access by emergency medical service (EMS) physicians, while it failed in two children (3.1%). On emergency department (ED) admission, IV cannulas of prehospital EMS had malfunctions or were dislodged in seven of 55 children (12.7%). IO access was performed in 17 children without complications, and was associated with younger age, higher injury severity and higher mortality. Fifty-two CVC placements (58 attempts) and 55 arterial line placements (59 attempts) were performed in 45 and 52 children, respectively. All CVC and arterial line placements were performed in the ED, operating room (OR) and intensive care unit (ICU). Ten mechanical complications related to CVC placement (17.8%) and seven related to arterial line placement (10.2%) were observed, none of which had outcome-relevant consequences. This case series suggests that mechanical issues of vascular access may frequently occur, underlining the need for special preparedness in prehospital, ED, ICU and OR environments.

A Description of Mechanically Ventilated Patients Admitted From the Emergency Department With a Short Critical Care Stay

BackgroundPatients admitted to an intensive care unit (ICU) requiring invasive mechanical ventilation who are discharged alive from the ICU within 24 h are poorly characterized in the literature. ObjectiveOur aim was to characterize a cohort of intubated emergency department (ED) patients who are extubated and discharged from the ICU within 24 h. MethodsWe conducted a retrospective, observational cohort study at a single level I trauma center from January 2017 to December 2019. We included adults who were admitted to an ICU from the ED requiring invasive mechanical ventilation. Our primary outcome was the proportion of patients who were discharged from the ICU alive within 24 h. ResultsOf 13,374 ED patients admitted to an ICU during the study period, 2871 patients were intubated and ventilated in the prehospital or ED settings. Of these, 14% were discharged alive from the ICU within 24 h of admission. Only 21% of these patients were intubated in the ED. We identified the following two distinct subpopulations comprising 62% of this short-stay group: patients with a primary discharge diagnosis of intoxication (47%) and minimally injured trauma patients (53%), with 4% of patients in both subgroups. ConclusionsA total of 14% of patients receiving intubation with mechanical ventilation in the prehospital environment or in the ED were discharged alive from the ICU within 24 h. We identified two distinct subgroups of patients with a short stay in intensive care who may be candidates for ED extubation, including patients with intoxication and minimally injured trauma patients.

Towards exploring current challenges and future opportunities relating to the prehospital triage of patients with traumatic brain injury: a mixed-methods study protocol

IntroductionTraumatic brain injury (TBI) is a major global health burden that results in disability and loss of health. Identifying those patients who require specialist neuroscience care can be challenging due...