Prehospital Critical Care Teams Research Articles

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.

The impact of a pre-hospital critical care team on survival from out of hospital cardiac arrest

Introduction: Survival from out of hospital cardiac arrest (OHCA) remains poor. A number of Emergency Medical Services (EMS) dispatch pre-hospital critical care teams (CCTs) to OHCA, but evidence to support this practice is lacking.

The impact of a pre-hospital critical care team on survival from out-of-hospital cardiac arrest.

To assess the impact of a pre-hospital critical care team (CCT) on survival from out-of-hospital cardiac arrest (OHCA). We undertook a retrospective observational study, comparing OHCA patients attended by advanced life support (ALS) paramedics with OHCA patients attended by ALS paramedics and a CCT between April 2011 and April 2013 in a single ambulance service in Southwest England. We used multiple logistic regression to control for an anticipated imbalance of prognostic factors between the groups. The primary outcome was survival to hospital discharge. All data were collected independently of the research. 1851 cases of OHCA were included in the analysis, of which 1686 received ALS paramedic treatment and 165 were attended by both ALS paramedics and a CCT. Unadjusted rates of survival to hospital discharge were significantly higher in the CCT group, compared to the ALS paramedic group (15.8% and 6.5%, respectively, p<0.001). After adjustment using multiple logistic regression, the effect of CCT treatment was no longer statistically significant (OR 1.54, 95% CI 0.89-2.67, p=0.13). Subgroup analysis of OHCA with first monitored rhythm of ventricular fibrillation or pulseless ventricular tachycardia showed similar results. Pre-hospital critical care for OHCA was not associated with significantly improved rates of survival to hospital discharge. These results are in keeping with previously published studies. Further research with a larger sample size is required to determine whether CCTs can improve outcome in OHCA.

Anaesthesiologist-provided pre-hospital advanced airway management in children

Background Pre-hospital advanced airway management has been named one of the top-five research priorities in physician-provided pre-hospital critical care [1]. Few studies have been made on paediatric pre-hospital advanced airway management. The aim of this study was to investigate first-pass success rates and complications related to pre-hospital advanced airway management in patients younger than 16 years of age treated by prehospital critical care teams in the Central Denmark Region (1.3 million inhabitants).

Anaesthesiologist-provided prehospital airway management in patients with traumatic brain injury

BackgroundGuidelines recommend that patients with brain trauma with a Glasgow Coma Scale (GCS) score of less than 9 should have an airway established. Hypoxia, hypotension and hypertension as well as hypoventilation and hyperventilation may worsen outcome in these patients.ObjectivesThe objectives were to investigate guideline adherence, reasons for nonadherence and the incidences of complications related to prehospital advanced airway management in patients with traumatic brain injury.Materials and methodsWe prospectively collected data from eight anaesthesiologist-staffed prehospital critical care teams in the Central Denmark Region according to the Utstein-style template.ResultsAmong 1081 consecutive prehospital advanced airway management patients, we identified 54 with a traumatic brain injury and an initial GCS score of less than 9. Guideline adherence in terms of airway management was 92.6%. The reasons for nonadherence were the patient’s condition, anticipated difficult airway management and short distance to the emergency department. Following rapid sequence intubation (RSI), 11.4% developed oxygen saturation below 90%, 9.1% had a first post-RSI systolic blood pressure below 90 mmHg and 48.9% had a first post-RSI systolic blood pressure below 120 mmHg. The incidence of hypertension following prehospital RSI was 4.5%. The incidence of postendotracheal intubation hyperventilation was as high as 71.1%.ConclusionThe guideline adherence was high. The incidences of post-RSI hypoxia and systolic blood pressure below 90 compare with the results reported from other physician-staffed prehospital services. The incidence of systolic blood pressure below 120 as well as that of hyperventilation following prehospital endotracheal intubation in patients with traumatic brain injury call for a change in our current practice.

Can an initial end-tidal CO2 &lt;1.33 kPa predict lack of return of spontaneous circulation during pre-hospital cardiac arrest?

Results We registered data from 595 cardiac arrest patients; in 58.9 % (n=350) of these cases the pre-hospital critical care teams performed pre-hospital endotracheal intubation. An initial end-tidal CO2 measurement following prehospital endotracheal intubation were available in 270 cases. We identified 22 patients, who had an initial ETCO2 below 1.33 kPa. Four of these patients achieved return of spontaneous circulation. All four patients were admitted to hospital, three with stable circulation and one with ongoing automated CPR due to recurrent cardiac arrest. Conclusion Our results indicates that an initial ETCO2 below 1.33 kPa during pre-hospital cardiac arrest should not be used as a cut-off value for the achievability of return of spontaneous circulation.

Capability of emergency departments to provide physician-based prehospital critical care teams

National Institute for Emergency Medicine, Lisbon, Portugal Correspondence to Miguel Soares-Oliveira, MD, Rua Almirante Barroso n° 36, 1000-013 Lisbon, Portugal Tel: +351 213 508 100; fax: +351 213 508 180; e-mail: [email protected] Received November 15, 2013 Accepted December 10, 2013

Predicting the lack of ROSC during pre-hospital CPR: Should an end-tidal CO2 of 1.3 kPa be used as a cut-off value?

AimThe aim of this study was to investigate if an initial ETCO2 value at or below 1.3kPa can be used as a cut-off value for whether return of spontaneous circulation during pre-hospital cardio-pulmonary resuscitation is achievable or not. Materials and methodsWe prospectively registered data according to the Utstein-style template for reporting data from pre-hospital advanced airway management from February 1st 2011 to October 31st 2012. Included were consecutive patients at all ages with pre-hospital cardiac arrest treated by eight anaesthesiologist-staffed pre-hospital critical care teams in the Central Denmark Region. ResultsWe registered data from 595 cardiac arrest patients; in 60.2% (n=358) of these cases the pre-hospital critical care teams performed pre-hospital advanced airway management beyond bag-mask ventilation. An initial end-tidal CO2 measurement following pre-hospital advanced airway management were available in 75.7% (n=271) of these 358 cases. We identified 22 patients, who had an initial end-tidal CO2 at or below 1.3kPa. Four of these patients achieved return of spontaneous circulation. ConclusionOur results indicates that an initial end-tidal CO2 at or below 1.3kPa during pre-hospital CPR should not be used as a cut-off value for the achievability of return of spontaneous circulation.

Standard operating procedure changed pre-hospital critical care anaesthesiologists’ behaviour: a quality control study

IntroductionThe ability of standard operating procedures to improve pre-hospital critical care by changing pre-hospital physician behaviour is uncertain. We report data from a prospective quality control study of the effect on pre-hospital critical care anaesthesiologists’ behaviour of implementing a standard operating procedure for pre-hospital controlled ventilation.Materials and methodsAnaesthesiologists from eight pre-hospital critical care teams in the Central Denmark Region prospectively registered pre-hospital advanced airway-management data according to the Utstein-style template. We collected pre-intervention data from February 1st 2011 to January 31st 2012, implemented the standard operating procedure on February 1st 2012 and collected post intervention data from February 1st 2012 until October 31st 2012. We included transported patients of all ages in need of controlled ventilation treated with pre-hospital endotracheal intubation or the insertion of a supraglottic airways device. The objective was to evaluate whether the development and implementation of a standard operating procedure for controlled ventilation during transport could change pre-hospital critical care anaesthesiologists’ behaviour and thereby increase the use of automated ventilators in these patients.ResultsThe implementation of a standard operating procedure increased the overall prevalence of automated ventilator use in transported patients in need of controlled ventilation from 0.40 (0.34-0.47) to 0.74 (0.69-0.80) with a prevalence ratio of 1.85 (1.57-2.19) (p = 0.00). The prevalence of automated ventilator use in transported traumatic brain injury patients in need of controlled ventilation increased from 0.44 (0.26-0.62) to 0.85 (0.62-0.97) with a prevalence ratio of 1.94 (1.26-3.0) (p = 0.0039). The prevalence of automated ventilator use in patients transported after return of spontaneous circulation following pre-hospital cardiac arrest increased from 0.39 (0.26-0.48) to 0.69 (0.58-0.78) with a prevalence ratio of 1.79 (1.36-2.35) (p = 0.00).ConclusionWe have shown that the implementation of a standard operating procedure for pre-hospital controlled ventilation can significantly change pre-hospital critical care anaesthesiologists’ behaviour.

Refraining from pre-hospital advanced airway management: a prospective observational study of critical decision making in an anaesthesiologist-staffed pre-hospital critical care service

IntroductionWe report prospectively recorded observational data from consecutive cases in which the attending pre-hospital critical care anaesthesiologist considered performing pre-hospital advanced airway management but decided to withhold such interventions.Materials and methodsAnaesthesiologists from eight pre-hospital critical care teams in the Central Denmark Region (a mixed rural and urban region with 1.27 million inhabitants) registered data from February 1st 2011 to October 31st 2012. Included were patients of all ages for whom pre-hospital advanced airway management were considered but not performed. The main objectives were to investigate (1) the pre-hospital critical care anaesthesiologists’ reasons for considering performing pre-hospital advanced airway management in this group of patients (2) the pre-hospital critical care anaesthesiologists’ reasons for not performing pre-hospital advanced airway management (3) the methods used to treat these patients (4) the incidence of complications related to pre-hospital advanced airway management not being performed.ResultsWe registered data from 1081 cases in which the pre-hospital critical care anaesthesiologists’ considered performing pre-hospital advanced airway management. The anaesthesiologists decided to withhold pre-hospital advanced airway management in 32.1% of these cases (n = 347). In 75.1% of these cases (n = 257) pre-hospital advanced airway management were withheld because of the patient’s condition and in 30.8% (n = 107) because of patient co-morbidity. The most frequently used alternative treatment was bag-mask ventilation, used in 82.7% of the cases (n = 287). Immediate complications related to the decision of not performing pre-hospital advanced airway management occurred in 0.6% of the cases (n = 2).ConclusionWe have illustrated the complexity of the critical decision-making associated with pre-hospital advanced airway management. This study is the first to identify the most common reasons why pre-hospital critical care anaesthesiologists sometimes choose to abstain from pre-hospital advanced airway management as well as the alternative treatment methods used.

Pre-hospital advanced airway management by experienced anaesthesiologists: a prospective descriptive study

IntroductionWe report data from the first Utstein-style study of physician-provided pre-hospital advanced airway management.Materials and methodsAnaesthesiologists from eight pre-hospital critical care teams in the Central Denmark Region (a mixed rural and urban region with 1.27 million inhabitants) prospectively registered data according to the template for reporting data from pre-hospital advanced airway management. Data collection took place from February 1st 2011 to October 31st 2012. Included were patients of all ages on whom pre-hospital advanced airway management was performed. The objective was to estimate the incidences of failed and difficult pre-hospital endotracheal intubation, and complications related to pre-hospital advanced airway management.ResultsThe overall incidence of successful pre-hospital endotracheal intubation among 636 intubation attempts was 99.7%, even though 22.4% of pre-hospital endotracheal intubations required more than one intubation attempt. The overall incidence of complications related to pre-hospital advanced airway management was 7.9%. Following rapid sequence intubation, the incidence of first pass success was 85.8%, the overall incidence of complications was 22.0%, the incidence of hypotension 7.3% and that of hypoxia 5.3%. Multiple endotracheal intubation attempts were associated with an increased overall incidence of complications. No airway management related deaths occurred.DiscussionThe overall incidence of successful pre-hospital endotracheal intubations compares to those found in other physician-staffed pre-hospital systems. The incidence of pre-hospital endotracheal intubations requiring more than one attempt is higher than suspected. The incidence of hypotension or hypoxia after pre-hospital rapid sequence intubation compares to those found in UK emergency departments.ConclusionPre-hospital advanced airway management including pre-hospital endotracheal intubation performed by experienced anaesthesiologists is associated with high success rates and relatively low incidences of complications. An increased first pass success rate following pre-hospital endotracheal intubation may further reduce the incidence of complications and enhance patient safety in our system.

Capability of Scottish emergency departments to provide physician-based prehospital critical care teams

The aim of this study was to establish the current capabilities of emergency departments in Scotland to provide a prehospital medical team at the request of the ambulance service. A prospective telephone survey of all major emergency departments in Scotland was conducted, requesting information on their ability to provide a prehospital team, the configuration of the team and the equipment, transport, training and governance arrangements for this service. All 25 major emergency departments in Scotland responded to the survey (100% response). Eighteen departments (72%) were able to provide a prehospital team, with 15 (60%) able to provide a team 24 h/day. Team composition was variable and only one-third of teams were able to deploy within 15 min. In total, 50% of departments able to respond had received no requests in the preceding 12 months and only two departments had each received more than 50 requests. Less than half of the departments checked prehospital equipment on a weekly or a more frequent basis and only three departments provided ongoing training in prehospital care. The majority of emergency departments in Scotland are able to provide a prehospital team on the request of the ambulance service. There is high variability in the composition and seniority of the team, with less ability to provide a team out of hours. With two notable exceptions, the overall activation of these prehospital teams is infrequent, and there are significant improvements required with regard to the clinical governance surrounding the provision of these teams.

Medical Evacuation and Triage of Combat Casualties in Helmand Province, Afghanistan: October 2010–April 2011

Medical evacuation of combat casualties in Operation Enduring Freedom-Afghanistan is achieved primarily by helicopter, because of distances involved as well as ground-based threats. In Helmand Province, evacuation from the point of injury may occur on a variety of helicopter evacuation platforms with disparate levels of attendant medical expertise. Furthermore, triage to a medical treatment facility may involve varying echelons of care before definitive management. Consequently, considerable differences in medical care may be encountered between point of injury and definitive treatment. We discuss the role of helicopter-based medical evacuation in Helmand, Afghanistan, as well as triage and timelines to the most appropriate medical facilities. Based on our experience and available evidence, we have made recommendations to regional commanders which favor the utilization of prehospital critical care teams aboard helicopter-based evacuation platforms and direct triage to the highest echelon of care available when feasible.

Efficacy of prehospital critical care teams for severe blunt head injury in the Australian setting

Objective: To determine whether prehospital critical care teams (CCT) would result in improved functional outcomes for road trauma related severe head injury in the Australian setting, when compared with standard advanced life support measures provided by paramedics. Methods: Retrospective review of 250 patients treated by paramedics and 46 patients treated by CCT transported directly from the accident scene, with a prehospital Glasgow coma scale (GCS)≤8. Results: CCT-treated patients had longer median prehospital times (113 versus 45 min, P<0.001), and a higher prehospital intubation rate (100% versus 36%, P<0.001) than paramedic-treated patients. On multivariate analysis, revised trauma score≥4.45 (odds ratio [OR] 2.31, 95% CI: 1.15–4.65), lower injury severity score (OR 1.04, 95% CI: 1.02–1.06), age≤25 years (OR 1.76, 95% CI: 1.13–2.75), absence of an acute subdural haematoma (OR 3.36, 95% CI: 1.89–5.95) and prehospital treatment by a CCT (OR 2.70, 95% CI: 1.48–4.95) independently predicted better outcome. Conclusion: The range of advanced interventions provided by the CCT were associated with improved functional outcome. Further studies are required to determine the individual factors responsible.