Prehospital Critical Care Research Articles

Intubation first-pass success in a high performing pre-hospital critical care system is not associated with 30-day mortality: a registry study of 4496 intubation attempts

BackgroundLower intubation first-pass success (FPS) rate is associated with physiological deterioration, and FPS is widely used as a quality indicator of the airway management of a critically ill patient. However, data on FPS’s association with survival is limited. We aimed to investigate if the FPS rate is associated with 30-day mortality or physiological complications in a pre-hospital setting. Furthermore, we wanted to describe the FPS rate in Finnish helicopter emergency medical services.MethodsThis was a retrospective observational study. Data on drug-facilitated intubation attempts by helicopter emergency medical services were gathered from a national database and analysed. Multivariate logistic regression, including known prognostic factors, was performed to assess the association between FPS and 30-day mortality, collected from population registry data.ResultsOf 4496 intubation attempts, 4082 (91%) succeeded on the first attempt. The mortality rates in FPS and non-FPS patients were 34% and 38% (P = 0.21), respectively. The adjusted odds ratio of FPS for 30-day mortality was 0.88 (95% CI 0.66–1.16). Hypoxia after intubation and at the time of handover was more frequent in the non-FPS group (12% vs. 5%, P < 0.001, and 5% vs. 3%, P = 0.01, respectively), but no significant differences were observed regarding other complications.ConclusionFPS is not associated with 30-day mortality in pre-hospital critical care delivered by advanced providers. It should therefore be seen more as a process quality indicator instead of a risk factor of poor outcome, at least considering the current limitations of the parameter.

Predictive value of shock index variants on 30-day mortality of trauma patients in helicopter emergency medical services: a nationwide observational retrospective multicenter study

The original shock index (SI) has been further developed to increase its prognostic value. We aimed to evaluate the predictive value of different SI variants on 30-day mortality among severely injured trauma patients in pre-hospital critical care settings. Adult trauma patients in the national Helicopter Emergency Medical Services (HEMS) registry were evaluated based on the primary outcome of 30-day mortality. SI, SIA (SI multiplied by age), SI/G (SI divided by Glasgow Coma Scale (GCS)), SIA/G (SI multiplied by age and divided by GCS), and SS (SI divided by oxygen saturation) were calculated based on the first vital signs measured at the time of HEMS contact. The area under the receiver operating curve (AUROC) was calculated for each SI variant. In total 4108 patients were included in the study. The overall 30-day mortality was 13.5%. The SIA/G and SI/G had the highest predictive ability (AUROC 0.884 [95% CI 0.869–0.899] and 0.8000 [95% CI 0.7780–0.8239], respectively). The SIA/G yielded good predictive performance between 30-day survivors and non-survivors in the pre-hospital critical care setting.

Association between physician's case volume in prehospital advanced trauma care and 30-day mortality: A registry-based analysis of 4,032 patients.

Seriously injured patients may benefit from prehospital interventions provided by a critical care physician. The relationship between case volume and outcome has been established in trauma teams in hospitals, as well as in prehospital advanced airway management. In this study, we aimed to assess if a volume-outcome relationship exists in prehospital advanced trauma care. We performed a retrospective cohort study using the national helicopter emergency medical services database, including trauma patients escorted from scene to hospital by a helicopter emergency medical services physician during January 1, 2013, to August 31, 2019. In addition, similar cases during 2012 were used to determine case volumes. We performed a multivariate logistic regression analysis, with 30-day mortality as the outcome. Age, sex, Glasgow Coma Scale, shock index, mechanism of injury, time interval from alarm to the patient and duration of transport, level of receiving hospital, and physician's trauma case volume were used as covariates. On-scene times, interventions performed, and status at hospital arrival were assessed in patients who were grouped according to physician's case volume. In total, 4,032 escorted trauma patients were included in the study. The median age was 40.2 (22.9-59.3) years, and 3,032 (75.2%) were male. Within 30 days, 498 (13.2%) of these patients had died. In the highest case volume group, advanced interventions were performed more often, and patients were less often hypotensive at handover. Data for multivariate analysis were available for 3,167 (78.5%) of the patients. Higher case volume was independently associated with lower mortality (odds ratio, 0.59; 95% confidence interval, 0.38-0.89). When a prehospital physician's case volume is higher in high-risk prehospital trauma, this seems to be associated with more active practice patterns and significantly lower 30-day mortality. The quality of prehospital critical care could be increased by ensuring sufficient case volume for the providers of such care. Prognostic and Epidemiologic; Level III.

Outcome of life-threatening arrhythmias among patients presenting in an emergency setting at a tertiary hospital in Accra-Ghana

BackgroundManagement of life-threatening arrhythmia can be incredibly challenging in advanced health systems. In sub-Saharan Africa (SSA), this is likely more challenging because of weak pre-hospital and in-hospital critical care systems. Little is known about life-threatening arrhythmia and their outcomes in SSA. The aim of this study was to examine the types and outcomes of arrhythmias among haemodynamically unstable patients presenting at a tertiary hospital in Accra-Ghana.MethodThis was a retrospective case series study conducted at the Korle-Bu Teaching Hospital (KBTH), Accra-Ghana. Medical records of patients who presented with or developed haemodynamically unstable arrhythmias within 24h of admission from January 2018 to December 2020 were reviewed. The demographic characteristics and clinical data including outcomes of patients were collected. Descriptive statistics were used and results presented in frequency tables.ResultsA total of 42 patients with life-threatening arrhythmias were included. Haemodynamically unstable tachyarrhythmias were the most common arrhythmias found among the patients (66.7%). Approximately 52% of patients had structural heart diseases whereas 26.2% had no apparent underlying cause or predisposing factor. Cardioversion (52.4%), commonly electrical (63.6%), and transvenous pacemaker implantation (23.8%) were the common initial interventions. The majority of the patients (88.1%) survived and were discharged home.ConclusionTachyarrhythmias are the most common haemodynamically unstable arrhythmias seen among patients presenting emergently in a leading tertiary hospital in Ghana. A high survival rate was observed and cannot be extrapolated to other healthcare settings in sub-Saharan Africa with limited resources to manage these clinical entities.

Pre-hospital blood products and calcium replacement protocols in UK critical care services: A survey of current practice

IntroductionIn the United Kingdom, prehospital blood products are increasingly carried for the early resuscitation of hypovolaemia in patients who are shocked or in cardiac arrest. There is an association between hypocalcaemia and mortality in trauma patients, but no current national guidelines on the timing or dose of calcium replacement exist. The objective of this study was to establish the availability of prehospital blood products, and the current calcium replacement protocols used by UK prehospital services. MethodsA cross sectional survey of all UK air ambulances and additional prehospital critical care organisations was conducted in April-May 2022 via an on-line questionnaire. The survey asked 11 questions about availability of prehospital blood products, calcium replacement for patients requiring prehospital blood products, and the use of point of care testing. ResultsThere was a 100% response rate with 20/22 UK air ambulances carrying blood products and five additional prehospital services identified. There were 15 different combinations of prehospital blood products. 23/25 services had a standard operating procedure for the replacement of calcium. This was recommended before any blood product administration in 5 services (22%), during or after the 1st unit in 5 services (22%), during or after the 2nd unit in 6 services (26%) and during or after the 4th unit in 7 services (30%). Only six services carried point of care testing and no services routinely used this to measure calcium levels in patients requiring prehospital blood products. ConclusionIn 2022, 91% of UK air ambulances carry prehospital blood products and there is significant variation between services in the combination of blood products provided. There is no consensus on the timing or dose of calcium replacement. Further prospective research should examine the association between traumatic bleeding and ionized calcium levels before and during blood product transfusion in order to produce more robust guidelines for routine calcium replacement.

The A to E (ABCDE) Pit Crew Model: A Novel Approach to Team Based Care of Critical Patients in the Prehospital Setting.

This study aimed to evaluate the effectiveness of a Pit Crew intervention to improve team dynamics and time to performance of critical actions in a prehospital critical care scenario. The primary outcome was successful completion of critical actions and time to completion of these critical actions. Secondary outcomes included effectiveness of communication and overall team functioning. The study was conducted with a fire-based Emergency Medical Services (EMS) system with 233 paramedics and 115 Emergency Medical Technicians (EMT). Eight EMS crews comprised of five members each were randomly selected and assigned to either the intervention or the control group. The intervention group (n=20) watched a thirty-minute video prior to the training describing the "Pit Crew Approach;" the control group (n=20) did not watch the video. Each crew was given the same simulation scenario of a pediatric patient that had overdosed on a beta-blocker. Completion of predetermined critical tasks were noted and timestamped. A survey was administered to the participants following the training to assess team dynamics and level of confidence. Three outcomes were statistically significant between the two arms: The interventional group felt they themselves had a more defined role in the resuscitation in comparison to the non-interventional group (p= 0.021). The interventional group also felt that their team members had a clearer and more defined role than the nonintervention group (p= 0.018). The interventional group also felt more confident managing a beta blocker overdose than the nonintervention group (p.007). The only statistically significant secondary outcome finding was in scene departure decision: the interventional arm spent more time on-scene (p=0.031). Of note, the non-intervention group missed performing tasks more often than the interventional group and team leaders of these groups often performed task(s) while also directing the patient care. The Pit Crew model was developed to optimize communication and team function. Our data identified that a formal instruction of the pit crew approach to a critical care scenario improved comfort in patient care. Future studies are needed evaluate other methods of training and the effects of continued formal pit-crew training over time.

Prehospital fluid therapy in patients with suspected infection: a survey of ambulance personnel’s practice

BackgroundFluid therapy in patients with suspected infection is controversial, and it is not known whether fluid treatment administered in the prehospital setting is beneficial. In the absence of evidence-based guidelines for prehospital fluid therapy for patients with suspected infection, Emergency Medical Services (EMS) personnel are challenged on when and how to initiate such therapy.This study aimed to assess EMS personnel’s decision-making in prehospital fluid therapy, including triggers for initiating fluid and fluid volumes, as well as the need for education and evidence-based guidelines on prehospital fluid therapy in patients with suspected infection.MethodsAn online survey concerning fluid administration in prehospital patients with suspected infection was distributed to all EMS personnel in the Central Denmark Region, including ambulance clinicians and prehospital critical care anaesthesiologists (PCCA). The survey consisted of sections concerning academic knowledge, statements about fluid administration, triggers to evaluate patient needs for intravenous fluid, and clinical scenarios.ResultsIn total, 468/807 (58%) ambulance clinicians and 106/151 (70%) PCCA responded to the survey. Of the respondents, 73% (n = 341) of the ambulance clinicians and 100% (n = 106) of the PCCA felt confident about administering fluids to prehospital patients with infections. However, both groups primarily based their fluid-related decisions on “clinical intuition”. Ambulance clinicians named the most frequently faced challenges in fluid therapy as “Unsure whether the patient needs fluid” and “Unsure about the volume of fluid the patient needs”. The five most frequently used triggers for evaluating fluid needs were blood pressure, history taking, skin turgor, capillary refill time, and shock index, the last of which only applied to ambulance clinicians. In the scenarios, the majority administered 500 ml to a normotensive woman with suspected sepsis and 1000 ml to a woman with suspected sepsis-related hypotension. Moreover, 97% (n = 250) of the ambulance clinicians strongly agreed or agreed that they were interested in more education about fluid therapy in patients with suspected infection.ConclusionThe majority of ambulance clinicians and PCCA based their fluid administration on “clinical intuition”. They faced challenges deciding on fluid volumes and individual fluid needs. Thus, they were eager to learn more and requested research and evidence-based guidelines.

Accuracy of prehospital clinicians’ perceived prognostication of long-term survival in critically ill patients: a nationwide retrospective cohort study on helicopter emergency service patients

ObjectivesPrehospital critical care physicians regularly attend to patients with poor prognosis and may limit the advanced therapies. The aim of this study was to evaluate the accuracy of poor prognosis...

Standardised data collection in prehospital critical care: a comparison of medical problem categories and discharge diagnoses

BackgroundPrehospital medical problem reporting is essential in the management of helicopter emergency medical services (HEMS) operations. The consensus-based template for reporting and documenting in physician-staffed prehospital services exists and the classification of medical problems presented in the template is widely used in research and quality improvement. However, validation of the reported prehospital medical problem is lacking. This study aimed to describe the in-hospital diagnoses, patient characteristics and medical interventions in different categories of medical problems.MethodsThis retrospective, observational registry study examined the 10 most common in-hospital International Statistical Classification of Disease (ICD-10) diagnoseswithin different prehospital medical problem categories, defined by the HEMS physician/paramedic immediately after the mission was completed. Data were gathered from a national HEMS quality registry and a national hospital discharge registry. Patient characteristics and medical interventions related to different medical problem categories are also described.ResultsA total of 33,844 patients were included in the analyses. All the medical problem categories included a broad spectrum of ICD-10 diagnoses (the number of diagnosis classes per medical problem category ranged from 73 to 403). The most frequent diagnoses were mainly consistent with the reported medical problems. Overlapping of ICD-10 diagnoses was mostly seen in two medical problem categories: stroke and acute neurology excluding stroke. Additionally, typical patient characteristics and disturbances in vital signs were related to adequate medical problem categories.ConclusionsMedical problems reported by HEMS personnel have adequate correspondence to hospital discharge diagnoses. However, the classification of cerebrovascular accidents remains challenging.

Cerebral oxygen desaturation events during and functional outcomes after prehospital anaesthesia: A prospective pilot study.

BackgroundDuring prehospital anaesthesia, oxygen delivery to the brain might be inadequate to match the oxygen consumption, with unknown long‐term functional outcomes. We aimed to evaluate the feasibility of monitoring cerebral oxygenation during prehospital anaesthesia and determining the long‐term outcomes.MethodsWe performed a prospective observational feasibility study in two helicopter emergency medical services units. Frontal lobe regional oxygen saturation (rSO2) of adult patients undergoing prehospital anaesthesia was monitored with near‐infrared spectroscopy (NIRS) by a Nonin H500 oximeter. The outcome was evaluated with a modified Rankin Scale (mRS) at 30 days and 1 year. Health‐related quality of life (HRQoL) was measured with a 15D instrument at 1 year.ResultsOf 101 patients enrolled, 83 were included. The mean baseline rSO2 was 79% (73–84). Desaturation for at least 5 min to rSO2 below 50% or a decrease of 10% from baseline occurred in four (5%, 95% CI 2%–12%) and 19 (23%, 95% CI 15–93) patients. At 1 year, 32 patients (53%, 95% CI 41–65) achieved favourable neurological outcomes. The median 15D score was 0.889 (Q1–Q3, 0.796–0.970).ConclusionMonitoring cerebral oxygenation with a hand‐held oximeter during prehospital anaesthesia and collecting data on functional outcomes and HRQoL are feasible. Only half of the patients achieved a favourable functional outcome. The effects of cerebral oxygenation on outcomes during prehospital critical care need to be assessed in future studies.

Evaluation of a Disposable Vascular Pressure Device for Pre- and Postmembrane Pressure Monitoring During Venovenous Extracorporeal Membrane Oxygenation.

Membrane pressure monitoring during extracorporeal membrane oxygenation (ECMO) is integral to monitoring circuit health. We compared a disposable vascular pressure device (DVPD) to the transducer pressure bag arterial line (TPBAL) monitoring system to determine whether the DVPD can reliably and accurately monitor membrane pressures during venovenous extracorporeal membrane oxygenation (VV ECMO). We analyzed existing quality assurance data collected at a single center as part of routine circuit performance monitoring and process improvement on a convenience sample of four VV ECMO circuits. We placed and zeroed a DVPD in line with the pre- and postmembrane TPBAL setups in coordination with a standard transducer setup. We recorded DVPD and TPBAL pressure measurements every 4 hours for 2.5 days on the four separate VV ECMO circuits. We compared the standard and DVPD pressures using Bland-Altman plots and methods that accounted for repeated measures in the same subject. We recorded 58 pre/postmembrane pressures. Mean membrane pressure values were similar in the DVPD (pre: 208 mmHg [SD, 50.8]; post: 175 mmHg [46.3]) compared to the standard TPBAL setup (pre: 205 mmHg [52.0]; post: 177 mmHg [46.3]). Using Bland-Altman methods, premembrane pressures were found to be 2.2 mmHg higher (95% confidence interval [CI]: -5.3 to 9.7) in the standard TPBAL setup compared to DVPD and 1.8 mmHg higher (95% CI: -5.3 to 8.9) than the postmembrane pressures. The DVPD provided an accurate measurement of circuit pressure as compared to the TPBAL setup. Across the range of pre- and postmembrane pressures, both methods reliably agreed. Future trials should investigate DVPD accuracy in different environments such as prehospital field cannulation or critical care transport of ECMO patients.

Resuscitation with blood products in patients with trauma-related haemorrhagic shock receiving prehospital care (RePHILL): a multicentre, open-label, randomised, controlled, phase 3 trial

SummaryBackgroundTime to treatment matters in traumatic haemorrhage but the optimal prehospital use of blood in major trauma remains uncertain. We investigated whether use of packed red blood cells (PRBC) and lyophilised plasma (LyoPlas) was superior to use of 0·9% sodium chloride for improving tissue perfusion and reducing mortality in trauma-related haemorrhagic shock.MethodsResuscitation with pre-hospital blood products (RePHILL) is a multicentre, allocation concealed, open-label, parallel group, randomised, controlled, phase 3 trial done in four civilian prehospital critical care services in the UK. Adults (age ≥16 years) with trauma-related haemorrhagic shock and hypotension (defined as systolic blood pressure <90 mm Hg or absence of palpable radial pulse) were assessed for eligibility by prehospital critial care teams. Eligible participants were randomly assigned to receive either up to two units each of PRBC and LyoPlas or up to 1 L of 0·9% sodium chloride administered through the intravenous or intraosseous route. Sealed treatment packs which were identical in external appearance, containing PRBC–LyoPlas or 0·9% sodium chloride were prepared by blood banks and issued to participating sites according to a randomisation schedule prepared by the co-ordinating centre (1:1 ratio, stratified by site). The primary outcome was a composite of episode mortality or impaired lactate clearance, or both, measured in the intention-to-treat population. This study is completed and registered with ISRCTN.com, ISRCTN62326938.FindingsFrom Nov 29, 2016 to Jan 2, 2021, prehospital critical care teams randomly assigned 432 participants to PRBC–LyoPlas (n=209) or to 0·9% sodium chloride (n=223). Trial recruitment was stopped before it achieved the intended sample size of 490 participants due to disruption caused by the COVID-19 pandemic. The median follow-up was 9 days (IQR 1 to 34) for participants in the PRBC–LyoPlas group and 7 days (0 to 31) for people in the 0·9% sodium chloride group. Participants were mostly white (62%) and male (82%), had a median age of 38 years (IQR 26 to 58), and were mostly involved in a road traffic collision (62%) with severe injuries (median injury severity score 36, IQR 25 to 50). Before randomisation, participants had received on average 430 mL crystalloid fluids and tranexamic acid (90%). The composite primary outcome occurred in 128 (64%) of 199 participants randomly assigned to PRBC–LyoPlas and 136 (65%) of 210 randomly assigned to 0·9% sodium chloride (adjusted risk difference –0·025% [95% CI –9·0 to 9·0], p=0·996). The rates of transfusion-related complications in the first 24 h after ED arrival were similar across treatment groups (PRBC–LyoPlas 11 [7%] of 148 compared with 0·9% sodium chloride nine [7%] of 137, adjusted relative risk 1·05 [95% CI 0·46–2·42]). Serious adverse events included acute respiratory distress syndrome in nine (6%) of 142 patients in the PRBC–LyoPlas group and three (2%) of 130 in 0·9% sodium chloride group, and two other unexpected serious adverse events, one in the PRBC-LyoPlas (cerebral infarct) and one in the 0·9% sodium chloride group (abnormal liver function test). There were no treatment-related deaths.InterpretationThe trial did not show that prehospital PRBC–LyoPlas resuscitation was superior to 0·9% sodium chloride for adult patients with trauma related haemorrhagic shock. Further research is required to identify the characteristics of patients who might benefit from prehospital transfusion and to identify the optimal outcomes for transfusion trials in major trauma. The decision to commit to routine prehospital transfusion will require careful consideration by all stakeholders.FundingNational Institute for Health Research Efficacy and Mechanism Evaluation.

Validation of Score to Detect Intracranial Lesions in Unconscious Patients in Prehospital Setting

ObjectivesRecognizing stroke and other intracranial pathologies in prehospital phase facilitates prompt recanalization and other specific care. Recognizing these can be difficult in patients with decreased level of consciousness. We previously derived a scoring system combining systolic blood pressure, age and heart rate to recognize patients with intracranial pathology. In this study we aimed to validate the score in a larger, separate population. Materials and methodsWe conducted a register based retrospective study on patients ≥16 years old and Glasgow Coma Score <15 encountered by helicopter emergency medical services. Diagnoses at the end of hospitalization were used to identify if patients had intracranial lesion or not. The performance of score was evaluated by area under the receiver operating characteristics curve (AUROC). ResultsOf 9,309 patients included, 1,925 (20.7%) had an intracranial lesion including 1,211 cases of stroke. Older age, higher blood pressure and lower heart rate were predictors for an intracranial lesion (P<0.001 for all). The score distinguished patients with intracranial lesion with AUROC of 0.749 (95% CI 0.737 to 0.761). The performance slightly improved if only patients intubated in prehospital phase were included AUROC 0.780 (95% CI 0.770 to 0.806) or convulsion related diagnosis excluded AUROC of 0.788 (95% CI 0.768 to 0.792). ConclusionsA scoring of systolic blood pressure, heart rate and age help differentiate intracranial lesions in patients with decreased level of consciousness in prehospital care. This may facilitate direct transportation to stroke center and application of neuroprotective measures in prehospital critical care.

Effect of time intervals in critical care provided by helicopter emergency medical services on 30-day survival after trauma

BackgroundTrauma is the leading cause of death especially in children and young adults. Prehospital care following trauma emphasizes swift transport to a hospital following initial care. Previous studies have shown conflicting results regarding the effect of time on the survival following major trauma. In our study we investigated the effect of prehospital time-intervals on 30-day mortality on trauma patients that received prehospital critical care. MethodsWe performed a retrospective study on all trauma patients encountered by helicopter emergency medical services in Finland from 2012 to 2018. Patients discharge diagnoses were classed into (1) trauma without traumatic brain injury, (2) isolated traumatic brain injury and (3) trauma with traumatic brain injury. Emergency medical services response time, helicopter emergency medical services response time, on-scene time and transport time were used as time-intervals and age, Glasgow coma scale, hypotension, need for prehospital airway intervention and ICD-10 based Injury Severity Score were used as variables in logistic regression analysis. ResultsMortality data was available for 4,803 trauma cases. The combined 30-day mortality was 12.1% (582/4,803). Patients with trauma without a traumatic brain injury had the lowest mortality, at 4.3% (111/2,605), whereas isolated traumatic brain injury had the highest, at 22.9% (435/1,903). Patients with both trauma and a traumatic brain injury had a mortality of 12.2% (36/295). Following adjustments, no association was observed between time intervals and 30-day mortality. DiscussionOur study revealed no significant association between different timespans and mortality following severe trauma in general. Trends in odds ratios can be interpreted to favor more expedited care, however, no statistical significance was observed. As trauma forms a heterogenous patient group, specific subgroups might require different approaches regarding the prehospital timeframes. Study typeprognostic/therapeutic/diagnostic test.

Effect of the First Wave of the Belgian COVID-19 Pandemic on Physician-Provided Prehospital Critical Care in the City of Antwerp (Belgium).

There is evidence to suggest that patients delayed seeking urgent medical care during the first wave of the coronavirus disease 2019 (COVID-19) pandemic. A delay in health-seeking behavior could increase the disease severity of patients in the prehospital setting. The combination of COVID-19-related missions and augmented disease severity in the prehospital environment could result in an increase in the number and severity of physician-staffed prehospital interventions, potentially putting a strain on this highly specialized service. The aim was to investigate if the COVID-19 pandemic influences the frequency of physician-staffed prehospital interventions, prehospital mortality, illness severity during prehospital interventions, and the distribution in the prehospital diagnoses. A retrospective, multicenter cohort study was conducted on prehospital charts from March 14, 2020 through April 30, 2020, compared to the same period in 2019, in an urban area. Recorded data included demographics, prehospital diagnosis, physiological parameters, mortality, and COVID-status. A modified National Health Service (NHS) National Early Warning Score (NEWS) was calculated for each intervention to assess for disease severity. Data were analyzed with univariate and descriptive statistics. There was a 31% decrease in physician-staffed prehospital interventions during the period under investigation in 2020 as compared to 2019 (2019: 644 missions and 2020: 446 missions), with an increase in prehospital mortality (OR = 0.646; 95% CI, 0.435 - 0.959). During the study period, there was a marked decrease in the low and medium NEWS groups, respectively, with an OR of 1.366 (95% CI, 1.036 - 1.802) and 1.376 (0.987 - 1.920). A small increase was seen in the high NEWS group, with an OR of 0.804 (95% CI, 0.566 - 1.140); 2019: 80 (13.67%) and 2020: 69 (16.46%). With an overall decrease in cases in all diagnostic categories, a significant increase was observed for respiratory illness (31%; P = .004) and cardiac arrest (54%; P < .001), combined with a significant decrease for intoxications (-58%; P = .007). Due to the national test strategy at that time, a COVID-19 polymerase chain reaction (PCR) result was available in only 125 (30%) patients, of which 20 (16%) were positive. The frequency of physician-staffed prehospital interventions decreased significantly. There was a marked reduction in interventions for lower illness severity and an increase in higher illness severity and mortality. Further investigation is needed to fully understand the reasons for these changes.

Feasibility of Prehospital Emergency Anesthesia in the Cabin of an AW169 Helicopter Wearing Personal Protective Equipment During Coronavirus Disease 2019

ObjectivePrehospital emergency anesthesia in the form of rapid sequence intubation (RSI) is a critical intervention delivered by advanced prehospital critical care teams. Our previous simulation study determined the feasibility of in-aircraft RSI. We now examine whether this feasibility is preserved in a simulated setting when clinicians wear personal protective equipment (PPE) for aerosol-generating procedures (AGPs) for in-aircraft, on-the-ground RSI. MethodsAir Ambulance Kent Surrey Sussex is a helicopter emergency medical service that uses an AW169 cabin simulator. Wearing full AGP PPE (eye protection, FFP3 mask, gown, and gloves), 10 doctor-paramedic teams performed RSI in a standard “can intubate, can ventilate” scenario and a “can't intubate, can't oxygenate” (CICO) scenario. Prespecified timings were reported, and participant feedback was sought by questionnaire. ResultsRSI was most commonly performed by direct laryngoscopy and was successfully achieved in all scenarios. The time to completed endotracheal intubation (ETI) was fastest (287 seconds) in the standard scenario and slower (370 seconds, P = .01) in the CICO scenario. The time to ETI was not significantly delayed by wearing PPE in the standard (P = .19) or CICO variant (P = .97). Communication challenges, equipment complications, and PPE difficulties were reported, but ways to mitigate these were also reported. ConclusionIn-aircraft RSI (aircraft on the ground) while wearing PPE for AGPs had no significant impact on the time to successful completion of ETI in a simulated setting. Patient safety is paramount in civilian helicopter emergency medical services, but the adoption of in-aircraft RSI could confer significant patient benefit in terms of prehospital time savings, and further research is warranted.

The contribution of helicopter emergency medical services in the pre-hospital care of penetrating torso injuries in a semi-rural setting

BackgroundAlthough the merit of pre-hospital critical care teams such as Helicopter Emergency Medical Services (HEMS) has been universally recognized for patients with penetrating torso injuries who present with unstable physiology, the potential merit in patients initially presenting with stable physiology is largely undetermined. The ability to predict the required pre-hospital interventions patients may have important implications for HEMS tasking, especially when transport times to definitive care are prolonged.MethodsWe performed a retrospective cohort study of patients who sustained a penetrating torso injury and were attended by the Air Ambulance Kent Surrey Sussex (AAKSS) over a 6-year period. Primary outcome was defined as the percentage of patients with penetrating torso injuries requiring HEMS-specific interventions anytime between HEMS arrival and arrival at hospital. Secondary outcomes were the association of individual patient- and injury characteristics with the requirement for HEMS interventions.ResultsDuring the study period 363 patients met inclusion criteria. 90% of patients were male with a median age of 30 years. 99% of penetrating trauma incident occurred more than 10-min drive from a Major Trauma Centre (MTC). Presenting GCS was > 13 in 83% of patients. Significant hemodynamic- or ventilatory compromise was present in more than 25% of the patients. Traumatic cardiac arrest was present in 34 patients (9.4%), profound hypotension with SBP < 80 mmHg in 30 (8.3%) and oxygen saturations < 92% in 30 (8.3%). A total of 121 HEMS-specific interventions were performed. Although HEMS-specific interventions were associated with presenting physiology (TCA OR 1.75 [1.41–2.16], SBP < 80 mmHg (OR 1.40 [1.18–1.67] and SpO2 < 92% (OR 1.39 [1.17–1.65], a minority of the patients presented initially with stable physiology but deteriorated on route to hospital and required HEMS interventions (n = 9, 3.3%).ConclusionHEMS teams provide potentially important contribution to the pre-hospital treatment of patients with penetrating torso injuries in rural and semi-rural areas, especially when they present with unstable physiology. A certain degree of over-triage is inevitable in these patients, as it is hard to predict which patients will deteriorate on route to hospital and will need HEMS interventions. The results of this study showing a potentially predictable geographical dispersion of penetrating trauma could inform multi-agency knife crime prevention strategy.

Pediatric Prehospital Advanced Airway Management by Anesthesiologist and Nurse Anesthetist Staffed Critical Care Teams.

Prehospital pediatric tracheal intubation (TI) is a possible life-saving intervention that requires adequate experience to mitigate associated complications. The pediatric airway and respiratory physiology present challenges in addition to a relatively rare incidence of prehospital pediatric TI. The aim of this study was to describe characteristics and outcomes of prehospital TI in pediatric patients treated by critical care teams. This is a sub-group analysis of all pediatric (<16 years old) patients from a prospective, observational, multi-center study on prehospital advanced airway management in the Nordic countries from May 2015 through November 2016. The TIs were performed by anesthesiologists and nurse anesthetists staffing six helicopter and six Rapid Response Car (RRC) prehospital critical care teams. In the study, 74 children were tracheal intubated, which corresponds to 3.7% (74/2,027) of the total number of patients. The pediatric patients were intubated by very experienced providers, of which 80% had performed ≥2,500 TIs. The overall TI success rate, first pass success rate, and airway complication rate were in all children (<16 years) 98%, 82%, and 12%. The corresponding rates among infants (<2 years) were 94%, 67%, and 11%. The median time on scene was 30 minutes. This study observed a high overall prehospital TI success rate in children with relatively few associated complications and short time on scene, despite the challenges presented by the pediatric prehospital TI.

Non-medical prescribing by paramedics in emergency, urgent and critical care

This article considers some of the unique considerations and challenges that are associated with non-medical prescribing in the context of paramedic emergency care. In contrast to primary care, advanced paramedics practicing in emergency settings are more likely to encounter patients who require an immediate supply or administration of medication and access to a range of controlled drugs. Furthermore, access to medical support for prescribing decision-making, restrictions on the prescribing of controlled drugs and potential challenges in obtaining access to patient records, may also impact non-medical prescribing in these settings. Currently, very little empirical evidence has been published on the topic of non-medical prescribing in paramedic practice. Further research is required to understand whether the anticipated benefits are being realised for patients and NHS services. This is particularly the case in the context of prehospital emergency, urgent and critical care settings.

Does experience in prehospital post-resuscitation critical care affect outcomes? A retrospective cohort study

Aims of the studyHelicopter Emergency Medical Services (HEMS) often provide post-resuscitation care. Our aims were to investigate whether physicians’ frequent exposure to prehospital post-resuscitation care is associated with differences in (1) medical management, (2) achieving treatment targets recommended by resuscitation guidelines, (3) survival. MethodsWe conducted a retrospective cohort study using data from a national HEMS quality register. We included patients between January 1st, 2012 and September 9th, 2019 who received post-resuscitation care by a HEMS physician. We excluded patients <16 years old. For each patient we determined the number of post-resuscitation cases the physician had attended in the previous 12 months. Patients were divided in to three groups: low (0–5), intermediate (6–11) and high exposure (≥12 cases). Medical management and proportions within treatment targets were compared. Survival at 30-days and 1-year was analysed by multivariate logistic regression analysis, controlling for known prognostic factors. Results2272 patients were analysed. Patients in the high exposure group had mechanical ventilation and vasoactive medications initiated more often (P < 0.001 and P = 0.008, respectively) and on-scene times were longer (P < 0.001). The target for blood pressure was achieved more often in this group (P = 0.026), but targets for oxygenation and ventilation were not. We did not see an association between survival and physicians’ exposure to post-resuscitation care (odds ratio 0.96, 95% confidence interval 0.70–1.33 for low and 0.78, 0.56–1.08 for intermediate, compared to high exposure). ConclusionsPhysicians with more, frequent exposure take a more active approach to post-resuscitation care, but this does not seem to improve survival.