Prehospital Management Of Patients Research Articles

Contribution of point-of-care ultrasound in the prehospital management of patients with non-trauma acute dyspnea: a systematic review and meta-analysis.

Acute dyspnea is a common symptom whose management is challenging in prehospital settings. Point-of-care ultrasound (POCUS) is increasingly accessible because of device miniaturization. To assess the contribution of POCUS in the prehospital management of patients with acute nontraumatic dyspnea, we performed a systematic review on nontrauma patients of any age managed in the prehospital setting for acute dyspnea and receiving a POCUS examination. We searched seven databases and gray literature for English-language studies published from January 1995 to November 2023. Two independent reviewers completed the study selection, data extraction, and risk of bias assessment. The primary outcome was the assessment of the contribution of POCUS to feasibility, diagnostic, therapeutic, prognosis, patient referral, and transport vector modification. Twenty-three studies were included. The risk of bias assessment identified 3 intermediate-risk, 18 serious-risk, and 2 critical-risk studies. Three studies reported moderate to excellent feasibility for lung POCUS, and three studies reported poor to mediocre feasibility for cardiac POCUS. The median duration of the POCUS examination was less than 5 minutes (six studies). POCUS improved diagnostic identification (seven studies). The diagnostic accuracy of POCUS was excellent for pneumothorax (sensitivity = 100%, specificity = 100%, two studies), very good for acute heart failure (sensitivity = 71-100%, specificity = 72-95%, eight studies), good for pneumonia (sensitivity = 88%, specificity = 59%, one study), and moderate for pleural effusion (sensitivity = 26-53%, specificity = 83-92%, two studies). Treatment was modified in 11 to 54% of the patients (seven studies). POCUS had no significant effect on patient prognosis (two studies). POCUS contributed to patient referrals and transport vectors in 51% (four studies) and 25% (three studies) of patients, respectively. The evidence supports the use of POCUS for managing acute nontraumatic dyspnea in the prehospital setting in terms of feasibility, overall diagnostic contribution, and, particularly, lung ultrasound for acute heart failure diagnosis. Moreover, POCUS seems to have a therapeutic contribution. There is not enough evidence supporting the use of POCUS for pneumonia, pleural effusion, pneumothorax, chronic obstructive pulmonary disease, or asthma exacerbation diagnosis, nor does it support prognostic, patient referral, and transport vector contribution. A high level of evidence is lacking and needed.

Prehospital care for traumatic brain injuries: A review of U.S. state emergency medical services protocols

Traumatic brain injury (TBIs) necessitates a rapid and comprehensive medical response to minimize secondary brain injury and reduce mortality. Emergency medical services (EMS) clinicians serve a critical role in the management of prehospital TBI, responding during an initial phase of care with significant impact on patient outcomes. We used versions two and three of the Brain Trauma Foundation (BTF) Prehospital Guidelines for the Management of Traumatic Brain Injury and the NASEMSO National Model Clinical Guidelines to determine key elements for a TBI prehospital protocol and included common factors across sources such as recommendations concerning patient monitoring, hypoxia, hypotension, hyperventilation, cerebral herniation, airway management, hyperosmolar therapy, and transport destination. We then conducted a cross-sectional evaluation of publicly available statewide EMS clinical protocols in the US to determine the degree of alignment with national guidelines. We calculated descriptive statistics for each factor in the state protocols. Despite adoption of some evidence-based recommendations for a standard approach to the prehospital management of patients with TBI, we found significant variability in statewide EMS treatment protocols for management of severe TBI, especially in the recommended frequency of patient reassessment and for the management of suspected herniation. Most statewide protocols provided guidance regarding oxygenation, ventilation, and blood pressure management that aligned with evidence-based guidelines. While most protocols did address management of oxygenation and ventilation, one in four protocols had no specific guidance for managing hypoxia and only 31% of protocols recommended avoiding hyperventilation. For the management of suspected cerebral herniation, over half of statewide protocols recommended hyperventilation, whereas only 31% explicitly advised against hyperventilation regardless of TBI severity. Interestingly, 94% of protocols do not mention the use of hyperosmolar therapy for TBI patients, neither recommending use or avoidance of hyperosmolar therapy. In conclusion, we found inconsistent adoption of national recommendations in available statewide protocols for prehospital TBI management. We identified significant gaps and variation in statewide protocols regarding patient monitoring and reassessment, as well as in several key areas of severe TBI management.

A Qualitative Analysis of Barriers to Evidence-Based Care in the Prehospital Management of Patients with Suspected Acute Coronary Syndrome

Objectives Prehospital electrocardiogram (ECG) and administration of aspirin are evidence-based strategies for patients with acute coronary syndrome (ACS). However, emergency medical services (EMS) compliance in patients with suspected ACS varies widely. We sought to understand the barriers to prehospital ECG acquisition and aspirin administration for patients with suspected ACS. Methods In this qualitative study, we interviewed EMS clinicians at three geographically diverse United States (U.S.)-based EMS agencies. We interviewed practicing clinicians and quality and operations leaders at these agencies. Based on the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework, interviews were recorded, transcribed, and analyzed using a grounded qualitative approach with open coding. The Systems Engineering Initiative for Patient Safety (SEIPS) framework and a constant comparison technique were used to identify and refine themes. Results Twenty-five paramedics and 20 additional agency personnel participated. Median age was 41 (IQR: 34–51) years and 13 (29%) were female. Themes were organized using SEIPS and longitudinally through four phases of an EMS call. During the pre-arrival phase, staffing challenges, training quality, and dispatch may anchor EMS clinicians on a diagnosis. During the diagnosis and treatment phase, safety and communication barriers may take priority over care delivery. Additionally, EMS clinicians must allocate assets (e.g. whether to send an advanced life support unit) and financial resources; veteran EMS clinicians identified their experience whereas newer clinicians cited their recent education when making these decisions. Also, diagnostic uncertainty due to increasing patient complexity and atypical presentations contributed to diagnostic errors. During the response and transport phase, the scope of practice limits the use and interpretation of the ECG, with clinicians reporting that liberal use of ECG led to more rapid decision-making. Finally, in the after phase, personnel reported the “psychologically taxing” nature of the job contributing to biases, bad habits, and burnout. Performance feedback was desired for personal development, though currently perceived as infrequent and punitive. Conclusions Multiple, interrelated themes underscored the complexities of delivering evidence-based care to prehospital patients with ACS. Education in ECG interpretation, resource allocation, bias, and enhancing feedback may serve as strategies to address the identified barriers.

Prehospital management of patients with isolated head injury with impending cerebral edema leading to intussusception

Prehospital management of patients with isolated head injury with impending cerebral edema leading to intussusception

Effect of the pandemic on prehospital management of patients with mental and behavioral disorders: a retrospective cohort study.

The novel severe acute respiratory syndrome coronavirus (SARS-CoV-2) infection and the accompanying coronavirus disease (Covid-19) have shifted the priority of human and technical resources toward their handling, thus affecting the usual standards of care for populations diagnosed with other clinical entities. The phenomenon becomes even more apparent in patients with presenting symptoms of mental and behavioral disorders, a category already vulnerable and underrepresented in regard to its prehospital approach and management. For the purposes of the current retrospective cohort study, we used records of the Polish National Emergency Medical Service Command Support System for the time period between April 1, 2019 and April 30, 2021, the official register of medical interventions delivered in Poland by Emergency Medical Services (EMS). We aimed to examine the potential impact of the COVID-19 pandemic across the Masovian Voivodeship on individuals seeking medical care for mental and behavioral disorders pertaining in the "F" category of the International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10). We examined the individuals' baseline characteristics, prehospital vital parameters and EMS processing times in a population of 59,651 adult patients (04/2019-03/2020, 28,089 patients, 04/2020-03/2021, 31,562 patients) handled by EMS teams. Compared to pre-COVID-19, EMS personnel handled fewer patients, but more patients required mental and behavioral care. Throughout the duration of the pandemic, all prehospital time periods were significantly delayed due to the increased time needed to prepare crew, vehicles, and technical equipment to ensure COVID-19 prevention and overcrowding in Emergency Departments (EDs).

Pre-Hospital Management of Patients with COVID-19 and the Impact on Hospitalization.

Background and Objectives: During the COVID-19 pandemic, patient care was mainly organized around the hospital. Pre-hospital care has, to our knowledge, never been evaluated. We aimed to study the impact of pre-hospital pathways on hospitalization during the last part of the pandemic. Materials and Methods: This was a monocentric, retrospective analysis of prospectively collected medical records. Data from patients admitted to our institute between 1 February and 7 March 2022 were analyzed. The primary outcomes were defined as the number of hospitalizations, resuscitations, and deaths at the time of interview and in the subsequent 30 days. The main explanatory variables were times from onset of symptoms to care, age, gender, News2 score, comorbidities, and pre-hospital pathways and their duration. Results: Three pre-hospital pathways were identified: a pathway in which the patient consults a general practitioner for a test (PHP1); a pathway in which the patient consults for care (PHP2); and no pre-hospital pathway and direct admission to hospital (PHP3). Factors independently associated with outcome (hospitalization) were being male (OR 95% CI; 2.21 (1.01-4.84), p = 0,04), News2 score (OR 95% CI; 2.04 (1.65-2.51), p < 0.001), obesity (OR 95% CI; 3.45 (1.48-8.09), p = 0.005), D-dimers > 0.5 µg/mL (OR 95% CI; 3.45 (1.47-8.12), p = 0.005), and prolonged time from symptoms to hospital care (PHP duration) (OR 95% CI; 1.07 (1.01-1.14), p = 0.03). All things being equal, patients with a "PHP2" pre-hospital pathway had a higher probability of hospitalization compared to those with a "PHP3" pre-hospital pathway (OR 95% CI; 4.31 (1.48-12.55), p = 0.007). Conclusions: Along with recognized risk factors such as gender, News 2 score, and obesity, the patient's pre-hospital pathway is an important risk factor associated with hospitalization.

Physicians’ experiences and perceived challenges working in an emergency setting in Bharatpur, Nepal: a qualitative study

BackgroundEmergency medical care, including prehospital treatment, forms an important component of any healthcare system. Like most low-middle-income countries, Nepal has an emergency medical system that can be described as underdeveloped. Emergency physicians navigating this system may experience challenges or barriers in their treatment of patients. This study aimed to investigate physicians’ perspectives on emergency and prehospital patient management in a low-income country, Nepal, and to understand the challenges and barriers they perceive in emergency treatment including both the prehospital treatment and the immediate in-hospital treatment at the emergency department.MethodsUsing a qualitative study, eight semi-structured interviews with physicians working in a Nepalese emergency department were performed. The interviews were conducted between September and November 2021 and were audio-recorded and transcribed verbatim. Data were subsequently analyzed using the systematic text condensation method.ResultsFour main themes and associated sub-themes were identified: (1) patients’ sociocultural, educational, and financial factors (such as financial issues and financial inequality) and regional differences; (2) emergency department’s organization and resources concerning human and material resources, protocols, and guidelines; (3) problems with the emergency department (ED) service’s qualities and availability caused by an insufficient integration of the ED and the EMS, prehospital resources, and financial interests in the EMS; and (4) surrounding healthcare system’s impact on the ED where, especially, the levels of organized primary care, governmental responsibilities, and healthcare structure were addressed.ConclusionsThe physicians identified numerous regularly encountered challenges and barriers. These challenges stretched beyond the ED and into various aspects of society. The patients’ financial problems were described as the greatest problem, restricting the treatment due to a given patient’s inability or unwillingness to pay for the required procedures. The physicians were thus restricted in completing their duties to the desired levels. The low quality of prehospital care and a lack of education and awareness of common diseases and symptoms in a significant proportion of patients were identified by many participants as being significant issues. The aforementioned challenges or barriers directly resulted in patients arriving in critical conditions that could have been avoided if the disease were treated earlier.

Striving for gender equity at theMedical Journal of Australia

Striving for gender equity at the<i>Medical Journal of Australia</i>

Effect of the COVID-19 Pandemic in the Prehospital Management of Patients with Suspected Acute Stroke: A Retrospective Cohort Study.

Acute Ischemic Stroke (AIS) can be successfully handled if it is noticed early in the prehospital setting and immediately diagnosed in the emergency department (ED). The coronavirus pandemic has altered the way health care is delivered and has had a profound impact on healthcare delivery. The effects could include prioritizing the prevention of COVID-19 spread, which could result in the discontinuation or deferral of non-COVID-19 care. We used the National Emergency Medical Service Command Support System, a register of medical interventions performed by emergency medical services (EMS) in Poland, to assess the impact of the COVID-19 epidemic across the Masovian Voivodeship on suspected stroke patients’ baseline characteristics, prehospital vital parameters, clinical and neurological status, emergency procedures performed on the prehospital phase and EMS processing times. Between 1 April 2019 and 30 April 2021, the study population included 18,922 adult suspected stroke patients who were treated by EMS teams, with 18,641 admitted to the emergency departments. The overall number of suspected stroke patients treated by EMS remained unchanged during COVID-19 compared to the pre-COVID-19 period; however, the average time from call to hospital admission increased by 15 min.

Prehospital Traumatic Brain Injury Management Clinical Pearls and Pathophysiology.

Traumatic brain injury (TBI) management is complex. The brain is a sensitive, high-maintenance organ that loses its ability to take care of itself upon injury, and our primary mission is to achieve and maintain optimal levels of cerebral blood flow (CBF) from the moment of injury until recovery. The authors provide a case and discuss prehospital patient management, including adequate oxygen saturation and blood pressure, early recognition of TBI, frequent exams, detailed charting and hand-off, and fast transport to the next echelon of care.

Management of respiratory distress following prehospital implementation of noninvasive ventilation in a physician-staffed emergency medical service: a single-center retrospective study

BackgroundNoninvasive ventilation (NIV) is recognized as first line ventilatory support for the management of acute pulmonary edema (APE) and chronic obstructive pulmonary disease (COPD) exacerbations. We aimed to study the prehospital management of patients in acute respiratory distress with an indication for NIV and whether they received it or not.MethodsThis retrospective study included patients ≥18 years old who were cared for acute respiratory distress in a prehospital setting. Indications for NIV were oxygen saturation (SpO2) <90% and/or respiratory rate (RR) >25/min with a presumptive diagnosis of APE or COPD exacerbation. Study population characteristics, initial and at hospital vital signs, presumptive and definitive diagnosis were analyzed. For patients who received NIV, dyspnea level was evaluated with a dyspnea verbal ordinal scale (D-VOS, 0-10) and arterial blood gas (ABG) values were obtained at hospital arrival.ResultsAmong the 187 consecutive patients included in the study, most (n = 105, 56%) had experienced APE or COPD exacerbation, and 56 (30%) received NIV. In comparison with patients without NIV, those treated with NIV had a higher initial RR (35 ± 8/min vs 29 ± 10/min, p < 0.0001) and a lower SpO2 (79 ± 10 vs 88 ± 11, p < 0.0001). The level of dyspnea was significantly reduced for patients treated with NIV (on-scene D-VOS 8.4 ± 1.7 vs 4.4 ± 1.8 at admission, p < 0.0001). Among the 131 patients not treated with NIV, 41 (31%) had an indication. In the latter group, initial SpO2 was 80 ± 10% in the NIV group versus 86 ± 11% in the non-NIV group (p = 0.0006). NIV was interrupted in 9 (16%) patients due to either discomfort (n = 5), technical problem (n = 2), persistent desaturation (n = 1), or vomiting (n = 1).ConclusionsThe results of this study contribute to a better understanding of the prehospital management of patients who present with acute respiratory distress and an indication for NIV. NIV was started on clinically more severe patients, even if predefined criteria to start NIV were present. NIV allows to improve vital signs and D-VOS in those patients. A prospective study could further elucidate why patients with a suspected diagnosis of APE and COPD are not treated with NIV, as well as the clinical impact of the different strategies.Trial registrationThe study was approved by our institutional ethical committee (CER-VD 2020-01363).

Association of Police Transport With Survival Among Patients With Penetrating Trauma in Philadelphia, Pennsylvania

Police in Philadelphia, Pennsylvania, routinely transport patients with penetrating trauma to nearby trauma centers. During the past decade, this practice has gained increased acceptance, but outcomes resulting from police transport of these patients have not been recently evaluated. To assess mortality among patients with penetrating trauma who are transported to trauma centers by police vs by emergency medical services (EMS). This cohort study used the Pennsylvania Trauma Outcomes Study registry and included 3313 adult patients with penetrating trauma from January 1, 2014, to December 31, 2018. Outcomes were compared between patients transported by police (n = 1970) and patients transported by EMS (n = 1343) to adult level I and II trauma centers in Philadelphia. Police vs EMS transport. The primary end point was 24-hour mortality. Secondary end points included death at multiple other time points. After whole-cohort regression analysis, coarsened exact matching was used to control for confounding differences between groups. Matching criteria included patient age, injury mechanism and location, Injury Severity Score (ISS), presenting systolic blood pressure, and Glasgow Coma Scale score. Subgroup analysis was performed among patients with low, moderate, or high ISS. Of the 3313 patients (median age, 29 years [interquartile range, 23-40 years]) in the study, 3013 (90.9%) were men. During the course of the study, the number of police transports increased significantly (from 328 patients in 2014 to 489 patients in 2018; P = .04), while EMS transport remained unchanged (from 246 patients in 2014 to 281 patients in 2018; P = .44). On unadjusted analysis, compared with patients transported by EMS, patients transported by police were younger (median age, 27 years [interquartile range, 22-36 years] vs 32 years [interquartile range, 24-46 years]), more often injured by a firearm (1741 of 1970 [88.4%] vs 681 of 1343 [50.7%]), and had a higher median ISS (14 [interquartile range, 9-26] vs 10 [interquartile range, 5-17]). Patients transported by police had higher mortality at 24 hours than those transported by EMS (560 of 1970 [28.4%] vs 246 of 1343 [18.3%]; odds ratio, 1.86; 95% CI, 1.57-2.21; P < .001) and at all other time points. After coarsened exact matching (870 patients in each transport cohort), there was no difference in mortality at 24 hours (210 [24.1%] vs 212 [24.4%]; odds ratio, 0.95; 95% CI, 0.59-1.52; P = .91) or at any other time point. On subgroup analysis, patients with severe injuries transported by police were less likely to be dead on arrival compared with matched patients transported by EMS (64 of 194 [33.0%] vs 79 of 194 [40.7%]; odds ratio, 0.48; 95% CI, 0.24-0.94; P = .03). For patients with penetrating trauma in an urban setting, 24-hour mortality was not different for those transported by police vs EMS to a trauma center. Timely transport to definitive trauma care should be emphasized over medical capability in the prehospital management of patients with penetrating trauma.

Epidemiology, Prehospital Characteristics and Outcomes of Severe Traumatic Brain Injury in The Netherlands: The BRAIN-PROTECT Study

Objective A thorough understanding of the epidemiology, patient characteristics, trauma mechanisms, and current outcomes among patients with severe traumatic brain injury (TBI) is important as it may inform potential strategies to improve prehospital emergency care. The aim of this study is to describe the prehospital epidemiology, characteristics and outcome of (suspected) severe TBI in the Netherlands. Methods The BRAIN-PROTECT study is a prospective observational study on prehospital management of patients with severe TBI in the Netherlands. The study population comprised all consecutive patients with clinical suspicion of TBI and a prehospital GCS score ≤ 8, who were managed by one of the 4 Helicopter Emergency Medical Services (HEMS). Patients were followed-up in 9 trauma centers until 1 year after injury. Planned sub-analyses were performed for patients with “confirmed” and “isolated” TBI. Results Data from 2,589 patients, of whom 2,117 (81.8%) were transferred to a participating trauma center, were analyzed. The incidence rate of prehospitally suspected and confirmed severe TBI were 3.2 (95% CI: 3.1;3.4) and 2.7 (95% CI: 2.5;2.8) per 100,000 inhabitants per year, respectively. Median patient age was 46 years, 58.4% were involved in traffic crashes, of which 37.4% were bicycle related. 47.6% presented with an initial GCS of 3. The median time from HEMS dispatch to hospital arrival was 54 minutes. The overall 30-day mortality was 39.0% (95% CI: 36.8;41.2). Conclusion This article summarizes the prehospital epidemiology, characteristics and outcome of severe TBI in the Netherlands, and highlights areas in which primary prevention and prehospital care can be improved.

Prehospital management of patients with suspected acute coronary syndrome : Real world experience reflecting current guidelines.

BackgroundIn case of suspected acute coronary syndrome (ACS), international guidelines recommend to obtain a 12-lead ECG as soon as possible after first medical contact, to administrate platelet aggregation inhibitors and antithrombins, and to transfer the patient as quickly as possible to an emergency department.MethodsA German emergency care service database was retrospectively analysed from 2014 to 2016. Data were tested for normal distribution and the Mann–Whitney test was used for statistical analysis. Results are presented as medians (IQR).ResultsA total of 1424 patients with suspected ACS were included in the present analysis. A 12-lead ECG was documented in 96% of patients (n = 1369). The prehospital incidence of ST-segment elevation myocardial infarction (STEMI) was 18% (n = 250). In 981 patients (69%), acetylsalicylic acid (ASA), unfractionated heparin (UFH), or ASA and UFH was given. Time in prehospital care differed significantly between non-STEMI (NSTEMI) ACS (37 [IQR 30, 44] min) and STEMI patients (33 [IQR 26, 40] min, n = 1395, p < 0.0001). Most of NSTEMI ACS and STEMI patients were brought to the emergency care unit, while 30% of STEMI patients were directly handed over to a cardiac catheterization laboratory.ConclusionsPrehospital ECG helps to identify patients with STEMI, which occurs in 18% of suspected ACS. Patients without ST-elevations suffered from longer prehospital care times. Thus, it is tempting to speculate that ST-elevations in patients prompt prehospital medical teams to act more efficiently while the absence of ST-elevations even in patients with suspected ACS might cause unintended delays. Moreover, this analysis suggests the need for further efforts to make the cardiac catheterization laboratory the standard hand-over location for all STEMI patients.

Assessment of Prehospital Management of Patients Transported to a Thai University Hospital

Objective: To assess the quality of prehospital care given to patients transported to a Thai university hospital.&nbsp; &nbsp;Methods: This prospective observational study collected data from EMS providers who transported patients to Siriraj Hospital during August 2017 to November 2017. Collected data was evaluated by at least 2 EMS medical directors for appropriateness of EMS dispatch and prehospital care. The primary outcome was to determine the quality of prehospital management among patients transported by EMS. Inter-rater variability in the evaluation of patient care between EMS medical directors and medical providers in the emergency department (ED) was performed using Cohen’s kappa coefficient, with a value lower than 0.7 indicating significant variability.Results: Data was collected from 246 EMS providers that transported patients to our center. Evaluation by EMS medical directors found EMS dispatch to be appropriate in 216 cases (87.8%), and patient management to be appropriate in 198 cases (80.5%). Inappropriate prehospital management was found most often in patients who presented with out-of-hospital cardiac arrest (OHCA) (87.5%), and with chest pain (63.6%). Medical providers in the ED rated prehospital management to be appropriate in 93.1% of cases. Cohen’s kappa coefficient between EMS medical directors and ED providers was 0.2, which indicates significant variability between the two groups of assessors.Conclusion: Quality assessment of the Thai EMS system revealed opportunities for improvement in prehospital management of patients dispatched by Thai EMS. Moreover, this study found variability in the evaluation of prehospital care between medical providers at the ED and EMS medical directors. Information from this study will help to influence and guide improvement in prehospital patient care in Thailand.

Changing perspectives in the prehospital management of patients with severe burns

Treatment for burn injuries has typically involved the immediate cooling of the affected area with water to reduce pain and halt the progression of heat-induced tissue necrosis. For patients suspected to be at risk of airway compromise following inhalation burn injury, historical research has long advocated early prophylactic endotracheal intubation. In contrast, current literature is showing a change in the evidence base. To investigate this, a literature review was carried out and the evidence scrutinised in conjunction with local and national guidance. Controversy has more recently emerged over whether prophylactic endotracheal intubation is appropriate in the initial emergency management of suspected inhalation burn injury. Compounding this, it appears that no appropriate evidence-based guidelines have yet been made available. Traditional indications for prophylactic endotracheal intubation are sensitive but not specific. Research has subsequently demonstrated that large numbers of patients are being unnecessarily intubated and thus placed at risk of avoidable iatrogenic harm. A higher threshold for airway intervention is warranted. Additionally, a consensus remains over the use of prehospital cooling for burn injuries. This practice is, however, informed primarily by anecdotal and animal evidence. Patients with severe burns are at significant risk of hypothermia, which is associated with mortality. There is significantly more literature demonstrating the detrimental effects of hypothermia over the benefits of burn injury cooling in patients with severe burns. Treatment should therefore focus on the maintenance of normothermia as a priority. If cooling burned areas risks inducing hypothermia, it should be postponed.

Are you Pulling My Leg? Does the Use of Traction Splints in the Pre-Hospital Management of Patients with Femur Fractures Reduce the Complications Compared to Traditional Splinting?

Introduction Femoral shaft fractures are a serious but infrequently seen injury in the pre-hospital environment. Management of these fractures includes immobilisation, analgesia, fluid administration and appropriate conveyance. Despite traction splints being widely used since World War I, there has been no systematic review published to date. In order to support evidence-based practice this systematic review will attempt to determine if the use of traction splints in the pre-hospital management of patients with femoral shaft fractures reduces the complications compared to traditional splinting. Methods A systematic review using the MEDLINE database (1946 to 27 August 2019) using a combination of keywords and medical subject headings. The reference lists of all relevant papers were reviewed to identify further papers. The title and abstracts of all records retrieved by the search strategy were reviewed by one independent author to identify potentially relevant papers. All potentially relevant papers were read in full text. Results A total of 42 papers were identified from the search strategy; 10 met the inclusion criteria and informed the results of this paper. Five key themes were identified: inappropriate application; on-scene times; effect on pain; vascular complications; and nerve complications. Conclusion Traction splints are frequently applied incorrectly but no statistical increase in on-scene times was found. A statistically significant decrease in the need for blood transfusions was demonstrated with the application of a traction splint.

Near-infrared spectroscopy monitoring in a pre-hospital trauma patient cohort: An analysis of successful signal collection.

Noninvasive monitoring of cerebral physiology could potentially guide pre-hospital management of patients with traumatic injuries. Near-infrared spectroscopy (NIRS) is one such modality but the consistency of monitoring performance remains unclear. This study assessed the proportion of successful signal collection during pre-hospital care. As part of a prospective observational study, an independent study observer placed three sensors for a Nonin 7610 NIRS device; two on the forehead and one on the forearm. NIRS records were analysed for time of adequate monitoring signal in each sensor (>70% of total pre-hospital time). We also compared pre-hospital scene and transport times for patients with or without NIRS monitoring. Sixty-three patients with monitoring sensors applied were compared to 255 patients where no study observer was on board and 97 without NIRS monitoring for various reasons within the same time period. The proportion of pre-hospital time with successful monitoring (>70%) was 71.4% (45 of 63) for all three sensors, with at least two sensors functional in 90.4% (57 of 63). The median (interquartile range) scene time was 19 (11-23) minutes in patients with NIRS monitoring compared to 18 (11-27) minutes without NIRS monitoring (P=.570). There was no difference in the median (interquartile range) total pre-hospital time between patients with or without monitoring sensors (72 [59-89] versus 72 [59-80] minutes; P=.605). In this pre-hospital observational feasibility study with dedicated personnel an acceptable proportion of measurement time was achieved in over 90% of monitored subjects. Addition of NIRS monitoring did not alter pre-hospital scene or transport times in this research setting.

Improving the prehospital management of ST elevation myocardial infarction: a national quality improvement initiative

ST elevation myocardial infarction (STEMI) is a time-dependent clinical emergency. Early recognition and intervention in the clinical course of STEMI are key to reducing mortality and morbidity. As a result,...

Effect of Physician-Staffed Emergency Medical Services (P-EMS) on the Outcome of Patients with Severe Traumatic Brain Injury: A Review of the Literature

Introduction: Traumatic injury is the fourth leading cause of death in western countries and the leading cause of death in younger age. However, it is still unclear which groups of patients benefit most from advanced prehospital trauma care. A minimal amount is known about the effect of prehospital physician-based care on patients with specifically traumatic brain injury (TBI). The aim of this review is to assess the effect of physician-staffed Emergency Medical Services (EMS) on the outcome of patients with severe TBI.Methods: Literature searches have been performed in the bibliographic databases of PubMed, EMBASE and The Cochrane Library. Data concerning (physician-staffed) prehospital care for patients with severe TBI were only included if the control group was based on non-physician-staffed EMS. Primarily the mortality rate and secondarily the neurological outcome were examined. Additionally, data concerning hypotension, hypoxia, length of stay (hospital and intensive care unit) and the number of required early neurosurgical interventions were taken into account.Results: The overall mortality was decreased in three of the fourteen included studies after the implementation of a physician in the prehospital setting. One study found also a decrease in mortality only for patients with a Glasgow Coma Scale of 6–8. Strikingly, two other studies reported higher mortality, one for all the included patients and one for patients with GCS 10–12 only. Neurological outcome was improved in five studies after prehospital deployment of a physician. One study reported that more patients had a poor neurological outcome in the P-EMS group. Results of the remaining outcome measures differed widely.Conclusion: The included literature did not show a clear beneficial effect of P-EMS in the prehospital management of patients with severe TBI. The available evidence showed contradictory results, suggesting more research should be performed in this field with focus on decreasing heterogeneity in the compared groups.