Prehospital Phase Of Care Research Articles

Pre-hospital lactate testing in the recognition and management of sepsis and septic shock

Sepsis a common condition, with a high mortality rate. Patients with this condition are routinely encountered by ambulance clinicians, but recognition of septic shock can be challenging. The pre-hospital phase of sepsis care provides the earliest opportunity for identification and treatment. Lactate measurement is a tool commonly used to stratify patient illness severity in sepsis, and is recommended as part of initial management in the acute hospital setting. A lack of evidence to inform the pre-hospital phase of care for patients with suspected sepsis prompted this pragmatic evaluation of point of care lactate measurement in an ambulance service. It is important to highlight that this study was carried out prior to the 2016 Sepsis-3 definitions and quickSOFA clinical criteria for recognising sepsis.

Prehospital deaths from trauma: Are injuries survivable and do bystanders help?

Background and objectivesDeaths from trauma occurring in the prehospital phase of care are typically excluded from analysis in trauma registries. A direct historical comparison with Hussain and Redmond's study on preventable prehospital trauma deaths has shown that, two decades on, the number of potentially preventable deaths remains high. Using updated methodology, we aimed to determine the current nature, injury severity and survivability of traumatic prehospital deaths and to ascertain the presence of bystanders and their role following the point of injury including the frequency of first-aid delivery. MethodsWe examined the Coroners’ inquest files for deaths from trauma, occurring in the prehospital phase, over a three-year period in the Cheshire and Manchester (City), subsequently referred to as Manchester, Coronial jurisdictions. Injuries were scored using the Abbreviated-Injury-Scale (AIS-2008), Injury Severity Score (ISS) calculated and probability of survival estimated using the Trauma Audit and Research Network's outcome prediction model. ResultsOne hundred and seventy-eight deaths were included in the study (one hundred and thirty-four Cheshire, forty-four Manchester). The World Health Organisation's recommendations consider those with a probability of survival between 25–50% as potentially preventable and those above 50% as preventable. The median ISS was 29 (Cheshire) and 27.5 (Manchester) with sixty-two (46%) and twenty-six (59%) respectively having a probability of survival in the potentially preventable and preventable ranges. Bystander presence during or immediately after the point of injury was 45% (Cheshire) and 39% (Manchester). Bystander intervention of any kind was 25% and 30% respectively. Excluding those found dead and those with a probability of survival less than 25%, bystanders were present immediately after the point of injury or “within minutes” in thirty-three of thirty-five (94%) Cheshire and ten of twelve (83%) Manchester. First aid of any form was attempted in fourteen of thirty-five (40%) and nine of twelve (75%) respectively. ConclusionsA high number of prehospital deaths from trauma occur with injuries that are potentially survivable, yet first aid intervention is infrequent. Following injury there is a potential window of opportunity for the provision of bystander assistance, particularly in the context of head injury, for simple first-aid manoeuvres to save lives.

Prehospital deaths from trauma: Are injuries survivable and do bystanders help?

Abstract Background and objectives Deaths from trauma occurring in the prehospital phase of care are typically excluded from analysis in trauma registries. A direct historical comparison with Hussain and Redmond's study on preventable prehospital trauma deaths has shown that, two decades on, the number of potentially preventable deaths remains high. Using updated methodology, we aimed to determine the current nature, injury severity and survivability of traumatic prehospital deaths and to ascertain the presence of bystanders and their role following the point of injury including the frequency of first-aid delivery. Methods We examined the Coroners’ inquest files for deaths from trauma, occurring in the prehospital phase, over a three-year period in the Cheshire and Manchester (City), subsequently referred to as Manchester, Coronial jurisdictions. Injuries were scored using the Abbreviated-Injury-Scale (AIS-2008), Injury Severity Score (ISS) calculated and probability of survival estimated using the Trauma Audit and Research Network's outcome prediction model. Results One hundred and seventy-eight deaths were included in the study (one hundred and thirty-four Cheshire, forty-four Manchester). The World Health Organisation's recommendations consider those with a probability of survival between 25–50% as potentially preventable and those above 50% as preventable. The median ISS was 29 (Cheshire) and 27.5 (Manchester) with sixty-two (46%) and twenty-six (59%) respectively having a probability of survival in the potentially preventable and preventable ranges. Bystander presence during or immediately after the point of injury was 45% (Cheshire) and 39% (Manchester). Bystander intervention of any kind was 25% and 30% respectively. Excluding those found dead and those with a probability of survival less than 25%, bystanders were present immediately after the point of injury or “within minutes” in thirty-three of thirty-five (94%) Cheshire and ten of twelve (83%) Manchester. First aid of any form was attempted in fourteen of thirty-five (40%) and nine of twelve (75%) respectively. Conclusions A high number of prehospital deaths from trauma occur with injuries that are potentially survivable, yet first aid intervention is infrequent. Following injury there is a potential window of opportunity for the provision of bystander assistance, particularly in the context of head injury, for simple first-aid manoeuvres to save lives.

A Call for Consensus on Methodology and Terminology to Improve Comparability in the Study of Preventable Prehospital Trauma Deaths: A Systematic Literature Review.

The study of preventable deaths is essential to trauma research for measuring service quality and highlighting avenues for improving care and as a performance indicator. However, variations in the terminology and methodology of studies on preventable prehospital trauma death limit the comparability and wider application of data. The objective of this study was to describe the heterogeneity in terminology and methodology. We performed a systematic literature review and report this using the PRISMA guidelines. Searches were conducted using PubMed (including Medline), Ovid, and Embase databases. Studies, with a full text available in English published between 1990 and 2015, meeting the following inclusion criteria were included: analysis of 1) deaths from trauma, 2) occurring in the prehospital phase of care, and 3) application of criteria to ascertain whether deaths were preventable. One author screened database results for relevance by title and abstract. The full text of identified papers was reviewed for inclusion. The reference list of included papers was screened for studies not identified by the database search. Data were extracted on predefined core elements relating to preventability reporting and definitions using a standardized form. Twenty-seven studies meeting the inclusion criteria were identified: 12 studies used two categories to assess the preventability of death while 15 used three categories. Fifteen variations in the terminology of these categories and combination with death descriptors were found. Eleven different approaches were used in defining what constituted a preventable death. Twenty-one included survivability of injuries as a criterion. Methods used to determine survivability differed and eight variations in parameters for categorization of deaths were used. Nineteen used panel review in determining preventability with six implementing panel blinding. Panelcomposition varied greatly by expertise of personnel. Separation of prehospital deaths differed with 10 separating those dead at scene (DAS) and dead on arrival, three excluding those DAS, three excluding deaths prior to EMS arrival, and 11 not separating prehospital deaths. The heterogeneity in methodology, terminology, and definitions of "preventable" between studies render data incomparable. To facilitate common understanding, comparability, and analysis, a commonly agreed ontology by the prehospital research community is required.

Management of Penetrating Trauma to the Major Abdominal Vessels

Penetrating abdominal vascular injuries result in significant mortality. In the pre-hospital phase of care, “scoop and run” is the optimal strategy while on-scene interventions are restricted only to basic airway maneuvers. Early in-hospital diagnosis and operative interventions are prerequisites for survival in vascular trauma. Hypotension and peritonitis following penetrating abdominal trauma mandate immediate access to the operating room with vascular surgery capabilities. Patients presenting in extremis should be managed with a resuscitative thoracotomy in the emergency department. The majority of abdominal vascular injuries surviving to the operating room are subjected to damage control intervention. In hemodynamically stable patients, diagnostic modality of choice is computed tomography angiography and endovascular interventions are evolving.

A Prevalence and Management Study of Acute Pain in Children Attending Emergency Departments by Ambulance

Pain is the most common symptom in the emergency setting and remains one of the most challenging problems for emergency care providers, particularly in the pediatric population. The primary objective of this study was to determine the prevalence of acute pain in children attending emergency departments (EDs) in Ireland by ambulance. In addition, this study sought to describe the prehospital and initial ED management of pain in this population, with specific reference to etiology of pain, frequency of pain assessment, pain severity, and pharmacological analgesic interventions. A prospective cross-sectional study was undertaken over a 12-month period of all pediatric patients transported by emergency ambulance to four tertiary referral hospitals in Ireland. All children (<16 years) who had pain as a symptom (regardless of cause) at any stage during the prehospital phase of care were included in this study. Over the study period, 6,371 children attended the four EDs by emergency ambulance, of which 2,635 (41.4%, 95% confidence interval 40.2–42.3%) had pain as a documented symptom on the ambulance patient care report (PCR) form. Overall 32% (n = 856) of children who complained of pain were subject to a formal pain assessment during the prehospital phase of care. Younger age, short transfer time to the ED, and emergency calls between midnight and 6 am were independently associated with decreased likelihood of having a documented assessment of pain intensity during the prehospital phase of care. Of the 2,635 children who had documented pain on the ambulance PCR, 26% (n = 689) received some form of analgesic agent prior to ED arrival. Upon ED arrival 54% (n = 1,422) of children had a documented pain assessment and some form of analgesic agent was administered to 50% (n = 1,324). Approximately 41% of children who attend EDs in Ireland by ambulance have pain documented as their primary symptom. This study suggests that the management of acute pain in children transferred by ambulance to the ED in Ireland is currently poor, with documentary evidence of only 26% receiving prehospital analgesic agents.

The Combat Medic Aid Bag: 2025. CoTCCC Top 10 Recommended Battlefield Trauma Care Research, Development, and Evaluation Priorities for 2015.

While the list presented here is by no means a comprehensive list of all of the research areas of interest in battlefield trauma care, much less a list of research needs across the entire continuum of combat casualty care, it does provide the collective judgment of the CoTCCC about the highest priorities for RDT&E that relate to battlefield trauma care. Two additional observations should be made regarding that point: (1) As the landmark Eastridge et al. 2012 study convincingly documented, most combat fatalities occur in the prehospital phase of care, so research efforts that enable Combat medics, corpsmen, and PJs to care for their casualties more effectively will convey the highest probability of further reducing the case fatality rate and preventable deaths among US Combat casualties; and (2) inasmuch as the mission of the CoTCCC is to update the TCCC Guidelines as needed, this group has excellent visibility of the most important current research questions in battlefield trauma care.

Prehospital use of i.m. ketamine for sedation of violent and agitated patients.

IntroductionViolent and agitated patients pose a serious challenge for emergency medical services (EMS) personnel. Rapid control of these patients is paramount to successful prehospital evaluation and also for the safety of both the patient and crew. Sedation is often required for these patients, but the ideal choice of medication is not clear. The objective is to demonstrate that ketamine, given as a single intramuscular injection for violent and agitated patients, including those with suspected excited delirium syndrome (ExDS), is both safe and effective during the prehospital phase of care, and allows for the rapid sedation and control of this difficult patient population.MethodsWe reviewed paramedic run sheets from five different catchment areas in suburban Florida communities. We identified 52 patients as having been given intramuscular ketamine 4mg/kg IM, following a specific protocol devised by the EMS medical director of these jurisdictions, to treat agitated and violent patients, including a subset of which would be expected to suffer from ExDS. Twenty-six of 52 patients were also given parenteral midazolam after medical control was obtained to prevent emergence reactions associated with ketamine.ResultsReview of records demonstrated that almost all patients (50/52) were rapidly sedated and in all but three patients no negative side effects were noted during the prehospital care. All patients were subsequently transported to the hospital before ketamine effects wore off.ConclusionKetamine may be safely and effectively used by trained paramedics following a specific protocol. The drug provides excellent efficacy and few clinically significant side effects in the prehospital phase of care, making it an attractive choice in those situations requiring rapid and safe sedation especially without intravenous access.

The use of impedance threshold devices in spontaneously breathing, hypotensive trauma patients

Impedance threshold devices are a novel therapeutic option to increase blood pressure in the spontaneously breathing, hypotensive, trauma patient. They have multiple potential mechanisms of action. The most important is their ability to induce a more negative intrathoracic pressure during inspiration. They achieve this by the presence of a series of valves. These valves only open once the patient has generated a more negative intrathoracic pressure than is normally required for inspiration to occur. This negative intrathoracic pressure is thought to increase venous return and therefore cardiac output and subsequently blood pressure. This narrative review examines the evidence pertaining to the use of these devices in spontaneously breathing, hypotensive, trauma patients. While the literature supports the ability of these devices to increase systolic blood pressure in both animal and human models of hypotension, and more recently in patients with true pathological hypotension, potential flaws are discussed, and several key questions that have not been addressed by studies to date are highlighted. Notwithstanding these problems, impedance threshold devices may have a role in hypotensive trauma patients, particularly during the pre-hospital phase of care when available resources limit treatment options. Further work is required to prove both their clinical effectiveness and safety.

Is there a requirement for advanced airway management for trauma patients in the pre-hospital phase of care?

Method Over a one year period (April 2012-March 2013) all prehospital trauma patients attended by the doctor-paramedic LAA team who were identified as having airway compromise or an indication for any airway intervention on scene were included in a prospective observational study. The doctor paramedic team recorded any airway compromise on arrival and prior interventions carried out by ambulance service personnel.

The prevalence of hypotension and hypoxaemia in blunt traumatic brain injury in the prehospital setting of Johannesburg, South Africa: A retrospective chart review.

Each year, ~89,000 (180/100,000) new cases of head injury are reported in South Africa (SA), with the majority of patients being in the economically active population. Hypotension and hypoxaemia significantly increase the morbidity and mortality in patients who have suffered a traumatic brain injury (TBI). Cerebral tissue is particularly vulnerable to these secondary insults in the period immediately following a TBI, emphasising the importance of prehospital care in TBI. To establish the prevalence of prehospital hypotension and hypoxaemia in moderate to severe blunt TBI in greater Johannesburg, Gauteng, SA. The records of adult patients who sustained a moderate to severe TBI between 1 January and 31 December 2011 were retrospectively reviewed for hypotension (systolic blood pressure <90 mmHg) and hypoxaemia (oxygen saturation <90%) during their prehospital phase of care. These results were subject to descriptive analysis. A total of 299 records were identified, 66 of which met the inclusion criteria. The prevalence of prehospital hypotension and hypoxaemia were 33.3% (n=22) and 37.9% (n=25), respectively, while 21.2% (n=14) of patients suffered double insults of hypotension and hypoxaemia. Hypotension and hypoxaemia were associated with haemorrhage (p=0.011) and chest injuries (p=0.001), respectively. The prevalence of hypotension in this study was similar to that observed in international studies, but the prevalence of hypoxaemia was much higher. There is a need for local guidelines to be developed to inform the quality of TBI care in the context of the developing world.

Challenges to improving combat casualty survival on the battlefield.

Abstract : The United States has achieved unprecedented survival rates (as high as 98 percent) for casualties arriving alive to a combat hospital. 1 Official briefings, informal communications, and even television documentaries such as CNN Presents Combat Hospital highlight the remarkable surgical care taking place overseas. Military physicians, medics, corpsmen, and other providers of battlefield medical care are rightly proud of this achievement. Commanders and their troops can be confident that once a wounded Service - member reaches the combat hospital, his or her care will be the best in the world. Combat casualty care, however, does not begin at the hospital. It begins in the field at the point of injury and continues through evacuation to the combat hospital or forward surgery. This prehospital phase of care is the first link in the chain of survival for those injured in combat and represents the next frontier for making significant improvements in battlefield trauma care. Even with superb in-hospital care, recent evidence suggests that up to 25 percent of deaths on the battlefield are potentially preventable. The vast majority of these deaths happen in the prehospital setting. The indisputable conclusion is that any meaningful future improvement in combat casualty outcomes depends on closing the gap in prehospital survival. Improving pre - hospital combat casualty care, however, may be significantly more challenging than improving hospital-based casualty care because of significant structural challenges facing the military medical establishment. I describe five key challenges and a plan to overcome them.

G236 Prevalence and Management of Acute Pain in Children Attending Emergency Departments in Ireland Via Ambulance

AimsPain is the commonest symptom in the emergency setting. It has previously been described that pre-hospital assessment of pain in children by paramedics is often inadequate and that pain severity...

Should resuscitative thoracotomy be performed in the pre-hospital phase of care?

Penetrating thoracic trauma is increasing in the UK and elsewhere and immediate transfer to a Major Trauma Centre with cardio-thoracic expertise is usually optimal management. Pre-hospital traumatic cardiac arrest has an extremely poor prognosis. Performing thoracotomy before arrival in hospital has produced neurologically intact survivors in several case series. The technique described involves rapid clamshell thoracotomy and release of pericardial tamponade. Favourable outcomes appear to be associated with a single stab wound to the heart causing cardiac tamponade. Pre-hospital thoracotomy is described in the current European Resuscitation Guidelines and courses for non-surgeons are now taught at the Royal College of Surgeons of England and at the Surgical Skills Training Centre at Newcastle Freeman Hospital. It is likely that further survivors will be reported as the technique becomes more widely used. Alternatives to pre-hospital thoracotomy in the future for patients with hypovolaemic cardiac arrest may include resuscitative endovascular balloon occlusion of the aorta and pre-hospital extended preservation and resuscitation.

Outcomes in Seriously Head-Injured Patients Undergoing Pre-Hospital Tracheal Intubation vs. Emergency Department Tracheal Intubation

Background: The optimal treatment of major head injuries in the resuscitative phase of care post-injury has yet to be determined. This study measured the effect on mortality of pre-hospital intubation (PHI) vs. emergency department in tubation (EDI) of patients suffering serious head injury. Methods: In the single emergency medical services system for this Canadian province, we used a population-based trauma database, conventional logistic regression (with and without the use of a propensity score to control for selection effect bias) to evaluate the effect of PHI vs. EDI on in-hospital mortality. Inclusion criteria were age ≥ 16 years, serious head injury (Abbreviated Injury Score ≥ 3, non-penetrating trauma) and resuscitative intubation (PHI or EDI). Results: Over 5 years, 283 patients (2000-2005) met inclusion crite ria. Conventional unconditional logistic regression modelled on mortality with “PHI vs. EDI” as the intervention of interest showed an odds ratio of 2.015 (95% CI 1.062 3.825) for improved survival if these patients were intubated in the emergency department rather than in the pre-hospital phase of care. A propensity score adjustment demonstrated a similar but more conservative point estimate (OR 1.727, 95% CI: 0.993 3.004). Conclusions: This observational study demonstrated a survival advantage with EDI (versus PHI) in seriously head-injured patients in a mature, province-wide emergency medical services system.

Early single-shot intravenous steroids do not affect pulmonary complications and mortality in burned or scalded patients

Background and objectivesInhalation injury, especially in combination with cutaneous burns, is the major cause of morbidity and mortality in patients admitted to burn care centers. Either with or without the presence of a cutaneous burn, inhalation injury contributes to high risk for developing severe pulmonary complications. Steroids may reduce a prolonged and destructive inflammatory response to toxic or allergic substances. The objective of this study was to evaluate the effect of early single-shot intravenous steroids on pulmonary complications and mortality in burned or scalded patients with or without inhalation injury. MethodsRetrospective analysis of a prospective single center database of patients registered between 1989 and 2011 who were admitted to the intensive care unit of our burn care center after burn or scald injury. Uni-variate statistical analysis was performed comparing two groups (steroid treated vs. non steroid treated patients) with regard to clinical outcome. Main parameters were sepsis, mortality and pulmonary complications such as pneumonia, ALI and ARDS. Multi-variate analysis was used by logistic regression with mortality and pulmonary complications as the dependent variables to identify independent risk factors after burn or scald injuries. ResultsA total of 1637 patients with complete data were included in the present analysis. 199 (12.2%) received single-shot intravenous steroids during the prehospital phase of care. In 133 (66.8%) of these patients, inhalation injury was diagnosed via bronchoscopy. Steroid treated patients had sustained a significantly higher severity of burn than non-steroid treated patients (Abbreviated Burn Severity Index 7.1±3 vs. 6.0±2.9; p<0.001). In a multivariate analysis using a logistic regression model early intravenous steroid treatment had no significant effect on pulmonary complications and mortality. ConclusionsIn our single center cohort of burned and scalded patients single-shot intravenous steroids during the pre-hospital phase of care was not associated with pulmonary complications or mortality.

Prognostic Value of a Single Prehospital Measurement of N-Terminal Pro-Brain Natriuretic Peptide and Troponin T after Acute Ischaemic Stroke

Data regarding the value of prehospital measurement of N-terminal pro-brain natriuretic peptide (NT-proBNP) and troponin T as prognostic indicators of in-hospital mortality are limited. This prospective pilot study aimed to determine the value of a single combined measurement of NT-proBNP and troponin T for predicting in-hospital mortality in patients with acute ischaemic stroke in a prehospital emergency medicine centre. Blood samples were collected in the prehospital setting and analysed for NT-proBNP and troponin T, using a portable device. Parameters previously associated with stroke severity (including prognostic scoring systems) were recorded and assessed as independent predictors of in-hospital mortality. In logistic regression analysis, elevated troponin T (odds ratio [OR] 1.8 [95% CI 1.1, 8.4) and elevated NT-proBNP (OR 5.80 [95% CI 1.3, 22.7]) were significantly associated with poor outcome in patients with acute ischaemic stroke. Combined measurement of troponin T plus NT-proBNP was most predictive of survival in stroke patients (93% sensitivity, 96% specificity, 80% negative predictive value, 98% positive predictive value and 92% area under the receiver operating curve). NT-proBNP and troponin T levels, measured during the prehospital phase of care after acute ischaemic stroke, are strong predictors of in-hospital mortality.

A6 Left bundle branch block: simplified Sgarbossa criteria applied to prehospital ECGs

IntroductionIn patients presenting with chest pain, the presence of Left Bundle Branch Block (LBBB) on the ECG may obscure the diagnosis of acute myocardial infarction (AMI). Patients with LBBB caused...

US Navy Experience With Research on, and Development of, Hemoglobin-Based Oxygen Carriers

Abstract : Following 9/11 and the advent of the wars in Iraq and Afghanistan, the Naval Medical Research Center (NMRC, Silver Spring, MD} embarked on an effort to develop an improved resuscitation fluid for use in the prehospital phase of care when blood is not available for transfusion. The long-range goal of this program was to develop a multifunctional blood substitute that had oxygen-carrying, hemostatic, and anti-inflammatory capabilities. A shorter-term goal was to deliver an oxygen-carrying resuscitation fluid to both military and civilian trauma medical communities via clinical trial(s) leading to approval from the US Food and Drug Administration (FDA). Trauma is the leading cause of mortality among young adults and causes significant disability among survivors. Exsanguinating hemorrhage causing hemorrhagic shock (HS} has been reported to account for 28% of combat deaths overall and for the preponderance of civilian and potentially salvageable combat deaths (60% vs. 33% and 6% for tension pneumothorax and airway obstruction, respectively). In Operation Iraqi Freedom (Iraq war) and Operation Enduring Freedom (Afghanistan war}, 83% to 87% of potentially survivable fatalities were caused by hemorrhage occurring before hospital arrival in 55% of cases. In the event of traumatic cardiopulmonary arrest, mortality remains unacceptably high (84-98%). Traumatic anemia as a result of blood loss has been correlated directly with mortality.

Body temperature of trauma patients on admission to hospital: a comparison of anaesthetised and non-anaesthetised patients

BackgroundHypothermia at hospital admission has been found to independently predict increased mortality in trauma patients.ObjectivesTo establish if patients anaesthetised in the prehospital phase of care had a higher rate of...