Prehospital Resuscitation Research Articles

Major haemorrhage fatalities in the Australian national coronial database.

The aim of the study is to describe the epidemiology of major bleeding fatalities. A case series analysis of Australia's National Coronial Information System was conducted. Keywords were used to search for closed cases of major haemorrhage in the state of Victoria for the period 1 January 2009 to 31 December 2011. Coroners' findings, autopsy reports and police reports of cases were reviewed. Demographic data were extracted, and cases were assigned to a clinical bleeding context. A total of 427 cases of major bleeding causing death were identified. The cohort was predominately men (69%), with a median age of 63 years (interquartile range 45-77 years). Trauma accounted for 38%, gastrointestinal haemorrhage 28%, surgical/procedural bleeding 14%, ruptured/leaking aneurysms 12% and other 8%. Most events began in homes (46%), hospitals (22%) and at the roadside (17%). Of those whose haemorrhage began in the community, 69% did not survive to hospital. Major bleeding fatalities occurred across a diverse range of contexts, with trauma and gastrointestinal bleeding accounting for most deaths. The majority of patients did not survive to reach hospital. Major haemorrhage occurring entirely outside hospital may be underrecognised from analyses of datasets based primarily on traumatic or in-hospital bleeding. These findings have implications for management of pre-hospital resuscitation and development of clinical practice guidelines for identification and management of major bleeding in the community.

Value of telephone guided prehospital cardiopulmonary resuscitation for patients with sudden death

2016年1至12月经我中心急救的猝死患者367例中，211例行前驱性电话指导心肺复苏(观察组)、156例未行前驱性电话指导(常规组)。常规组的现场自救的正确率、复苏成功率、回访满意度分别为5.1%、0.1%，69.2%，观察组分别为40.8%、10.9%、96.2%，均明显高于常规组。提示，观察组经前驱性电话指导急救院前猝死患者后，能初步快速评估病情，提供恰当的电话急救指导，提高抢救成功率和回访满意度。

Comparison of manual and mechanical cardiopulmonary resuscitation on the move using a manikin: a service evaluation

Aim: The aim of this study was to assess the effect that transporting a patient has on the quality of cardiopulmonary resuscitation (CPR) provided during pre-hospital resuscitation. Utilising the 2010 European Resuscitation Council (ERC) guidelines as a framework, one- and two-person manual CPR (SCPR) and mechanical CPR (MCPR) were directly compared in a simulated prehospital transport setting. Methods: Ten practising paramedics each volunteered to participate in four pre-hospital CPR scenarios. The MCPR device used for this study was the LUCASTM2. Data were captured electronically using QCPRTM wireless technology (Resusci Anne® Wireless SkillReporterTM manikin and software by Laerdal Medical©). Results: A reduction in the rate, depth and percentage of correct compressions was noted when the paramedics were moving the patient. In relation to the 2010 ERC guidelines, the SCPR did not meet current guidelines and was of more variable quality than MCPR. MCPR was consistent and conformed to the guidelines. However, the application of the LUCASTM2 when only one paramedic was present resulted in a significant delay in commencing chest compressions. Conclusion: In the pre-hospital setting, transporting a patient during a cardiac arrest can have a deleterious effect on the quality of chest compressions being provided. When provided by a mechanical device rather than manually, the quality of chest compressions produced is closer to that currently recommended, but two persons would be required for timely deployment of the device and to maximise the chest compression fraction. This could suggest a potential use for pre-hospital MCPR even in the absence of recommendation for routine use. Keywords CPR; mechanical CPR; transport

Mortality in Spanish pediatric emergency departments: a 5-year multicenter survey.

Analysis of the causes of death in children in the pediatric emergency department (ED) may aid the development of management and prevention practices. To identify the causes of death in Spanish pediatric EDs and to analyze the management of these children in the prehospital and hospital settings. This was a retrospective descriptive multicenter survey including all patients whose death was certified in 18 Spanish pediatric EDs between 2008 and 2013. During the study period, 3 542 426 episodes were registered in the EDs. Of these, 54 patients died (mortality rate: 1.5/100 000 visits). Data of 53 patients are analyzed (male 36, 67%, 31 younger than 2 years old and 43.3% nonpreviously healthy children). The main causes of death were related to their previous illnesses (24.5%), sudden infant death syndrome (20.7%), and traumatism (18.8%).Prehospital cardiopulmonary resuscitation (CPR) was performed in 31 patients, and exclusively by health workers in 19 patients. In 35 patients, the parents witnessed the event and seven began CPR.Thirty children were transferred to the pediatric EDs by medical transport (56.6%) and all of them received prehospital CPR (vs. one patient out of 23 arrived in a nonmedical transportation).In 37 patients, CPR was performed in the pediatric EDs. Overall, CPR lasted 40±23 min (range, 10-120 min). CPR was not performed in seven patients at any time. The main causes of death in Spanish pediatric EDs are related to previous illnesses, sudden infant death syndrome, and nonintentional lesions. Several actions have to be considered to improve the quality of care of these children in prehospital and emergency settings.

Prehospital Supraglottic Airway Was Associated With Good Neurologic Outcome in Cardiac Arrest Victims Especially Those Who Received Prolonged Cardiopulmonary Resuscitation.

We performed this study to investigate the association of prehospital supraglottic airway (SGA) on neurologic outcome in cardiac arrest victims with adjustment of postresuscitation variables as well as prehospital and resuscitation variables. This study was a retrospective study based on a multicenter prospective cohort registry from December 2013 to April 2016. According to the 28-day cerebral performance categories (CPCs) scale, patients were divided into the good-outcome group (CPC1-2) and the poor-outcome group (CPC3-5). We compared the two groups with respect to demographic variables, prehospital and in-hospital resuscitation variables, and postresuscitation variables. A total of 869 cardiac arrest victims who received in-progress cardiopulmonary resuscitation (CPR) were delivered to the emergency department of three hospitals, and 310 patients were admitted to the intensive care unit. The use of a prehospital SGA was independently associated with 28-day good neurologic outcome (odds ratio [OR]= 7.88; 95% confidence interval [CI]= 1.33-46.53; p=0.023] when postresuscitation variables were adjusted, although there were no significant association with the acquisition of sustained return of spontaneous circulation (OR= 0.992; 95% CI= 0.591-1.666; p=0.976). Furthermore, a prehospital SGA was significantly associated with good neurologic outcome, especially in patients who received prolonged CPR (low flow time>15 minutes; OR= 3.41; 95% CI= 1.23-9.45; p=0.018) rather than in patients with nonprolonged CPR (OR= 4.50; 95% CI= 0.75-27.13; p=0.101). When postresuscitation variables were adjusted, the prehospital SGA was independently associated with 28-day good neurologic outcome in cardiac arrest victims.

Prehospital hemostatic resuscitation to achieve zero preventable deaths after traumatic injury.

To describe how hemostatic resuscitation can be used in the prehospital phase of resuscitation to reduce preventable deaths after traumatic injury. Hemorrhagic shock is the leading cause of death that is preventable after injury. The National Academy of Sciences, recently, recommended that achievement of zero preventable deaths after traumatic injury should be the goal of a national trauma system. In the United States, there are an estimated 25 000 preventable deaths per year in the prehospital phase of resuscitation because of traumatic hemorrhagic shock. Therefore, to achieve the goal of zero preventable deaths after injury, both shock and hemostatic dysfunction need to be addressed rapidly in the prehospital phase of resuscitation. This review will highlight the epidemiology and outcomes of traumatic hemorrhagic shock, and explore potential solutions such as group O whole blood and platelets stored at 2-6°C. Trauma research receives the lowest funding relative to the burden of morbidity and mortality it creates when compared with all other diseases. Increased resources are required to achieve zero preventable deaths after injury. Prehospital hemostatic resuscitation has the potential to significantly reduce preventable death from hemorrhage.

Update on critical care for acute spinal cord injury in the setting of polytrauma.

Traumatic spinal cord injury (SCI) often occurs in patients with concurrent traumatic injuries in other body systems. These patients with polytrauma pose unique challenges to clinicians. The current review evaluates existing guidelines and updates the evidence for prehospital transport, immobilization, initial resuscitation, critical care, hemodynamic stability, diagnostic imaging, surgical techniques, and timing appropriate for the patient with SCI who has multisystem trauma. Initial management should be systematic, with focus on spinal immobilization, timely transport, and optimizing perfusion to the spinal cord. There is general evidence for the maintenance of mean arterial pressure of > 85 mm Hg during immediate and acute care to optimize neurological outcome; however, the selection of vasopressor type and duration should be judicious, with considerations for level of injury and risks of increased cardiogenic complications in the elderly. Level II recommendations exist for early decompression, and additional time points of neurological assessment within the first 24 hours and during acute care are warranted to determine the temporality of benefits attributable to early surgery. Venous thromboembolism prophylaxis using low-molecular-weight heparin is recommended by current guidelines for SCI. For these patients, titration of tidal volumes is important to balance the association of earlier weaning off the ventilator, with its risk of atelectasis, against the risk for lung damage from mechanical overinflation that can occur with prolonged ventilation. Careful evaluation of infection risk is a priority following multisystem trauma for patients with relative immunosuppression or compromise. Although patients with polytrauma may experience longer rehabilitation courses, long-term neurological recovery is generally comparable to that in patients with isolated SCI after controlling for demographics. Bowel and bladder disorders are common following SCI, significantly reduce quality of life, and constitute a focus of targeted therapies. Emerging biomarkers including glial fibrillary acidic protein, S100β, and microRNAs for traumatic SCIs are presented. Systematic management approaches to minimize sources of secondary injury are discussed, and areas requiring further research, implementation, and validation are identified.

Utility of prehospital electrocardiogram characteristics as prognostic markers in out-of-hospital pulseless electrical activity arrests

BackgroundIt is unclear if there are predictors of survival, including ECG characteristics, that can guide resuscitative efforts in pulseless electrical activity (PEA) cardiac arrests. We studied the predictive potential of...

In-hospital mortality after acute STEMI in patients undergoing primary PCI.

Acute myocardial infarction (AMI) is the main cause of global and in-hospital mortality in patients with cardiovascular diseases. We aimed to examine the association between the coronary artery involved and the in-hospital mortality in patients who underwent primary percutaneous coronary intervention (pPCI) after ST segment elevation myocardial infarction (STEMI). The in-hospital mortality of STEMI patients who underwent pPCI was assessed at the Department of Cardiology, Harzklinik Goslar, Germany, which has no access to immediate mechanical circulatory support (MCS), between 2013 and 2017. We enrolled 312 STEMI patients, with amean age of 67.1± 13.4years, of whom 211 (68%) were male. In-hospital mortality was documented in 31patients (10%). In-hospital mortality was associated with pre-hospital cardiopulmonary resuscitation (CPR; n= 39/12.5%), older age, lower systolic blood pressure, Killip class> 1,triple-vessel disease (each p< 0.0001), female gender (p= 0.0158), and with the localization of the treated culprit lesion in the left main coronary artery (LMCA; p= 0.0083) and in the ramus circumflexus (RCX; p= 0.0141). In this monocentric cohort, all-cause in-hospital mortality of STEMI patients after pPCI was significantly higher in those patients with culprit lesions in the LMCA and in the RCX, which may prove to be asubstantial novel risk factor for STEMI-related mortality. Increasing age and female gender may be interdependent risk factors for mortality in this patient population. Furthermore, our data highlight the importance of the availability of MCS options in pPCI centers for patients after CPR.

Analysis of out-of-hospital emergency treatment for ventricular fibrillation between 2013 and 2016 in Shanghai

To investigate the epidemiological features of out-of-hospital patients with ventricular fibrillation (VF) in Shanghai and to analysis factors associated with outcomes, and to provide evidence for improving the success rate of VF. The data of patients with VF admitted to Shanghai Medical Emergency Center from January 2013 to December 2016 were analyzed retrospectively. All the data were recorded including the clinical data, medical service time, return of spontaneous circulation (ROSC) at scene/en route, survival to hospital discharge. Factors that associated with successful resuscitation were analyzed by Logistic regression. From 2013 to 2016, 21 096 patients with suspected cardiac arrest were admitted to the Shanghai Medical Emergency Center. After excluding ventricular tachycardia (13 cases) and ventricular asystole (20 995 cases), 88 patients with VF were enrolled, with 62 male and 26 female; the average age was (63.22±16.15) years old. While bystander cardiopulmonary resuscitation (CPR) was performed in only 21 cases (23.86%). Fifty-seven cases occurred during the day (08:00-20:00), while 31 cases occurred in the night. And the average emergency response time was (6.47±4.13) minutes; the average on-site time was (14.76±10.88) minutes; the average transport to hospital time was (5.95±4.00) minutes. There were no significant differences in response time, on-site time and transport to hospital time each year, and there were no significant differences in emergency medical service time between day and night either. From 2013 to 2016, prehospital successful resuscitation rate was decreased by years [95.65% (22/23), 87.50% (14/16), 83.33% (20/24) vs. 80.00% (20/25), respectively, χ2 = 1.895, P = 0.595]. Survival to hospital discharge rate was increased by years [21.74% (5/23), 31.25% (5/16), 37.50% (9/24), 40.00% (10/25), respectively, χ 2 = 2.862, P = 0.413]. The success rate of prehospital resuscitation for patients with 1, 2, ≥3 defibrillation was 35.23% (31/88), 23.08% (12/52), 89.19% (33/37), respectively (χ2 = 42.811, P = 0.000). The on-site time in successful final resuscitation group was shorter than that in final resuscitation failure group (minutes: 10.85±8.83 vs. 16.79±11.36, t = 2.367, P = 0.020), the ROSC time in successful final resuscitation group was shorter than that of final resuscitation failure group (minutes: 3.24±3.17 vs. 7.43±6.64, t = 3.175, P = 0.002). It was shown by Logistic regression that long ROSC time was the risk factor for final resuscitation failure [odds ratio (OR) = 0.771, P = 0.024]. Gender, age, availability of witnesses CPR, call time, emergency response time, on-site time and transport to hospital time had no significant impact on the prehospital successful resuscitation and final successful resuscitation. In prehospital successful resuscitation group, there was significant difference in survival to hospital discharge rate among different defibrillation times group [48.39% (15/31), 58.33% (7/12) vs. 21.21% (7/33), χ2 = 7.460, P = 0.024]. From 2013 to 2016, there were no significant changes in the emergency response time, prehospital successful resuscitation rate and survival to hospital discharge rate of patients with VF in Shanghai. Though, repeated defibrillation could significantly increased prehospital successful resuscitation rate, multiple defibrillation indicated decline of survival to hospital discharge rate in prehospital successful resuscitation group. Additionally, long on-site time and long ROSC time indicated poor prognosis.

“First, Do No Harm”: Old and New Paradigms in Prehospital Resuscitation in the Aquatic Domain

The balance between benefit and risk is central to the work of all those involved in aquatic services. The Hippocratic exhortation of Primum non nocere, First, do no harm, has a history of over 2000 years. Superficially, all would support this dictum, but harm can result from inaction. The balance between no or little intervention on the one hand and proactive intervention with iatrogenic risk on the other is complex and enduring. Risk implies that one does not have all the information available to know the exact likelihood of an outcome, a common situation involving rescue, first aid, and resuscitation. The theme of Primum non nocere (and its congener, risk-benefit ratios) in the aquatic rescue and resuscitation domain has both ethical (e.g., Good Samaritan) and legal (e.g., tort action) implications. Recently, a reversal in intervention philosophy, Any attempt at resuscitation is better than no attempt, has emerged. This aphorism is in stark contrast to the traditionally conservative, Don’t do anything for which you are untrained. Current and continuing research audits are needed to assess whether this newer paradigm results in a risk-benefit ratio low enough to counter the traditional Primum non nocere.

GW28-e0593 Shorter pre-hospital resuscitation duration is independently associated with improved outcomes in out-of-hospital cardiac arrest

Our data showed that out-of-hospital cardiac arrest (OHCA) patients with return of spontaneous circulation (ROSC) obtained in the field did not typically survive with favorable neurological outcomes, whereas more than half of OHCA cases who survived to hospital with favorable neurological recovery

Prehospital plasma resuscitation associated with improved neurologic outcomes after traumatic brain injury.

Trauma-related hypotension and coagulopathy worsen secondary brain injury in patients with traumatic brain injuries (TBIs). Early damage control resuscitation with blood products may mitigate hypotension and coagulopathy. Preliminary data suggest resuscitation with plasma in large animals improves neurologic function after TBI; however, data in humans are lacking. We retrospectively identified all patients with multiple injuries age >15 years with head injuries undergoing prehospital resuscitation with blood products at a single Level I trauma center from January 2002 to December 2013. Inclusion criteria were prehospital resuscitation with either packed red blood cells (pRBCs) or thawed plasma as sole colloid resuscitation. Patients who died in hospital and those using anticoagulants were excluded. Primary outcomes were Glasgow Outcomes Score Extended (GOSE) and Disability Rating Score (DRS) at dismissal and during follow-up. Of 76 patients meeting inclusion criteria, 53% (n = 40) received prehospital pRBCs and 47% (n = 36) received thawed plasma. Age, gender, injury severity or TBI severity, arrival laboratory values, and number of prehospital units were similar (all p > 0.05). Patients who received thawed plasma had an improved neurologic outcome compared to those receiving pRBCs (median GOSE 7 [7-8] vs. 5.5 [3-7], p < 0.001). Additionally, patients who received thawed plasma had improved functionality compared to pRBCs (median DRS 2 [1-3.5] vs. 9 [3-13], p < 0.001). Calculated GOSE and DRS scores during follow-up, median 6 [5-7] months, demonstrated increased function in those resuscitated with thawed plasma compared to pRBCs by both median GOSE (8 [7-8] vs. 6 [6-7], p < 0.001) and DRS (0 [0-1] vs. 4 [2-8], p < 0.001). In critically injured trauma patients with TBI, early resuscitation with thawed plasma is associated with improved neurologic and functional outcomes at discharge and during follow-up compared to pRBCs alone. These preliminary data support the further investigation and use of plasma in the resuscitation of critically injured TBI patients. Therapeutic, level V.

A systematic literature review and triage tool for pre-hospital extracorporeal cardiopulmonary resuscitation in London

Introduction: The probability of surviving an out-of-hospital cardiac arrest remains low despite the introduction of novel therapies. Extracorporeal cardiopulmonary resuscitation (eCPR) may have a role to play in certain patients in whom conventional cardiopulmonary resuscitation (cCPR) is not successful, but the clarification of which patients remains unclear. This project systematically reviewed the evidence comparing the outcomes of eCPR over cCPR, before analysing which patients might benefit from eCPR to create a potential triage tool.

Body Mass Index &gt;35 as Independent Predictor of Mortality in Severe Traumatic Brain Injury

Severe traumatic brain injury (TBI) has a major influence on polytrauma outcome. The aim of this study was to evaluate the impact of body mass index (BMI) on mortality and early neurologic outcome in patients suffering from severe TBI with a special focus on obesity classes II and III (BMI ≥35). A retrospective cohort analysis of patients suffering from a leading, at least severe TBI and registered in the TraumaRegister DGU was conducted. Patients alive on admission with full status documentation on Glasgow Coma Scale, height, and weight were classified into 4 BMI subgroups. Early neurologic outcome was classified using the Glasgow Outcome Scale. A total of 1634 patients met the inclusion criteria. Lowest mortality was documented for BMI group 1 (15.2%, BMI 25.0-29.9918.5). Highest mortality was found in BMI group 5 (25.6%, BMI ≥35). BMI ≥35 was an independent predictor of mortality with an odds ratio of 3.15 (95% confidence interval [1.06-9.36], P= 0.039). Further independent mortality predictors were >65 years of age, a Glasgow Coma Scale of ≤13, an Abbreviated Injury Scalehead ≥5, prehospital cardiopulmonary resuscitation, and a prehospital blood pressure of <90 mm Hg. In terms of good early neurologic outcomes, no differences were recorded between the BMI groups (range 59.0%-62.6%, P= 0.087). In this study a BMI ≥35 is an independent predictor of mortality and is associated with an inferior early functional neurologic outcome.

A comparison of Selective Aortic Arch Perfusion and Resuscitative Endovascular Balloon Occlusion of the Aorta for the management of hemorrhage-induced traumatic cardiac arrest: A translational model in large swine.

BackgroundSurvival rates remain low after hemorrhage-induced traumatic cardiac arrest (TCA). Noncompressible torso hemorrhage (NCTH) is a major cause of potentially survivable trauma death. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) at the thoracic aorta (Zone 1) can limit subdiaphragmatic blood loss and allow for IV fluid resuscitation when intrinsic cardiac activity is still present. Selective Aortic Arch Perfusion (SAAP) combines thoracic aortic balloon hemorrhage control with intra-aortic oxygenated perfusion to achieve return of spontaneous circulation (ROSC) when cardiac arrest has occurred.Methods and findingsMale Yorkshire Landrace cross swine (80.0 ± 6.0 kg) underwent anesthesia, instrumentation for monitoring, and splenectomy. TCA was induced by laparoscopic liver lobe resection combined with arterial catheter blood withdrawal to achieve a sustained systolic blood pressure <10 mmHg, cardiac arrest. After 3 min of arrest, swine were allocated to one of three interventions: (1) REBOA plus 4 units of IV fresh whole blood (FWB), (2) SAAP with oxygenated lactated Ringer’s (LR), 1,600 mL/2 min, or (3) SAAP with oxygenated FWB 1,600 mL/2 min. Primary endpoint was survival to the end of 60 min of resuscitation, a simulated prehospital phase. Thirty animals were allocated to 3 groups (10 per group)—5 protocol exclusions resulted in a total of 35 animals being used. Baseline measurements and time to cardiac arrest were not different amongst groups. ROSC was achieved in 0/10 (0%, 95% CI 0.00–30.9) REBOA, 6/10 (60%, 95% CI 26.2–87.8) SAAP-LR and 10/10 (100%, 95% CI 69.2–100.0) SAAP-FWB animals, p < 0.001. Survival to end of simulated 60-minute prehospital resuscitation was 0/10 (0%, 95% CI 0.00–30.9) for REBOA, 1/10 (10%, 95% CI 0.25–44.5) for SAAP-LR and 9/10 (90%, 95% CI 55.5–99.7) for SAAP-FWB, p < 0.001. Total FWB infusion volume was similar for REBOA (2,452 ± 0 mL) and SAAP-FWB (2,250 ± 594 mL). This study was undertaken in laboratory conditions, and as such may have practical limitations when applied clinically. Cardiac arrest in this study was defined by intra-aortic pressure monitoring that is not feasible in clinical practice, and as such limits the generalizability of findings. Clinical trials are needed to determine if the beneficial effects of SAAP-FWB observed in this laboratory study will translate into improved survival in clinical practice.ConclusionsSAAP conferred a superior short-term survival over REBOA in this large animal model of hemorrhage-induced traumatic cardiac arrest with NCTH. SAAP using an oxygen-carrying perfusate was more effective in this study than non-oxygen carrying solutions in TCA. SAAP can effect ROSC from hemorrhage-induced electrocardiographic asystole in large swine.

Measuring the impact of emergency medical services (EMS) on out-of-hospital cardiac arrest survival in a developing country: A key metric for EMS systems' performance.

Out-of-hospital cardiac arrest (OHCA) can be used to evaluate the overall performance of the emergency medical services’ (EMS) system. This study assessed the impact of EMS on OHCA survival rates in a setting where the prehospital system is underdeveloped.A retrospective chart review was carried out over a 5-year period of all adult OHCA patients admitted to the emergency department (ED) of a tertiary care center in Lebanon.A total of 271 patients with OHCA (179 [66.1%] men, mean age of 69.9 [standard deviation = 15.0 years] were enrolled. The most common OHCA location was residence/home (58.7%). The majority of arrests were witnessed (51.7%) with 6.1% witnessed by EMS; 211 patients (75.6%) were transported to the ED by EMS. Prehospital cardiopulmonary resuscitation (CPR) was done by EMS for 43.2% of the patients, whereas only 4.4% received CPR from a family member/bystander. Prehospital automated external defibrillator use was documented in 1.5% of cases in the prehospital setting. Only 2 patients had return of spontaneous circulation prior to ED arrival. Most patients (96.7%) were resuscitated in the ED. Patients presented to the ED mostly in asystole (79.3%). Forty-three patients (15.9%) survived to hospital admission and 13 (4.8%) were discharged alive with over half of them (53.8%) had a good neurological outcome upon discharge (cerebral performance category 1 or 2).Survival of EMS-treated OHCA victims in Lebanon is not as expected. Medical oversight of EMS activities is needed to link EMS activities to clinical outcomes and improve survival from cardiac arrest in Lebanon.

Multicenter observational prehospital resuscitation on helicopter study.

Earlier use of in-hospital plasma, platelets, and red blood cells (RBCs) has improved survival in trauma patients with severe hemorrhage. Retrospective studies have associated improved early survival with prehospital blood product transfusion (PHT). We hypothesized that PHT of plasma and/or RBCs would result in improved survival after injury in patients transported by helicopter. Adult trauma patients transported by helicopter from the scene to nine Level 1 trauma centers were prospectively observed from January to November 2015. Five helicopter systems had plasma and/or RBCs, whereas the other four helicopter systems used only crystalloid resuscitation. All patients meeting predetermined high-risk criteria were analyzed. Patients receiving PHT were compared with patients not receiving PHT. Our primary analysis compared mortality at 3 hours, 24 hours, and 30 days, using logistic regression to adjust for confounders and site heterogeneity to model patients who were matched on propensity scores. Twenty-five thousand one hundred eighteen trauma patients were admitted, 2,341 (9%) were transported by helicopter, of which 1,058 (45%) met the highest-risk criteria. Five hundred eighty-five of 1,058 patients were flown on helicopters carrying blood products. In the systems with blood available, prehospital median systolic blood pressure (125 vs 128) and Glasgow Coma Scale (7 vs 14) was significantly lower, whereas median Injury Severity Score was significantly higher (21 vs 14). Unadjusted mortality was significantly higher in the systems with blood products available, at 3 hours (8.4% vs 3.6%), 24 hours (12.6% vs 8.9%), and 30 days (19.3% vs 13.3%). Twenty-four percent of eligible patients received a PHT. A median of 1 unit of RBCs and plasma were transfused prehospital. Of patients receiving PHT, 24% received only plasma, 7% received only RBCs, and 69% received both. In the propensity score matching analysis (n = 109), PHT was not significantly associated with mortality at any time point, although only 10% of the high-risk sample were able to be matched. Because of the unexpected imbalance in systolic blood pressure, Glasgow Coma Scale, and Injury Severity Score between systems with and without blood products on helicopters, matching was limited, and the results of this study are inconclusive. With few units transfused to each patient and small outcome differences between groups, it is likely large, multicenter, randomized studies will be required to detect survival differences in this important population. Level II.

Identification of common locations of out-of-hospital cardiac arrests in aGerman metropolis

Most patients who suffer asudden cardiac arrest initially have ashockable rhythm. Fast defibrillation and correctly performed cardiopulmonary resuscitation (CPR) are key factors for patient survival. These can be carried out by bystanders if an automated external defibrillator (AED) is available even in the absence of emergency services. The place and time of CPRs in a German city were investigated and the strategic placement of emergency medical services and AEDs necessary were evaluated. All prehospital resuscitation attempts by Bochum's emergency services in 2011 were retrospectively analyzed. The city was divided into agrid, according to the city map to describe the location of every resuscitation. The distribution of cases was correlated to the city grid and time of day. There were 299 cardiac arrests (mean age 74.2± 12.47years; 59% of patients were male). Most resuscitations happened in ahome environment between 8am and 8pm. There was ahigher proportion of resuscitation attempts in grid squares with ahigh population density. Of the resuscitations in public places 16 of 47 (34%) happened in city district centers. In 72% of all cases, only anonshockable rhythm could be documented as primary arrhythmia on the arrival of the emergency services. Of the 299 attempted resuscitations, areturn of spontaneous circulation was achieved in 41%. The knowledge about increased frequency of resuscitations in city centers provides insight for strategic placement of emergency devices and services in those areas. This can possibly minimize the time until first response and enables early defibrillation with AED in afirst-responder program. In addition, bystanders should obtain clear instructions for resuscitation by the dispatcher of the emergency services.

Prehospital hypertonic fluid resuscitation for trauma patients: A systematic review and meta-analysis.

Prehospital assessment of a patient's circulation status and appropriate resuscitation with intravenous fluids plays a critical role in patients with obvious hemorrhage or systolic blood pressure below 90 mm Hg. We assessed the efficacy and safety of prehospital administration of crystalloids or colloids to improve the survival rate of trauma patients with acceptable safety profile. We searched SCOPUS, Embase, TRIP database, Cochrane Central Register of Controlled Trials, Ovid MEDLINE, and PubMed as per search protocol from January 1, 1900 to February 12, 2015. All randomized controlled trials were considered. All patients had penetrating or blunt trauma, excluding traumatic brain or thermal injuries. At least one of the comparators should be a crystalloid or colloid. Detailed search strategy was developed and utilized. Duplicates were removed from the search results. We, the co-first authors (C.d.C. and F.G.), independently reviewed the article titles and abstracts to assess eligibility. Eligible articles were downloaded for full text review to determine inclusion in the review and analysis. We (C.d.C. and F.G.) performed a methodological quality assessment of each included article. The primary outcome was mortality. The secondary outcomes included adverse events, infections, multiple organ dysfunction score, and length of stay at the hospital. Heterogeneity was measured by I value. An I value greater than 50% was considered to be substantial heterogeneity. Fixed effect analysis and random effect analysis were performed when needed. A total of nine trials (3,490 patients) were included in the systematic review, and six trials were included in meta-analyses. There were no significant differences between hypertonic saline with dextran and lactated Ringer's solution in 1 day using two studies (2.91; 95% CI, 0.58-14.54; p = 0.19) and 28- to 30-day survival rates using another two studies (1.47; 95% CI, 0.30-7.18; p = 0.63). Adding dextran to hypertonic saline did not increase the survival rate (0.94; 95% CI, 0.65-1.34; p = 0.71). Overall, complications were comparable between all groups. The quality of some of the included studies is not optimal. There is no beneficial effect of hypertonic saline with or without dextran in general traumatic patients. Further trials to evaluate its benefit in patients with penetrating trauma requiring surgery are warranted. Systematic review and meta-analysis, level I.