Prehospital Teams Research Articles

High-energy blunt pelvic ring injuries and pre-hospital pelvic binder applications – A retrospective assessment based on a prospective registry

IntroductionApplication of a pelvic binder in the pre-hospital settings is a crucial step of high-energy blunt pelvic ring injury (PRI) management protocols. The aim of this retrospective cohort study was to evaluate the percentage of pre-hospital pelvic binder's applications in high-energy blunt type B or C PRI patients managed at a single level I trauma center, and to assess its impact on the medical resource requirements and patients' outcomes. MethodsThe institutional Severely Injured Patients’ Registry was screened for patients meeting the following inclusion criteria: (1) high-energy blunt PRI; (2) admission between 2014.01.01 and 2022.12.31; (3) age ≥16 years; and (4) available computed tomography of the pelvis. Exclusion criteria were: (1) death before admission; (2) low-energy injury; (3) penetrating, blast and electrical injuries; and (4) secondary transfers. Study variables, including pre-hospital application of a pelvic binder and demographic, clinical, management and outcome data were extracted from the registry. Additionally, AO/OTA classifications were determined. ResultsA consecutive series of 262 patients was included into the final analysis. Of these, 58.8 % received a pre-hospital pelvic binder (PPB), increasing from type A (45.1 %) to type B (57.8 %) and type C (73.7 %). Pre-hospital hemodynamic instability was a major factor triggering the use of PPB in high-energy blunt type B PRI patients with PPB in 76.9 % of the cases with hemodynamic instability vs. 51.3 % of the cases without hemodynamic instability (p = 0.009). This difference was not statistically significant for high-energy blunt type C PRI patients (82.8 % vs. 64.3 %, p = 0.200). The presence of a physician on the trauma site contributed to the increased percentage of PRI managed with PPB from 43.5 % to 67.3 % in type B PRI (p = 0.011), and from 50 % to 77.1 % in type C PRI (p = 0.257).This study showed an increased need for packed red blood cells (PRBC) transfusions in subgroups treated with PPB and no statistically significant differences in term of intensive care unit (ICU) and total hospital length of stay and complications between high-energy blunt type B or C PRI patients with or without PPB.Comparison of mortality rates in patients with and without PPB showed a trend towards lower mortality rates with PPB in patients with AIS extremity participating in at least 50 % of the total ISS. ConclusionIn the ideal pre-hospital scenario, every high-energy blunt type B or C PRI patient should be managed with a PPB. Continuous pre-hospital team training and information is crucial to achieve this goal. The preparation of Emergency Department and ICU who admit a patient with PPB should include a sufficient number of PRBC ready for transfusion. Mortality rates did not seem to be affected by PPB, except for a trend towards lower mortality rates in patients in whom their PRI was the major component of the global severity of their injury. This might point out the critical and positive effect of PPB in high-energy blunt PRI patients.

Non-invasive versus arterial pressure monitoring in the pre-hospital critical care environment: a paired comparison of concurrently recorded measurements

BackgroundBlood pressure monitoring is important in the pre-hospital management of critically ill patients. Non-invasive blood pressure (NIBP) measurements are commonly used but the accuracy of standard oscillometric cuff devices may be affected by extremes of physiology and adverse conditions (e.g. vibration) during transport. This study aimed to quantify the accuracy of NIBP measurements amongst patients requiring pre-hospital critical care.MethodsA retrospective cohort study was undertaken using data from patients treated by a pre-hospital critical team between 1st May 2020 and 30th April 2023 that had NIBP measured concurrently with invasive blood pressure (IBP) arterial manometry. An acceptable difference was determined a priori to be < 20mmHg for systolic blood pressure (SBP) and diastolic blood pressure (DBP), and < 10mmHg for mean arterial pressure (MAP). The primary outcome was “pairwise agreement”, i.e. the proportion of paired observations that fell within this range of acceptability. Bland-Altman plots were constructed together with 95% limits of agreement to visualise differences between pairs of data. Associations with patient age, reason for critical care, transport status, haemodynamic shock, severe hypertension, and arterial catheter position were explored in univariate analyses and by fitting multivariable logistic regression models.ResultsThere were 2,359 paired measurements from 221 individual patients with a median age of 57. The most frequent reason for transport was cardiac arrest (79, 35.7%). Bland-Altman analyses suggested unacceptably wide limits of agreement with NIBP overestimating both SBP and MAP during hypotension and underestimating these values during hypertension. Haemodynamic shock (SBP < 90mmHg) was independently associated with reduced pairwise agreement for SBP (adjusted odds ratio [aOR] 0.52, 95% CI 0.35 to 0.77), DBP (aOR 0.65, 95% CI 0.42 to 0.99) and MAP (aOR 0.53, 95% CI 0.36 to 0.78) and severe hypertension (SBP > 160mmHg) with reduced pairwise agreement for SBP (aOR 0.17, 95% CI 0.11 to 0.27). There was no association between patient transport and agreement between the methods for SBP, DBP, or MAP.ConclusionsNon-invasive blood pressure measurements are often inaccurate in the pre-hospital critical care setting, particularly in patients with haemodynamic instability. Clinicians should be cautious when interpreting NIBP measurements and consider direct arterial pressure monitoring when circumstances allow.

Mastering multicasualty trauma care with the Trauma Non-technical Skills Scale.

Multicasualty events present complex medical challenges. This is the first study to investigate the role of nontechnical skills in prehospital multicasualty trauma care. We assessed the feasibility of using the Trauma Nontechnical Skills Scale (T-NOTECHS) instrument, which has not yet been investigated to evaluate these scenarios. We conducted an observational study involving military medical teams with Israel Defense Forces Military Trauma Life Support training to assess the T-NOTECHS' utility in predicting prehospital medical team performance during multicasualty event simulations. These teams were selected from a pool of qualified military Advanced Life Support providers. Simulations were conducted in a dedicated facility resembling a field setting, with video recordings to ensure data accuracy. Teams faced a single multicasualty scenario, assessed by two instructors, and were evaluated using a 37-item checklist. The T-NOTECHS scores were analyzed using regression models to predict simulation performance. We included 27 teams for analysis, led by 28% physicians and 72% paramedics. Interrater reliability for simulation performance and T-NOTECHS scores showed good agreement. Overall T-NOTECHS scores were positively correlated with simulation performance scores ( R = 0.546, p < 0.001). Each T-NOTECHS domain correlated with simulation performance. The Communication and Interaction domain explained a unique part of the variance ( β = 0.406, p = 0.047). Assessment and Decision Making had the highest correlation ( R = 0.535, p < 0.001). These domains significantly predicted specific items on the simulation performance checklist. Cooperation and Resource Management showed the least correlation with checklist items. This study confirms the T-NOTECHS' reliability in predicting prehospital trauma team performance during multicasualty scenarios. Key nontechnical skills, especially Communication and Interaction, and Assessment and Decision Making, play vital roles. These findings underscore the importance of training in these skills to enhance trauma care in such scenarios, offering valuable insights for medical team preparation. Diagnostic Tests or Criteria; Level III.

Prehospital transfusion of labile blood product using intraosseous perfusion with multi-lumen extender: Why not?

French prehospital military medical teams are provided with labile blood products to effectively address hemorrhagic shock. In combat environment, standard good medical practice may limit efficacy of therapeutic goals regarding damage control resuscitation. We present here a case report describing the management of a soldier heavily wounded during a helicopter forward medical evacuation in Sahel region. We report the challenge encountered by medical team using only a humeral intraosseous route available due to severity of lesions and challenging environment. In this configuration, multi-lumen extender enabled transfusion of two units of packed red blood cells and two units of plasma, and analgesia while limiting manipulation and dislodgment of the fragile intraosseous route. This situation, outside of usual good medical practice, raises issues of hemolysis, physicochemical compability of drugs and blood products, and consequences on flow rate reduction. With this case, we emphasize the benefit of multi-lumen extender associated with intraosseous route for early management of heavy casualties in harsh prehospital environment. Literature suggests that hemolysis and physicochemical compability should remain limited. The main issue of this setting consists of flow reduction and can be addressed by prioritizing humeral route, and using counter pressure cuffs, until a second peripheral or central line is available and management can resume without the need for multi-lumen extender.

Transfusion préhospitalière des traumatisés sévères

AbstractPre-hospital transfusion of severe trauma patients is developing in many countries, including France, despite a particularly demanding regulatory context. Indeed, there is a growing body of scientific evidence to support the earliest possible use of transfusion in hemorrhagic wounded. However, performing transfusion procedures outside the hospital must not lead to a reduction in transfusion safety, and can therefore represent real logistical and training challenges for pre-hospital emergency teams, as well as for the entire transfusion chain.

A protocol for the ERICA-ARREST feasibility study of Emergency Resuscitative Endovascular Balloon occlusion of the Aorta in Out-of-Hospital Cardiac Arrest

BackgroundFewer than one in ten out-of-hospital cardiac arrest (OHCA) patients survive to hospital discharge in the UK. For prehospital teams to improve outcomes in patients who remain in refractory OHCA despite advanced life support (ALS); novel strategies that increase the likelihood of return of spontaneous circulation, whilst preserving cerebral circulation, should be investigated. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) has been shown to improve coronary and cerebral perfusion during cardiopulmonary resuscitation. Early, prehospital initiation of REBOA may improve outcomes in patients who do not respond to standard ALS. However, there are significant clinical, technical, and logistical challenges with rapidly delivering prehospital REBOA in OHCA; and the feasibility of delivering this intervention in the UK urban–rural setting has not been evaluated. MethodsThe Emergency Resuscitative Endovascular Balloon Occlusion of the Aorta in Out-of-Hospital Cardiac Arrest (ERICA-ARREST) study is a prospective, single-arm, interventional feasibility study. The trial will enrol 20 adult patients with non-traumatic OHCA. The primary objective is to assess the feasibility of performing Zone I (supra-coeliac) aortic occlusion in patients who remain in OHCA despite standard ALS in the UK prehospital setting. The trial’s secondary objectives are to describe the hemodynamic and physiological responses to aortic occlusion; to report key time intervals; and to document adverse events when performing REBOA in this context. DiscussionUsing compressed geography, and targeted dispatch, alongside a well-established femoral arterial access programme, the ERICA-ARREST study will assess the feasibility of deploying REBOA in OHCA in a mixed UK urban and rural setting.Trial registration.ClinicalTrials.gov (NCT06071910), registration date October 10, 2023, https://classic.clinicaltrials.gov/ct2/show/NCT06071910

Nationwide status of aeromedical pre-hospital and retrieval medicine in Australia.

To survey the current structure, capability and operational scope of pre-hospital and retrieval aeromedical teams across Australia. The medical directors of all Australian civilian adult aeromedical retrieval organisations with pre-hospital teams and/or doctors for inter-hospital critical care patient transport were contacted in a survey to qualitatively assess capacity and team structure. All 17 organisations contacted completed the survey. While there is diversity in team structure with the pairing of doctors, paramedics and nurses, capacity for patient care is generally homogenous. A doctor/paramedic model is the more common team structure for rotary-wing missions, and doctor/nurse for fixed-wing. Differences are mostly due to state government controlled aspects of their health services. An advanced degree of intensive patient care occurs outside of the hospital. Land and sea rescue is an important aspect of Australian aeromedical work. Aeromedicine in Australia has many consistent elements, but variable contexts have resulted in a diversity of operational models.

Attributes of leadership skill development in high-performance pre-hospital medical teams: results of an international multi-service prospective study

BackgroundsTeam leadership skills of physicians working in high-performing medical teams are directly related to outcome. It is currently unclear how these skills can best be developed. Therefore, in this multi-national cross-sectional prospective study, we explored the development of these skills in relation to physician-, organization- and training characteristics of Helicopter Emergency Medicine Service (HEMS) physicians from services in Europe, the United States of America and Australia.MethodsPhysicians were asked to complete a survey regarding their HEMS service, training, and background as well as a full Leader Behavior Description Questionnaire (LBDQ). Primary outcomes were the 12 leadership subdomain scores as described in the LBDQ. Secondary outcome measures were the association of LBDQ subdomain scores with specific physician-, organization- or training characteristics and self-reported ways to improve leadership skills in HEMS physicians.ResultsIn total, 120 HEMS physicians completed the questionnaire. Overall, leadership LBDQ subdomain scores were high (10 out of 12 subdomains exceeded 70% of the maximum score). Whereas physician characteristics such as experience or base-specialty were unrelated to leadership qualities, both organization- and training characteristics were important determinants of leadership skill development. Attention to leadership skills during service induction, ongoing leadership training, having standards in place to ensure (regular) scenario training and holding structured mission debriefs each correlated with multiple LBDQ subdomain scores.ConclusionsOngoing training of leadership skills should be stimulated and facilitated by organizations as it contributes to higher levels of proficiency, which may translate into a positive effect on patient outcomes.Trial registrationNot applicable.

Brain Injury Associated Shock: An Under-Recognized and Challenging Prehospital Phenomenon.

Hemodynamic collapse in multi-trauma patients with severe traumatic brain injury (TBI) poses both a diagnostic and therapeutic challenge for prehospital clinicians. Brain injury associated shock (BIAS), likely resulting from catecholamine storm, can cause both ventricular dysfunction and vasoplegia but may present clinically in a manner similar to hemorrhagic shock. Despite different treatment strategies, few studies exist describing this phenomenon in the early post-injury phase. This retrospective observational study aimed to describe the frequency of shock in isolated TBI in prehospital trauma patients and to compare their clinical characteristics to those patients with hemorrhagic shock and TBI without shock. All prehospital trauma patients intubated by prehospital medical teams from New South Wales Ambulance Aeromedical Operations (NSWA-AO) with an initial Glasgow Coma Scale (GCS) of 12 or less were investigated. Shock was defined as a pre-intubation systolic blood pressure under 90mmHg and the administration of blood products or vasopressors. Injuries were classified from in-hospital computed tomography (CT) reports. From this, three study groups were derived: BIAS, hemorrhagic shock, and isolated TBI without shock. Descriptive statistics were then produced for clinical and treatment variables. Of 1,292 intubated patients, 423 had an initial GCS of 12 or less, 24 patients (5.7% of the original cohort) had shock with an isolated TBI, and 39 patients had hemorrhagic shock. The hemodynamic parameters were similar amongst these groups, including values of tachycardia, hypotension, and elevated shock index. Prehospital clinical interventions including blood transfusion and total fluids administered were also similar, suggesting they were indistinguishable to prehospital clinicians. Hemodynamic compromise in the setting of isolated severe TBI is a rare clinical entity. Current prehospital physiological data available to clinicians do not allow for easy delineation between these patients from those with hemorrhagic shock.

English

Background: For patients sustaining major trauma, decreasing time to definitive care remains a primary goal. Specialized trauma team involvement is essential for coordinating the emergency department care of complex major trauma patients. The aim of this study was to evaluate if the timing of trauma team involvement impacts length of stay and time to definitive care in the emergency department. Methods: This is a single-centre retrospective medical record review, including patients meeting Quebec pre-hospital triage criteria for major trauma from May 15, 2018 to December 31, 2020. We assessed time from patient arrival until departure from the resuscitation room, time to CT scan, time to disposition, and overall length of emergency department stay. Patients were grouped according to the timing of trauma team activation (TTA) as (1) pre-hospital notification, (2) on arrival in the emergency department, (3) receiving a trauma consult only, or (4) no trauma team involvement. Mean times and standard deviations were calculated, and group differences were assessed using the Kruskal-Wallis test and the independent sample Mann-Whitney U test. Results: We identified 371 patients meeting our inclusion criteria; there were no differences between groups in mean time spent in the resuscitation room based on the timing of trauma team involvement (45-51 minutes, p=0.422). A trauma team activation with pre-hospital notification was associated with a statistically significant shorter time to CT scan (62-81 minutes, p=0.010), time to disposition (6:37-13:41, p&lt;0.001), and total emergency department length of stay (9:22-23:16 hours: minutes, p&lt;0.001). Conclusion: Appropriate trauma team activation improves performance indicators used to evaluate the quality of care in the emergency department. This research suggests that pre-hospital trauma team activation should be considered the standard of care for all patients meeting pre-hospital field triage criteria for major trauma. Keywords: trauma, triage, pre-hospital, trauma team activation, trauma quality indicators

Cardiorespiratory consequences of attenuated fentanyl and augmented rocuronium dosing during protocolised prehospital emergency anaesthesia at a regional air ambulance service: a retrospective study

BackgroundPre-Hospital Emergency Anaesthesia (PHEA) has undergone significant developments since its inception. However, optimal drug dosing remains a challenge for both medical and trauma patients. Many prehospital teams have adopted a drug regimen of 3 mcg/kg fentanyl, 2 mg/kg ketamine and 1 mg/kg rocuronium (‘3:2:1’). At Essex and Herts Air Ambulance Trust (EHAAT) a new standard dosing regimen was introduced in August 2021: 1 mcg/kg fentanyl, 2 mg/kg ketamine and 2 mg/kg rocuronium (up to a maximum dose of 150 mg) (‘1:2:2’). The aim of this study was to evaluate the cardiorespiratory consequences of a new attenuated fentanyl and augmented rocuronium dosing regimen.MethodsA retrospective study was conducted at EHAAT as a service evaluation. Anonymized records were reviewed from an electronic database to compare the original (‘3:2:1’) drug dosing regimen (December 2019-July 2021) and the new (‘1:2:2’) dosing regimen (September 2021-May 2023). The primary outcome was the incidence of absolute hypotension within ten minutes of induction. Secondary outcomes included immediate hypertension, immediate hypoxia and first pass success (FPS) rates.ResultsFollowing exclusions (n = 121), 720 PHEA cases were analysed (360 new vs. 360 original, no statistically significant difference in demographics). There was no difference in the rate of absolute hypotension (24.4% ‘1:2:2’ v 23.8% ‘3:2:1’, p = 0.93). In trauma patients, there was an increased first pass success (FPS) rate with the new regimen (95.1% v 86.5%, p = 0.01) and a reduced incidence of immediate hypoxia (7.9% v 14.8%, p = 0.05). There was no increase in immediate hypertensive episodes (22.7% vs. 24.2%, p = 0.73). No safety concerns were identified.ConclusionAn attenuated fentanyl and augmented rocuronium dosing regimen showed no difference in absolute hypotensive episodes in a mixed cohort of medical and trauma patients. In trauma patients, the new regimen was associated with an increased FPS rate and reduced episodes of immediate hypoxia. Further research is required to understand the impact of such drug dosing in the most critically ill and injured subpopulation.

The association between regional guidelines compliance and mortality in severe trauma patients: an observational, retrospective study.

Trauma is a major cause of mortality and morbidity. Regional trauma systems are the cornerstones of healthcare systems, helping to improve outcomes and avoid preventable deaths in severe trauma patients. The goal of this study was to evaluate the association between compliance with the guidelines of a regional trauma management system and survival at 28 days of severe trauma patients. We conducted a retrospective observational study from 1 January 2019 to 31 December 2019. All adult patients admitted for trauma at the University Hospital of Marseille (France) and requiring a pre-hospital medical team were analysed. Compliance with a list of 30 items based on the regional guidelines for the trauma management was evaluated. Each item was classified as compliant, not compliant or not applicable. The global compliance was calculated for each patient as the ratio between the number of compliant items over the number of applicable items. The primary aim was to measure the association between compliance with the guidelines and survival at 28 days using a logistic regression. Secondary objectives were to measure the association between compliance with the guidelines and survival at 28 days and 6 months according to the severity of the patients, using a cut-off of the injury severity score at 24. A total of 494 patients with a median age of 35.0 (25.0-50.0) years were analysed. Global compliance with guidelines was 63%. Mortality at 28 days and 6 months was assessed at 33 (6.7%) and 37 (7.5%) patients, respectively. The level of compliance was associated with reduced mortality at 28 days [odds ratio (OR) at 0.94 and 95% confidence interval (CI) at 0.89-0.98]. In the subgroup of 122 patients with an injury severity score above 23, the level of compliance was associated with reduced mortality at 28 days [OR: 0.93 (95% CI: 0.88-0.99)] and 6 months [OR: 0.93 (95% CI: 0.87-0.99)]. Increased levels of compliance with the guidelines in severe trauma patients were associated with an increase in survival, notably in the most severe patients.

Exploring the Effect of Head-Worn Displays on Prehospital Teamwork Using Online Simulation: A Crossover Randomized Controlled Trial.

Prehospital teamwork occurs in dynamic environments where paramedics work together using technologies to care for patients. Despite increasing interest in using head-worn displays (HWDs) to support prehospital workers, little is known about how HWDs affect teamwork. We tested the effect of HWDs on the team processes and patient care of paramedic trainee teams in a laboratory study using an online prehospital simulation environment, SPECTRa. In a randomized crossover design, 20 two-person teams worked in the SPECTRa laptop environment from separate physical rooms to assess and treat 2 simulated patients in 3 prehospital patient care scenarios. In each scenario, each trainee used either an HWD, a tablet computer (TAB), or no mobile device (CON) to help them monitor the vital signs of both patients. We measured team processes based around 3 themes of mutual understanding, team performance, and administered an 18-item questionnaire about teamwork and use of the devices. The mean number (HWD = 11; TAB = 7; P = 0.061) and duration (HWD = 1746 milliseconds; TAB = 1563 milliseconds; P = 0.504) of attention switches that teams made toward the mobile device did not differ with HWDs or TABs. However, teams switched attention between patients less with HWDs than with TABs ( P = 0.026) or CON ( P = 0.007) (medians: HWD = 5; TAB = 8; CON = 8). Teams communicated less when using HWDs than TABs ( P = 0.017) (medians: HWD = 76; TAB = 96; CON = 83), but there were other mixed effects on communication. Team performance did not differ across device conditions on the timeliness to notice critical patient changes ( P = 0.387) (medians: HWD = 244 seconds; TAB = 246 seconds; CON = 168 seconds) or to complete the scenarios ( P = 0.212) (medians: HWD = 800 seconds; TAB = 913 seconds; CON = 835 seconds). Questionnaire results revealed some perceived benefits of the HWD. Head-worn displays may let prehospital teams monitor each other's performance more efficiently than TABs or CON, requiring less communication to maintain patient care performance with lower workload than with TABs. However, improvements in mutual understanding with HWDs compared with CON were more evident in teams' preferences than in actual behavior. Further research is needed to confirm and extend these results.

Prevalence and clustering of NANDA-I nursing diagnoses in the pre-hospital emergency care setting: A retrospective records review study.

To determine the prevalence and clustering of NANDA-International nursing diagnoses in patients assisted by pre-hospital emergency teams. Retrospective descriptive study of electronic record review. Episodes recorded during 2019, including at least a nursing diagnosis, were recovered from the electronic health records of a Spanish public emergency agency (N = 28,847). Descriptive statistics were used to characterize the sample and determine prevalence. A two-step cluster analysis was used to group nursing diagnoses. A comparison between clusters in sociodemographic and medical problems was performed. Data were accessed in November 2020. Risk for falls (00155) (27.3%), Anxiety (00146) (23.2%), Acute pain (00132), Fear (00148) and Ineffective breathing pattern (00032) represented 96.1% of all recorded diagnoses. A six-cluster solution (n = 26.788) was found. Five clusters had a single high-prevalence diagnosis predominance: Risk for falls (00155) in cluster 1, Anxiety (00146) in cluster 2, Fear (00148) in cluster 3, Acute pain (00132) in cluster 4 and Ineffective breathing pattern (00032) in cluster 6. Cluster 5 had several high prevalence diagnoses which co-occurred: Risk for unstable blood glucose level (00179), Ineffective coping (00069), Ineffective health management (00078), Impaired comfort (00214) and Impaired verbal communication (00051). Five nursing diagnoses accounted for almost the entire prevalence. The identified clusters showed that pre-hospital patients present six patterns of nursing diagnoses. Five clusters were predominated by a predominant nursing diagnosis related to patient safety, coping, comfort, and activity/rest, respectively. The sixth cluster grouped several nursing diagnoses applicable to exacerbations of chronic diseases. Knowing the prevalence and clustering of nursing diagnoses allows a better understanding of the human responses of patients attended by pre-hospital emergency teams and increases the evidence of individualized/standardized care plans in the pre-hospital clinical setting. What problem did the study address? There are different models of pre-hospital emergency care services. The use of standardized nursing languages in the pre-hospital setting is not homogeneous. Studies on NANDA-I nursing diagnoses in the pre-hospital context are scarce, and those available are conducted on small samples. What were the main findings? This paper reports the study with the largest sample among the few published on NANDA-I nursing diagnoses in the pre-hospital care setting. Five nursing diagnoses represented 96.1% of all recorded. These diagnoses were related to patients' safety/protection and coping/stress tolerance. Patients attended by pre-hospital care teams are grouped into six clusters based on the nursing diagnoses, and this classification is independent of the medical conditions the patient suffers. Where and on whom will the research have an impact? Knowing the prevalence of nursing diagnoses allows a better understanding of the human responses of patients treated in the pre-hospital setting, increasing the evidence of individualized and standardized care plans for pre-hospital care. STROBE checklist has been used as a reporting method. Only patients' records were reviewed without further involvement.

Resuscitation with pre-hospital blood products in adults with trauma-related haemorrhagic shock: the RePHILL RCT

Background The treatment of traumatic haemorrhagic shock has been transformed through better haemorrhage control, use of tranexamic acid and use of blood products. The improved survival seen from these strategies has stimulated an interest in pre-hospital transfusion. Objectives To determine if the clinical effectiveness of resuscitation with red blood cells and lyophilised plasma was superior to 0.9% saline for improving tissue perfusion and reducing mortality in adults with haemorrhagic shock following major trauma. Design A multi-centre, allocation concealed, open-label, parallel group, randomised controlled trial (with internal pilot). Setting The trial was conducted in four civilian pre-hospital critical care services who operated within the National Health Service (NHS) England Major Trauma Networks. Participants Adults (aged ≥16 years) who had sustained traumatic injuries, were attended by a pre-hospital emergency medical team and were hypotensive (systolic blood pressure &lt;90 mmHg or absence of radial pulse) as a consequence of traumatic haemorrhage were eligible for inclusion. The exclusion criteria were known or apparently &lt;16 years, blood administered on scene prior to arrival of the RePHILL team, traumatic cardiac arrest where (1) the arrest occurred prior to arrival of the team and/or (2) the primary cause is not hypovolaemia, refusal of blood product administration, known Jehovah’s Witness, pregnancy, isolated head injury without evidence of external haemorrhage, prisoners in the custody of HM Prison and Probation Service. Interventions Participants were randomised to receive up to either two units each of red blood cells and lyophilised plasma or up to 1 L 0.9% saline. Treatment was administered through the intravenous or intraosseous route. Main outcome measures The primary outcome was a composite of episode mortality and/or impaired lactate clearance. The secondary outcomes included the individual components of the primary outcome. Results From 6 December 2016 to 2 January 2021, pre-hospital medical teams randomised 432 participants to red blood cell/lyophilised plasma (n = 209) or 0.9% saline (n = 223) out of a target sample size of 490. Most participants were white (62%), males (82%), median age 38 (interquartile range 26 to 58), involved in a road traffic collision (62%) with severe injuries (median injury severity score 36, interquartile range 25 to 50). Prior to randomisation participants had received on average 430 ml crystalloid fluids and tranexamic acid (90%). The primary outcome occurred in 128/199 (64.3%) of participants randomised to red blood cell/lyophilised plasma and 136/210 (64.8%) randomised to 0.9% saline [adjusted risk difference –0.025% (95% confidence interval –9.0% to 9.0%), p = 0.996]. The event rates for the individual components of the primary outcome, episode mortality and lactate clearance were not statistically different between groups [adjusted average differences −3% (−12% to 7%); p = 0.57 and −5% (−14% to 5%), p = 0.33, respectively]. Limitations Recruitment stopped prematurely due to disruption caused by the COVID-19 pandemic. Future work Identify the characteristics of patients who may benefit from pre-hospital blood products and whether alternative transfusion regimens are superior to standard care. Conclusions The trial did not demonstrate that pre-hospital red blood cell/lyophilised plasma resuscitation was superior to 0.9% saline for trauma-related haemorrhagic shock. Trial registration This trial is registered as ISRCTN62326938. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Efficacy and Mechanism Evaluation Programme (NIHR award ref: 14/152/14) and is published in full in Efficacy and Mechanism Evaluation; Vol. 11, No. 2. See the NIHR Funding and Awards website for further award information.

Strategi Dalam Meningkatkan Survival Rate Pada Penderita Henti Jantung Di Luar Rumah Sakit Out- Hospital Cardiac Arrest

The incidence of out-hospital cardiac arrest (OHCA) continues to increase. The survival rates of out hospital cardiac arrest decrease by 7-10% every minute. Therefore, Emergency medical services (EMS) as a part of the chain of survival needs to implement paramount strategies in order to increase survival rates. Socialization and discussion to strengthen the strategy has been conducted on December 2023 which involved pre-hospital team of Manambai Abdulkadir hospital (8 nurses, 1 doctor). It was followed by developing action plans. The pre-hospital team has chosen 2 of 10 action plans (rapid dispatch and community CPR) as main strategy to improve survival rates of out-hospital cardiac arrest patients. The Manambai Hospital are recommended to improve their support to develop human resources, medical equipment and funding to EMS team in order to improving survival rates of OHCA patients

Evaluating the impact of pre-hospital trauma team activation criteria.

Little evidence exists studying the benefits of pre-hospital trauma team activation. Our study measured the impact of pre-hospital trauma team activation on 24-h survival. Our secondary objectives assessed the effects of pre-hospital trauma team activation on time to emergency procedure, computed tomography, blood transfusion, and critical administration threshold, as well as emergency department length of stay. We conducted a 40-month health records review on all trauma team activations at The Ottawa Hospital, a Level 1 Trauma Center. Outcomes were compared between pre-hospital and in-hospital trauma team activations. We used logistic and linear regression models to assess outcomes, while controlling for injury severity score, age, systolic blood pressure, and anti-coagulation use. A P value < 0.05 was considered statistically significant. A sensitivity analysis was also used to validate the primary outcome results. Of the 1013 trauma team activations occurring during the study period, 762 patients were included. The mean age (41.3 vs. 43.8) and percentage of males (79.4% vs. 77.5%) for pre-hospital activations were similar to their counterparts. Pre-hospital activations did not have a statistically significant effect on 24-h mortality (14.4% vs. 4.5%; P = 0.30). However, pre-hospital activations did demonstrate a statistically significant reduction in time (minutes) to emergency procedure (18.0 vs. 27.0; P < 0.001), computed tomography (37.0 vs 42.0; P = 0.009), and blood transfusion (14.0 vs. 28.0; P < 0.001), as well as emergency department length of stay (101.0 vs. 171.0; P < 0.001). When controlling for key covariates, pre-hospital trauma team activation did not have a significant effect on 24-h mortality, but did result in a significant reduction in time to emergency procedure, computed tomography, and blood transfusion, as well as emergency department length of stay. Our study demonstrates that pre-hospital trauma team activation can expedite patient intervention and disposition.

Abstract 266: Texas Out of Hospital Cardiac Arrest Gender Disparities From Statewide Out-of-Hospital Cardiac Arrest Data Registry - The Texas Cares Project

Introduction: Female out-of-hospital cardiac arrest (OHCA) victims experience differences in care and worse rates of survival compared to male victims. Gender differences in time spent by prehospital care teams on scene with patients has not been studied. Hypothesis: There are gender disparities in scene time and outcomes. Increased scene time is associated with worse outcomes for Males and Females. Methods: We performed a retrospective, cohort study of the Texas Cardiac Arrest Registry to Enhance Survival (CARES) from 2014-201. We included adult OHCAs not witnessed by prehospital personnel that included scene time data and did not result in return of spontaneous circulation in the field that were transferred to emergency departments for ongoing resuscitation. We described OHCA demographics. We evaluated the association between gender and scene time. Using multivariable logistic regression, we evaluated the association of scene time with favorable neurologic outcome, (cerebral performance category (CPC) of 1 or 2). Results: We include 11,782 encounters with OHCA not witnessed by prehospital personnel, of these 7,185 were male and 4,597 female. Female OHCAs were older than male (mean 63.7 vs 61.3, p &amp;lt; 0.01). Female patients had slightly longer scene times than males (mean 29.2 vs 27.9). Female patients were less likely to have favorable neurologic outcomes (12.5% women vs 17.3% men, p &lt; 0.01 by chi2). Adjusting for age, gender, race, initial rhythm and bystander CPR in the multivariable model, increased scene time remained associated with a lower odds of favorable neurologic outcome (OR 0.96, 95%CI 0.95-0.96). Conclusions: OHCAs with longer duration scene time were associated with a lower likelihood of favorable neurologic outcome. Female patients were likely to have longer scene time duration and worse rate of favorable neurologic outcome.

Comparison of chest compression quality between the overlapping hands and interlocking hands techniques: A randomised cross-over trial

BackgroundPerforming quality chest compressions is fundamental to the management of cardiopulmonary arrest. The aim of this study was to compare the efficacy of two hand positions: overlapping versus interlocking for performing chest compressions during cardiopulmonary arrest. MethodsThe HP2C (for Hands Position and Chest Compression) was a prospective, randomised, open-label, cross-over, single-centre study. Participants were recruited from the Emergency Medical Service (EMS) teams and the prehospital firefighter teams. They were randomised to start chest compressions either with overlapping or interlocking hands and then performed the other technique after a washout period. The judgement criteria were the overall chest compressions success score generated by software in accordance with ILCOR recommendations, the quality of compression, release, rate and subjective intensity measured with the Borg scale. ResultsA total of 100 participants were included in the study. The mean age of the caregivers was 38 ± 9.3 years. The median CPR score was 79.5% IQR [48.5–94.0] in the overlapping hands group and 71% IQR [38.0–92.8] in the interlocking hands group (p-value = 0.37). There was no significant difference for the other criteria, especially no difference in term of intensity of effort. However, there was a trend towards better results with overlapping hands. ConclusionsThis study failed to demonstrate a difference in effectiveness between overlapping and interlocking hand chest compressions during cardiopulmonary resuscitation.

Epidemiological Determinants of Patient Non-Conveyance to the Hospital in an Emergency Medical Service Environment.

The increasing prevalence of comorbidities worldwide has spurred the need for time-effective pre-hospital emergency medical services (EMS). Some pre-hospital emergency calls requesting EMS result in patient non-conveyance. Decisions for non-conveyance are sometimes driven by the patient or the clinician, which may jeopardize the patients' healthcare outcomes. This study aimed to explore the distribution and determinants of patient non-conveyance to hospitals in a Middle Eastern national Ambulance Service that promotes the transportation of all emergency call patients and does not adopt clinician-based non-conveyance decision. Using R Language, descriptive, bivariate, and binary logistic regression analyses were conducted for 334,392 multi-national patient non-conveyance emergency calls from June 2018 to July 2022, from a total of 1,030,228 calls to which a response unit was dispatched. After data pre-processing, 237,862 cases of patient non-conveyance to hospital were retained, with a monthly average of 41.96% (n = 8799) of the emergency service demands and a standard deviation of 5.49% (n = 2040.63). They predominantly involved South Asians (29.36%, n = 69,849); 64.50% (n = 153,427) were of the age category from 14 to 44 years; 61.22% (n = 145,610) were male; 74.59% (n = 177,424) from the urban setting; and 71.28% (n = 169,552) had received on-scene treatment. Binary logistic regression with full variables and backward methods identified the final models of the determinants of patient non-conveyance decisions with an Akaike information criterion prediction estimator, respectively, of (250,200) and (250,169), indicating no significant difference between both models (Chi-square test; p-value = 0.63). Despite exercising a cautious protocol by encouraging patient transportation to hospital, patient non-conveyance seems to be a problem in the healthcare system that strains the pre-hospital medical response teams' resources. Policies and regulations should be adopted to encourage individuals to access other primary care centers when required rather than draining emergency services for non-emergency situations.