Air medical transport for the trauma patient requiring cardiopulmonary resuscitation: a 10-year experience

Prehospital Management of Adults With Traumatic Out-of-Hospital Circulatory Arrest-A Joint Position Statement

The National Association of Emergency Medical Services Physicians (NAEMSP), American College of Surgeons Committee on Trauma (ACS-COT), and American College of Emergency Physicians (ACEP) believe that evidence-based, pragmatic, and collaborative protocols addressing the care of patients with traumatic out-of-hospital circulatory arrest (TOHCA) are needed to optimize patient outcomes and clinician safety. When the etiology of arrest is unclear, particularly without clear signs of life-threatening trauma, standard basic and advanced cardiac life support (BCLS/ACLS) treatments for medical cardiac arrest are appropriate. Traumatic circulatory arrest may result from massive hemorrhage, airway obstruction, obstructive shock, respiratory disturbances, cardiogenic causes, or massive head trauma. While resuscitation and/or transport is appropriate for some populations, it is appropriate to withhold or discontinue resuscitation attempts for TOHCA patients for whom these efforts are nonbeneficial. This position statement and resource document were written as an update to the 2013 joint position statements. NAEMSP, ACEP, and ACS-COT recommend.

An Air Medical Approach to In-Flight Cardiac Arrest Management

OBJECTIVE

Cardiac arrest during air medical transport is a complex and challenging issue, with unique factors such as limited physical space with restricted access to patients and equipment, small transport teams, limited resources, clinical isolation, effects of altitude, and the need for rapid decision making. The American Heart Association proposed 10 steps to improve outcomes of in-hospital cardiac arrest and serve as the framework for this article. This article aimed to explore these unique challenges and propose a contextual approach that might serve as the basis for improvement projects looking to improve outcomes for affected patients.

METHODS

This article represents a narrative review of the subject to consolidate the issue of cardiac arrest in the air medical setting specifically. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses literature search extension was used to guide the search strategy and methodology. The applicable items in the literature were selected through searches of the PubMed and Google Scholar databases. The Medical Subject Headings search terms used included "cardiopulmonary resuscitation" or "heart arrest" and "air ambulance" or "air medical transport,'' yielding 477 results. Screening for relevant results for inclusion was based on the relevance of the title or abstract. Articles not written in English or German or addressing commercial air transport were excluded. The reference lists of the included articles were searched for additional literature not included in the original search.

RESULTS

Three distinct phases are arbitrarily identified by the authors, and the results are discussed under the following headings: pre-arrest, intra-arrest, and post-arrest phases. The pre-arrest phase is characterized by a wide array of concepts such as appropriate goals of care, advanced preparation and action, good clinical governance, patient assessment and handover, system design and ergonomics, sterile cockpit management, appropriate alarm management, and contingency planning in the case of failed resuscitation. The intra-arrest phase is characterized by the contextualization of the usual resuscitation approach, and specific recommendations for immediate nonresuscitative actions, history, hazards, help, airway, breathing, circulation, drugs, and reversible causes are suggested. The post-arrest phase highlights the vulnerable nature of the post-cardiac arrest patient in the air medical setting. Specific considerations regarding postresuscitation care and practitioner well-being are highlighted.

CONCLUSION

This article outlines a systematic approach to various physical, clinical, mental, and systemic factors that can be used during various phases of the transport journey as well as the individual patient journey. This overview sensitizes individual clinicians or program directors to the factors needing consideration when looking to improve cardiac arrest patient outcomes.

Neurological outcomes after traumatic cardiopulmonary arrest: a systematic review

Background

Despite appropriate care, most patients do not survive traumatic cardiac arrest, and many survivors suffer from permanent neurological disability. The prevalence of non-dismal neurological outcomes remains unclear.

Objectives

The aim of the current review is to summarize and assess the quality of reporting of the neurological outcomes in traumatic cardiac arrest survivors.

Data sources

A systematic review of Embase, Medline, PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and ProQuest databases was performed from inception of the database to July 2020.

Study eligibility criteria

Observational cohort studies that reported neurological outcomes of patients surviving traumatic cardiac arrest were included.

Participants and interventions

Patients who were resuscitated following traumatic cardiac arrest.

Study appraisal and synthesis methods

The quality of the included studies was assessed using ROBINS-I (Risk of Bias in Non-Randomized Studies - of Interventions) for observational studies.

Results

From 4295 retrieved studies, 40 were included (n=23 644 patients). The survival rate was 9.2% (n=2168 patients). Neurological status was primarily assessed at discharge. Overall, 45.8% of the survivors had good or moderate neurological recovery, 29.0% had severe neurological disability or suffered a vegetative state, and 25.2% had missing neurological outcomes. Seventeen studies qualitatively described neurological outcomes based on patient disposition and 23 studies used standardized outcome scales. 28 studies had a serious risk of bias and 12 had moderate risk of bias.

Limitations

The existing literature is characterized by inadequate outcome reporting and a high risk of bias, which limit our ability to prognosticate in this patient population.

Conclusions or implications of key findings

Good and moderate neurological recoveries are frequently reported in patients who survive traumatic cardiac arrest. Prospective studies focused on quality of survivorship in traumatic arrest are urgently needed.

Level of evidence

Systematic review, level IV.

PROSPERO registration number

CRD42020198482.

A retrospective comparison of helicopter transport versus ground transport in patients with severe sepsis and septic shock

Background

Helicopter emergency medical services (HEMS) extend the reach of a tertiary care center significantly. However, its role in septic patients is unclear. Our study was performed to clarify the role of HEMS in severe sepsis and septic shock.

Methods

This is a single-center retrospective cohort study. This study was performed at Mayo Clinic, Rochester, MN, in years 2007–2009. This study included a total of 181 consecutive adult patients admitted to the medical intensive care unit meeting criteria for severe sepsis or septic shock within 24 h of admission and transported from an acute care facility by a helicopter or ground ambulance. The primary predictive variable was the mode of transport. Multiple demographic, clinical, and treatment variables were collected and analyzed with univariate analysis followed by multivariate analysis.

Results

The patients transported by HEMS had a significantly faster median transport time (1.3 versus 1.7 h, p < 0.01), faster time to meeting criteria for severe sepsis or septic shock (1.2 versus 2.9 h, p < 0.01), a higher SOFA score (9 versus 7, p < 0.01), higher incidence of acute respiratory distress syndrome (38 versus 18 %, p = 0.013), higher need for invasive mechanical ventilation (60 versus 41 % p = 0.014), higher ICU mortality (13.3 versus 4.1 %, p = 0.024), and an increased hospital mortality (17 versus 30 %, p = 0.04) when compared to those transported by ground. Distance traveled was not an independent predictor of hospital mortality on multivariate analysis.

Conclusions

HEMS transport is associated with faster transport time, carries sicker patients, and is associated with higher hospital mortality compared with ground ambulance services for patients with severe sepsis or septic shock.

Performance of an automated external defibrillator during simulated rotor-wing critical care transports

OBJECTIVE

This study aimed to evaluate whether an automated external defibrillator (AED) was accurate enough to analyze the heart rhythm during a simulated rotor wing critical care transport. We hypothesized that AED analysis of the simulated rhythms during a helicopter flight would result in significant errors (i.e., inappropriate shocks, analysis delay).

METHODS

Three commercial AEDs were tested for analyzing the heart rhythm in a helicopter using a manikin and a human volunteer. Ventricular fibrillation (VF), sinus rhythm, and asystole were simulated by using an arrhythmia simulator of the manikin. The intervals from analysis to shock recommendation were collected on a stationary and in-motion helicopter. Sensitivity and specificity of three AEDs were also calculated. Vibration intensities were measured with a digital vibration meter placed on the chest of the manikin/human volunteer both on the stretcher and on the floor of the helicopter.

RESULTS

All AEDs correctly recommended shock delivery for the cardiac rhythms of the manikin. Sensitivity for VF was 100.0% (95% CI 91.2-100.0) and specificity for sinus rhythm and asystole were 100.0% (95% CI 91.2-100.0). Although the recorded ECG rhythms of the volunteer in an in-motion helicopter showed baseline artifacts, all AEDs analyzed the cardiac rhythm of the volunteer correctly and did not recommend shock delivery. On the floor of the helicopter, the median measured vibration intensity was 6.6 m/s(2) (IQR 5.5-7.7 m/s(2)) with significantly less vibrations transmitted to the manikin/human volunteer chest (manikin median 3.1 m/s(2), IQR 2.2-4.0 m/s(2); human volunteer median 0.95 m/s(2), IQR 0.65-1.25 m/s(2)).

CONCLUSION

This study suggested that current AEDs could analyze the heart rhythm correctly during simulated helicopter transport. Further studies using an animal model would be needed before applying to patients.

The empirical basis for determinations of medical futility

BACKGROUND

Decisions to limit treatment in critically ill patients often rely on publications that make claims of futility based on outcome data. Our objective was to systematically review the criteria for futility and the strength of empirical evidence across clinical studies that purport to support or refute claims of futility.

METHODS

The MEDLINE database was searched for relevant articles published between 1980 and 2008. Selected studies reported original outcome data in critically ill or cardiac arrest patients and claimed that these data can support or refute decisions to limit treatment in comparable patients. Two authors independently abstracted data on patient characteristics, intervention, outcomes, cost, and design.

RESULTS

Forty seven studies supporting a claim of futility and 45 refuting it were reviewed. Median point estimate for adverse outcome in studies supporting claims of futility was 100% (range 75% to 100%); median lower 95% confidence limit was 91% (range 48% to 99%). Explicit thresholds for futility were missing in 88% of articles. The original criteria for quantitative futility were fulfilled by only 28% of data, and almost exclusively in studies of cardiopulmonary resuscitation (CPR) for cardiac arrest. Substantial statistical overlap was observed between data brought in support of futility claims and data brought to refute them.

CONCLUSIONS

Most studies that purport to guide determinations of futility are based on insufficient data to provide statistical confidence for clinical decision-making. They usually lack explicit a priori thresholds for determination of futility. Many studies draw disparate conclusions based on statistically similar data. In most circumstances these problems preclude confident determinations of futility.

Quality of closed chest compression in ambulance vehicles, flying helicopters and at the scene

CONTEXT

Transport of patients during resuscitation is a critical procedure. In both, ambulances and helicopters the quality of resuscitation is potentially hampered due to the movement of the vehicle and confined space. To date, however, no direct comparison of the quality of resuscitation at the scene, during a helicopter flight and in a moving ambulance has been made.

OBJECTIVE

Direct comparison of the quality of resuscitation at the scene, during a helicopter flight and in a moving ambulance.

DESIGN

The study was performed in July 2005 as a randomised cross-over trial comparing different environments for resuscitation.

SETTING

Medical University of Vienna.

PARTICIPANTS

Eleven European Resuscitation Council (ERC) approved health care professionals.

INTERVENTIONS

Interventions during resuscitation: (a) in a moving ambulance, (b) in a flying helicopter, were compared to those staying at the (c) scene (control). Each participant performed resuscitation in all three environments.

MAIN OUTCOME MEASURES

Quality of chest compression during resuscitation.

RESULTS

Compared to resuscitation at the scene, efficiency of chest compressions during a helicopter flight was 86% and 95% in the moving ambulance 95%. There were no differences in secondary outcomes (time without chest compression, total number of incorrect hand position relative to total compressions, and total number of incorrect pressure release relative to total compressions).

CONCLUSIONS

Resuscitation during transport is feasible and relatively efficient. There is some difference between the environments, but there is no relevant difference between helicopters and ambulances regarding the effectiveness of CPR.

Appropriate use of helicopters to transport trauma patients from incident scene to hospital in the United Kingdom: an algorithm

A simple algorithm has been produced to assist front line ground ambulance personnel, air ambulance crews, and immediate care doctors attending trauma patients in selecting the most appropriate mode of transport from the incident scene to hospital.

When is dead, dead? The ethics of resuscitation in emergency care

Each year thousands of people suffer a cardiac arrest. Technology, care provider education, and emergency services access have made it possible to successfully resuscitate many patients. The outcome however, may not always be positive for the patient or their family. This article looks at the ethics of resuscitation and how to determine when to start and stop resuscitation so that patients, families, and emergency care providers may make informed and acceptable decisions related to resuscitation and its potential outcomes.