Development and internal validation of an algorithm for estimating mortality in patients encountered by physician-staffed helicopter emergency medical services

BACKGROUND

Severity of illness scoring systems are used in intensive care units to enable the calculation of adjusted outcomes for audit and benchmarking purposes. Similar tools are lacking for pre-hospital emergency medicine. Therefore, using a national helicopter emergency medical services database, we developed and internally validated a mortality prediction algorithm.

METHODS

We conducted a multicentre retrospective observational register-based cohort study based on the patients treated by five physician-staffed Finnish helicopter emergency medical service units between 2012 and 2019. Only patients aged 16 and over treated by physician-staffed units were included. We analysed the relationship between 30-day mortality and physiological, patient-related and circumstantial variables. The data were imputed using multiple imputations employing chained equations. We used multivariate logistic regression to estimate the variable effects and performed derivation of multiple multivariable models with different combinations of variables. The models were combined into an algorithm to allow a risk estimation tool that accounts for missing variables. Internal validation was assessed by calculating the optimism of each performance estimate using the von Hippel method with four imputed sets.

RESULTS

After exclusions, 30 186 patients were included in the analysis. 8611 (29%) patients died within the first 30 days after the incident. Eleven predictor variables (systolic blood pressure, heart rate, oxygen saturation, Glasgow Coma Scale, sex, age, emergency medical services vehicle type [helicopter vs ground unit], whether the mission was located in a medical facility or nursing home, cardiac rhythm [asystole, pulseless electrical activity, ventricular fibrillation, ventricular tachycardia vs others], time from emergency call to physician arrival and patient category) were included. Adjusted for optimism after internal validation, the algorithm had an area under the receiver operating characteristic curve of 0.921 (95% CI 0.918 to 0.924), Brier score of 0.097, calibration intercept of 0.000 (95% CI -0.040 to 0.040) and slope of 1.000 (95% CI 0.977 to 1.023).

CONCLUSIONS

Based on 11 demographic, mission-specific, and physiologic variables, we developed and internally validated a novel severity of illness algorithm for use with patients encountered by physician-staffed helicopter emergency medical services, which may help in future quality improvement.

Exploring paramedic perspectives on emergency medical service (EMS) delivery in Alberta: a qualitative study

PURPOSE

Emergency Medical Services (EMS) in Alberta are facing critical challenges. This qualitative study aims to describe and understand the frontline perspective regarding system level issues and propose provider-informed policy recommendations.

METHODS

19 semi-structured one-on- one interviews were conducted with Primary or Advanced Care Paramedics (PCP/ACP) across Alberta. Participants were asked to share their perspectives, experiences and recommendations in relation to EMS response times and the working environment. Interviews were analyzed using thematic analysis to identify themes and subthemes.

RESULTS

Two core themes were identified as areas of concern: poor response times and the EMS working environment, which each influence and impact the other. Within response times, paramedics highlighted specific difficulties with ED offloading, a lack of resources, low-acuity calls, and rural challenges. In terms of the EMS working environment, four subthemes were apparent including attrition, unhealthy culture, organizational barriers and the need for paramedic empowerment. Providers made many recommendations including creating and expanding emergency mobile integrated health (MIH) branches, sharing 811 and 911 responses, and enforcing ED target offload times amongst other suggestions.

CONCLUSIONS

While response times are a key and highly visible problem, there are many critical factors like the EMS working environment that degrade patient care and cause concern amongst frontline practitioners. Multifaceted policy changes are to be explored to reduce disfunction within EMS services, enhance the well-being of the workforce and deliver improved patient care. Specific EMS-oriented policies are important for moving forward to reduce transfers to EDs, but the broader health system which is over capacity is causing downstream effects into EMS must be addressed by government and health administrators.

Pre-hospital emergency medicine: a spectrum of imaging findings

The goal of emergency medical services (EMS) is to provide urgent medical care and stabilization prior to patient transport to a healthcare facility for definitive treatment. The number and variety of interventions performed in the field by EMS providers continues to grow as early management of severe injuries and critical illness in the pre-hospital setting has been shown to improve patient outcomes. The sequela of many field interventions, including those associated with airway management, emergent vascular access, cardiopulmonary resuscitation (CPR), patient immobilization, and hemorrhage control may be appreciated on emergency department admission imaging. Attention to these imaging findings is important for the emergency radiologist, who may be the first to identify a malpositioned device or an iatrogenic complication arising from pre-hospital treatment. Recognition of these findings may allow for earlier corrective action to be taken in the acute care setting. This review describes common EMS interventions and their imaging findings.

Effectiveness and safety of tourniquet utilization for civilian vascular extremity trauma in the pre-hospital settings: a systematic review and meta-analysis

BACKGROUND

Tourniquets (TQ) have been increasingly adopted in pre-hospital settings recently. This study examined the effectiveness and safety of applying TQ in the pre-hospital settings for civilian patients with traumatic vascular injuries to the extremities.

MATERIALS AND METHODS

We systematically searched the Ovid Embase, PubMed, and Cochrane Central Register of Controlled Trials databases from their inception to June 2023. We compared pre-hospital TQ (PH-TQ) use to no PH-TQ, defined as a TQ applied after hospital arrival or no TQ use at all, for civilian vascular extremity trauma patients. The primary outcome was overall mortality rate, and the secondary outcomes were blood product use and hospital stay. We analyzed TQ-related complications as safety outcomes. We tried to include randomized controlled trials (RCTs) and non-randomized studies (including non-RCTs, interrupted time series, controlled before-and-after studies, cohort studies, and case-control studies), if available. Pooled odds ratios (ORs) were calculated and the certainty of evidence was assessed using Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology.

RESULTS

Seven studies involving 4,095 patients were included. In the primary outcome, pre-hospital TQ (PH-TQ) use significantly decrease mortality rate in patients with extremity trauma (odds ratio [OR], 0.48, 95% confidence interval [CI] 0.27-0.86, I2 = 47%). Moreover, the use of PH-TQ showed the decreasing trend of utilization of blood products, such as packed red blood cells (mean difference [MD]: -2.1 [unit], 95% CI: -5.0 to 0.8, I2 = 99%) or fresh frozen plasma (MD: -1.0 [unit], 95% CI: -4.0 to 2.0, I2 = 98%); however, both are not statistically significant. No significant differences were observed in the lengths of hospital and intensive care unit stays. For the safety outcomes, PH-TQ use did not significantly increase risk of amputation (OR: 0.85, 95% CI: 0.43 to 1.68, I2 = 60%) or compartment syndrome (OR: 0.94, 95% CI: 0.37 to 2.35, I2 = 0%). The certainty of the evidence was very low across all outcomes.

CONCLUSION

The current data suggest that, in the pre-hospital settings, PH-TQ use for civilian patients with vascular traumatic injury of the extremities decreased mortality and tended to decrease blood transfusions. This did not increase the risk of amputation or compartment syndrome significantly.

Pre-hospital mortality among pediatric trauma patients in Nova Scotia

OBJECTIVES

Limited data exist on pre-hospital pediatric trauma mortality in Canada. The Nova Scotia Trauma Registry is a provincial population-based registry that captures data from the Medical Examiner Service. This study examined the characteristics of pediatric trauma patient mortality in the pre-hospital and in-hospital settings.

METHODS

We conducted a cohort study of major pediatric traumas recorded in our provincial database from April 1, 2001 to March 31, 2018. Characteristics of pre-hospital and in-hospital deaths were compared with t tests and Chi-square analyses. Multivariate regression modeling was used to identify predictors of pre-hospital mortality. The geographic distribution of pre-hospital trauma was assessed using choropleth maps.

RESULTS

We identified 1,258 pediatric traumas, resulting in 217 deaths (137 pre-hospital, 80 in-hospital). Males accounted for 62.7% of fatalities. The 15-17 age group accounted for most deaths in both groups (pre-hospital 61.3%; in-hospital 41.3%). Injuries sustained in rural areas resulted in 74.7% of all deaths. For both groups, blunt trauma was the predominant injury type and motor vehicle collisions, the most prevalent injury mechanism. Patients who died pre-hospital had a higher mean age (13.3 vs. 10.7, p = 0.002) and a greater proportion were intentional injuries (23.4% vs. 15%; p = 0.02). Urban residency was more frequently observed in in-hospital deaths (57.5% vs. 36.5%, p < 0.001). Pre-hospital mortality was associated with increasing age (OR 1.1), higher injury severity score (OR 1.1), and intentional injury (OR 15.6).

CONCLUSION

Over 10% of major pediatric traumas resulted in pre-hospital death, primarily from motor vehicle collisions in rural areas. Compared to in-hospital mortality, patients who died pre-hospital were older with more severe injuries and more likely to have intentionally injured themselves. These results underscore the importance for emergency physicians and EMS systems to consider geographic factors and injury patterns, advocate for improved injury prevention programs, mental health supports, and delivery of on-scene critical care services.

The Danish Nationwide Electrocardiogram (ECG) Cohort

The electrocardiogram (ECG) is a non-invasive diagnostic tool holding significant clinical importance in the diagnosis and risk stratification of cardiac disease. However, access to large-scale, population-based digital ECG data for research purposes remains limited and challenging. Consequently, we established the Danish Nationwide ECG Cohort to provide data from standard 12-lead digital ECGs in both pre- and in-hospital settings, which can be linked to comprehensive Danish nationwide administrative registers on health and social data with long-term follow-up. The Danish Nationwide ECG Cohort is an open real-world cohort including all patients with at least one digital pre- or in-hospital ECG in Denmark from January 01, 2000, to December 31, 2021. The cohort includes data on standardized and uniform ECG diagnostic statements and ECG measurements including global parameters as well as lead-specific measures of waveform amplitudes, durations, and intervals. Currently, the cohort comprises 2,485,987 unique patients with a median age at the first ECG of 57 years (25th-75th percentiles, 40-71 years; males, 48%), resulting in a total of 11,952,430 ECGs. In conclusion, the Danish Nationwide ECG Cohort represents a novel and extensive population-based digital ECG dataset for cardiovascular research, encompassing both pre- and in-hospital settings. The cohort contains ECG diagnostic statements and ECG measurements that can be linked to various nationwide health and social registers without loss to follow-up.

Influence of antibiotic therapy with hemodynamic optimization on 30-day mortality among septic shock patients cared for in the prehospital setting

BACKGROUND

In order to reduce septic shock mortality, international guidelines recommend early treatment implementation, antibiotic therapy (ABT) and hemodynamic optimisation, within 1-h. This retrospective multicentric study aims to investigate the relationship between prehospital ABT delivered within 1st hour and mean blood pressure (MAP) ≥ 65 mmHg at the end of the prehospital stage, and 30-day mortality among patients with septic shock.

METHODS

From May 2016 to December 2021, patients with septic shock requiring pre-hospital Mobile Intensive Care Unit intervention (MICU) were retrospectively analysed. To assess the relationship between 30-day mortality and prehospital ABT delivered within 1st hour and/or MAP ≥ 65 mmHg at the end of the prehospital stage, Inverse Probability Treatment Weighting (IPTW) propensity score method was performed.

RESULTS

Among the 530 patients included, 341 were male gender (64%) with a mean age of 69 ± 15 years. One-hundred and thirty-two patients (25%) patients received prehospital ABT, among which 98 patients (74%) were treated with 3rd generation cephalosporin. Suspected pulmonary, urinary and digestive infections were the cause of sepsis in respectively 43%, 25% and 17%. The 30-day overall mortality was 31%. A significant association was observed between 30-day mortality rate and (i) ABT administration within the first hour: RRa = 0.14 [0.04-0.55], (ii) ABT administration within the first hour associated with a MAP ≥ 65 mmHg: RRa = 0.08 [0.02-0.37] and (iii) ABT administration within the first hour in the prehospital setting associated with a MAP < 65 mmHg at the end of the prehospital stage: RRa = 0.75 [0.45-0.85]. Patients who received prehospital ABT after the first hour have also a 30-day mortality rate decrease: RRa = 0.87 [0.57-0.99], whereas patients who did not received ABT had an increased 30-day mortality rate: RRa = 2.36 [1.89-2.95].

CONCLUSION

In this study, we showed that pre-hospital ABT within the first hour and MAP≥65 mmHg at the end of prehospital stage are both associated with 30-day mortality decrease among patients suffering from septic shock cared for by a MICU. Further prospective studies are needed to confirm these preliminary results.

Pre-hospital tranexamic acid administration in patients with a severe hemorrhage: an evaluation after the implementation of tranexamic acid administration in the Dutch pre-hospital protocol

PURPOSE

To evaluate the pre-hospital administration of tranexamic acid in ambulance-treated trauma patients with a severe hemorrhage after the implementation of tranexamic acid administration in the Dutch pre-hospital protocol.

METHODS

All patients with a severe hemorrhage who were treated and conveyed by EMS professionals between January 2015, and December 2017, to any trauma-receiving emergency department in the eight participating trauma regions in the Netherlands, were included. A severe hemorrhage was defined as extracranial injury with > 20% body volume blood loss, an extremity amputation above the wrist or ankle, or a grade ≥ 4 visceral organ injury. The main outcome was to determine the proportion of patients with a severe hemorrhage who received pre-hospital treatment with tranexamic acid. A Generalized Linear Model (GLM) was performed to investigate the relationship between pre-hospital tranexamic acid treatment and 24 h mortality.

RESULTS

A total of 477 patients had a severe hemorrhage, of whom 124 patients (26.0%) received tranexamic acid before arriving at the hospital. More than half (58.4%) of the untreated patients were suspected of a severe hemorrhage by EMS professionals. Patients treated with tranexamic acid had a significantly lower risk on 24 h mortality than untreated patients (OR 0.43 [95% CI 0.19-0.97]).

CONCLUSION

Approximately a quarter of the patients with a severe hemorrhage received tranexamic acid before arriving at the hospital, while a severe hemorrhage was suspected in more than half of the non-treated patients. Severely hemorrhaging patients treated with tranexamic acid before arrival at the hospital had a lower risk to die within 24 h after injury.

The SEE-IT Trial: emergency medical services Streaming Enabled Evaluation In Trauma: a feasibility randomised controlled trial

BACKGROUND

Use of bystander video livestreaming from scene to Emergency Medical Services (EMS) is becoming increasingly common to aid decision making about the resources required. Possible benefits include earlier, more appropriate dispatch and clinical and financial gains, but evidence is sparse.

METHODS

A feasibility randomised controlled trial with an embedded process evaluation and exploratory economic evaluation where working shifts during six trial weeks were randomised 1:1 to use video livestreaming during eligible trauma incidents (using GoodSAM Instant-On-Scene) or standard care only. Pre-defined progression criteria were: (1) ≥ 70% callers (bystanders) with smartphones agreeing and able to activate live stream; (2) ≥ 50% requests to activate resulting in footage being viewed; (3) Helicopter Emergency Medical Services (HEMS) stand-down rate reducing by ≥ 10% as a result of live footage; (4) no evidence of psychological harm in callers or staff/dispatchers. Observational sub-studies included (i) an inner-city EMS who routinely use video livestreaming to explore acceptability in a diverse population; and (ii) staff wellbeing in an EMS not using video livestreaming for comparison to the trial site.

RESULTS

Sixty-two shifts were randomised, including 240 incidents (132 control; 108 intervention). Livestreaming was successful in 53 incidents in the intervention arm. Patient recruitment (to determine appropriateness of dispatch), and caller recruitment (to measure potential harm) were low (58/269, 22% of patients; 4/244, 2% of callers). Two progression criteria were met: (1) 86% of callers with smartphones agreed and were able to activate livestreaming; (2) 85% of requests to activate livestreaming resulted in footage being obtained; and two were indeterminate due to insufficient data: (3) 2/6 (33%) HEMS stand down due to livestreaming; (4) no evidence of psychological harm from survey, observations or interviews, but insufficient survey data from callers or comparison EMS site to be confident. Language barriers and older age were reported in interviews as potential challenges to video livestreaming by dispatchers in the inner-city EMS.

CONCLUSIONS

Progression to a definitive RCT is supported by these findings. Bystander video livestreaming from scene is feasible to implement, acceptable to both 999 callers and dispatchers, and may aid dispatch decision-making. Further assessment of unintended consequences, benefits and harm is required.

TRIAL REGISTRATION

ISRCTN 11449333 (22 March 2022). https://www.isrctn.com/ISRCTN11449333.

A review of pre-hospital extracorporeal cardiopulmonary resuscitation and its potential application in the North East of England

Patients in the UK who suffer an out-of-hospital cardiac arrest are treated with cardiopulmonary resuscitation in the pre-hospital environment. Current survival outcomes are low in out-of-hospital cardiac arrest. Extracorporeal cardiopulmonary resuscitation is a technique which is offered to patients in specialised centres which provides better blood flow and oxygen delivery than conventional chest compressions. Shortening the interval between cardiac arrest and restoration of circulation is associated with improved outcomes in extracorporeal cardiopulmonary resuscitation. Delivering extracorporeal cardiopulmonary resuscitation in the pre-hospital environment can shorten this interval, improving outcomes in out-of-hospital cardiac arrest. This article will review recently published studies and summarise studies currently being undertaken in pre-hospital extracorporeal cardiopulmonary resuscitation. It will also discuss the potential application of a pre-hospital extracorporeal cardiopulmonary resuscitation programme in the North East of England.

How can quality be measured within a physician-led Community Emergency Medical service? A scoping review protocol

BACKGROUND

Quality measurement as part of quality improvement in healthcare is integral for service delivery and development. This is particularly pertinent for health services that deliver care in ways that differ from traditional practice. Community Emergency Medicine (CEM) is a novel and evolving concept of care delivered by services in parts of the UK and Ireland. This scoping review aims to provide a broad overview of how quality may be measured within services delivering CEM.

METHODS AND ANALYSIS

The methodology follows both the Preferred Reporting Items for Systematic Review and Meta-Analysis extension for Scoping Reviews (PRISMA-ScR). It is guided by recognised work of Arksey and O'Malley and the guidelines developed by the Joanna Briggs Institute. Several databases will be searched: MEDLINE, EMbase, EMcare, CINAHL, Scopus, the Cochrane Library and grey literature. Search terms have been developed by representatives within Community Emergency Medicine services. Two reviewers will independently screen eligible studies for final study selection. Results will be collected and analysed in descriptive and tabular form to illustrate the breadth of quality indicators that may be applicable to CEM services. This scoping review protocol has been registered with the Open Science Framework platform (osf.io/e7qxg).

DISCUSSION

This is the first stage of a larger research study aimed at developing national quality indicators for CEM. The purpose of this scoping review is to provide a comprehensive review of quality indicators that could be used within CEM. The results will be mapped using a framework and identify gaps in the literature to help guide future-focused research.

The nature and timing of coagulation dysfunction in a cohort of trauma patients in the Australian pre-hospital setting

BACKGROUND

Acute Traumatic Coagulopathy (ATC) is a complex pathological process that is associated with patient mortality and increased blood transfusion requirements. It is evident on hospital arrival, but there is a paucity of information about the nature of ATC and the characteristics of patients that develop ATC in the pre-hospital setting. The objective of this study was to describe the nature and timing of coagulation dysfunction in a cohort of injured patients and to report on patient and pre-hospital factors associated with the development of ATC in the field.

METHODS

This was a prospective observational study of a convenience sample of trauma patients. Patients had blood taken during the pre-hospital phase of care and evaluated for derangements in Conventional Coagulation Assays (CCA) and Rotational Thromboelastometry (ROTEM). Associations between coagulation derangement and pre-hospital factors and patient outcomes were evaluated.

RESULTS

A total of 216 patients who had either a complete CCA or ROTEM were included in the analysis. One hundred and eighty (83 %) of patients were male, with a median injury severity score of 17 [interquartile range (IQR) 10-27] and median age of 34 years [IQR = 25.0-52.0]. Hypofibrinogenemia was the predominant abnormality seen, (CCA Hypofibrinogenemia: 51/193, 26 %; ROTEM hypofibrinogenemia: 65/204, 32 %). Increased CCA derangement, the presence of ROTEM coagulopathy, worsening INR, worsening FibTEM and decreasing fibrinogen concentration, were all associated with both mortality and early massive transfusion.

CONCLUSION

Clinically significant, multifaceted coagulopathy develops early in the clinical course, with hypofibrinogenemia being the predominant coagulopathy. In keeping with the ED literature, pre-hospital coagulation dysfunction was associated with mortality and early massive transfusion. Further work is required to identify strategies to identify and guide the pre-hospital management of the coagulation dysfunction seen in trauma.

Preparing undergraduate student paramedics to consider their mental health during clinical placement in Australia

INTRODUCTION

This article explores the impact of mental health issues on paramedics in Australia, particularly Post-Traumatic Stress Disorder, caused by their exposure to high levels of stress. The prevalence of Post-Traumatic Stress Disorder is higher among paramedics than any other occupation, and this could be a cause for concern, especially for undergraduate student paramedics. The article examines the need to build resilience among student paramedics to help them handle the trauma they may experience during clinical placement.

METHODS

This study conducted a two-step process to review literature and university handbooks to determine the level of education provided to paramedic students on Post-Traumatic Stress Disorder and resilience during clinical placement, due to the lack of research in this area. The first step involved a search for relevant articles, while the second step involved a search of the Australian Health Practitioner Regulation Agency website to identify paramedicine programs and a manual evaluation of each undergraduate pre-registration paramedicine curriculum in Australia.

RESULTS

This study conducted a systematic search of national and international literature and Australian undergraduate pre-registration paramedicine programs to identify any studies pertaining to the education of paramedic students in resilience and Post Traumatic Stress Disorder. The search found that only 15 (5.95 %) of the 252 reviewed subjects had reference to mental health, resilience or Post-Traumatic Stress Disorder, with only 4 (1.59 %) of them discussing these topics in preparation for clinical practice. The study highlights the lack of emphasis on student paramedic self-care as an essential underpinning for clinical placement preparation in the curriculum.

CONCLUSION

This literature review concludes that appropriate training and support, teaching resilience, and promoting self-care are crucial in preparing paramedic students for the emotional and psychological demands of their work. Equipping students with these tools and resources can improve their mental health and well-being and enhance their ability to provide high-quality care to patients. Promoting self-care as a core value in the profession is essential in creating a culture that supports paramedics in maintaining their own mental health and well-being.

Prehospital tourniquet placement in extremity trauma

BACKGROUND

Extremity tourniquets (ET) use has increased in trauma systems to manage traumatic hemorrhage. This study aims to evaluate prehospital ET placement.

METHODS

This is a retrospective review of a prospectively collected cohort of 211 adult patients who underwent prehospital ET placement over 3 ½ years. Data regarding ET placement was analyzed regarding ET applier, reported indications, extremity appearance at arrival and outcomes.

RESULTS

A total of 211 patients had completed data sheets. Of these patients, 63.2% had no other intervention prior to ET placement. On arrival, nearly 1/3 of the patients had palpable pulses with ET in place and less than ½ had arterial bleeding upon ET release.

DISCUSSION/CONCLUSIONS

This study shows that ET are frequently used as the initial intervention in the field. It is of paramount importance that we adapt our first responders training to teach wound assessment and appropriate steps in management of extremity hemorrhagic trauma.

Considerations for the development of a field-based medical device for the administration of adjunctive therapies for snakebite envenoming

The timely administration of antivenom is the most effective method currently available to reduce the burden of snakebite envenoming (SBE), a neglected tropical disease that most often affects rural agricultural global populations. There is increasing interest in the development of adjunctive small molecule and biologic therapeutics that target the most problematic venom components to bridge the time-gap between initial SBE and the administration antivenom. Unique combinations of these therapeutics could provide relief from the toxic effects of regional groupings of medically relevant snake species. The application a PRISMA/PICO literature search methodology demonstrated an increasing interest in the rapid administration of therapies to improve patient symptoms and outcomes after SBE. Advice from expert interviews and considerations regarding the potential routes of therapy administration, anatomical bite location, and species-specific venom delivery have provided a framework to identify ideal metrics and potential hurdles for the development of a field-based medical device that could be used immediately after SBE to deliver adjunctive therapies. The use of subcutaneous (SC) or intramuscular (IM) injection were identified as potential routes of administration of both small molecule and biologic therapies. The development of a field-based medical device for the delivery of adjunctive SBE therapies presents unique challenges that will require a collaborative and transdisciplinary approach to be successful.

Evaluating the impact of pre-hospital trauma team activation criteria

BACKGROUND

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.

METHODS

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.

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).

CONCLUSION

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.

The SWiFT trial (Study of Whole Blood in Frontline Trauma)-the clinical and cost effectiveness of pre-hospital whole blood versus standard care in patients with life-threatening traumatic haemorrhage: study protocol for a multi-centre randomised controlled trial

BACKGROUND

Early blood transfusion improves survival in patients with life-threatening bleeding, but the optimal transfusion strategy in the pre-hospital setting has yet to be established. Although there is some evidence of benefit with the use of whole blood, there have been no randomised controlled trials exploring the clinical and cost effectiveness of pre-hospital administration of whole blood versus component therapy for trauma patients with life-threatening bleeding. The aim of this trial is to determine whether pre-hospital leukocyte-depleted whole blood transfusion is better than standard care (blood component transfusion) in reducing the proportion of participants who experience death or massive transfusion at 24 h.

METHODS

This is a multi-centre, superiority, open-label, randomised controlled trial with internal pilot and within-trial cost-effectiveness analysis. Patients of any age will be eligible if they have suffered major traumatic haemorrhage and are attended by a participating air ambulance service. The primary outcome is the proportion of participants with traumatic haemorrhage who have died (all-cause mortality) or received massive transfusion in the first 24 h from randomisation. A number of secondary clinical, process, and safety endpoints will be collected and analysed. Cost (provision of whole blood, hospital, health, and wider care resource use) and outcome data will be synthesised to present incremental cost-effectiveness ratios for the trial primary outcome and cost per quality-adjusted life year at 90 days after injury. We plan to recruit 848 participants (a two-sided test with 85% power, 5% type I error, 1-1 allocation, and one interim analysis would require 602 participants-after allowing for 25% of participants in traumatic cardiac arrest and an additional 5% drop out, the sample size is 848).

DISCUSSION

The SWiFT trial will recruit 848 participants across at least ten air ambulances services in the UK. It will investigate the clinical and cost-effectiveness of whole blood transfusion versus component therapy in the management of patients with life-threatening bleeding in the pre-hospital setting.

TRIAL REGISTRATION

ISRCTN: 23657907; EudraCT: 2021-006876-18; IRAS Number: 300414; REC: 22/SC/0072, 21 Dec 2021.

What is the impact of a pre-hospital geriatrician led telephone 'Silver Triage' for older people living with frailty?

PURPOSE

Most older people are conveyed to hospital via ambulance, therefore presenting a focus to reduce hospitalisation. North Central London has introduced 'Silver Triage', a pre-hospital telephone support scheme where geriatricians support the London Ambulance Service with clinical decision-making.

METHODS

Data from the first 14 months was analysed descriptively.

RESULTS

There have been 452 Silver Triage cases (November 2021 to January 2023). 80% resulted in a decision to not convey. The mode clinical frailty scale (CFS) was 6. CFS did not influence conveyance rates. Prior to triage, paramedics thought hospitalisation was not required in 44% of cases (n = 72/165). All paramedics surveyed (n = 176) would use the service again. Most (66%, n = 108/164) felt they learnt something and 16% (n = 27/164) reported it changed their decision-making process.

CONCLUSION

Silver Triage has the potential to improve the care of older people by preventing unnecessary hospitalisation and has been well received by paramedics.

Comparison of three regimens with inhalational methoxyflurane versus intranasal fentanyl versus intravenous morphine in pre-hospital acute pain management: study protocol for a randomized controlled trial (PreMeFen)

BACKGROUND

Pre-hospital pain management has traditionally been performed with intravenous (IV) morphine, but oligoanalgesia remain a recognized problem. Pain reduction is essential for patient satisfaction and is regarded as a measure of successful treatment. We aim to establish whether non-invasive methods such as inhalation of methoxyflurane is non-inferior to intranasal fentanyl or non-inferior to the well-known IV morphine in the pre-hospital treatment of acute pain.

METHOD/DESIGN

The PreMeFen study is a phase three, three-armed, randomized, controlled, non-inferiority trial to compare three regimens of analgesics: inhalation of methoxyflurane and intranasal (IN) fentanyl versus IV morphine. It is an open-label trial with a 1:1:1 randomization to the three treatment groups. The primary endpoint is the change in pain numeric rating scale (NRS) (0-10) from baseline to 10 min after start of investigational medicinal product administration (IMP). The non-inferiority margin was set to 1.3, and a sample size of 270 patients per protocol (90 in each treatment arm) will detect this difference with 90% power.

DISCUSSION

We chose a study design with comparison of analgesic regimens rather than fixed doses because of the substantial differences in drug characteristics and for the results to be relevant to inform policymakers in the pre-hospital setting. We recognize that easier administration of analgesics will lead to better pain management for many patients if the regimens are as good as the existing, and hence, we chose a non-inferiority design. The primary endpoint, the change in pain (NRS) after 10 min, is set to address the immediate need of pain reduction for patients with acute prehospital pain. On a later stage, more analgesic methods are often available. PreMeFen is a non-inferiority randomized controlled trial comparing three analgesic regimens aiming to establish whether inhalation of methoxyflurane or intranasal fentanyl is as good as IV morphine for fast reduction of acute pain in the prehospital setting.

Understandings, attitudes, practices and responses to GHB overdose among GHB consumers

BACKGROUND

Gamma-hydroxybutyrate (GHB) is used at disproportionately high rates within sexuality and gender diverse communities and carries a high risk of overdose. GHB overdose can result in death. Internationally, recent increases in GHB overdoses have been observed. Coronial reviews of GHB-related death highlight the pivotal roles that bystanders to GHB overdose play in preventing fatality. No research has examined, in detail, how bystanders respond to GHB overdose. This qualitative study was conducted among people who use GHB and explored how they responded upon witnessing a GHB overdose experienced by someone else.

METHODS

Interviews were conducted with 31 sexuality and gender diverse Australian residents reporting three or more occasions of GHB use in the previous 12 months. Participants were asked questions about witnessed GHB overdose, their actions and decision-making processes throughout overdose. Data were analysed thematically.

RESULTS

Participants described witnessing GHB overdose, commonly in private settings involving sexualized GHB use. Variable definitions of GHB overdose were reported, ranging from GHB-induced symptoms of distress to comatose intoxication. Drastic actions to keep someone alert and responsive post-GHB ingestion were reported; these included the administration of stimulant substances and citrus. Decisions to call or not call for emergency medical services (EMS) were influenced by many circumstantial variables. In most instances, an EMS call was resisted and response practices deviated from established first aid protocols.

CONCLUSIONS

GHB overdose prevention and response training programs targeting people who use GHB are urgently required. These education interventions ought to address inaccuracies that inform street remedies for GHB overdose, teach people how to safely check breathing and response, promote basic first aid principles and address barriers to contacting EMS.

Patient outcomes before and after implementation of a selective pre-hospital spinal immobilization protocol: A comparative cohort pilot study in a level 2 trauma center

BACKGROUND

A new selective preventive spinal immobilization (PSI) protocol was introduced in the Netherlands. This may have led to an increase in non-immobilized spinal fractures (NISFs) and consequently adverse patient outcomes.

AIM

A pilot study was conducted to describe the adverse patient outcomes in NISF of the PSI protocol change and assess the feasibility of a larger effect study.

METHODS

Retrospective comparative cohort pilot study including records of trauma patients with a presumed spinal injury who were presented at the emergency department of a level 2 trauma center by the emergency medical service (EMS). The pre-period 2013-2014 (strict PSI protocol), was compared to the post-period 2017-2018 (selective PSI protocol). Primary outcomes were the percentage of records with a NISF who had an adverse patient outcome such as neurological injuries and mortality before and after the protocol change. Secondary outcomes were the sample size calculation for a larger study and the feasibility of data collection.

RESULTS

1,147 records were included; 442 pre-period, and 705 post-period. The NISF-prevalence was 10% (95% CI 7-16, n = 19) and 8% (95% CI 6-11, n = 33), respectively. In both periods, no neurological injuries or mortality due to NISF were found, by which calculating a sample size is impossible. Data collection showed to be feasible.

CONCLUSIONS

No neurological injuries or mortality due to NISF were found in a strict and a selective PSI protocol. Therefore, a larger study is discouraged. Future studies should focus on which patients really profit from PSI and which patients do not.

Decision-making on the fly: a qualitative study of physicians in out-of-hospital emergency medical services

BACKGROUND

Out-of-hospital Emergency Medical Services (OHEMS) require fast and accurate assessment of patients and efficient clinical judgment in the face of uncertainty and ambiguity. Guidelines and protocols can support staff in these situations, but there is significant variability in their use. Therefore, the aim of this study was to increase our understanding of physician decision-making in OHEMS, in particular, to characterize the types of decisions made and to explore potential facilitating and hindering factors.

METHODS

Qualitative interview study of 21 physicians in a large, publicly-owned and operated OHEMS in Croatia. Data was subjected to an inductive content analysis.

RESULTS

Physicians (mostly young, female, and early in their career), made three decisions (transport, treat, and if yes on either, how) after an initial patient assessment. Decisions were influenced by patient needs, but to a greater extent by factors related to themselves and patients (microsystem), their organization (mesosystem), and the larger health system (macrosystem). This generated a high variability in quality and outcomes. Participants desired support through further training, improved guidelines, formalized feedback, supportive management, and health system process redesign to better coordinate and align care across organizational boundaries.

CONCLUSIONS

The three decisions were made complex by contextual factors that largely lay outside physician control at the mesosystem level. However, physicians still took personal responsibility for concerns more suitably addressed at the organizational level. This negatively impacted care quality and staff well-being. If managers instead adopt a learning orientation, the path from novice to expert physician could be more ably supported through organizational demands and practices aligned with real-world practice. Questions remain on how managers can better support the learning needed to improve quality, safety, and physicians' journey from novice to expert.

What is the potential benefit of pre-hospital extracorporeal cardiopulmonary resuscitation for patients with an out-of-hospital cardiac arrest? A predictive modelling study

AIM

In this predictive modelling study we aimed to investigate how many patients with an out-of-hospital cardiac arrest (OHCA) would benefit from pre-hospital as opposed to in-hospital initiation of extracorporeal cardiopulmonary resuscitation (ECPR).

METHODS

A temporal spatial analysis of Utstein data was performed for all adult patients with a non-traumatic OHCA attended by three emergency medical services (EMS) covering the north of the Netherlands during a one-year period. Patients were considered potentially eligible for ECPR if they had a witnessed arrest with immediate bystander CPR, an initial shockable rhythm (or signs of life during resuscitation) and could be presented in an ECPR-centre within 45 minutes of the arrest. Endpoint of interest was defined as the hypothetical number of ECPR eligible patients after 10, 15 and 20 minutes of conventional CPR and upon (hypothetical) arrival in an ECPR-centre as a fraction of the total number of OHCA patients attended by EMS.

RESULTS

During the study period 622 OHCA patients were attended, of which 200 (32%) met ECPR eligibility criteria upon EMS arrival. The optimal transition point between conventional CPR and ECPR was found to be after 15 minutes. Hypothetical intra-arrest transport of all patients in whom no return of spontaneous circulation (ROSC) was obtained after that point (n=84) would have yielded 16/622 (2.5%) patients being potentially ECPR eligible upon hospital arrival (average low-flow time 52 minutes), whereas on-scene initiation of ECPR would have resulted in 84/622 (13.5%) potential candidates (average estimated low-flow time 24 minutes before cannulation).

CONCLUSION

Even in healthcare systems with relatively short transport distances to hospital, consideration should be given to pre-hospital initiation of ECPR for OHCA as it shortens low-flow time and increases the number of potentially eligible patients.

A systematic review of sufentanil for the management of adults with acute pain in the emergency department and pre-hospital setting

BACKGROUND

Pain is commonly encountered in the Emergency Department (ED) and pre-hospital setting and often requires opioid analgesia. We sought to synthesize the available evidence on the effectiveness of sufentanil for acute pain relief for adult patients in the pre-hospital or ED setting.

METHODS

This systematic review was conducted in accordance with PRISMA guidelines. Medline, Embase, Cochrane CENTRAL, and CINAHL were searched from inception to February 1, 2022. The grey literature was also searched. We included randomized controlled trials of adult patients with acute pain who were treated with sufentanil. Two reviewers independently completed screening, full text review, and data extraction. Primary outcome was reduction in pain. Secondary outcomes included adverse events, need for rescue analgesia, and patient and provider satisfaction. Risk of bias was assessed using the Cochrane Risk of Bias 2 tool. A meta-analysis was not performed due to heterogeneity.

RESULTS

Of 1120 unique citations, four studies (3 ED and 1 pre-hospital) met full inclusion criteria (n = 467 participants). The overall quality of the included studies was high. Intranasal (IN) sufentanil was superior to placebo for pain relief at 30 min (difference 20.8%, 95% CI 4.0-36.2%, p = 0.01). Both IN (two studies) and IV sufentanil (one study) were comparable to IV morphine. Mild adverse events were common and there was a higher propensity for minor sedation in patients receiving sufentanil. There were no serious adverse events requiring advanced interventions.

CONCLUSION

Sufentanil was comparable to IV morphine and was superior to placebo for rapid relief of acute pain in the ED setting. The safety profile of sufentanil is similar to IV morphine in this setting, with minimal concern for serious adverse events. The intranasal formulation may provide an alternative, rapid, non-parenteral route that could benefit our unique emergency department and pre-hospital patient population. Due to the overall small sample size of this review, larger studies are required to confirm safety.

Challenges and opportunities for conducting pre-hospital trauma trials: a behavioural investigation

BACKGROUND

Trials in pre-hospital trauma care are relatively uncommon. There are logistical and methodological challenges related to designing and delivering trials in this setting. Previous studies have assessed challenges reported in individual trials rather than across the pre-hospital trial landscape to identify over-arching factors. The aim of this study was to investigate the challenges and opportunities related to the set-up, design and conduct of pre-hospital trauma trials from across the pre-hospital trial landscape and a specific pre-hospital trauma feasibility study.

METHODS

Semi-structured interviews were conducted with two cohorts of participants: research personnel who had experience of pre-hospital trials, either through direct involvement in conduct or through strategic oversight of national initiatives (n = 7), and clinical staff (n = 16) involved in recruitment to a pre-hospital trauma feasibility study. Thematic analyses were used to assess the barriers and enablers of conducting pre-hospital trauma trials. Two frameworks (The Capability Opportunity Motivation-Behaviour and the Theoretical Domains Framework) were used to guide analyses.

RESULTS

The barriers and enablers reported were relevant to several TDF domains and COM-B components. Across both cohorts, challenges associated with opportunities were reported and included the lack of research experience amongst pre-hospital staff, team dynamics within a rotating shift schedule, and the involvement of external organisations with diverse institutional priorities and infrastructures (e.g. Air Ambulances). The infrequency of eligible cases was also reported to affect the trial design, set-up, and conduct. Other barriers reported related to clinical equipoise amongst staff and institutional pressures, which affected motivation.

CONCLUSIONS

This study has highlighted that pre-hospital trials face many context-specific but also generic challenges. Pre-hospital trauma trial teams could consider the findings to develop targeted, behaviourally focused, solutions to the challenges identified in order to enhance the set-up and conduct of trials in this setting.

TRIAL REGISTRATION

NCT04145271. Trial registration date: October 30, 2019. Note that this paper does not report results from a specific trial but does include participants who were involved in the conduct of a registered pre-hospital feasibility study.

Prediction of pre-hospital blood transfusion in trauma patients based on scoring systems

BACKGROUND

Pre-hospital blood transfusion (PHBT) is a safe and gradually expanding procedure applied to trauma patients. A proper decision to activate PHBT with the presently limited diagnostic options at the site of an incident poses a challenge for pre-hospital crews. The purpose of this study was to compare the selected scoring systems and to determine whether they can be used as valid tools in identifying patients with PHBT requirements.

METHODS

A retrospective single-center study was conducted between June 2018 and December 2020. Overall, 385 patients (aged [median; IQR]: 44; 24-60; 73% males) were included in this study. The values of five selected scoring systems were calculated in all patients. To determine the accuracy of each score for the prediction of PHBT, the Receiver Operating Characteristic (ROC) analysis was used and to measure the association, the odds ratio with 95% confidence intervals was counted (Fig. 1).

RESULTS

Regarding the proper indication of PHBT, shock index (SI) and pulse pressure (PP) revealed the highest value of AUC and sensitivity/specificity ratio (SI: AUC 0.88; 95% CI 0.82-0.93; PP: AUC 0.85 with 95% CI 0.79-0.91).

CONCLUSION

Shock index and pulse pressure are suitable tools for predicting PHBT in trauma patients.

Adverse outcomes of GHB use: Analysis of ambulance attendances in metropolitan and regional Victoria

BACKGROUND

Gamma-hydroxybutyrate (GHB) use and attributable harms have been increasing in Australia, however changes over time, including the impact of COVID-19 lockdowns and restrictions on harms requiring an ambulance attendance, are unknown. This study utilised a novel population-based surveillance system to identify the types of GHB-related harms between January 2018 and 31 December 2021 in Victoria, Australia.

METHODS

A cross-sectional, retrospective analysis of all GHB-related ambulance attendances between January 2018 and 31 December 2021 in Victoria, Australia was undertaken. Paramedic clinical notes and Glasgow Coma Scale scores were used to assess conscious state. Event codes were classified using dispatch information available in the database. Crude rates (per 100,000 population) and descriptive analyses were calculated for metropolitan and regional settings. Adjusted Odds ratios (aOR) with 95% confidence intervals [95% CI] were used to assess the relationship between GCS severity and polysubstance combinations with GHB.

RESULTS

There were 6,836 ambulance attendances for GHB recorded during the study period. A statistically significant increase in GHB-related attendance numbers was observed State-wide in 2019 (n = 1,402, p<0.001) and 2020 (n = 2,622, p<0.001), when comparing year on year attendances. While both numbers and rates (per 100,000 population) of GHB-related attendances were significantly lower in regional areas, significant increases were evident in both metropolitan and regional areas in 2019 and 2020 (both p<0.001). Attendances involving GHB and alcohol had higher odds of a severe GCS score (aOR:1.25; 95%: 1.04-1.49; p<0.019). A high proportion of GHB-attendances involved harms of significant concern including: overdose (56%) and a loss of, or altered state of consciousness (45%).

CONCLUSIONS

We observed increases in GHB-related ambulance attendances over time in both metropolitan and regional areas, placing a significant burden on ambulance services. Our study demonstrates the value of using ambulance surveillance to obtain representative data on acute GHB-related harms.

Clinical validation of a 13-lead electrocardiogram derived from a self-applicable 3-lead recording for diagnosis of myocardial supply ischaemia and common non-ischaemic electrocardiogram abnormalities at rest

Aims

In this study, we compare the diagnostic accuracy of a standard 12-lead electrocardiogram (ECG) with a novel 13-lead ECG derived from a self-applicable 3-lead ECG recorded with the right exploratory left foot (RELF) device. The 13th lead is a novel age and sex orthonormalized computed ST (ASO-ST) lead to increase the sensitivity for detecting ischaemia during acute coronary artery occlusion.

Methods and results

A database of simultaneously recorded 12-lead ECGs and RELF recordings from 110 patients undergoing coronary angioplasty and 30 healthy subjects was used. Five cardiologists scored the learning data set and five other cardiologists scored the validation data set. In addition, the presence of non-ischaemic ECG abnormalities was compared. The accuracy for detection of myocardial supply ischaemia with the derived 12 leads was comparable with that of the standard 12-lead ECG (P = 0.126). By adding the ASO-ST lead, the accuracy increased to 77.4% [95% confidence interval (CI): 72.4-82.3; P < 0.001], which was attributed to a higher sensitivity of 81.9% (95% CI: 74.8-89.1) for the RELF 13-lead ECG compared with a sensitivity of 76.8% (95% CI: 71.9-81.7; P < 0.001) for the 12-lead ECG. There was no significant difference in the diagnosis of non-ischaemic ECG abnormalities, except for Q-waves that were more frequently detected on the standard ECG compared with the derived ECG (25.9 vs. 13.8%; P < 0.001).

Conclusion

A self-applicable and easy-to-use 3-lead RELF device can compute a 12-lead ECG plus an ischaemia-specific 13th lead that is, compared with the standard 12-lead ECG, more accurate for the visual diagnosis of myocardial supply ischaemia by cardiologists.

Resuscitative endovascular balloon occlusion of the aorta in civilian pre-hospital care: a systematic review of the literature

Background

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a damage control tool with a potential role in the hemodynamic resuscitation of severely ill patients in the civilian pre-hospital setting. REBOA ensures blood flow to vital organs by early proximal control of the source of bleeding. However, there is no consensus on the use of REBOA in the pre-hospital setting. This article aims to perform a systematic review of the literature about the feasibility, survival, indications, complications, and potential candidates for civilian pre-hospital REBOA.

Methods

A literature search was conducted using Medline, EMBASE, LILACS and Web of Science databases. Primary outcome variables included overall survival and feasibility. Secondary outcome variables included complications and potential candidates for endovascular occlusion.

Results

The search identified 8 articles. Five studies described the use of REBOA in pre-hospital settings, reporting a total of 47 patients in whom the procedure was attempted. Pre-hospital REBOA was feasible in 68–100% of trauma patients and 100% of non-traumatic patients with cardiac arrest. Survival rates and complications varied widely. Pre-hospital REBOA requires a coordinated and integrated emergency health care system with a well-trained and equipped team. The remaining three studies performed a retrospective analysis identifying 784 potential REBOA candidates.

Conclusions

Pre-hospital REBOA could be a feasible intervention for a significant portion of severely ill patients in the civilian setting. However, the evidence is limited. The impact of pre-hospital REBOA should be assessed in future studies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40001-022-00836-3.

Early risk assessment in patients with suspected NSTE-ACS; a retrospective cohort study

INTRODUCTION

Chest pain is among the most common reasons for Emergency Department (ED) presentation, while most patients should be considered low risk for Acute Coronary Syndrome (ACS). Management of these patients places a significant burden on our health care system. Various risk scores have been developed to facilitate the triage of patients with chest pain. However, it remains unclear which score performs best in identifying low risk patients, in various settings. The aim of this study was to determine which risk score performs best in ruling out non-ST elevation ACS (NSTE-ACS).

METHODS

Data was collected from all patients >18 years presenting to the ED between 01 and 01-2019 and 01-07-2019, if they were suspected of NSTE-ACS. Primary endpoint was NSTE-ACS during presentation to the ED or hospitalization, according to the 2020 ESC guidelines. In a secondary analysis we determined the number low-risk patients, at set safety levels of 95% and 98%.

RESULTS

A total of 536 patients were included, 192 (35.9%) were admitted to the hospital and NSTE-ACS occurred in 134 of 536 patients (25.0%). When areas under the curve (AUC) were compared, pre-HEART (0.869; CI 0.835-0.903), T-MACS (0.862; CI 0.825-0.898) and HEART (0.850; CI 0.815-0.885) performed best. At a safety level of 98%, the HEART score was the best performing risk score and identified 28.9% of patients as low risk, and missed 0 cases of NSTE-ACS. Followed by the pre-HEART score, which identified 18.3% of all patients as low risk, and missed 0% of NSTE-ACS.

CONCLUSIONS

The newly developed pre-HEART score is both practical and has accurate diagnostic properties, closely followed by the HEART score, and T-MACS. New pre-hospital risk scores are promising and much needed. Future studies should focus on the usage of pre-hospital scores for triage of patients with chest pain, in order to reduce the burden on emergency health care.

Development and validation of a comprehensive early risk prediction model for patients with undifferentiated acute chest pain

Aims

Existing risk scores for undifferentiated chest pain focus on excluding coronary events and do not represent a comprehensive risk assessment if an alternate serious diagnosis is present. This study aimed to develop and validate an all-inclusive risk prediction model among patients with undifferentiated chest pain.

Methods

We developed and validated a multivariable logistic regression model for a composite measure of early all-inclusive risk (defined as hospital admission excluding a discharge diagnosis of non-specific pain, 30-day all-cause mortality, or 30-day myocardial infarction [MI]) among adults assessed by emergency medical services (EMS) for non-traumatic chest pain using a large population-based cohort (January 2015 to June 2019). The cohort was randomly divided into development (146,507 patients [70%]) and validation (62,788 patients [30%]) cohorts.

Results

The composite outcome occurred in 28.4%, comprising hospital admission in 27.7%, mortality within 30-days in 1.8%, and MI within 30-days in 0.4%. The Early Chest pain Admission, MI, and Mortality (ECAMM) risk model was developed, demonstrating good discrimination in the development (C-statistic 0.775, 95% CI 0.772-0.777) and validation cohorts (C-statistic 0.765, 95% CI 0.761-0.769) with excellent calibration. Discriminatory performance for the composite outcome and individual components was higher than existing scores commonly used in undifferentiated chest pain risk stratification.

Conclusions

The ECAMM risk score model can be used as an all-inclusive risk stratification assessment of patients with non-traumatic chest pain without the limitation of a single diagnostic outcome. This model could be clinically useful to help guide decisions surrounding the need for non-coronary investigations and safety of early discharge.

The experience of pre-hospital emergency personnel in breaking death news: a phenomenological study

BACKGROUND

Today, breaking the death of patients to their families has become one of the challenges for medical staff. Considering the lack of study in the pre-hospital emergency, the present study aimed to explore the experience of pre-hospital emergency personnel regarding the breaking death news to families.

METHOD

In this qualitative study with a descriptive phenomenological method, data were collected by purposeful sampling method through in-depth interviews with thirteen pre-hospital emergency personnel in Kermanshah and Kurdistan provinces. After recording and writing the interviews, the data were managed by MAQUDA-10 software and analyzed using the Collaizi approach.

RESULTS

Of 13 participants, five from Kermanshah, eight from Kurdistan, and 12 (92%) were married. The mean age and work experience were 34.38 and 10.38 years, respectively. Five main extracted themes were 1) perceived stress, 2) challenge factors of breaking death news, 3) unnecessary actions, 4) death breaking precautions, and 5) BDN requirements. They were covered fifteen sub-themes.

CONCLUSION

In this study, emergency medical employees were always faced with stress and challenges to announce the patient's death to families, including the stress of violence against employees. Hereof, personnel had to take unnecessary care actions such as slow resuscitation to transfer the patient to the hospital.

Emergency services utilization in Jakarta (Indonesia): a cross-sectional study of patients attending hospital emergency departments

BACKGROUND

Pre-hospital and emergency services in Indonesia are still developing. Despite recent improvements in the Indonesian healthcare system, issues with the provision of pre-hospital and emergency services persist. The demand for pre-hospital and emergency services has not been the subject of previous research and, therefore, has not been fully understood. Our research explored the utilization of emergency medical services by patients attending hospital emergency departments in Jakarta, Indonesia.

METHODS

The study used a cross-sectional survey design involving five general hospitals (four government-funded and one private). Each patient's demographic profile, medical conditions, time to treatment, and mode of transport to reach the hospital were analysed using descriptive statistics.

RESULTS

A total of 1964 (62%) patients were surveyed. The median age of patients was 44 years with an interquartile range (IQR) of 26 to 58 years. Life-threatening conditions such as trauma and cardiovascular disease were found in 8.6 and 6.6% of patients, respectively. The majority of patients with trauma travelled to the hospital using a motorcycle or car (59.8%). An ambulance was used by only 9.3% of all patients and 38% of patients reported that they were not aware of the availability of ambulances. Ambulance response time was longer as compared to other modes of transportation (median: 24 minutes and IQR: 12 to 54 minutes). The longest time to treatment was experienced by patients with neurological disease, with a median time of 120 minutes (IQR: 78 to 270 minutes). Patients who used ambulances incurred higher costs as compared to those patients who did not use ambulances.

CONCLUSION

The low utilization of emergency ambulances in Jakarta could be contributed to patients' lack of awareness of medical symptoms and the existence of ambulance services, and patients' disinclination to use ambulances due to high costs and long response times. The emergency ambulance services can be improved by increasing population awareness on symptoms that warrant the use of ambulances and reducing the cost burden related to ambulance use.

Evaluating pre-hospital triage and decision-making in patients who died within 30 days post-trauma: A multi-site, multi-center, cohort study

INTRODUCTION

Evaluating pre-hospital triage and decision-making in patients who died post-trauma is crucial to decrease undertriage and improve future patients' chances of survival. A study that has adequately investigated this is currently lacking. The aim of this study was therefore to evaluate pre-hospital triage and decision-making in patients who died within 30 days post-trauma.

MATERIALS AND METHODS

A multi-site, multi-center, cohort study was conducted. Trauma patients who were transported from the scene of injury to a trauma center by ambulance and died within 30 days post-trauma, were included. The main outcome was undertriage, defined as erroneously transporting a severely injured patient (Injury Severity Score ≥ 16) to a lower-level trauma center.

RESULTS

Between January 2015 and December 2017, 2116 patients were included, of whom 765 (36.2%) were severely injured. A total of 103 of these patients (13.5%) were undertriaged. Undertriaged patients were often elderly with a severe head and/or thoracic injury as a result of a minor fall (< 2 m). A majority of the undertriaged patients were triaged without assistance of a specialized physician (100 [97.1%]), did not meet field triage criteria for level-I trauma care (81 [78.6%]), and could have been transported to the nearest level-I trauma center within 45 min (93 [90.3%]).

CONCLUSION

Approximately 14% of the severely injured patients who died within 30 days were undertriaged and could have benefited from treatment at a level-I trauma center (i.e., specialized trauma care). Improvement of pre-hospital triage is needed to potentially increase future patients' chances of survival.

[Add-on-LUCAS2™ resuscitation at NEF Innsbruck]

Studienziel

Ziele sind die Verlaufsanalyse und der Vergleich mit ausschließlich manuell reanimierten Patienten sowie die Erfassung der Einflussfaktoren bei Patienten, bei denen die mechanische Thoraxkompressionshilfe Lund University Cardiac Assist System (LUCAS2^TM) als Add-on-Therapie am Notarzteinsatzfahrzeug (NEF) Innsbruck verwendet wurde.

Material und Methodik

Retrospektive Verlaufsdatenanalyse von Patienten im Studienzeitraum 01.01.2014 bis 31.12.2019 des NEF Innsbruck aus dem Deutschen Reanimationsregister (GRR), bei denen LUCAS2™ nach notärztlicher Anordnung als Add-on-Therapie verwendet wurde.

Ergebnis

Bei 653 Reanimationen kam es zu 123 Add-on-LUCAS2™-Anwendungen (18,8 %). Von allen Patienten überlebten 16,2 % die ersten 30 Tage. Mithilfe der Add-on-LUCAS2^TM Anwendung überlebten 7,3 % (9/123) aller Add-on-LUCAS2™-Reanimationen bzw. 1,4 % (n = 9) aller CPRs. Bei 8/9 Add-On-LUCAS2™-„30 Tage-Überlebenden“ war der Herz-Kreislauf-Stillstand (HKS) beobachtet, und eine Laien-CPR wurde durchgeführt. Als Primärrhythmus wiesen 8/9 Kammerflimmern auf.

Im Vergleich zur ausschließlich manuellen CPR wurde eine Add-on-LUCAS2™-Reanimation hoch signifikant (p < 0,001) häufiger bei jüngeren, bei männlichen Patienten, in der Öffentlichkeit, bei schockbarem Erstrhythmus und beim Transport eingesetzt sowie signifikant häufiger bei beobachteten HKS (p < 0,05).

Die 30-Tage-Mortalität bei additiver Lysetherapie betrug 100 %.

Diskussion

Durch die Verwendung der Add-on-LUCAS2™-CPR kann eine prozentuelle Erhöhung der Überlebensrate erzielt werden und erscheint somit vorteilhaft (1,4 % in dieser Studie). Durch diese kann bei Patienten mit günstigen Prognosefaktoren eine hochwertige HDM auch bei technisch aufwendiger Bergung (Drehleiter, Stiegenhaus, Transport im RTW) durchgeführt und somit ein Transport ermöglicht werden. Jedoch kommt es dabei zu einer höheren Aufnahmerate unter CPR und somit zur Verlagerung der Therapiezielentscheidung in den Schockraum.

hospital mortality due to road traffic injuries in an Iranian population: results from Tabriz integrated road traffic injury registry

Background

Road Traffic Injuries (RTIs) is considered as one of the main health challenges and causes of mortality, worldwide and especially in Iran. Predicting the place where RTIs-related death takes place is vital in decreasing this type of mortality. The purpose of the present study was to identify the predictors of RTI fatalities with respect to the place of death (hospital vs. pre-hospital) during the recent decade in East Azerbaijan Province, Iran.

Methods

Overall, 7347 RTI fatalities were retrieved from the road traffic injuries registry which is supported by the Forensic Medicine Organization in East Azerbaijan. Among these cases, 2758(37.5%)) were hospital deaths. The registered variables of these cases were analysed using bivariate and multiple logistic regression (STATA version 15).

Results

Out of 7347 deaths, 5862 (79.8%) were men and the rest were women 1485 (20.2%).The mean age was 40.3 (SD = 20.8). Of the total number of cases, 2758 (37.5%) died in hospital death and the rest 4589 (62.5) were pre-hospital death. According to the results of the present study, inter-city RTI (OR = 1.7, CI 95% = (1.5–2)) and RTIs inside the city of Tabriz (OR = 1.4, CI 95% = (1.2–1.6)) increases the chance of hospitals death. In addition, having a heavy counterpart vehicle compared to no counterpart vehicle decreased the chances of hospitals death (OR = 0.46, CI 95% = (0.39–0.55)) while motorcycle or bike counterpart vehicle compared to no counterpart vehicle increased the chances of hospital death (OR = 2.26, CI 95% = (1.59–3.22)). Also the users of the motorcycle or bike vehicle compared to the pedestrians increased the chances of hospital death (OR = 1.43, CI 95% = (1.19–1.71)) while any the other vehicle users compared to the pedestrians have significantly lower chances for hospital death. Other factors that increased hospitals death were transferring injured people by ambulance (OR = 1.3, CI 95% = (1.1–1.6)) and being elderly (OR = 1.5, CI 95% = (1.2–1.7)). Moreover, it was found that the annual trend of change in hospital death is strongly affected by the above-identified factors.

Conclusions

The effective predictors in hospital death were RTI location, type of counterpart vehicle, used vehicles and lighting condition. The identified factors related to the location of deaths by RTI can be divided into the RTI severity-related factors as well as factors related to the services quality and speed of delivery. According to the present results, through professional training of people in the field and providing immediate assistance in RTIs pre-hospital mortality can be significantly prevented.

Out-of-hospital or pre-hospital: Is it time to reconsider the language used to describe and define paramedicine?

The professionalisation of paramedicine in Australasia necessitates discussion about how the profession defines and describes itself in the literature and more broadly. This editorial discusses the descriptors pre-hospital care and out-of-hospital care, and the connotations, relevance and implications of their use to describe paramedic roles and practice.

Opioids for Treatment of Pre-hospital Acute Pain: A Systematic Review

INTRODUCTION

Acute pain is a frequent symptom among patients in the pre-hospital setting, and opioids are the most widely used class of drugs for the relief of pain in these patients. However, the evidence base for opioid use in this setting appears to be weak. The aim of this systematic review was to explore the efficacy and safety of opioid analgesics in the pre-hospital setting and to assess potential alternative therapies.

METHODS

The PubMed, EMBASE, Cochrane Library, Centre for Reviews and Dissemination, Scopus, and Epistemonikos databases were searched for studies investigating adult patients with acute pain prior to their arrival at hospital. Outcomes on efficacy and safety were assessed. Risk of bias for each included study was assessed according to the Cochrane approach, and confidence in the evidence was assessed using the GRADE method.

RESULTS

A total of 3453 papers were screened, of which the full text of 125 was assessed. Twelve studies were ultimately included in this systematic review. Meta-analysis was not undertaken due to substantial clinical heterogeneity among the included studies. Several studies had high risk of bias resulting in low or very low quality of evidence for most of the outcomes. No pre-hospital studies compared opioids with placebo, and no studies assessed the risk of opioid administration for subgroups of frail patients. The competency level of the attending healthcare provider did not seem to affect the efficacy or safety of opioids in two observational studies of very low quality. Intranasal opioids had a similar effect and safety profile as intravenous opioids. Moderate quality evidence supported a similar efficacy and safety of synthetic opioid compared to morphine.

CONCLUSIONS

Available evidence for pre-hospital opioid administration to relieve acute pain is scarce and the overall quality of evidence is low. Intravenous administration of synthetic, fast-acting opioids may be as effective and safe as intravenous administration of morphine. More controlled studies are needed on alternative routes for opioid administration and pre-hospital pain management for potentially more frail patient subgroups.

A National Survey of Prehospital Care Services of United Kingdom for Use, Governance and Perception of Prehospital Point of Care Ultrasound

Introduction: Point of care ultrasound (POCUS) has become a common practice in prehospital care over the last 10 years. There is lack of literature on its use and governance structure in United Kingdom (UK) prehospital care services. We aimed to survey the use, governance of prehospital POCUS among UK prehospital services and perceptions of clinicians and services regarding its utility and barriers to its implementation. Methods: Four electronic questionnaire surveys were delivered to UK helicopter emergency medical service (HEMS) & clinicians, ambulance and community emergency medicine (CEM) services between 1^st of April and 31^st of July 2021 investigating current use, governance structure for POCUS and perception about its benefits and barriers. Invitations were sent via email to medical directors or research leads of services and using social media. Survey links remained live for two months each. Results: Overall, 90%, 62% and 60% of UK HEMS, ambulance and CEM services respectively, responded to surveys. Most of the services used prehospital POCUS, however only two HEMS organisations fulfilled the Royal College of Radiology governance criteria for POCUS. The most commonly performed POCUS modality was echo in cardiac arrest. Majority of clinicians judged POCUS to be beneficial and the common perceived benefit was promotion of enhanced and effective clinical care. Major barriers to its implementation included a lack of formal governance, limited literature supporting its use and difficulties in performing POCUS in prehospital environment. Conclusion: This survey demonstrates that prehospital POCUS is being provided by a majority of the prehospital care services and clinicians have found it beneficial in providing enhanced clinical care to their patients. However, the barriers to its implementation are relative lack of governance structure and supportive literature.

INTEnsive ambulance-delivered blood pressure Reduction in hyper-ACute stroke Trial (INTERACT4): study protocol for a randomized controlled trial

Background

Early pre-hospital initiation of blood pressure (BP) lowering could improve outcomes for patients with acute stroke, by reducing hematoma expansion in intracerebral hemorrhage (ICH), and time to reperfusion treatment and risk of intracranial hemorrhage in ischemic stroke (IS). We present the design of the fourth INTEnsive ambulance-delivered blood pressure Reduction in hyper-ACute stroke Trial (INTERACT4).

Methods

A multi-center, ambulance-delivered, prospective, randomized, open-label, blinded endpoint (PROBE) assessed trial of pre-hospital BP lowering in 3116 hypertensive patients with suspected acute stroke at 50+ sites in China. Patients are randomized through a mobile phone digital system to intensive BP lowering to a target systolic BP of < 140 mmHg within 30 min, or guideline-recommended BP management according to local protocols. After the collection of in-hospital clinical and management data and 7-day outcomes, trained blinded assessors conduct telephone or face-to-face assessments of physical function and health-related quality of life in participants at 90 days. The primary outcome is the physical function on the modified Rankin scale at 90 days, analyzed as an ordinal outcome with 7 categories. The sample size was estimated to provide 90% power (α = 0.05) to detect a 22% reduction in the odds of a worse functional outcome using ordinal logistic regression.

Discussion

INTERACT4 is a pragmatic clinical trial to provide reliable evidence on the effectiveness and safety of ambulance-delivered hyperacute BP lowering in patients with suspected acute stroke.

Trial registration

ClinicalTrials.gov NCT03790800. Registered on 2 January 2019; Chinese Trial Registry ChiCTR1900020534. Registered on 7 January 2019. All items can be found in this protocol paper.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05860-y.

Helicopter emergency medical services use of thoracic point of care ultrasound for pneumothorax: a systematic review and meta-analysis

Background

Auscultating for breath sounds to assess for pneumothorax in the helicopter emergency medical services (HEMS) settings can be extremely challenging. Thoracic point of care ultrasound (POCUS) offers a seemingly more useful visual (rather than audible) alternative. This review critically and quantitatively evaluates the use of thoracic POCUS for pneumothorax in the HEMS setting.

Methods

A systematic literature review with meta-analysis was conducted. Only papers reporting on patients undergoing POCUS for pneumothorax in the helicopter or pre-hospital setting were included. Primary outcome was accuracy, focusing on sensitivity and specificity. Secondary outcome was practicality. PubMed, Embase and the Cochrane Library were searched. The Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) was used to assess validity of studies.

Results

Twelve studies reporting on n = 1,936 images from medical and trauma patients were included in qualitative synthesis. Studies were nearly all observational designs. Most images were acquired by nurses or paramedics who were previously novices to ultrasound. The reference standard was predominantly CT. Specificity results were unanimously precise and very high, whereas sensitivity results were imprecise and extremely variable. Meta-analysis of eight studies involving n = 1,713 images yielded pooled sensitivity 61% (95% CI: 27–87%; I² = 94%) and pooled specificity 99% (95% CI: 98–100%; I² = 89%). Six studies involving n = 315 images reported practicality. The highest or second highest categorisation of image quality was reported in around half of those images.

Conclusion

Thoracic POCUS is highly specific but has extremely variable sensitivity for pneumothorax when performed in the HEMS setting. This is from purely a diagnostic (not clinical) perspective. Sensitivity increases when only clinically significant pneumothoraces are considered. Case reports reveal thoracic POCUS can appropriately alter treatment and triage decisions, but only for a small number of patients. It appears predominantly useful in mitigating against unnecessary interventions. More research reporting patient focused outcomes is required. In the meantime, thoracic POCUS appears to offer a more appropriate visual alternative to auscultation for breath sounds when assessing for pneumothorax in the HEMS setting.

The Alternative Pre-hospital Pathway team: reducing conveyances to the emergency department through patient centered Community Emergency Medicine

Background

Internationally increasing demand for emergency care is driving innovation within emergency services. The Alternative Pre-Hospital Pathway (APP) Team is one such Community Emergency Medicine (CEM) initiative developed in Cork, Ireland to target low acuity emergency calls.

In this paper the inception of the APP Team is described, and an observational descriptive analysis of the APP Team’s service data presented for the first 12 months of operation. The aim of this study is to describe and analyse the APP team service.

Methods

The APP Team, consisting of a Specialist Registrar (SpR) in Emergency Medicine (EM) and an Emergency Medical Technician (EMT) based in Cork, covers a mixed urban and rural population of approximately 300,000 people located within a 40-min drive time of Cork University Hospital. The team are dispatched to low acuity 112/999 calls, aiming to provide definitive care or referring patients to the appropriate community or specialist service.

A retrospective analysis was performed of the team’s first 12 months of operation using the prospectively maintained service database.

Results

Two thousand and one patients were attended to with a 67.8% non-conveyance rate. The median age was 62 years, with 33.0% of patients aged over 75 years. For patients over 75 years, the non-conveyance rate was 62.0%. The average number of patients treated per shift was 7. Medical complaints (319), falls (194), drug and alcohol related presentations (193), urological (131), and respiratory complaints (119) were the most common presentations.

Conclusion

Increased demand for emergency care and an aging population is necessitating a re-design of traditional models of emergency care delivery. We describe the Alternative Pre-Hospital Pathway service, delivered by an EMT and an Emergency Medicine SpR responding to low acuity calls. This service achieved a 68% non-conveyance rate; our data demonstrates that a community emergency medicine outreach team in collaboration with the National Ambulance Service offering Alternative Pre-Hospital Pathways is an effective model for reducing conveyances to hospital.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-021-00536-x.

The Role of Plasma Transfusion in Pre-Hospital Haemostatic Resuscitation

Traumatic haemorrhage remains a major cause of preventable death and early haemostatic resuscitation is now a mainstay of treatment internationally. Recently, 2 randomized control trials (RCTs) - PAMPer (Prehospital Air Medical Plasma) and COMBAT (Control of Major Bleeding After Trauma), evaluating the effect of pre-hospital use of plasma on mortality provided conflicting results, raising important questions on the role of plasma resuscitation in pre-hospital environment. Both PAMPer (n = 501 patients) and COMBAT (n = 144 patients) trials were pragmatic RCTs that evaluated the effect of pre-hospital plasma transfusion (two units) versus standard of care on 28/30 days mortality in trauma patients who presented with clinical signs of haemorrhagic shock (defined as hypotension or tachycardia). The PAMPer trial showed that plasma transfusion reduced 30-day mortality compared with standard of care (23% vs 33%, 95% confidence interval -18.6; -1.0%; P = 0.03), while COMBAT trial showed no difference in 28-day survival. The post-hoc analyses of the 2 trials have suggested that the benefit of pre-hospital plasma transfusion may be greater for patients who are coagulopathic, have blunt injury and have a transport time from the scene of injury to the hospital of >20 minutes. In this review we evaluate strengths and limitations of the two trials and their differences and similarities, which may explain the conflicting results, as well as provide directions for future trials to better define the target population that would most benefit from pre-hospital plasma resuscitation. Further, considering the logistical challenges of carrying any blood components on an aircraft, cost/safety of plasma, and the scarcity of universal blood group donors, there is a need for a health economic evaluation of pre-hospital plasma transfusion in trauma patients, prior to this intervention becoming universal.

Pre-hospital management of penetrating neck injuries: a scoping review of current evidence and guidance

Penetrating injuries to the neck pose a unique challenge to clinicians due to the proximity of multiple significant anatomical structures with little protective soft tissue coverage. Injuries to this area, whilst low in incidence, are potentially devastating. Respiratory, vascular, gastro-oesophageal and neurological structures may all be involved, either in isolation or combination. These injuries are particularly difficult to manage in the resource poor, often austere and/or remote, pre-hospital environment. A systematic scoping review of the literature was conducted to evaluate the current available research pertaining to managing this injury profile, prior to the patient arriving in the emergency department. The available research is discussed in sections based on the commonly used trauma management acronym ‘cABCD’ (catastrophic haemorrhage, Airway, Breathing, Circulation, Disability) to facilitate a systematic approach and clinical evaluation familiar to clinicians. Based on the available reviewed evidence, we have proposed a management algorithm for this cohort of patients. From this we plan to instigate a Delphi process to develop a consensus statement on the pre-hospital management of this challenging presentation.

Ketamine versus propofol for rapid sequence induction in trauma patients: a retrospective study

BACKGROUND

Rapid Sequence Induction (RSI) is used for emergency tracheal intubation to minimise the risk of pulmonary aspiration of stomach contents. Ketamine and propofol are two commonly used induction agents for RSI in trauma patients. Yet, no consensus exists on the optimal induction agent for RSI in the trauma population. The aim of this study was to compare 30-day mortality in trauma patients after emergency intubation prehospitally or within 30 min after arrival in the trauma centre using either ketamine or propofol for RSI.

METHODS

In this investigator-initiated, retrospective study we included adult trauma patients emergently intubated with ketamine or propofol registered in the local trauma registry at Rigshospitalet, a tertiary university hospital that hosts a level-1 trauma centre. The primary outcome was 30-day mortality. Secondary outcomes included hospital and Intensive Care Unit length of stay as well as duration of mechanical ventilation. We analysed outcomes using multivariable logistic regression models adjusting for age, sex, injury severity score, shock (systolic blood pressure < 90 mmHg) and Glasgow Coma Scale score before intubation and present results as odds ratios (ORs) with 95% confidence intervals.

RESULTS

From January 1st, 2015 through December 31st, 2019 we identified a total of 548 eligible patients. A total of 228 and 320 patients received ketamine and propofol, respectively. The 30-day mortality for patients receiving ketamine and propofol was 20.2% and 22.8% (P = 0.46), respectively. Adjusted OR for 30-day mortality was 0.98 [0.58-1.66], P = 0.93. We found no significant association between type of induction agent and hospital length of stay, Intensive Care Unit length of stay or duration of mechanical ventilation.

CONCLUSIONS

In this study, trauma patients intubated with ketamine did not have a lower 30-day mortality as compared with propofol.

Neurological outcomes associated with prehospital advanced airway management in patients with out-of-hospital cardiac arrest due to foreign body airway obstruction

OBJECTIVES

Several studies have examined the association between advanced airway management (AAM) and survival for arrest that is non-shockable, noncardiac in origin, or due to suffocation; however, the efficacy of prehospital AAM compared with no AAM following foreign body removal by emergency medical services (EMS) has not been examined. We aimed to compare neurological outcomes in patients after out-of-hospital cardiac arrest (OHCA) due to foreign body airway obstruction (FBAO) managed with and without AAM after foreign body removal.

METHODS

This retrospective observational cohort study used all emergency transportation data of Japan and the All-Japan Utstein Registry. We included patients with OHCA aged ≥18 years undergoing resuscitation and removal of airway foreign bodies by EMS from January 2015 to December 2017. The exposure of interest was prehospital AAM by EMS after foreign body removal, and the primary outcome was a favorable neurological outcome at hospital discharge (i.e., a cerebral performance category of 1-2).

RESULTS

Overall, 329,098 adults had OHCAs and 23,060 had foreign bodies removed from their airways; 3681 adult patients met our eligibility criteria and were divided as: AAM (2045) and non-AAM (1636) groups. Propensity score matching resulted in 1210 matched pairs with balanced baseline characteristics between the groups. The rate of favorable neurological outcome was significantly lower in the AAM group than in the non-AAM group (OR 0.34, 95% CI 0.19-0.62). However, survival was not significantly different between the two groups (OR 1.08, 95% CI 0.84-1.37).

CONCLUSIONS

We have not demonstrated the benefit of AAM for patients with OHCA due to FBAO. Further study will be required to confirm the efficacy of AAM for those patients.

Pre-Hospital Administration of Opioids in Trauma Patients: Is Dose Associated With Outcomes?

BACKGROUND

Opioids are commonly used as an analgesic agent in the prehospital setting. Current efforts to prevent and control prescription opioid overuse are focused on the in-hospital and post-discharge phases. The aim of our study was to assess the associations between pre-hospital opioids use and in-hospital outcomes among trauma patients.

METHODS

We performed a 2 year (2016-2017) retrospective analysis of our Level-I trauma center database. We included all adult trauma patients (age > 18y) who received pre-hospital opioids (Fentanyl (F) or Morphine-Sulfate (MS)). Outcome measures were emergency-department (ED) hypotension (SPB < 90 mmHg), ED intubation, prescription opioid medication upon discharge, and mortality. Multivariate logistic regression was performed.

RESULTS

In total, 709 patients were included in the analysis. Cutoff values of 200 mcg F and 15 mg MS were significantly associated with adverse outcomes. Overall, the ED hypotension rate was 14.4%, ED intubation rate was 6%, and ED mortality rate was 3.1%. On regression analysis, higher dosages of both pre-hospital F and pre-hospital MS were independently associated with increased odds of ED hypotension, ED intubation, and discharge on opioid medications, but not with ED mortality.

CONCLUSION

Pre-hospital administration of high dose opioids is associated with increased odds of adverse outcomes. Collaborative efforts to standardize and control the overuse of opioids should target the pre-hospital setting to limit opioid associated adverse effects.

Idle peripheral intravenous cannulation: an observational cohort study of pre-hospital and emergency department practices

BACKGROUND

Unused ('idle') peripheral intravenous catheters (PIVC) are those not used within 24 hours of insertion. There is little data on cannulation practices and idle PIVC rates in emergency settings, especially the pre-hospital environment.

METHODS

This was an observational cohort study set in south-east Queensland, Australia using data from a large tertiary level emergency department (ED) and the local statutory ambulance service. Demographic, clinical and PIVC data were collected over two periods; 9 February-18 March 2017 and 5 January-4 February 2018. Adult patients were included if they were allocated an Australasian triage scale (ATS) category between 2 and 5, and had a PIVC inserted in the pre-hospital setting or ED. PIVC use was defined as idle if no fluids, medications or contrast were administered intravenously within 24 hours of insertion. Comparisons between pre-hospital and ED practice and idle PIVC status were undertaken using descriptive statistics and logistic regression.

RESULTS

A total of 1249 patients with a PIVC (372 pre-hospital; 877 ED) were included. Overall, 366 PIVCs (29.3%; 95% CI 26.9%-31.9%) remained idle at 24 hours. In the pre-hospital group, 147 (39.5%) PIVCs inserted were not used pre-hospital, and 74 (19.9%) remained idle. In comparison, 292 (33.3%) PIVCs placed in the ED remained idle. ED staff more frequently inserted PIVCs in the antecubital fossa than paramedics (65.5% vs. 49.7%), where forearm PIVC insertion was more common pre-hospital than in ED (13.7% vs. 7.4%). Nursing staff inserted idle PIVCs at a rate of (35.1%) compared to doctors (29.6%) and paramedics (19.9%). Having a PIVC inserted in the ED was the only factor significantly (p ≤ .001) predicting an idle outcome (Odds Ratio: 2.4; 95% CI 1.7-3.3).

CONCLUSION

One-third of PIVCs inserted within the emergency setting remained idle, suggesting unnecessary risk and costs. Pre-hospital and ED PIVC insertion practices differed, with idle PIVCs 2.4 times more prevalent if inserted in the ED than pre-hospital and with greater use of antecubital insertion. Reasons for these differences are not well understood and requires more targeted research.