Evaluation of the prehospital administration of tranexamic acid for injured patients: a state-wide observational study with sex and age-disaggregated analysis.

BACKGROUND: Tranexamic acid (TXA) decreases mortality in injured patients and should be administered as soon as possible. Despite international guidelines recommending TXA in the prehospital setting, its use remains low. The aim of this study was to assess the prehospital administration of TXA for injured patients in a Swiss region. METHODS: We conducted a retrospective observational study in Switzerland between 2018 and 2021. Inclusion criteria were injured patients ≥18 years for whom an ambulance or helicopter was dispatched. The exclusion criterion was minor injury defined by a National Advisory Committee for Aeronautics score <3. The primary outcome was the proportion of patients treated with TXA according to guidelines. The European guidelines were represented by the risk of death from bleeding (calculated retrospectively using the Bleeding Audit for Trauma and Triage (BATT) score). Factors impacting the likelihood of receiving TXA were assessed by multivariate analysis. RESULTS: Of 13 944 patients included in the study, 2401 (17.2%) were considered at risk of death from bleeding. Among these, 257 (11%) received prehospital TXA. This represented 38% of those meeting US guidelines. For European guidelines, the treatment rate increased with the risk of death from bleeding: 6% (95% CI 4.4% to 7.0%) for low risk (BATT score 3-4); 13% (95% CI 11.1% to 15.9%) for intermediate risk (BATT score 5-7); and 21% (95% CI 17.6% to 25.6%) for high risk (BATT score ≥8) (p<0.01). Women and the elderly were treated less often than men and younger patients, irrespective of the risk of death from bleeding and the mechanism of injury. CONCLUSION: The proportion of injured patients receiving TXA in the prehospital setting of the State of Vaud in Switzerland was low, with even lower rates for women and older patients. The reasons for this undertreatment are probably multifactorial and would require specific studies to clarify and correct them.

Higher pre-hospital anaesthesia case volumes result in lower mortality rates: implications for mass casualty care.

Senior physicians with a higher pre-hospital anaesthesia case volume have higher first-pass tracheal intubation success rates, shorter on-site times, and lower patient mortality rates than physicians with lower case volumes. A senior physician's skill set includes the basics of management of airway and breathing (ventilating and oxygenating the patient), circulation, disability (anaesthesia), and environment (especially maintaining core temperature). Technical rescue skills may be required to care for patients requiring pre-hospital airway management especially in hazardous environments, such as road traffic accidents, chemical incidents, terror attacks or warfare, and natural disasters. Additional important tactical skills in mass casualty situations include patient triage, prioritising, allocating resources, and making transport decisions.

Prehospital Use of Ultrathin Reflective Foils.

Ultrathin reflective foils (URFs) are widely used to protect patients from heat loss, but there is no clear evidence that they are effective. We review the physics of thermal insulation by URFs and discuss their clinical applications. A conventional view is that the high reflectivity of the metallic side of the URF is responsible for thermal protection. In most circumstances, the heat radiated from a well-clothed body is minimal and the reflecting properties of a URF are relatively insignificant. The reflection of radiant heat can be impaired by condensation and freezing of the moisture on the inner surface and by a tight fit of the URF against the outermost layer of insulation. The protection by thermal insulating materials depends mostly on the ability to trap air and increases with the number of covering layers. A URF as a single layer may be useful in low wind conditions and moderate ambient temperature, but in cold and windy conditions a URF probably best serves as a waterproof outer covering. When a URF is used to protect against hypothermia in a wilderness emergency, it does not matter whether the gold or silver side is facing outward.

The efficiency of continuous renal replacement therapy for rewarming of patients in accidental hypothermia--An experimental study.

Severe accidental hypothermia carries high mortality and morbidity and is often treated with invasive extracorporeal methods. Continuous veno-venous hemodiafiltration (CVVHDF) is widely available in intensive care units. We sought to provide theoretical basis for CVVHDF use in rewarming of hypothermic patients. CVVHDF system was used in the laboratory setting. Heat balance and transferred heat units were evaluated for the system without using blood. We used 5L of crystalloid solution at the temperature of approximately 25°C, placed in a thermally insulated tank (representing the "central compartment" of a hypothermic patient). Time of warming the central compartment from 24.9 to 30.0°C was assessed with different flow combinations: "blood" (central compartment fluid) 50 or 100 or 150 mL/min, dialysate solution 100 or 1500 mL/h, and substitution fluid 0 or 500 mL/h. The total circulation time was 1535 minutes. There were no differences between heat gain values on the filter depending on blood flow (P = .53) or dialysate flow (P = .2). The mean heating time for "blood" flow rates 50, 100, and 150 mL/min was 113.7 minutes (95% CI, 104.9-122.6 minutes), 83.3 minutes (95% CI, 76.2-90.3 minutes), and 74.7 minutes (95% CI, 62.6-86.9 minutes), respectively (P < .01). The respective median rewarming rate for different "blood" flows was 3.6°C/h (IQR, 3.0-4.2°C/h), 4.8 (IQR, 4.2-5.4°C/h), and 5.4 (IQR, 4.8-6.0°C/h), respectively (P < .01). The dialysate flow did not affect the warming rate. Based on our experimental model, CVVHDF may be used for extracorporeal rewarming, with the rewarming rates increasing achieved with higher blood flow rates.

Outcomes of patients suffering unwitnessed hypothermic cardiac arrest rewarmed with extracorporeal life support: A systematic review.

Prolonged cardiac arrest (CA) may lead to neurologic deficit in survivors. Good outcome is especially rare when CA was unwitnessed. However, accidental hypothermia is a very specific cause of CA. Our goal was to describe the outcomes of patients who suffered from unwitnessed hypothermic cardiac arrest (UHCA) supported with Extracorporeal Life Support (ECLS). We included consecutive patients' cohorts identified by systematic literature review concerning patients suffering from UHCA and rewarmed with ECLS. Patients were divided into four subgroups regarding the mechanism of cooling, namely: air exposure; immersion; submersion; and avalanche. A statistical analysis was performed in order to identify the clinical parameters associated with good outcome (survival and absence of neurologic impairment). A total of 221 patients were included into the study. The overall survival rate was 27%. Most of the survivors (83%), had no neurologic deficit. Asystole was the presenting CA rhythm in 48% survivors, of which 79% survived with good neurologic outcome. Variables associated with survival included the following: female gender (P < .001); low core temperature (P = .005); non-asphyxia-related mechanism of cooling (P < .001); pulseless electrical activity as an initial rhythm (P < .001); high blood pH (P < .001); low lactate levels (P = .003); low serum potassium concentration (P < .001); and short resuscitation duration (P = .004). Severely hypothermic patients with unwitnessed CA may survive with good neurologic outcome, including those presenting as asystole. The initial blood pH, potassium, and lactate concentration may help predict outcome in hypothermic CA.

Resuscitation of an Unconscious Victim of Accidental Hypothermia in 1805.

In 1805, W.D., a 16-y-old boy, became hypothermic after he was left alone on a grounded boat in Leith Harbour, near Edinburgh, Scotland. He was brought to his own house and resuscitated with warm blankets, smelling salts, and massage by Dr. George Kellie. W.D. made an uneventful recovery. We discuss the pathophysiology and treatment of accidental hypothermia, contrasting treatment in 1805 with treatment today. W.D. was hypothermic when found by passersby. Although he appeared dead, he was rewarmed with help from Dr. Kellie and his assistants over 200 y ago using simple methods. One concept that has not changed is the critical importance of attempting resuscitation, even if it seems to be futile. Don't give up!

Prehospital Use of Ketamine in Mountain Rescue: A Survey of Emergency Physicians of a Single-Center Alpine Helicopter-Based Emergency Service.

INTRODUCTION: Although ketamine use in emergency medicine is widespread, studies investigating prehospital use are scarce. Our goal was to assess the self-reported modalities of ketamine use, knowledge of contraindications, and occurrence of adverse events associated with its use by physicians through a prospective online survey. METHODS: The survey was administered to physicians working for Air-Glaciers, a Swiss alpine helicopter-based emergency service, and was available between September 24 and November 23, 2018. We enrolled 39 participants (participation rate of 87%) in our study and collected data regarding their characteristics, methods of ketamine use, knowledge of contraindications, and encountered side effects linked to the administration of ketamine. We also included a clinical scenario to investigate an analgesic strategy. RESULTS: Ketamine was considered safe and judged irreplaceable by most physicians. The main reason for ketamine use was acute analgesia during painful procedures, such as manipulation of femur fractures. The doses of ketamine administered with or without fentanyl ranged from 0.2 to 0.7 mg·kg-1 intravenously. Most physicians reported using fentanyl and midazolam along with ketamine. The median dose of midazolam was 2 (interquartile range 1-2) mg for a 70-kg adult. Monitoring and oxygen administration were used infrequently. Hallucinations were the most common adverse events. Knowledge of ketamine contraindications was poor. CONCLUSIONS: Ketamine use was reported by mountain rescue physicians to be safe and useful for acute analgesia. Most physicians use fentanyl and midazolam along with ketamine. Adverse neuropsychiatric events were rare. Knowledge regarding contraindications to the administration of ketamine should be improved.

Successful Defibrillation at a Core Temperature of 18.2 Degrees Celsius.

Both the temperature at which defibrillation can be effectively used and how often it should be repeated in severe accidental hypothermia have not been definitely established. Current recommendations are based mainly on expert opinion and suggest withholding defibrillation after 3 shocks when the core temperature is below 30°C (86°F). However, growing evidence supports the effectiveness of defibrillation in patients with a core temperature below 30°C (86°F). We present a case of successful defibrillation of a 54-y-old, severely hypothermic patient with a core temperature of 18.2°C (64.8°F). The shock was delivered automatically by an implanted cardioverter-defibrillator shortly after the implementation of extracorporeal rewarming. The patient survived and was discharged from the hospital neurologically intact. It might be reasonable to consider defibrillation attempts in severely hypothermic patients despite current guidelines to the contrary. Increasing coronary perfusion using extracorporeal circulation may result in a better response to defibrillation.

[Emergency department : COVID-19 crisis and organizational aspects]. / Urgences hospitalières : crise COVID-19 et aspects organisationnels.

Emergency departments are on the front line in the management of COVID-19 cases, from screening to the initial management of the most severe cases. The clinical presentation of COVID-19 range from non-specific symptoms to adult acute respiratory distress syndrome (ARDS). Diagnosis is based on PCR from a nasopharyngeal swab and emergency treatment rely on oxygen therapy. Patient's orientation (home, hospitalization, admission in intensive care unit) is a central aspect of emergency management. The shift from a strategy of systematic recognition of potential cases to the one of epidemic mitigation required hospital emergency medicine services to implement crisis management measures, to guarantee admission and hospitalization capacity.

Les services d'urgences sont en première ligne dans la gestion des cas de COVID-19, qu'il s'agisse du dépistage ou de la prise en charge des cas les plus sévères. La clinique associée au COVID-19 va de symptômes non spécifiques au syndrome de détresse respiratoire aiguë de l'adulte. Le diagnostic repose sur la PCR à partir d'un frottis nasopharyngé et le traitement d'urgence sur l'oxygénothérapie. L'orientation du patient (retour à domicile, hospitalisation, indication aux soins intensifs) est un aspect central de la prise en charge aux urgences. Le passage de la stratégie de reconnaissance systématique des cas potentiels à celle de la mitigation de l'épidémie a impliqué pour les services d'urgences hospitaliers la mise en place de mesures exceptionnelles afin de garantir une capacité d'accueil et d'hospitalisation.

[Emergency Medical Services: COVID-19 crisis]. / Urgences préhospitalières†: crise COVID-19.

The COVID-19 epidemic required rapid and frequent adaptations from the prehospital emergency medical services (EMS). The exposure of EMS providers is significant, particularly during procedures at risk of aerosolization such as advanced airways management or cardiopulmonary resuscitation. EMS personal need to be equipped with appropriate personal protective equipment and trained in its use. Interhospital transfers from COVID-19 patients are complex and involve mainly intubated patients. The possible shortage of resources may motivate the implementation of dedicated pre-hospital triage and orientation recommendations, which should be consistent with the hospital processes.

L'épidémie de COVID-19 a nécessité de la part des services d'urgence préhospitaliers des adaptations rapides et fréquentes. L'exposition des intervenants au risque infectieux est significative, notamment en cas de procédures à risque d'aérosolisation (réanimation cardiopulmonaire, gestion des voies aériennes supérieures). Les moyens de protection individuelle ont dû être adaptés en conséquence et leur manipulation entraînée. Les transferts interhospitaliers médicalisés de patients COVID-19 concernent surtout des patients intubés et sont complexes. L'éventuelle pénurie des ressources motiverait la mise en application de directives préhospitalières spécifiques rédigées en cohérence avec les processus de triage hospitaliers.

Fascia iliaca block in the emergency department for hip fracture: a randomized, controlled, double-blind trial.

BACKGROUND: Hip fracture causes moderate to severe pain and while fascia iliaca block has been reported to provide analgesic benefit, most previous trials were unblinded, with subsequent high risks of performance, selection and detection biases. In this randomized, control double-blind trial, we tested the hypothesis that a fascia iliaca block provides effective analgesia for patients suffering from hip fracture. METHODS: Thirty ASA I-III hip fracture patients over 70 years old, who received prehospital morphine, were randomized to receive either a fascia iliaca block using 30 ml of bupivacaine 0.5% with epinephrine 1:200,000 or a sham injection with normal saline. The fascia iliaca block was administered by emergency medicine physicians trained to perform an anatomic landmark-based technique. The primary outcome was the comparison between groups of the longitudinal pain score profiles at rest over the first 45 min following the procedure (numeric rating scale, 0-10). Secondary outcomes included the longitudinal pain score profiles on movement and the comparison over 4 h, 8 h, 12 h, and 24 h after the procedure, along with cumulative intravenous morphine consumption at 24 h. RESULTS: At baseline, the fascia iliaca group had a lower mean pain score than the sham injection group, both at rest (difference = - 0.9, 95%CI [- 2.4, 0.5]) and on movement (difference = - 0.9, 95%CI [- 2.7; 0.9]). These differences remained 45 min after the procedure and the two longitudinal pain score profiles were parallel both for patients at rest and on movement (test of parallelism for patients at rest p = 0.53 and on movement p = 0.45). The same parallel change in pain scores over time was observed over 24 h of follow-up (test of parallelism for patients at rest p = 0.82 and on movement p = 0.12). These results were confirmed after adjustment for gender, ASA score, and cumulative sums of intravenous morphine received pre-procedure and during-follow-up. In addition, there was no difference between the two groups in total cumulative intravenous morphine consumption at 24 h. CONCLUSION: Fascia iliaca block following anatomic landmarks may not provide supplementary analgesia for patients suffering from hip fracture, when low pain scores are reported after prehospital morphine. Additional larger trials will help reach definitive conclusion. TRIAL REGISTRATION NUMBER: Clinicaltrials.gov - NCT02433548 . The study was registered retrospectively.

HEMS inter-facility transfer: a case-mix analysis.

BACKGROUND: Helicopter emergency medical services (HEMS) are popular rescue systems despite inconsistent evidence in the scientific literature to support their use for primary interventions, as well as for inter-facility transfer (IFT). There is little research about IFT by HEMS, hence questions remain about the appropriateness of this method of transport. The aim of this study was to describe a case-mix of operational and medical characteristics for IFT activity of a sole HEMS base, and identify indicators of over-triage. METHODS: This is a retrospective study on HEMS IFT over 36 months, from January 1st 2013 to December 31st 2015. Medical and operational data from the database of the Emergency Department of Lausanne University Hospital, which provides the emergency physicians for this helicopter base, were reviewed. It included distance and time of flight transport, type of care during flight, and estimated distance of transport if conducted by ground. RESULTS: There were 2194 HEMS missions including 979 IFT (44.6%). Most transfers involved adults (> 17 years old; 799 patients, 81.6%). Forty patients (4.1%) were classified as having benefitted from resuscitation or life-saving measures performed in flight, 615 (62.8%) from emergency treatment and 324 (33.1%) from simple clinical examination. The median distance by air between hospitals was 35.4 km. The estimated median distance by road was 47.7 km. The median duration time from origin to destination by air was 12 min. CONCLUSIONS: This case-mix of IFTs by HEMS presents a high severity. There are many signs in favour of over-triage. We propose indicators to help choosing whether HEMS is the most appropriate mean of transport to perform the transfer regarding patient condition, geography, and medical competences available aboard ground ambulances; this may reduce over-triage.

[Emergency medicine : update 2017]. / Médecine d'urgence.

Emergency medicine is part of the current stream of efficient and qualitative medicine : 1) the modified Valsava maneuver results in the resolution of almost 50% of supra-ventricular tachycardia without any drug; 2) lung echography performed by emergency physicians is a very sensitive and specific diagnostic tool for most thoracic emergencies; 3) cardiopulmonary resuscitation initiated by lay-rescuers improves short and long-term outcome; 4) no anticoagulant treatment is warranted in distal deep vein thrombosis and 5) systematic unenhanced abdominal CT might improve evaluation of elderly patients with acute abdominal pain.

Dans le courant actuel d'une médecine de qualité visant l'efficience, la médecine d'urgence n'est pas en reste : 1) la manœuvre de Valsalva modifiée permet une cardioversion dans près de 50 % des tachycardies supraventriculaires paroxystiques sans aucun autre traitement ; 2) l'échographie pulmonaire pratiquée par l'urgentiste est rapide avec de très bonnes sensibilité et spécificité dans plusieurs pathologies thoraciques ; 3) une réanimation initiée par des témoins permet une meilleure survie et améliore le pronostic à long terme ; 4) un traitement anticoagulant n'est pas nécessaire lors de thrombose veineuse profonde sous-poplitée et 5) un scanner abdominal non injecté systématique pourrait améliorer la prise en charge de patients âgés souffrant de douleurs abdominales aiguës.

Association of pelvic fracture patterns, pelvic binder use and arterial angio-embolization with transfusion requirements and mortality rates; a 7-year retrospective cohort study.

BACKGROUND: Pelvic fractures are severe injuries with frequently associated multi-system trauma and a high mortality rate. The value of the pelvic fracture pattern for predicting transfusion requirements and mortality is not entirely clear. To address hemorrhage from pelvic injuries, the early application of pelvic binders is now recommended and arterial angio-embolization is widely used for controlling arterial bleeding. Our aim was to assess the association of the pelvic fracture pattern according to the Tile classification system with transfusion requirements and mortality rates, and to evaluate the correlation between the use of pelvic binders and arterial angio-embolization and the mortality of patients with pelvic fractures. METHODS: Single-center retrospective cohort study including all consecutive patients with a pelvic fracture from January 2008 to June 2015. All radiological fracture patterns were independently reviewed and grouped according to the Tile classification system. Data on patient demographics, use of pelvic binders and arterial angio-embolization, transfusion requirements and mortality were extracted from the institutional trauma registry and analyzed. RESULTS: The present study included 228 patients. Median patient age was 43.5 years and 68.9% were male. The two independent observers identified 105 Tile C (46.1%), 71 Tile B (31.1%) and 52 Tile A (22.8%) fractures, with substantial to almost perfect interobserver agreement (Kappa 0.70-0.83). Tile C fractures were associated with a higher mortality rate (p = 0.001) and higher transfusion requirements (p < 0.0001) than Tile A or B fractures. Arterial angio-embolization for pelvic bleeding (p = 0.05) and prehospital pelvic binder placement (p = 0.5) were not associated with differences in mortality rates. CONCLUSIONS: Tile C pelvic fractures are associated with higher transfusion requirements and a higher mortality rate than Tile A or B fractures. No association between the use of pelvic binders or arterial angio-embolization and survival was observed in this cohort of patients with pelvic fractures.

[Prehospital misconceptions]. / Idées reçues en préhospitalier.

We confronted some of the most prevalent prehospital misconceptions with the available literature. We found that: the diminution of a retrosternal pain following nitrate administration is not predictive of a cardiac origin of the pain ; survival of traumatic cardiac arrest may not be as bad as usually believed ; peripheral venous administration of vasopressors through proximal catheters during short times may be considered as a safe temporary alternative to central venous access ; using the pulse palpation usually lead to an under-estimation of the systolic blood pressure ; applying a pelvic belt at the level of the iliac crests doesn't aggravate an open-book fracture; there is no 90 mmHg threshold values below which mortality increases in traumatic brain injuries.

Nous nous sommes intéressés à certaines idées reçues en médecine d'urgence préhospitalière, en les confrontant avec les évidences de la littérature. Certaines de ces notions sont ainsi remises en question : les douleurs rétrosternales d'origine non cardiaque s'améliorent tout autant suite à l'administration de nitrés que celles d'origine cardiaque ; les arrêts cardiaques traumatiques ne sont pas toujours irréversibles ; les vasopresseurs peuvent être donnés transitoirement de manière sécuritaire sur une voie veineuse périphérique ; l'estimation de la tension artérielle à l'aide du pouls n'est pas fiable ; une ceinture pelvienne sur les crêtes iliaques n'aggrave pas une fracture « open-book ¼ ; il n'y a pas de « valeur seuil ¼ de tension artérielle systolique à 90 mmHg au-dessous de laquelle la mortalité augmenterait lors de traumatisme crânien.