Advanced interventions in the pre-hospital resuscitation of patients with non-compressible haemorrhage after penetrating injuries.

Early haemorrhage control and minimizing the time to definitive care have long been the cornerstones of therapy for patients exsanguinating from non-compressible haemorrhage (NCH) after penetrating injuries, as only basic treatment could be provided on scene. However, more recently, advanced on-scene treatments such as the transfusion of blood products, resuscitative thoracotomy (RT) and resuscitative endovascular balloon occlusion of the aorta (REBOA) have become available in a small number of pre-hospital critical care teams. Although these advanced techniques are included in the current traumatic cardiac arrest algorithm of the European Resuscitation Council (ERC), published in 2021, clear guidance on the practical application of these techniques in the pre-hospital setting is scarce. This paper provides a scoping review on how these advanced techniques can be incorporated into practice for the resuscitation of patients exsanguinating from NCH after penetrating injuries, based on available literature and the collective experience of several helicopter emergency medical services (HEMS) across Europe who have introduced these advanced resuscitation interventions into routine practice.

Requirement for urgent tracheal intubation after traumatic injury: a retrospective analysis of 11,010 patients in the Trauma Audit Research Network database.

Advanced airway management is a treatment priority in trauma care. It is likely that a proportion of patients who receive urgent airway management on arrival in the emergency department represent an unmet demand for airway intervention in the pre-hospital phase. This study aimed to investigate emergency airway practice in major trauma patients and establish any unmet demand in this patient group. A retrospective review of the Trauma Audit and Research Network database was performed to identify airway intervention(s) performed for patients admitted to major trauma centres in England from 01 April 2012 to 27 June 2016. In total, 11,010 patients had airway interventions: 4375 patients (43%) had their tracheas intubated in the pre-hospital setting compared with 5889 patients (57%) in the emergency department. Of the patients whose tracheas were intubated in the emergency department, this was done within 30 min of hospital arrival in 3264 patients (75%). Excluding tracheal intubation, 1593 patients had a pre-hospital airway intervention of which 881 (55%) subsequently had their trachea intubated in the emergency department; tracheal intubation was done within 30 min of arrival in the majority of these cases (805 patients (91%)). Over 70% of emergency department tracheal intubations in patients with traumatic injuries were performed within 30 min of hospital arrival; this suggests there may be an unmet demand in pre-hospital advanced airway management for trauma patients in England.

Pre-hospital transfusion of red blood cells in civilian trauma patients.

INTRODUCTION: The current management of severely injured patients includes damage control resuscitation strategies that minimise the use of crystalloids and emphasise earlier transfusion of red blood cells (RBC) to prevent coagulopathy. In 2012, London's air ambulance (LAA) became the first UK civilian pre-hospital service to routinely carry RBC to the trauma scene. OBJECTIVE: To investigate the effect of pre-hospital RBC transfusion (phRTx) on overall blood product consumption. METHODS: A retrospective trauma database study compares before implementation with after implementation of phRTx in exsanguinating trauma patients transported directly to one major trauma centre. Pre-hospital deaths were excluded. Univariate and multivariate Poisson regression analyses on data subject to multiple imputation were conducted. RESULTS: We included 137 and 128 patients in the before and after the implementation of phRTx groups, respectively. LAA transfused 304 RBC units (median 2, inter quartile range 1-3). We found a significant reduction in total RBC usage and reduced early use of platelets and fresh-frozen plasma (FFP) after the implementation of phRTx in both univariate (P < 0·001) and multivariate analyses (P < 0·001). No immediate adverse transfusion reactions were identified. CONCLUSION: Pre-hospital trauma transfusion practice is feasible and associated with overall reduced RBC, platelets and FFP consumption.

Pre-hospital emergency anaesthesia in awake hypotensive trauma patients: beneficial or detrimental?

BACKGROUND: The benefits of pre-hospital emergency anaesthesia (PHEA) are controversial. Patients who are hypovolaemic prior to induction of anaesthesia are at risk of severe cardiovascular instability post-induction. This study compared mortality for hypovolaemic trauma patients (without major neurological injury) undergoing PHEA with a patient cohort with similar physiology transported to hospital without PHEA. METHODS: A retrospective database review was performed to identify patients who were hypotensive on scene [systolic blood pressure (SBP) < 90 mmHg], and GCS 13-15. Patient records were reviewed independently by two pre-hospital clinicians to identify the likelihood of hypovolaemia. Primary outcome measure was mortality defined as death before hospital discharge. RESULTS: Two hundred and thirty-six patients were included; 101 patients underwent PHEA. Fifteen PHEA patients died (14.9%) compared with six non-PHEA patients (4.4%), P = 0.01; unadjusted OR for death was 3.73 (1.30-12.21; P = 0.01). This association remained after adjustment for age, injury mechanism, heart rate and hypovolaemia (adjusted odds ratio 3.07 (1.03-9.14) P = 0.04). Fifty-eight PHEA patients (57.4%) were hypovolaemic prior to induction of anaesthesia, 14 died (24%). Of 43 PHEA patients (42.6%) not meeting hypovolaemia criteria, one died (2%); unadjusted OR for mortality was 13.12 (1.84-578.21). After adjustment for age, injury mechanism and initial heart rate, the odds ratio for mortality remained significant at 9.99 (1.69-58.98); P = 0.01. CONCLUSION: Our results suggest an association between PHEA and in-hospital mortality in awake hypotensive trauma patients, which is strengthened when hypotension is due to hypovolaemia. If patients are hypovolaemic and awake on scene it might, where possible, be appropriate to delay induction of anaesthesia until hospital arrival.

The success of pre-hospital tracheal intubation by different pre-hospital providers: a systematic literature review and meta-analysis.

BACKGROUND: Pre-hospital basic airway interventions can be ineffective at providing adequate oxygenation and ventilation in some severely ill or injured patients, and advanced airway interventions are then required. Controversy exists regarding the level of provider required to perform successful pre-hospital intubation. A previous meta-analysis reported pre-hospital intubation success rates of 0.849 for non-physicians versus 0.991 for physicians. The evidence base on the topic has expanded significantly in the last 10 years. This study systematically reviewed recent literature and presents comprehensive data on intubation success rates. METHODS: A systematic search of MEDLINE and EMBASE was performed using PRISMA methodology to identify articles on pre-hospital tracheal intubation published between 2006 and 2016. Overall success rates were estimated using random effects meta-analysis. The relationship between intubation success rate and provider type was assessed in weighted linear regression analysis. RESULTS: Of the 1838 identified studies, 38 met the study inclusion criteria. Intubation was performed by non-physicians in half of the studies and by physicians in the other half. The crude median (range) reported overall success rate was 0.969 (0.616-1.000). In random effects meta-analysis, the estimated overall intubation success rate was 0.953 (0.938-0.965). The crude median (range) reported intubation success rates for non-physicians were 0.917 (0.616-1.000) and, for physicians, were 0.988 (0.781-1.000) (p = 0.003). DISCUSSION: The reported overall success rate of pre-hospital intubation has improved, yet there is still a significant difference between non-physician and physician providers. The finding that less-experienced personnel perform less well is not unexpected, but since there is considerable evidence that poorly performed intubation carries a significant risk of morbidity and mortality careful consideration should be given to the training and experience required to deliver this intervention safely.

AAGBI: Safer pre-hospital anaesthesia 2017: Association of Anaesthetists of Great Britain and Ireland.

Pre-hospital emergency anaesthesia with oral tracheal intubation is the technique of choice for trauma patients who cannot maintain their airway or achieve adequate ventilation. It should be carried out as soon as safely possible, and performed to the same standards as in-hospital emergency anaesthesia. It should only be conducted within organisations with comprehensive clinical governance arrangements. Techniques should be straightforward, reproducible, as simple as possible and supported by the use of checklists. Monitoring and equipment should meet in-hospital anaesthesia standards. Practitioners need to be competent in the provision of in-hospital emergency anaesthesia and have supervised pre-hospital experience before carrying out pre-hospital emergency anaesthesia. Training programmes allowing the safe delivery of pre-hospital emergency anaesthesia by non-physicians do not currently exist in the UK. Where pre-hospital emergency anaesthesia skills are not available, oxygenation and ventilation should be maintained with the use of second-generation supraglottic airways in patients without airway reflexes, or basic airway manoeuvres and basic airway adjuncts in patients with intact airway reflexes.

Advanced airway management is necessary in prehospital trauma patients.

BACKGROUND: Treatment of airway compromise in trauma patients is a priority. Basic airway management is provided by all emergency personnel, but the requirement for on-scene advanced airway management is controversial. We attempted to establish the demand for on-scene advanced airway interventions. Trauma patients managed with standard UK paramedic airway interventions were assessed to determine whether airway compromise had been effectively treated or whether more advanced airway management was required. METHODS: A prospective observational study was conducted to identify trauma patients requiring prehospital advanced airway management attended by a doctor-paramedic team. The team assessed and documented airway compromise on arrival, interventions performed before and after their arrival, and their impact on airway compromise. RESULTS: Four hundred and seventy-two patients required advanced airway intervention and received 925 airway interventions by ground-based paramedics. Two hundred and sixty-nine patients (57%) still had airway compromise on arrival of the enhanced care team; no oxygen had been administered to 52 patients (11%). There were 45 attempted intubations by ground paramedics with a 64% success rate and 11% unrecognized oesophageal intubation rate. Doctor-paramedic teams delivering prehospital anaesthesia achieved definitive airway management for all patients. CONCLUSIONS: A significant proportion of severely injured trauma patients required advanced airway interventions to effectively treat airway compromise. Standard ambulance service interventions were only effective for a proportion of patients, but might not have always been applied appropriately. Complications of advanced airway management occurred in both provider groups, but failed intubation and unrecognized oesophageal intubation were a particular problem in the paramedic intubation group.

Pre-hospital anaesthesia: the same but different.

Advanced airway management is one of the most controversial areas of pre-hospital trauma care and is carried out by different providers using different techniques in different Emergency Medical Services systems. Pre-hospital anaesthesia is the standard of care for trauma patients arriving in the emergency department with airway compromise. A small proportion of severely injured patients who cannot be managed with basic airway management require pre-hospital anaesthesia to avoid death or hypoxic brain injury. The evidence base for advanced airway management is inconsistent, contradictory and rarely reports all key data. There is evidence that poorly performed advanced airway management is harmful and that less-experienced providers have higher intubation failure rates and complication rates. International guidelines carry many common messages about the system requirements for the practice of advanced airway management. Pre-hospital rapid sequence induction (RSI) should be practiced to the same standard as emergency department RSI. Many in-hospital standards such as monitoring, equipment, and provider competence can be achieved. Pre-hospital and emergency in-hospital RSI has been modified from standard RSI techniques to improve patient safety, physiological disturbance, and practicality. Examples include the use of opioids and long-acting neuromuscular blocking agents, ventilation before intubation, and the early release of cricoid pressure to improve laryngoscopic view. Pre-hospital RSI is indicated in a small proportion of trauma patients. Where pre-hospital anaesthesia cannot be carried out to a high standard by competent providers, excellent quality basic airway management should be the mainstay of management.

Haemodynamic response to pre-hospital emergency anaesthesia in trauma patients within an urban helicopter emergency medical service.

PURPOSE: Pre-hospital emergency anaesthesia is routinely used in the care of severely injured patients by pre-hospital critical care services. Anaesthesia, intubation, and positive pressure ventilation may lead to haemodynamic instability. The aim of this study was to identify the frequency of new-onset haemodynamic instability after induction in trauma patients with a standardised drug regime. METHODS: A retrospective database analysis was undertaken of all adult patients treated by a physician-led urban pre-hospital care service over a 6-year period. The primary outcome measure was the frequency of new haemodynamic instability following pre-hospital emergency anaesthesia. The association of patient characteristics and drug regimes with new haemodynamic instability was also analysed. RESULTS: A total of 1624 patients were included. New haemodynamic instability occurred in 231 patients (17.4%). Patients where a full-dose regime was administered were less likely to experience new haemodynamic instability than those who received a modified dose regime (9.7% vs 24.8%, p < 0.001). The use of modified drug regimes became more common over the study period (p < 0.001) but there was no change in the rates of pre-existing (p = 0.22), peri-/post-anaesthetic (p = 0.36), or new haemodynamic instability (p = 0.32). CONCLUSION: New haemodynamic instability within the first 30 min following pre-hospital emergency anaesthesia in trauma patients is common despite reduction of sedative drug doses to minimise their haemodynamic impact. It is important to identify non-drug factors that may improve cardiovascular stability in this group to optimise the care received by these patients.

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

BACKGROUNDS: Team leadership skills of physicians working in high-performing medical teams are directly related to outcome. It is currently unclear how these skills can best be developed. Therefore, in this multi-national cross-sectional prospective study, we explored the development of these skills in relation to physician-, organization- and training characteristics of Helicopter Emergency Medicine Service (HEMS) physicians from services in Europe, the United States of America and Australia. METHODS: Physicians were asked to complete a survey regarding their HEMS service, training, and background as well as a full Leader Behavior Description Questionnaire (LBDQ). Primary outcomes were the 12 leadership subdomain scores as described in the LBDQ. Secondary outcome measures were the association of LBDQ subdomain scores with specific physician-, organization- or training characteristics and self-reported ways to improve leadership skills in HEMS physicians. RESULTS: In total, 120 HEMS physicians completed the questionnaire. Overall, leadership LBDQ subdomain scores were high (10 out of 12 subdomains exceeded 70% of the maximum score). Whereas physician characteristics such as experience or base-specialty were unrelated to leadership qualities, both organization- and training characteristics were important determinants of leadership skill development. Attention to leadership skills during service induction, ongoing leadership training, having standards in place to ensure (regular) scenario training and holding structured mission debriefs each correlated with multiple LBDQ subdomain scores. CONCLUSIONS: Ongoing training of leadership skills should be stimulated and facilitated by organizations as it contributes to higher levels of proficiency, which may translate into a positive effect on patient outcomes. TRIAL REGISTRATION: Not applicable.

Trauma system development.

The word 'trauma' describes the disease entity resulting from physical injury. Trauma is one of the leading causes of death worldwide and deaths due to injury look set to increase. As early as the 1970s, it became evident that centralisation of resources and expertise could reduce the mortality rate from serious injury and that organisation of trauma care delivery into formal systems could improve outcome further. Internationally, trauma systems have evolved in various forms, with widespread reports of mortality and functional outcome benefits when major trauma management is delivered in this way. The management of major trauma in England is currently undergoing significant change. The London Trauma System began operating in April 2010 and others throughout England became operational this year. Similar systems exist internationally and continue to be developed. Anaesthetists have been and continue to be involved with all levels of trauma care delivery, from the provision of pre-hospital trauma and retrieval teams, through to chronic pain management and rehabilitation of patients back into society. This review examines the international development of major trauma care delivery and the components of a modern trauma system.

Prehospital tracheal intubation in severe facial trauma: a short window of opportunity.

A case of severe facial injury is described. The pre-hospital management including pre-hospital anaesthesia and intubation and the importance of advanced anaesthetic skills in rare trauma cases is discussed. In addition the rare situation where large bone fragments are retrieved from the scene and potentially used in reconstruction is mentioned.

Falls from height: injury and mortality.

OBJECTIVES: To determine how Injury Severity Score (ISS) and mortality relate to height fallen, and to determine other predictors of mortality including intent and body region injured. METHODS: A pre-hospital retrospective, observational database study was conducted. Injured or deceased patients following a fall from height (FFH), aged 16 or over, attended to by London Helicopter Emergency Medical Services (HEMS), between Jan 2008 to July 2009 were included in the study. In addition to the database, HEMS mission 'run sheets' provided further information. RESULTS: 117 (91 males and 26 females) patients met the inclusion criteria. The mean age was 37 years (range 16 - 85). 34/117 (29%) died. The mean ISS was 28.6 (median 17) and the mean height fallen 9.9m (3rd floor). In the group that died the mean height was 16.7m (5th floor). Height fallen was found to be a significant predictor of mortality (p < 0.001), as were injuries to the chest and/or head (p < 0.05). In patients with head and chest injuries, a 50% mortality rate was estimated to occur at falls from 10.5m, compared to 22.4m in those without injuries to head or chest. Deliberate falls were more common amongst females than males (chi-squared test, p = 0.001), were associated with greater ISS (Mann Whitney test, p < 0.001) and were more likely to result in death (chi-squared test, p < 0.001). CONCLUSIONS: Height fallen correlates with ISS and is a significant predictor of death. Chest and/or head injuries significantly increased the likelihood of death following a FFH. This information may enhance triage criteria applied to tasking of emergency response vehicles, and strategies in injury prevention. Other potential predictors of mortality were not found to be significant.

Time to definitive care within major trauma networks in England.

BACKGROUND: Significant mortality improvements have been reported following the implementation of English trauma networks. Timely transfer of seriously injured patients to definitive care is a key indicator of trauma network performance. This study evaluated timelines from emergency service (EMS) activation to definitive care between 2013 and 2016. METHODS: An observational study was conducted on data collected from the UK national clinical audit of major trauma care of patients with an Injury Severity Score above 15. Outcomes included time from EMS activation to: arrival at a trauma unit (TU) or major trauma centre (MTC); to CT; to urgent surgery; and to death. RESULTS: Secondary transfer was associated with increased time to urgent surgery (median 7·23 (i.q.r. 5·48-9·28) h versus 4·37 (3·00-6·57) h for direct transfer to MTC; P < 0·001) and an increased crude mortality rate (19·6 (95 per cent c.i. 16·9 to 22·3) versus 15·7 (14·7 to 16·7) per cent respectively). CT and urgent surgery were performed more quickly in MTCs than in TUs (2·00 (i.q.r. 1·55-2·73) versus 3·15 (2·17-4·63) h and 4·37 (3·00-6·57) versus 5·37 (3·50-7·65) h respectively; P < 0·001). Transfer time and time to CT increased between 2013 and 2016 (P < 0·001). Transfer time, time to CT, and time to urgent surgery varied significantly between regional networks (P < 0·001). CONCLUSION: Secondary transfer was associated with significantly delayed imaging, delayed surgery, and increased mortality. Key interventions were performed more quickly in MTCs than in TUs.

ANTECEDENTES: Se han demostrado mejoras significativas en la mortalidad tras la implementación de las redes de trauma en Inglaterra. El traslado a tiempo de pacientes con lesiones graves para el tratamiento definitivo es un indicador clave del rendimiento de la red de traumatismos. Este estudio evaluó los plazos de tiempo desde la activación del servicio de emergencia (emergency service,EMS) hasta el tratamiento definitivo entre 2013 y 2016. MÉTODOS: Se realizó un estudio observacional en base a los datos obtenidos de la auditoría clínica nacional del Reino Unido de la atención de traumatismos graves en pacientes con puntuación de gravedad de lesiones superior a 15. Los resultados incluyeron los intervalos de tiempo entre la activación del EMS hasta la llegada a una Unidad de Trauma (Trauma Unit, TU) o a un centro de traumatismos graves (Major Trauma Center, MTC), la práctica de una tomografía computarizada (computerised tomography, CT), la práctica de cirugía de urgencia, y la mortalidad. RESULTADOS: El traslado secundario se asoció con un aumento en el tiempo hasta la cirugía urgente (7,23 h (rango intercuartílico, RIQ 5,48-9,28 versus 4,37 (3,00-6,57), P < 0,001)) y un aumento de la mortalidad cruda (19,6% (i.c. del 95% 16,9-22,3) versus 15,7% (14,7-16,7)). La CT y la cirugía urgente se efectuaron con mayor rapidez en los centros MTC que TU (2,00 h (RIQ 1,55-2,73) versus 3,15 h (RIQ 2,17-4,63) y 4,37 h (RIQ 3,00-6,57) versus 5,37 h (RIQ 3,50-7,65), respectivamente (P < 0,001)). El tiempo de traslado y el tiempo hasta la práctica de la CT aumentaron entre 2013 y 2016 (P < 0,001). El tiempo de traslado, el tiempo hasta la práctica de la CT y el tiempo hasta la práctica de cirugía urgente variaron significativamente entre las redes regionales (P < 0,001). CONCLUSIÓN: El traslado secundario se asoció de forma significativa con el retraso en las imágenes radiológicas, retraso en la cirugía y aumento de la mortalidad. Las intervenciones clave se realizaron más rápidamente en centro MTC que en centros TU.

Pre-hospital use of ketamine in paediatric trauma.

OBJECTIVES: To describe the use of ketamine in children by a pre-hospital physician-based service. METHODS: A five and a half year retrospective database review of all patients aged <16 years who were attended by London's Helicopter Emergency Medical Service and given ketamine. RESULTS: One hundred and sixty-four children met the inclusion criteria. The median age was 10 years (range 0-15 years). One hundred and four (63%) had a Glasgow Coma Scale (GCS) of 15 and 153 (93%) had a GCS>8 before administration of ketamine. Patients received from 2 to 150 mg ketamine IV (mean=1.0 mg/kg) and 112 (68%) received concomitant midazolam (0.5-18 mg, mean=0.1 mg/kg). One hundred and forty-one (86%) received ketamine intravenously and 23 (14%) intramuscularly. Only 12 patients (7%) were trapped. The most common mechanisms of injury in those who received ketamine were road traffic collisions, burns and falls. CONCLUSION: The safe delivery of adequate analgesia and appropriate sedation is a priority in paediatric pre-hospital care. Ketamine was predominantly used in awake non-trapped patients with blunt trauma for procedural sedation and analgesia. Detailed database searches did not demonstrate loss of airway, oxygen desaturation or clinically significant emergence reactions after ketamine administration. This study failed to demonstrate any major side effects of the drug and reassured us that the safety profile of the drug in this environment is likely to be satisfactory. The use of ketamine in trapped children was rare.

Pre-hospital use of ketamine for analgesia and procedural sedation.

The safe delivery of adequate analgesia and appropriate sedation is a priority in prehospital care. The use of ketamine is described for analgesia and sedation in 1030 trauma patients in a physician-led prehospital trauma service. Ketamine was mainly used in awake non-trapped patients with blunt trauma for procedural sedation and analgesia. Detailed database searches did not demonstrate loss of airway, oxygen desaturation or clinically significant emergence reactions after ketamine administration. Ketamine is relatively safe when used by physicians in prehospital trauma care.

Clinical care in the "Hot Zone".

The threat of chemical, biological, radiological and nuclear incidents is unlikely to decrease and preparations to deal with this type of incident are well established in most European emergency medical systems. In the UK medical care is not currently provided in the "Hot" or contaminated zone. This article discusses the background to the current threat and suggests that, where survivors are present in the "Hot Zone", medical care should be started there to minimise delay and maximise the chances of survival.