Managing accidental hypothermia: a UK-wide survey of prehospital and search and rescue providers.

AIM: The management of hypothermic casualties is a challenge faced by all prehospital and search and rescue (SAR) teams. It is not known how the practice of these diverse teams compare. The aim of this study was to review prehospital hypothermia management across a wide range of SAR providers in the UK. METHODS: A survey of ground ambulances (GAs), air ambulances (AAs), mountain rescue teams (MRTs, including Ministry of Defence), lowland rescue teams (LRTs), cave rescue teams (CRTs), and lifeboats and lifeguard organisations (LLOs) across the UK was conducted between May and November 2017. In total, 189 teams were contacted. Questions investigated packaging methods, temperature measurement and protocols for managing hypothermic casualties. RESULTS: Response rate was 59%, comprising 112 teams from a wide range of organisations. Heavyweight (>3 kg) casualty bags were used by all CRTs, 81% of MRTs, 29% of LRTs, 18% of AAs and 8% of LLOs. Specially designed lightweight (<0.5 kg) blankets or wraps were used by 93% of LRTs, 85% of LLOs, 82% of GAs, 71% of AAs and 50% of MRTs. Bubble wrap was used mainly by AAs, with 35% of AAs reporting its use. Overall, 94% of packaging methods incorporated both insulating and vapour-tight layers. Active warming by heated pads or blankets was used by 65% of AAs, 60% of CRTs, 54% of MRTs, 29% of LRTs and 9% of GAs, with no LLO use. Temperature measurement was reported by all AAs and GAs, 93% of LRTs, 80% of CRTs, 75% of MRTs and 31% of LLOs. The favoured anatomical site for temperature measurement was tympanic. Protocols for packaging hypothermic casualties were reported by 73% of services. CONCLUSIONS: This survey describes current practice in prehospital hypothermia management, comparing the various methods used by different teams, and provides a basis to direct further education and research.

The Need for a UK Helicopter Emergency Medical Service by Night: A Prospective, Simulation Study.

BACKGROUND: Major trauma commonly occurs at night. Helicopter emergency medical services (HEMS) can provide advanced prehospital care to victims of major trauma but do not routinely operate at night in the United Kingdom. We sought to prospectively examine the need for a night HEMS service in Kent, Surrey, and Sussex in the United Kingdom. METHODS: A 4-month, prospective study was conducted (July 1, 2012-October 31, 2012). HEMS dispatch paramedics were present in the ambulance dispatch center and undertook simulated HEMS activations when a suitable case was identified. All trauma cases from the 4-month study period were collated. Five independent HEMS clinicians reviewed the simulated tasking and trauma cases and gave an opinion on whether the patient met HEMS activation criteria. RESULTS: A mission rate of 1 case per night was predefined as cost-effective. During the prospective study, 145 calls were identified by the HEMS dispatch paramedic as appropriate for an HEMS response. If HEMS had deployed to all 145 incidents, this would have resulted in an average mission rate of 1.2 activations per night. Two hundred eight incidents were identified as potentially appropriate for HEMS activation. Responding to all 208 incidents would have resulted in a mean activation rate of 1.7 per night. CONCLUSION: This study justifies the need for Kent, Surrey and Sussex Air Ambulance Trust to operate a service at night for a trial period, with an estimated average mission load of 1 per night spread over the entire night period. Further research is warranted to determine the potential impact of a night HEMS service on outcome from major trauma.

Recommendation for changes to the guidelines of trauma patients with potential spinal injury within a regional UK ambulance trust.

Background: Spinal assessment and immobilisation has been a topic of debate for many years where, despite an emerging evidence base and the delivery of new guidance overseas, little has changed within UK pre-hospital practice. Since 2018, South East Coast Ambulance Service NHS Foundation Trust has spent time working with local trauma networks and expertise from within the region and international colleagues to develop a set of C-spine assessment and immobilisation guidelines that reflect the current best available international evidence and significant changes in international pre-hospital practice from settings such as Scandinavia and Australasia. Methods: A specialist group was commissioned to review the topic of pre-hospital spinal immobilisation and explore potential for evidence-based improvement. In conjunction with local trauma networks, subject matter experts and a thorough review of recent literature, a series of recommendations were made in order to improve spinal care within the authoring trust. Results: Seven recommendations were made, and an updated set of guidelines produced. These included the removal of semi-rigid collars from pre-hospital spinal immobilisation; the creation of two tiers of patients to ensure that the high-risk and low-risk populations are considered separately and an accompanying decision tool to safeguard both cohorts; an increased emphasis on the risk of spinal injury in the frail and older patient; an emphasis on spinal motion restriction rather than rigid immobilisation; an increased emphasis on self-extrication; and the use of a marker for emergency departments. Summary: An updated set of guidance has been produced using a combination of specialist and expert opinion alongside a literature review with close involvement of key stakeholders, both public and professional. The new guidance helps to ensure a patient-centred approach where each person is considered an individual with their risk of injury and management measures tailored to their specific needs.

The Epidemiology and Effectiveness of Synchronized Cardioversion in a UK Prehospital Setting: A Retrospective Cross-Sectional Study.

BACKGROUND: Synchronized cardioversion is an internationally accepted standard therapy for unstable tachyarrhythmias, but it is conventionally an in-hospital physician-led intervention. Increasingly, it is being brought forward into the prehospital setting as part of a specialist paramedic scope of practice; however, very little literature exists regarding the epidemiology or efficacy in this setting. METHODS: All patients receiving cardioversion within a United Kingdom (UK) ambulance service were identified using an electronic database. The period of inclusion was March 1, 2017 through October 31, 2020. These data were then interrogated to provide demographic, physiological, and efficacy data, and then a sub-group was created to identify those who presented with a primary arrhythmia (as opposed to post-cardiac arrest). RESULTS: From a total of 93 patients, prehospital synchronized cardioversion successfully terminated the tachyarrhythmia in 96% of patients presenting with a primary arrhythmia (85% in the allcomers group) with a predominance towards males (82% of patients) and an average age of 67 years. Hypotension and reduced level of consciousness were the most commonly documented unstable features (84.4% and 44.4%). CONCLUSION: Cardioversion within a paramedic-led service results in efficacy rates of 96% in patients presenting with a primary tachyarrhythmia. This is a similar efficacy rate to traditional doctor-led therapies. Demographic data show that males make up over 80% of the patient population, in keeping with previously published work across the spectrum of cardiac interventions.

Pre-hospital transfusion of packed red blood cells in 147 patients from a UK helicopter emergency medical service.

BACKGROUND: Early transfusion of packed red blood cells (PRBC) has been associated with improved survival in patients with haemorrhagic shock. This study aims to describe the characteristics of patients receiving pre-hospital blood transfusion and evaluate their subsequent need for in-hospital transfusion and surgery. METHODS: The decision to administer a pre-hospital PRBC transfusion was based on clinical judgment. All patients transfused pre-hospital PRBC between February 2013 and December 2014 were included. Pre-hospital and in-hospital records were retrospectively reviewed. RESULTS: One hundred forty-seven patients were included. 142 patients had traumatic injuries and 5 patients had haemorrhagic shock from a medical origin. Median Injury Severity Score was 30. 90% of patients receiving PRBC had an ISS of >15. Patients received a mean of 2.4(±1.1) units of PRBC in the pre-hospital phase. Median time from initial emergency call to hospital arrival was 114 min (IQR 103-140). There was significant improvement in systolic (p < 0.001), diastolic (p < 0.001) and mean arterial pressures (p < 0.001) with PRBC transfusion but there was no difference in HR (p = 0.961). Patients received PRBC significantly faster in the field than waiting until hospital arrival. At the receiving hospital 57% required an urgent surgical or interventional radiology procedure. At hospital arrival, patients had a mean lactate of 5.4(±4.4) mmol/L, pH of 6.9(±1.3) and base deficit of -8.1(±6.7). Mean initial serum adjusted calcium was 2.26(±0.29) mmol/L. 89% received further blood products in hospital. No transfusion complications or significant incidents occurred and 100% traceability was achieved. DISCUSSION: Pre-hospital transfusion of packed red cells has the potential to improvde outcome for trauma patients with major haemorrhage. The pre-hospital time for trauma patients can be several hours, suggesting transfusion needs to start in the pre-hospital phase. Hospital transfusion research suggests a 1:1 ratio of packed red blood cells to plasma improves outcome and further research into pre-hospital adoption of this strategy is needed. CONCLUSION: Pre-hospital PRBC transfusion significantly reduces the time to transfusion for major trauma patients with suspected major haemorrhage. The majority of patients receiving pre-hospital PRBC were severely injured and required further transfusion in hospital. Further research is warranted to determine which patients are most likely to have outcome benefit from pre-hospital blood products and what triggers should be used for pre-hospital transfusion.

Helicopter emergency medical services (HEMS) response to out-of-hospital cardiac arrest.

BACKGROUND: Out-of-hospital cardiac arrest (OHCA) is a common medical emergency with significant mortality and significant neurological morbidity. Helicopter emergency medical services (HEMS) may be tasked to OHCA. We sought to assess the impact of tasking a HEMS service to OHCA and characterise the nature of these calls. METHOD: Retrospective case review of all HEMS calls to Surrey and Sussex Air Ambulance, United Kingdom, over a 1-year period (1/9/2010-1/9/2011). All missions to cases of suspected OHCA, of presumed medical origin, were reviewed systematically. RESULTS: HEMS was activated 89 times to suspected OHCA. This represented 11% of the total HEMS missions. In 23 cases HEMS was stood-down en-route and in 2 cases the patient had not suffered an OHCA on arrival of HEMS. 25 patients achieved return-of-spontaneous circulation (ROSC), 13 (52%) prior to HEMS arrival. The HEMS team were never first on-scene. The median time from first collapse to HEMS arrival was 31 minutes (IQR 22-40). The median time from HEMS activation to arrival on scene was 17 minutes (IQR 11.5-21). 19 patients underwent pre-hospital anaesthesia, 5 patients had electrical or chemical cardioversion and 19 patients had therapeutic hypothermia initiated by HEMS. Only 1 post-OHCA patient was transported to hospital by air. The survival to discharge rate was 6.3%. CONCLUSION: OHCA represents a significant proportion of HEMS call outs. HEMS most commonly attend post-ROSC OHCA patients and interventions, including pre-hospital anaesthesia and therapeutic hypothermia should be targeted to this phase. HEMS are rarely first on-scene and should only be tasked as a first response to OHCA in remote locations. HEMS may be most appropriately utilised in OHCA by only attending the scene if a patient achieves ROSC.