Establishing quality indicators for pre-hospital advanced airway management: a modified nominal group technique consensus process.

BACKGROUND: Pre-hospital advanced airway management is a complex intervention composed of numerous steps, interactions, and variables that can be delivered to a high standard in the pre-hospital setting. Standard research methods have struggled to evaluate this complex intervention because of considerable heterogeneity in patients, providers, and techniques. In this study, we aimed to develop a set of quality indicators to evaluate pre-hospital advanced airway management. METHODS: We used a modified nominal group technique consensus process comprising three email rounds and a consensus meeting among a group of 16 international experts. The final set of quality indicators was assessed for usability according to the National Quality Forum Measure Evaluation Criteria. RESULTS: Seventy-seven possible quality indicators were identified through a narrative literature review with a further 49 proposed by panel experts. A final set of 17 final quality indicators composed of three structure-, nine process-, and five outcome-related indicators, was identified through the consensus process. The quality indicators cover all steps of pre-hospital advanced airway management from preoxygenation and use of rapid sequence induction to the ventilatory state of the patient at hospital delivery, prior intubation experience of provider, success rates and complications. CONCLUSIONS: We identified a set of quality indicators for pre-hospital advanced airway management that represent a practical tool to measure, report, analyse, and monitor quality and performance of this complex intervention.

Freeze dried plasma and fresh red blood cells for civilian prehospital hemorrhagic shock resuscitation.

BACKGROUND: The last decade of military trauma care has emphasized the role of blood products in the resuscitation of hemorrhaging patients. Damage-control resuscitation advocates decreased crystalloid use and reintroduces blood components as primary resuscitative fluids. The systematic use of blood products have been described in military settings, but reports describing the use of freeze dried plasma (FDP) or red blood cells (RBCs) in civilian prehospital care are few. We describe our preliminary results after implementing RBCs and FDP into our Helicopter Emergency Medical Service (HEMS). METHODS: We collected data on the use of FDP (LyoPlas N-w (AB)) during a 12-month period from May 31, 2013, to May 30, 2014, before RBC (0Rh (D) negative) introduction in June 2014. FDP and RBCs were indicated in trauma and medical patients presenting with clinical significant hemorrhage on scene. Data were obtained from HEMS registry and patient records. RESULTS: Our preliminary results show that FDP was used in 16 patients (88% males) during the first year. Main patient categories were blunt trauma (n = 5), penetrating trauma (n = 4), and nontrauma (n = 7). Ten patients (62%) were hypotensive with systolic blood pressures less than 90 mm Hg on scene. The majority (75%) received tranexamic acid. Of 14 patients admitted to the hospital, 11 received emergency surgery and 8 needed additional transfusions within the first 24 hours. No transfusion-related complications were recorded. Two of the FDP patients died on scene, and the remaining 14 patients were alive after 30 days. Early results from the recent introduction of RBC show that RBCs were given to four patients. Two patients (one penetrating trauma and one blunt trauma patient) died on scene because of exsanguination, while additional two patients (one blunt trauma patient and one with ruptured aortic aneurism) survived to hospital discharge. CONCLUSION: Our small study indicates that introduction of FDP into civilian HEMS seems feasible and may be safe and that logistical and safety issues for the implementation of RBCs are solvable. FDP ensures both coagulation factors and volume replacement, has a potentially favorable safety profile, and may be superior to other types of plasma for prehospital use. Further prospective studies are needed to clarify the role of FDP (and RBCs) in civilian prehospital hemorrhagic shock resuscitation and to aid the development of standardized protocols for prehospital use of blood products. LEVEL OF EVIDENCE: Therapeutic study, level V.

Laryngeal tube use in out-of-hospital cardiac arrest by paramedics in Norway.

BACKGROUND: Although there are numerous supraglottic airway alternatives to endotracheal intubation, it remains unclear which airway technique is optimal for use in prehospital cardiac arrests. We evaluated the use of the laryngeal tube (LT) as an airway management tool among adult out-of-hospital cardiac arrest (OHCA) patients treated by our ambulance services in the Haukeland and Innlandet hospital districts. METHODS: Post-resuscitation forms and data concerning airway management in 347 adult OHCA victims were retrospectively assessed with regard to LT insertion success rates, ease and speed of insertion and insertion-related problems. RESULTS: A total of 402 insertions were performed on 347 OHCA patients. Overall, LT insertion was successful in 85.3% of the patients, with a 74.4% first-attempt success rate. In the minority of patients (n = 46, 13.3%), the LT insertion time exceeded 30 seconds. Insertion-related problems were recorded in 52.7% of the patients. Lack of respiratory sounds on auscultation (n = 100, 28.8%), problematic initial tube positioning (n = 85, 24.5%), air leakage (n = 61, 17.6%), vomitus/aspiration (n = 44, 12.7%), and tube dislocation (n = 17, 4.9%) were the most common problems reported. Insertion difficulty was graded and documented for 95.4% of the patients, with the majority of insertions assessed as being "Easy" (62.5%) or "Intermediate" (24.8%). Only 8.1% of the insertions were considered to be "Difficult". CONCLUSIONS: We found a high number of insertion related problems, indicating that supraglottic airway devices offering promising results in manikin studies may be less reliable in real-life resuscitations. Still, we consider the laryngeal tube to be an important alternative for airway management in prehospital cardiac arrest victims.

Emergency intraosseous access in a helicopter emergency medical service: a retrospective study.

BACKGROUND: Intraosseous access (IO) is a method for providing vascular access in out-of-hospital resuscitation of critically ill and injured patients when traditional intravenous access is difficult or impossible. Different intraosseous techniques have been used by our Helicopter Emergency Medical Services (HEMS) since 2003. Few articles document IO use by HEMS physicians. The aim of this study was to evaluate the use of intraosseous access in pre-hospital emergency situations handled by our HEMS. METHODS: We reviewed all medical records from the period May 2003 to April 2010, and compared three different techniques: Bone Injection Gun (B.I.G® - Waismed), manual bone marrow aspiration needle (Inter V - Medical Device Technologies) and EZ-IO® (Vidacare), used on both adults and paediatric patients. RESULTS: During this seven-year period, 78 insertion attempts were made on 70 patients. Overall success rates were 50% using the manual needle, 55% using the Bone Injection Gun, and 96% using the EZ-IO®. Rates of success on first attempt were significantly higher using the EZ-IO® compared to the manual needle/Bone Injection Gun (p < 0.01/p < 0.001). Fifteen failures were due to insertion-related problems (19.2%), with four technical problems (5.1%) and three extravasations (3.8%) being the most frequent causes. Intraosseous access was primarily used in connection with 53 patients in cardiac arrest (75.7%), including traumatic arrest, drowning and SIDS. Other diagnoses were seven patients with multi-trauma (10.0%), five with seizures/epilepsy (7.1%), three with respiratory failure (4.3%) and two others (2.9%). Nearly one third of all insertions (n = 22) were made in patients younger than two years. No cases of osteomyelitis or other serious complications were documented on the follow-up. CONCLUSIONS: Newer intraosseous techniques may enable faster and more reliable vascular access, and this can lower the threshold for intraosseous access on both adult and paediatric patients in critical situations. We believe that all emergency services that handle critically ill or injured paediatric and adult patients should be familiar with intraosseous techniques.