Determinants of prehospital lactate in trauma patients: a retrospective cohort study.

BACKGROUND: Point of care serum lactate measurement is emerging as an adjunct to prehospital clinical assessment and has the potential to guide triage and advanced treatment decision-making. In this study we aimed to assess which factors potentially affect prehospital lactate levels. METHODS: We performed a retrospective cohort study of all trauma patients attended by the Air Ambulance, Kent, Surrey & Sussex (AAKSS) between July 2017 and April 2018 in whom a pre-hospital lactate was measured. Lactate was measured before AAKSS treatments were commenced, but generally after prehospital treatment by ground ambulance crews was initiated. Primary endpoint of interest was the association of various patient- and treatment characteristics with prehospital lactate levels. RESULTS: During the study period, lactate was measured in 156 trauma patients. Median lactate was 3.0 [2.0-4.1] mmol/l. Patients with an elevated lactate more often had deranged indices of end organ perfusion- and oxygenation (shock index 0.80 [0.58-1.03] vs 0.61 [0.40-0.82], p < 0.001, SpO2 96 [89-100%] vs 98 [96-100%], p = 0.025). They more often suffered from head injuries (62% vs 41%, p = 0.008), and received less analgesia prior to arrival of the AAKSS team (51.6% vs 67.2%, p = 0.03). In multivariate analysis, indices of end organ perfusion- and oxygenation only explained 15% of the variation in lactate levels. CONCLUSIONS: Prehospital lactate levels are not solely associated with indices of end organ perfusion- and oxygenation. Injury type, treatments given on scene and many other (unmeasured) factors likely play an important role as well. This should be taken into account when lactate is used in clinical algorithms to guide prehospital triage or treatment.

Mortality of civilian patients with suspected traumatic haemorrhage receiving pre-hospital transfusion of packed red blood cells compared to pre-hospital crystalloid.

BACKGROUND: Major haemorrhage is a leading cause of mortality following major trauma. Increasingly, Helicopter Emergency Medical Services (HEMS) in the United Kingdom provide pre-hospital transfusion with blood products, although the evidence to support this is equivocal. This study compares mortality for patients with suspected traumatic haemorrhage transfused with pre-hospital packed red blood cells (PRBC) compared to crystalloid. METHODS: A single centre retrospective observational cohort study between 1 January 2010 and 1 February 2015. Patients triggering a pre-hospital Code Red activation were eligible. The primary outcome measure was all-cause mortality at 6 hours (h) and 28 days (d), including a sub-analysis of patients receiving a major and massive transfusion. Multivariable regression models predicted mortality. Multiple Imputation was employed, and logistic regression models were constructed for all imputed datasets. RESULTS: The crystalloid (n = 103) and PRBC (n = 92) group were comparable for demographics, Injury Severity Score (p = 0.67) and mechanism of injury (p = 0.73). Observed 6 h mortality was smaller in the PRBC group (n = 10, 10%) compared to crystalloid group (n = 19, 18%). Adjusted OR was not statistically significant (OR 0.48, CI 0.19-1.19, p = 0.11). Observed mortality at 28 days was smaller in the PRBC group (n = 21, 26%) compared to crystalloid group (n = 31, 40%), p = 0.09. Adjusted OR was not statistically significant (OR 0.66, CI 0.32-1.35, p = 0.26). A statistically significant greater proportion of the crystalloid group required a major transfusion (n = 62, 60%) compared to the PRBC group (n = 41, 40%), p = 0.02. For patients requiring a massive transfusion observed mortality was smaller in the PRBC group at 28 days (p = 0.07). CONCLUSION: In a single centre UK HEMS study, in patients with suspected traumatic haemorrhage who received a PRBC transfusion there was an observed, but non-significant, reduction in mortality at 6 h and 28 days, also reflected in a massive transfusion subgroup. Patients receiving pre-hospital PRBC were significantly less likely to require an in-hospital major transfusion. Further adequately powered multi-centre prospective research is required to establish the optimum strategy for pre-hospital volume replacement in patients with traumatic haemorrhage.

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.

The minimalist approach to road traffic collision management.

The management of casualties involved at the scene of a RoadTraffic Collision or Accident (RTC or RTA) is hazardous, challenging and resource intensive. Some pre-hospital care providers work in locations where there is little or no support and where they act as both the rescuer and the medical carer. This paper tries to break down the management of the extrication into key areas in order to suggest how the rescue can, where necessary, be managed with only a small amount of simple equipment.