Prehospital Tranexamic Acid for Severe Trauma.

BACKGROUND: Whether prehospital administration of tranexamic acid increases the likelihood of survival with a favorable functional outcome among patients with major trauma and suspected trauma-induced coagulopathy who are being treated in advanced trauma systems is uncertain. METHODS: We randomly assigned adults with major trauma who were at risk for trauma-induced coagulopathy to receive tranexamic acid (administered intravenously as a bolus dose of 1 g before hospital admission, followed by a 1-g infusion over a period of 8 hours after arrival at the hospital) or matched placebo. The primary outcome was survival with a favorable functional outcome at 6 months after injury, as assessed with the use of the Glasgow Outcome Scale-Extended (GOS-E). Levels on the GOS-E range from 1 (death) to 8 ("upper good recovery" [no injury-related problems]). We defined survival with a favorable functional outcome as a GOS-E level of 5 ("lower moderate disability") or higher. Secondary outcomes included death from any cause within 28 days and within 6 months after injury. RESULTS: A total of 1310 patients were recruited by 15 emergency medical services in Australia, New Zealand, and Germany. Of these patients, 661 were assigned to receive tranexamic acid, and 646 were assigned to receive placebo; the trial-group assignment was unknown for 3 patients. Survival with a favorable functional outcome at 6 months occurred in 307 of 572 patients (53.7%) in the tranexamic acid group and in 299 of 559 (53.5%) in the placebo group (risk ratio, 1.00; 95% confidence interval [CI], 0.90 to 1.12; P = 0.95). At 28 days after injury, 113 of 653 patients (17.3%) in the tranexamic acid group and 139 of 637 (21.8%) in the placebo group had died (risk ratio, 0.79; 95% CI, 0.63 to 0.99). By 6 months, 123 of 648 patients (19.0%) in the tranexamic acid group and 144 of 629 (22.9%) in the placebo group had died (risk ratio, 0.83; 95% CI, 0.67 to 1.03). The number of serious adverse events, including vascular occlusive events, did not differ meaningfully between the groups. CONCLUSIONS: Among adults with major trauma and suspected trauma-induced coagulopathy who were being treated in advanced trauma systems, prehospital administration of tranexamic acid followed by an infusion over 8 hours did not result in a greater number of patients surviving with a favorable functional outcome at 6 months than placebo. (Funded by the Australian National Health and Medical Research Council and others; PATCH-Trauma ClinicalTrials.gov number, NCT02187120.).

Aeromedical retrievals in Queensland: A five-year review.

OBJECTIVE: Aeromedical services are an essential part of the healthcare system. Centralised coordination of aeromedical retrieval tasking offers benefits for safety, timeliness and efficiency in service delivery. The aim of the present study is to review aeromedical retrievals in Queensland exploring patient demographics, temporal patterns and usage characteristics. METHODS: This is a retrospective cases series for the period 1 January 2010 to 31 December 2014 incorporating data from Retrieval Services Queensland and Queensland Newborn Emergency Transport Service. Ethics approval was obtained (JCU-HREC H6137 and Public Health Act #RD005673). Descriptive analysis of the de-identified data was undertaken included patient demographics, referral and receiving locations, retrieval platform and acuity of transport request. RESULTS: There were 73 042 aeromedical retrievals undertaken during the period, with an average of 40 cases per day (range 16-89). The majority (95%) of retrievals were for Queensland residents. Overall 23.1% of cases were cardiology-related and 12.7% were injury-related. Older adults aged 75-84 years had the highest rate of retrievals relative to the population with a crude rate of 942.4 per 100 000 per annum. Overall 14.9% of cases were Priority 1, which represents the tasking with the highest acuity but majority were Priority 4 (41.6%). One third (37.6%) of all patients were from inner regional locations. CONCLUSIONS: Potential investments in health service planning may alleviate the burden on aeromedical services, particularly related to cardiology services in inner and outer regional Queensland. Aeromedical services are pivotal in enabling all sick and injured residents' access to the highest quality of care regardless of the remoteness of their residence.

Review article: Primary aeromedical retrievals in Australia: An interrogation and search for context.

Primary aeromedical retrievals are a direct scene response to patients with a critical injury or illness using a medically equipped aircraft. They are often high-acuity taskings. In Australia, information on primary retrieval taskings is housed by service providers, of which there are many across the country. This exploratory literature review aims to explore the contemporary peer-reviewed literature on primary aeromedical retrievals in Australia. The focus is on adult primary aeromedical retrievals undertaken in Australia and clinical tools used in this pre-hospital setting. Included articles were reviewed for research theme (clinical and equipment, systems and/or outcomes), data coverage and appraisal of the evidence. Of the 37 articles included, majority explored helicopter retrievals (n = 32), retrieval systems (n = 21), compared outcomes within a service (n = 10) and explored retrievals in the state of New South Wales (n = 19). Major topics of focus included retrieval of trauma patients and airway management. Overall, the publications had a lower strength of evidence because of the preponderance of cross-sectional and case-study methodology. This review provides some preliminary but piecemeal insight into primary retrievals in Australia through a localised systems lens. However, there are several areas for research action and service outcome improvements suggested, all of which would be facilitated through the creation of a national pre-hospital and retrieval registry. The creation of a registry would enable consideration of the frequency and context of retrievals, comparison across services, more sophisticated data interrogation. Most importantly, it can lead to service and pre-hospital and retrieval system strengthening.

Prehospital extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest: A retrospective eligibility study.

OBJECTIVE: We sought to identify out-of-hospital cardiac arrest (OOHCA) patients who might benefit from a future prehospital extracorporeal cardiopulmonary resuscitation (ECPR) programme in a moderately sized city. We described the 2014 OOHCA data and identified those who fulfilled hypothetical prehospital ECPR eligibility criteria. METHODS: We identified patients aged 18-65 years in cardiac arrest, where CPR was commenced by paramedics on arrival. Traumatic cardiac arrest and end-of-life needs were patient exclusions. Patients were then included in one of three hypothetical 'ECPR eligible' groups. Patients were included in an 'ECPR eligible' group if they met author agreed criteria. Select patients in refractory VT/VF; pulseless electrical activity (PEA); and non-refractory VT/VF, or asystole with subsequent VT/VF or transient return of spontaneous circulation (ROSC), were assigned to three separate groups. Descriptive statistics were applied to each group. Outcomes of ECPR eligible patients who developed sustained ROSC after 20 min of conventional CPR were characterised. RESULTS: A total of 206 patients were included. A significant positive association between initial shockable rhythm (odds ratio [OR] 15.32, confidence interval [CI] 5.4-43.2) and sustained ROSC, and PEA (OR 6.93, CI 2.4-19.8) and sustained ROSC, versus asystole was identified (P < 0.001). Sixty-eight (33%) patients were eligible for one of the hypothetical ECPR groups. Twelve (17.6%) of the 68 ECPR eligible patients developed sustained ROSC after 20 min of conventional CPR, with only two surviving neurologically intact to hospital discharge. CONCLUSION: Sixty-three (30.6%) patients could have derived benefit from a prehospital ECPR programme. Further analyses of prehospital ECPR logistics and economics are necessary to ensure that any future prehospital ECPR programme is effective and efficient.

Cardiac transvenous pacing in the retrieval setting: A retrospective case series.

OBJECTIVES: To report on the safety and efficacy of transvenous cardiac pacing wire insertion outside a tertiary hospital by a medical retrieval service. METHODS: SAAS MedSTAR Emergency Medical Retrieval Service transports symptomatic bradycardic patients in rural South Australia to Adelaide on transvenous pacing for ongoing management. This is a retrospective case review of all transvenous cardiac pacing wires inserted by SAAS MedSTAR between January 2015 and October 2017. RESULTS: This study demonstrated successful insertion of cardiac transvenous pacing wires and cardiac capture in 10 of 11 cases (91%) by pre-hospital and retrieval doctors. There were no immediate or long-term complications from insertion. All of the patients were successfully transferred by helicopter or fixed wing to their receiving facility, with nine of the 11 patients (82%) surviving to hospital discharge. CONCLUSION: This paper demonstrates that transvenous cardiac pacing can be safely and successfully implemented for symptomatic patients by pre-hospital and retrieval physicians in the aeromedical retrieval setting.

Transport and use of point-of-care ultrasound by a disaster medical assistance team.

The role of ultrasound in disaster medicine has not been not well established. This report describes the transport and use of point-of-care ultrasound by a Disaster Medical Assistance Team (DMAT) responding to a mass-casualty incident due to a cyclone. Ultrasound-competent physicians on the team were able to use portable ultrasound on cyclone casualties to exclude intra-abdominal hemorrhage, pericardial fluid, pneumothoraces, and hemothoraces. Information obtained using ultrasound made initial patient management, and subsequent decisions regarding triage for transport safer and based on more detailed clinical information.

The F.A.S.T.E.R. trial. Focused assessment by sonography in trauma during emergency retrieval: a feasibility study.

INTRODUCTION: This feasibility study aimed to establish if retrieval physicians can overcome the transport environment and obtain F.A.S.T. (focused assessment by sonography in trauma) images of suitable quality during patient retrieval in rotary wing aircraft such that diagnostic interpretation of free intra-abdominal fluid or pericardial fluid would be possible. MATERIALS AND METHODS: During a 6-month trial period, one of three retrieval physicians attempted to obtain the standard four quadrant F.A.S.T. views using a portable ultrasound on patients they retrieved. Ultrasound images were obtained whilst in-flight in a rotary wing aircraft. Image adequacy was assessed by the retrieval physician and by an independent blinded physician using strict clinical criteria. RESULTS: Thirty-eight patients were enrolled. Thirty-six patients had a complete F.A.S.T. scan attempted whilst a further two patients had their abdominal quadrants scanned without a pericardial view being attempted. Independent blinded physician review of scans agreed with the scanning retrieval physician that images were adequate for showing the F.A.S.T. quadrants appropriately in 143 of 150 quadrants imaged and inadequate in two. Blinded physician review disagreed with scanning physician regarding adequacy of image in 5 of 150 quadrants imaged. Scanning physicians were happy with adequacy of the view in all F.A.S.T. quadrants in 34 of the 36 patients in whom a complete F.A.S.T. was performed. Blinded physician review agreed in 30 of those cases. DISCUSSION: The physicians performing the F.A.S.T. examination, all incorporate ultrasound into their daily clinical practice thereby maintaining their skill level. This is likely to contribute to the high level of view adequacy. Independent blinded image review controlled for bias regarding view adequacy. Disagreement between scanning physician and reviewing physician assessment of view adequacy in 5 of the 150 views obtained is likely to relate to the difficulties in interpreting still ultrasound images, compared to interpreting real time images at point-of-care. There were no machine limitations. CONCLUSION: This study demonstrates that it is possible for critical care retrieval physicians to obtain adequate ultrasound F.A.S.T. images on patients using a portable ultrasound machine en-route to definitive care, in a rotary wing aircraft.

Use of point-of-care ultrasound by a critical care retrieval team.

Point-of-care ultrasound in the prehospital and retrieval environments has now become possible owing to decreased size and weight, and increasing robustness of some ultrasound machines. This report describes the initial experience of point-of-care ultrasound by an Australian critical care retrieval service using a portable ultrasound machine.

The use of point-of-care ultrasound by a critical care retrieval team to diagnose acute abdominal aortic aneurysm in the field.

The potential benefit of point-of-care ultrasound by medical retrieval teams is unclear. In the present case report, the diagnosis of an abdominal aortic aneurysm by a critical care retrieval team equipped with a portable ultrasound machine resulted in significant corrective alteration in patient management and subsequent disposition at the receiving institution.