Tranexamic Acid for Traumatic Injury in the Emergency Setting: A Systematic Review and Bias-Adjusted Meta-Analysis of Randomized Controlled Trials.

STUDY OBJECTIVE: Traumatic injury causes a significant number of deaths due to bleeding. Tranexamic acid (TXA), an antifibrinolytic agent, can reduce bleeding in traumatic injuries and potentially enhance outcomes. Previous reviews suggested potential TXA benefits but did not consider the latest trials. METHODS: A systematic review and bias-adjusted meta-analysis were performed to assess TXA's effectiveness in emergency traumatic injury settings by pooling estimates from randomized controlled trials. Researchers searched Medline, Embase, and Cochrane Central for randomized controlled trials comparing TXA's effects to a placebo in emergency trauma cases. The primary endpoint was 1-month mortality. The methodological quality of the trials underwent assessment using the MASTER scale, and the meta-analysis applied the quality-effects method to adjust for methodological quality. RESULTS: Seven randomized controlled trials met the set criteria. This meta-analysis indicated an 11% decrease in the death risk at 1 month after TXA use (odds ratio [OR] 0.89, 95% confidence interval [CI] 0.84 to 0.95) with a number needed to treat of 61 to avoid 1 additional death. The meta-analysis also revealed reduced 24-hour mortality (OR 0.76, 95% CI 0.65 to 0.88) for TXA. No compelling evidence of increased vascular occlusive events emerged (OR 0.96, 95% CI 0.73 to 1.27). Subgroup analyses highlighted TXA's effectiveness in general trauma versus traumatic brain injury and survival advantages when administered out-of-hospital versus inhospital. CONCLUSIONS: This synthesis demonstrates that TXA use for trauma in emergencies leads to a reduction in 1-month mortality, with no significant evidence of problematic vascular occlusive events. Administering TXA in the out-of-hospital setting is associated with reduced mortality compared to inhospital administration, and less mortality with TXA in systemic trauma is noted compared with traumatic brain injury specifically.

Use of point of care ultrasound (POCUS) by intensive care paramedics to achieve peripheral intravenous access in patients predicted to be difficult: An out-of-hospital pilot study.

INTRODUCTION: Intravenous cannulation is a common procedure for paramedics. Difficulty is often encountered and may result in escalation of care to an intensive care paramedic (ICP). Ultrasound-guided peripheral intravenous access (USGPIVA) is used in-hospital as an alternative approach. Historically limited to physicians, it is increasingly embraced by non-physicians, with point of care ultrasound (POCUS) devices more affordable, portable, and suited to the out of hospital environment. OBJECTIVE: To explore the utility of ICP-performed USGPIVA for patients who are predicted to be difficult according to a difficult intravenous access scoring tool. METHODS: This was a prospective observational pilot study of ICPs who used the adult difficult intravenous access (A-DIVA) scale to predict difficulty and perform USGPIVA using a contemporary POCUS device. RESULTS: For the 32 patients enroled, the overall success rate was 50% of which 87% were successful on the first attempt. Mean A-DIVA score was 4.1/5, and paradoxically, success improved with A-DIVA-predicted difficulty. CONCLUSION: ICPs can perform USGPIVA with moderate success. The A-DIVA score could be useful for paramedics to predict difficult cannulation. Future research should focus on increasing exposure, training time and enhancing feedback to paramedics performing USGPIVA.

Use of Point-of-Care Ultrasound by Intensive Care Paramedics to Assess Respiratory Distress in the Out-of-Hospital Environment: A Pilot Study.

BACKGROUND: Respiratory distress is a common presentation attended by paramedics. Chest auscultation has been shown to have low accuracy for diagnosing respiratory complaints, and this can lead to inaccurate patient assessment and potentially poor patient outcomes. Conversely, lung ultrasound is a relatively simple exam allowing for rapid differentiation of respiratory complaints with comparable accuracy to more advanced imaging modalities. Evidence suggests that lung ultrasound is easy to learn and apply and could be ideal for assessment of respiratory illness by paramedics. OBJECTIVE: This study aimed to explore the utility of out-of-hospital lung ultrasound performed by intensive care paramedics (ICP) for patients with medical causes of respiratory distress, and explore whether the use of lung ultrasound affects the ICP's clinical impression or management. METHODS: This was a prospective observational pilot study. After a training program, a sample of ICPs working in metropolitan and regional Victoria, Australia used ultrasound to assess adult patients with respiratory distress and/or dyspnea. ICPs used a handheld point-of-care ultrasound device to scan respiratory patients using a modified protocol, and completed a worksheet with their scan findings. The scans were then reviewed by a subject matter expert for quality and agreement. RESULTS: Ninety-five patients were enrolled over the study period. The average image quality score was 2.68/5, and 56% of scans were of interpretable quality. Interrater agreement (between the ICPs and the subject matter expert) was reported using Cohen's kappa. Moderate overall agreement (0.44) was shown, with the highest reliability reported in A-profile and B-profile (0.49 and 0.57). In 42% of cases performance of the scan affected paramedic clinical impression and/or management. CONCLUSION: ICPs can perform lung ultrasound with moderate accuracy for some respiratory conditions, and the scans may affect clinical impression and management. Future research should focus on enhanced education, expert feedback, and clinical outcomes.

Use of Point-of-Care Ultrasound by Non-Physicians to Assess Respiratory Distress in the Out-of-Hospital Environment: A Scoping Review.

BACKGROUND: The use of ultrasound in the out-of-hospital environment is increasingly feasible. The potential uses for point-of-care ultrasound (POCUS) by paramedics are many, but have historically been limited to traumatic indications. This study utilized a scoping review methodology to map the evidence for the use of POCUS by paramedics to assess respiratory distress and to gain a broader understanding of the topic. METHODS: Databases Ovid MEDLINE, EMBASE, CINAHL Plus, and PUBMED were searched from January 1, 1990 through April 14, 2021. Google Scholar was searched, and reference lists of relevant papers were examined to identify additional studies. Articles were included if they reported on out-of-hospital POCUS performed by non-physicians for non-traumatic respiratory distress. RESULTS: A total of 591 unique articles were identified, of which seven articles met the inclusion criteria. The articles reported various different scan protocols and, with one exception, suffered from low enrolments and low participation. Most articles reported that non-physician-performed ultrasound was feasible. Articles reported moderate to high levels of agreement between paramedics and expert reviewers for scan interpretation in most studies. CONCLUSION: Paramedics and emergency medical technicians (EMTs) have demonstrated the feasibility of lung ultrasound in the out-of-hospital environment. Further research should investigate the utility of standardized education and scanning protocols in paramedic-performed lung ultrasound for the differentiation of respiratory distress and the implications for patient outcomes.

Can Non-Physician Providers Use Ultrasound to Aid in Establishing Peripheral IV Access in Patients Who are Difficult to Cannulate? A Scoping Review.

INTRODUCTION: Non-physician performed point-of-care ultrasound (POCUS) is emerging as a diagnostic adjunct with the potential to enhance current practice. The scope of POCUS utility is broad and well-established in-hospital, yet limited research has occurred in the out-of-hospital environment. Many physician-based studies expound the value of POCUS in the acute setting as a therapeutic and diagnostic tool. This study utilized a scoping review methodology to map the literature pertaining to non-physician use of POCUS to improve success of peripheral intravenous access (PIVA), especially in patients predicted to be difficult to cannulate. METHODS: Ovid MEDLINE, CINAHL Plus, EMBASE, and PubMed were searched from January 1, 1990 through April 15, 2021. A thorough search of the grey literature and reference lists of relevant articles was also performed to identify additional studies. Articles were included if they examined non-physician utilization of ultrasound-guided PIVA (USGPIVA) for patients anticipated to be difficult to cannulate. RESULTS: A total of 158 articles were identified. A total of 16 articles met the inclusion criteria. The majority of participants had varied experience with ultrasound, making accurate comparison difficult. Training and education were non-standardized, as was the approach to determining difficult intravenous access (DIVA). Despite this, the majority of the studies demonstrated high first attempt and overall success rates for PIVA performed by non-physicians. CONCLUSION: Non-physician USGPIVA appears to be a superior method for PIVA when difficulty is anticipated. Additional benefits include reduced requirement for central venous catheter (CVC) or intraosseous (IO) needle placement. Paramedics, nurses, and emergency department (ED) technicians are able to achieve competence in this skill with relatively little training. Further research is required to explore the utility of this practice in the out-of-hospital environment.

Physiological Response in a Specialist Paramedic During Helicopter Winch Rescue in Remote Wilderness and Extreme Heat.

Tasks performed by search and rescue (SAR) teams can be physically demanding. SAR organizations are faced with mounting challenges due to increased participation in recreation in remote locations and more frequent extreme weather. We sought to describe the physiological response and the methods for data collection during helicopter emergency medical service (HEMS) winch rescue from remote wilderness in extreme heat. A flight paramedic sustained 81% of maximum heart rate (VO2 ~44.8 mL/kg/min) for ~10 minutes at a rate of perceived exertion of 19/20, and a relative heart rate of 77.5% in 37.1°C. Maximal acceptable work time for this task was calculated at 37.7 minutes. Our data collection methods were feasible, and the data captured demonstrated the level of physiological strain that may be encountered during HEMS SAR operations in austere environments and hot climate. It is essential that SAR teams that perform physically demanding tasks use a scientific approach to adapt and evolve. This is necessary to ensure personnel are appropriately selected, trained, and equipped to respond in an era of increasing demand and extreme environments.