Prehospital Management of Penetrating Neck Injuries: An Evaluation of Practice.

OBJECTIVE: Penetrating neck injuries (PNIs) can occur at multiple anatomic sites and involve airway, nerve, vascular, and gastrointestinal structures. They pose a unique challenge to clinicians, especially in the prehospital setting. Published guidance on the prehospital management of PNIs is limited, and there is no review of the current prehospital practice. METHODS: A retrospective electronic case note review of PNIs managed within 1 UK helicopter emergency medical service (HEMS) over a 7-year period was undertaken. Data were collected on the zone of injury, mechanism of injury, prehospital times, patient demographics, prehospital interventions, and on-scene mortality. RESULTS: Ninety-eight patients met the study inclusion criteria, 40% of whom had zone 2 neck injuries. Eighty-three percent were male with a mean age of 42 years. The predominant injury mechanism was interpersonal violence (51%) followed by self-harm (47%). Fifteen percent underwent prehospital emergency anesthesia, 17% underwent prehospital blood transfusion, and 30% had a hemostatic dressing applied. No patients underwent cervical spine immobilization. One percent underwent resuscitative thoracotomy. Five percent were pronounced life extinct after HEMS arrival following interventions by the HEMS team. CONCLUSION: Time-critical and emergent interventions in this select patient population must be minimal and focus on optimizing care during rapid transfer to the hospital. Airway and hemorrhagic pathologies must be managed, often concomitantly. Targeted injury prevention to reduce interpersonal violence must ensue. The author group intends to devise a national Delphi and derive consensus guidelines for the management of prehospital PNIs.

A data-driven algorithm to support the clinical decision-making of patient extrication following a road traffic collision.

BACKGROUND: Some patients involved in a road traffic collision (RTC) are physically entrapped and extrication is required to provide critical interventions. This can be performed either in an expedited way, or in a more controlled manner. In this study we aimed to derive a data-driven extrication algorithm intended to be used as a decision-support tool by on scene emergency service providers to decide on the optimal method of patient extrication from the vehicle. METHODS: A retrospective observational study was performed of all trauma patients trapped after an RTC who were attended by a Helicopter Emergency Medical Service (HEMS) in the United Kingdom between March 2013 and December 2021. Variables were identified that were associated with the need for HEMS interventions (as a surrogate for the need for expedited extrication), based on which a practical extrication algorithm was devised. RESULTS: During the study period 12,931 patients were attended, of which 920 were physically trapped. Patients who scored an "A" on the AVPU score (n = 531) rarely required HEMS interventions (3%). Those who did were characterised by a shorter than average (29 vs. 37 min) 999/112 emergency call to HEMS on-scene arrival interval. A third of all patients responding to voice required HEMS interventions. Absence of a patent airway (OR 6.98 [1.74-28.03] p < .001) and the absence of palpable radial pulses (OR 9.99 [2.48-40.18] p < .001) were independently associated with the need for (one or more) HEMS interventions in this group. Patients only responding to pain and unresponsive patients almost invariably needed HEMS interventions post extrication (90% and 86% respectively). Based on these findings, a practical and easy to remember algorithm "APEX" was derived. CONCLUSION: A simple, data-driven algorithm, remembered by the acronym "APEX", may help emergency service providers on scene to determine the preferred method of extrication for patients who are trapped after a road traffic collision. This has the potential to facilitate earlier recognition of a 'sick' critical patient trapped in an RTC, decrease entrapment and extrication time, and may contribute to an improved outcome for these patients.

Haemodynamic effects of a prehospital emergency anaesthesia protocol consisting of fentanyl, ketamine and rocuronium in patients with trauma: a retrospective analysis of data from a Helicopter Emergency Medical Service.

OBJECTIVES: Prehospital rapid sequence induction (RSI) of anaesthesia is an intervention with significant associated risk. In this study, we aimed to investigate the haemodynamic response over time of a prehospital RSI protocol of fentanyl, ketamine and rocuronium in a heterogeneous population of trauma patients. DESIGN, SETTING AND PARTICIPANT: We performed a retrospective study of all trauma patients who received a prehospital RSI for trauma by a physician staffed Helicopter Emergency Medical Service in the UK between 1 June 2018 and 1 February 2020. PRIMARY OUTCOME MEASURE: Primary outcome was defined as the incidence of clinically relevant hypotensive (systolic blood pressure (SBP) or mean arterial pressure (MAP) >20% below baseline, with an absolute SBP <90 mm Hg or MAP <65 mm Hg) or hypertensive (SBP or MAP >20% above baseline) episodes in the first 10 minutes post-RSI. RESULTS: In total, 322 patients were included. 204 patients (63%) received a full-dose induction of 3 µg/kg fentanyl, 2 mg/kg ketamine and 1 mg/kg rocuronium, whereas 128 patients (37%) received a reduced-dose induction. Blood pressures decreased on average 12 mm Hg (95% CI 7 to 16) in the full-dose group and 6 mm Hg (95% CI 1 to 11) in the reduced-dose group, p=0.10). A hypotensive episode (mean SBP drop 53 mm Hg) was noted in 29 patients: 17 (8.3%) receiving a full dose and 12 (10.2%) receiving a reduced-dose induction, p=0.69. The blood pressure nadir was recorded on average 6-8 min after RSI. A hypertensive episode was present in 22 patients (6.8%). The highest blood pressures were recorded in the first 3 min after RSI. CONCLUSION: Prehospital induction of anaesthesia for trauma with fentanyl, ketamine and rocuronium is not related to a significant change in haemodynamics in most patients. However, a (delayed) hypotensive response with a significant drop in SBP should be anticipated in a minority of patients irrespective of the dose regimen chosen.

Feasibility of Prehospital Emergency Anesthesia in the Cabin of an AW169 Helicopter Wearing Personal Protective Equipment During Coronavirus Disease 2019.

OBJECTIVE: Prehospital emergency anesthesia in the form of rapid sequence intubation (RSI) is a critical intervention delivered by advanced prehospital critical care teams. Our previous simulation study determined the feasibility of in-aircraft RSI. We now examine whether this feasibility is preserved in a simulated setting when clinicians wear personal protective equipment (PPE) for aerosol-generating procedures (AGPs) for in-aircraft, on-the-ground RSI. METHODS: Air Ambulance Kent Surrey Sussex is a helicopter emergency medical service that uses an AW169 cabin simulator. Wearing full AGP PPE (eye protection, FFP3 mask, gown, and gloves), 10 doctor-paramedic teams performed RSI in a standard "can intubate, can ventilate" scenario and a "can't intubate, can't oxygenate" (CICO) scenario. Prespecified timings were reported, and participant feedback was sought by questionnaire. RESULTS: RSI was most commonly performed by direct laryngoscopy and was successfully achieved in all scenarios. The time to completed endotracheal intubation (ETI) was fastest (287 seconds) in the standard scenario and slower (370 seconds, P = .01) in the CICO scenario. The time to ETI was not significantly delayed by wearing PPE in the standard (P = .19) or CICO variant (P = .97). Communication challenges, equipment complications, and PPE difficulties were reported, but ways to mitigate these were also reported. CONCLUSION: In-aircraft RSI (aircraft on the ground) while wearing PPE for AGPs had no significant impact on the time to successful completion of ETI in a simulated setting. Patient safety is paramount in civilian helicopter emergency medical services, but the adoption of in-aircraft RSI could confer significant patient benefit in terms of prehospital time savings, and further research is warranted.

Outcome measures used in clinical research evaluating prehospital blood component transfusion in traumatically injured bleeding patients: A systematic review.

BACKGROUND: Trial outcomes should be relevant to all stakeholders and allow assessment of interventions' efficacy and safety at appropriate timeframes. There is no consensus regarding outcome measures in the growing field of prehospital trauma transfusion research. Harmonization of future clinical outcome reporting is key to facilitate interstudy comparisons and generate cohesive, robust evidence to guide practice. The objective of this study was to evaluate outcome measures reported in prehospital trauma transfusion trials. METHODS: Data Sources, Eligibility Criteria, Participants, and InterventionsWe conducted a scoping systematic review to identify the type, number, and definitions of outcomes reported in randomized controlled trials, and prospective and retrospective observational cohort studies investigating prehospital blood component transfusion in adult and pediatric patients with traumatic hemorrhage. Electronic database searching of PubMed, Embase, Web of Science, Cochrane, OVID, clinical trials.gov, and the Transfusion Evidence Library was completed in accordance with Preferred Reporting Items for Meta-analyses guidelines.Study Appraisal and Synthesis MethodsTwo review authors independently extracted outcome data. Unique lists of salutogenic (patient-reported health and wellbeing outcomes) and nonsalutogenic focused outcomes were established. RESULTS: A total of 3,471 records were identified. Thirty-four studies fulfilled the inclusion criteria: 4 military (n = 1,566 patients) and 30 civilian (n = 14,398 patients), all between 2000 and 2020. Two hundred twelve individual non-patient-reported outcomes were identified, which collapsed into 20 outcome domains with varied definitions and timings. All primary outcomes measured effectiveness, rather than safety or complications. Sixty-nine percent reported mortality, with 11 different definitions. No salutogenic outcomes were reported. CONCLUSION: There is heterogeneity in outcome reporting and definitions, an absence of patient-reported outcome, and an emphasis on clinical effectiveness rather than safety or adverse events in prehospital trauma transfusion trials. We recommend stakeholder consultation and a Delphi process to develop a clearly defined minimum core outcome set for prehospital trauma transfusion trials. LEVEL OF EVIDENCE: Scoping systematic review, level III.

Feasibility of Prehospital Rapid Sequence Intubation in the Cabin of an AW169 Helicopter.

OBJECTIVE: Prehospital rapid sequence intubation (RSI) is an important aspect of prehospital care for helicopter emergency medical services (HEMS). This study examines the feasibility of in-aircraft (aircraft on the ground) RSI in different simulated settings. METHODS: Using an AW169 aircraft cabin simulator at Air Ambulance Kent Surrey Sussex, 3 clinical scenarios were devised. All required RSI in a "can intubate, can ventilate" (easy variant) and a "can't intubate, can't ventilate" scenario (difficult variant). Doctor-paramedic HEMS teams were video recorded, and elapsed times for prespecified end points were analyzed. RESULTS: Endotracheal intubation (ETI) was achieved fastest outside the simulator for the easy variant (median = 231 seconds, interquartile range = 28 seconds). Time to ETI was not significantly longer for in-aircraft RSI compared with RSI outside the aircraft, both in the easy (p = .14) and difficult variant (p = .50). Wearing helmets with noise distraction did not impact the time to intubation when compared with standard in-aircraft RSI, both in the easy (p = .28) and difficult variant (p = .24). CONCLUSION: In-aircraft, on-the-ground RSI had no significant impact on the time to successful completion of ETI. Future studies should prospectively examine in-cabin RSI and explore the possibilities of in-flight RSI in civilian HEMS services.

Single-Case Study of Appetite Control in Prader-Willi Syndrome, Over 12-Years by the Indian Extract Caralluma fimbriata.

This paper reports on the successful management of hyperphagia (exaggerated hunger) in a 14yr-old female with Prader-Willi syndrome (PWS). This child was diagnosed with PWS, (maternal uniparental disomy) at 18 months due to developmental delay, hypertonia, weight gain and extreme eating behaviour. Treatment of a supplement for appetite suppression commenced at 2 years of age. This single-case records ingestion of an Indian cactus succulent Caralluma fimbriata extract (CFE) over 12 years, resulting in anecdotal satiety, free access to food and management of weight within normal range. CFE was administered in a drink daily and dose was slowly escalated by observation for appetite suppression. Rigorous testing determined blood count, vitamins, key minerals, HbA1c, IGF-1 and function of the liver and thyroid all within normal range. The report suggests a strategy for early intervention against hyperphagia and obesity in PWS. This case was the instigator of the successful Australian PWS/CFE pilot and though anecdotal, the adolescent continues to ingest CFE followed by paediatricians at the Royal Children's Hospital Melbourne, Victoria, Australia. Future clinical trials are worth considering, to determine an appropriate dose for individuals with PWS.

Prehospital Death After Traumatic Cardiac Arrest: Time for Better Feedback?

OBJECTIVE: The aim of this study was to establish if in patients who die at scene as a result of traumatic cardiac arrest (TCA), their cause of death could be determined through coroners reports, and to ascertain the quality of the feedback provided. METHODS: This is a retrospective study of all patients presenting in TCA who were attended by the Air Ambulance Kent, Surrey and Sussex between January 1, 2015, and June 30, 2016. RESULTS: In total, 159 patients were attended to during the study period. Postmortem reports could not be obtained for 37 patients, mainly because of unestablished identities at the scene. Forty of the 122 reports obtained were full postmortem reports, 3 were inquest reports, and for 79 patients only their (presumed) cause of death was provided. A specific cause of death was provided for 68 patients, whereas in the remaining 54 patients the cause of death was given as "multiple injuries." In 32% of the patients with a full postmortem report, injuries were identified during the postmortem examination that had not been noted on scene. CONCLUSION: Feedback from coroners to prehospital teams after patients die as a result of TCA is important but currently suboptimal.

Feasibility of prehospital freeze-dried plasma administration in a UK Helicopter Emergency Medical Service.

BACKGROUND: Early transfusion of patients with major traumatic haemorrhage may improve survival. This study aims to establish the feasibility of freeze-dried plasma transfusion in a Helicopter Emergency Medical Service in the UK. PATIENTS AND METHODS: A retrospective observational study of major trauma patients attended by Kent, Surrey and Sussex Helicopter Emergency Medical Service and transfused freeze-dried plasma since it was introduced in April 2014. RESULTS: Of the 1873 patients attended over a 12-month period before its introduction, 79 patients received packed red blood cells (4.2%) with a total of 193 units transfused. Of 1881 patients after the introduction of freeze-dried plasma, 10 patients received packed red blood cells only and 66 received both packed red blood cells and freeze-dried plasma, with a total of 158 units of packed red blood cells transfused, representing an 18% reduction between the two 12-month periods. In the 20 months since its introduction, of 216 patients transfused with at least one unit of freeze-dried plasma, 116 (54.0%) patients received both freeze-dried plasma and packed red blood cells in a 1: 1 ratio. Earlier transfusion was feasible, transferring the patient to the hospital before transfusion would have incurred a delay of 71 min (interquartile range: 59-90 min). CONCLUSION: Prehospital freeze-dried plasma and packed red blood cell transfusion is feasible in a 1: 1 ratio in patients with suspected traumatic haemorrhage. The use of freeze-dried plasma as a first-line fluid bolus reduced the number of prehospital packed red blood cell units required and reduced the time to transfusion.

Caralluma fimbriata extract activity involves the 5-HT2c receptor in PWS Snord116 deletion mouse model.

INTRODUCTION: In Prader-Willi syndrome (PWS), nonprotein coding small nucleolar (sno) RNAs are involved in the paternally deleted region of chromosome 15q11.2-q13, which is believed to cause the hyperphagic phenotype of PWS. Central to this is SnoRNA116. The supplement Caralluma fimbriata extract (CFE) has been shown to decrease appetite behavior in some individuals with PWS. We therefore investigated the mechanism underpinning the effect of CFE on food intake in the Snord116del mouse. Experiments utilized appetite stimulants which included a 5-hydroxytryptamine (5-HT) 2c receptor antagonist (SB242084), as the 5-HT2cR is implicated in central signaling of satiety. METHODS: After 9-week chronic CFE treatment (33 mg or 100 mg kg-1  day-1 ) or placebo, the 14-week-old Snord116del (SNO) and wild-type mice (n = 72) were rotated through intraperitoneal injections of (a) isotonic saline; (b) 400 mg/kg of 2-deoxyglucose (2DG) (glucose deprivation); (c) 100 mglkg beta-mercaptoacetate (MA), fatty acid signaling; and (d) SB242084 (a selective 5HT2cR antagonist), with 5 days between reagents. Assessments of food intake were from baseline to 4 hr, followed by immunohistochemistry of neural activity utilizing c-Fos, neuropeptide Y, and alpha-melanocyte-stimulating hormone within hypothalamic appetite pathways. RESULTS: Caralluma fimbriata extract administration decreased food intake more strongly in the SNO100CFE group with significantly stimulated food intake demonstrated during coadministration with SB242084. Though stimulatory deprivation was expected to stimulate food intake, 2DG and MA resulted in lower intake in the snord116del mice compared to the WT animals (p = <0.001). Immunohistochemical mapping of hypothalamic neural activity was consistent with the behavioral studies. CONCLUSIONS: This study identifies a role for the 5-HT2cR in CFE-induced appetite suppression and significant stimulatory feeding disruptions in the snord116del mouse model.

Caralluma Fimbriata Supplementation Improves the Appetite Behavior of Children and Adolescents with Prader-Willi Syndrome.

BACKGROUND: Prader-Willi syndrome (PWS) results from a deletion of the paternal genes in the region of chromosome 15q11-q13. PWS develops hyperphagia, which when left unmanaged, leads to an excessive ingestion of food. To date there is inadequate pharmacological treatment or supplementation for modification of the PWS hyperphagia and/or the associated behaviors. Therefore, the best practice is familial supervision and restriction of diet and environment. AIM: We aimed to determine if the natural supplement of Caralluma fimbriata extract (CFE) could attenuate hyperphagia or the associated appetite behaviors in children and adolescents with PWS over the 4-week pilot trial period. MATERIALS AND METHODS: We conducted a placebo-controlled, double-blind, randomized crossover trial over a 10-week period to investigate the effects of CFE on hunger control, in a cohort of children and adolescents with confirmed PWS (n =15, mean age 9.27 ± 3.16 years, body weight 43.98 ± 23.99 kg). Participants from Australia and New Zealand ingested CFE or a placebo of maltodextrin/cabbage leaf over a 4-week period, with a 2-week washout before the crossover to the other treatment. Weekly comparisons in appetite behavior, severity, and drive were recorded by parents, as scaled time-point measures on a hyperphagia questionnaire validated for PWS. RESULTS: CFE administration was found to induce a significant accumulative easing of hyperphagia (P = 0.05), with decreases evident in one-third of the participants. Furthermore due to CFE supplementation, a significant decrease (P ≤ 0.05) was recorded in the category of behavior and a decrease in hyperphagia (n = 8, P = 0.009) was observed at the highest dose 1,000 mg/day (recommended adult dose). There were no reported adverse effects at any dose. CONCLUSION: We demonstrate that an extract of the Indian cactus succulent Caralluma fimbriata eases hyperphagic appetite behavior within a cohort of children and adolescents (n = 15) with PWS without notable adverse effects. The outcomes of this study will have a potential positive impact on PWS management.

Prader-Willi syndrome: From genetics to behaviour, with special focus on appetite treatments.

Prader-Willi syndrome (PWS) is a neurodevelopmental disorder resulting from a deletion in the expression of the paternally derived alleles in the region of 15q11-q13. PWS has a prevalence rate of 1:10,000-1:30,000 and is characterized by marked endocrine abnormalities including growth hormone deficiency and raised ghrelin levels. The hyperphagic phenotype in PWS is established over a number of phases and is exacerbated by impaired satiety, low energy expenditure and intellectual difficulties including obsessive-compulsive disorder and/or autistic behaviours. Clinical management in PWS typically includes familial/carer restriction and close supervision of food intake. If the supervision of food is left unmanaged, morbid obesity eventuates, central to the risk of cardiorespiratory disorder. None of the current appetite management/intervention strategies for PWS include pharmacological treatment, though recent research shows some promise. We review the established aberrant genetics and the endocrine and neuronal attributes which may determine disturbed regulatory processes in PWS. Focusing on clinical trials for appetite behaviours in PWS, we define the effectiveness of pharmacological treatments with a view to initiating and focusing research towards possible targets for modulating appetite in PWS.

Infant well-being following neonatal cardiac surgery.

AIMS AND OBJECTIVES: To investigate infant well-being as measured by feeding and sleeping and parental support following discharge from the NICU in infants following major cardiac surgery. BACKGROUND: Infant feeding and sleeping have been identified as two of the most important concerns reported by parents. These concerns have been reported anecdotally for infants who have undergone cardiac surgery in the neonatal period. DESIGN: A prospective study using questionnaires and phone interviews followed a cohort of parents of neonates who underwent surgery in the neonatal period for congenital heart disease. METHODS: The study was conducted using validated questionnaires and phone interviews with a semi-structured questionnaire. The questionnaires were administered prior to discharge from the NICU and interviews took place following discharge on five occasions within nine months. RESULTS: Fifty six infants and mothers were followed for nine months following discharge from NICU. Sixty-eight per cent were breastfeeding on discharge however the rates decline over time in line with healthy infants. Mothers were not bothered by their infant's sleep patterns which were consistent with those of healthy infants at six months. There were 37 episodes of re-hospitalisation and the average time of further surgery was five months following discharge from their initial period of hospitalisation. CONCLUSION: The issues from this pilot study warrant further investigation. Factors such as multiple hospitalisations, parent education and support may vary within contexts and need to be studied to ensure optimal supports are identified for this high risk population. RELEVANCE TO CLINICAL PRACTICE: This study identified several issues that can improve care provided to these infants and their parents. Support following discharge could include: lactation consultant to provide follow-up calls to identify concerns with breastfeeding, lactation course for paediatric nurses providing follow-up and education for Early Childhood Clinics on Congenital Heart Disease.