Stopping infusions before PCI transfer

Posted on March 14, 2010 by Cliff Reid

An interhospital transport service introduced a no infusions policy for patients being transferred for primary coronary intervention, instead giving a bolus of heparin and glycoprotein 2b-3a inhibitor prior to transfer, along with non-intravenous nitrates (if needed). Discontinuing infusions during transport resulted in a significant reduction in transport times with no adverse effect on hospital length of stay or mortality. It did not significantly extend the time the patient spent in the catheterisation laboratory, nor did it impact the incidence of TIMI III flow. It did not impact the incidence of readmission to the hospital for cardiac-related chief complaints.

Transporting without infusions: effect on door-to-needle time for acute coronary syndrome patients
Prehosp Emerg Care. 2010 Apr 6;14(2):159-63

Posted in General PH&RM | Tagged , , | Leave a comment

Better TBI outcome with HEMS

Posted on March 14, 2010 by Cliff Reid

A retrospective study from Italy compared outcomes of head injured patients cared for by a ground ambulance service (GROUND) with those managed by a HEMS team that included an experienced pre-hospital anaesthetist. Interestingly 73% of the ground group were also attended by a physician, but one ‘with only basic life-support capabilities and no formal training in airways management’. Despite these limited skills a results table shows that 36% of the GROUND group were intubated on scene (compared with 92% of the HEMS group), although without the use of neuromuscular blockers.

The HEMS group consisted of 89 patients and the GROUND group of 105 patients. There were no statistical differences in age, ISS, aISShead, or GCS, although arterial hypotension at arrival at the ER was present in 18% of HEMS patients and in 36% of GROUND patients (P < 0.001).

The overall mortality rate was lower in the HEMS than in the GROUND group (21 vs. 25% , P < 0.05). The survival with or without only minor neurological disabilities was higher in the HEMS than in the GROUND group (54 vs. 44% respectively, P < 0.05); among the survivors, the rate of severe neurological disabilities was lower in the HEMS than in the GROUND group (25 vs. 31%, P < 0.05). The out-of-hospital phase duration was longer in the HEMS group but this group had a faster time to definitive care (neurosurgery or neurocritical care).

Influence of prehospital treatment on the outcome of patients with severe blunt traumatic brain injury: a single-centre study
Eur J Emerg Med. 2009 Dec;16(6):312-7

Posted in General PH&RM | Tagged , , , , | Leave a comment

Ketamine use by paramedics

Posted on March 9, 2010 by Cliff Reid

A poster presentation at the Australasian College of Emergency Medicine’s Annual Scientific Conference in Melbourne in November 2009 reports 100 cases of pre-hospital ketamine use for analgesia by paramedics in New Zealand – reproduced below with permission of the author:

Ketamine is a safe and effective analgesic for pre-hospital paramedic led pain relief
HM Hussey & BC Ellis
Introduction: There have been a number of reports on the use of ketamine by pre-hospital physicians, with many advocating its use as the ideal pre-hospital analgesic and sedative due to its airway and cardiovascular stability. There however is little published on its use by paramedics. This study aims to review its effectiveness and safety when administered pre-hospital by paramedics.

Method: Prospective observational study of 100 consecutive administrations by St Johns ambulance paramedics in 2008–09 using a specifically designed data sheet. Demographic data, adjuvant analgesics used, ketamine dose, pre and post dose pain scores on VNRS and physiological parameters were collected. In addition paramedics and patients completed a satisfaction rating score.

Results: The mean dose of ketamine used was 30.2 mg and the mean improvement in pain was 5.10. Ketamine was used both as a lone agent and with morphine; excellent analgesia was achieved in both groups. The most common reason for use was limb trauma followed by burns and extractions from scene. There were no episodes of hypotension or airway compromise. 15% of patients had an adverse reaction all mild and mostly comprising minor psychotropic effects. The median satisfaction rating for both paramedics and patients was ‘Good’.

Conclusion: These results back the use of Ketamine by St John’s Ambulance paramedics and the authors support its use by other pre-hospital services as a safe and effective analgesic.

Emergency Medicine Australasia 2010;22(S1):A30

Posted in General PH&RM | Tagged , , , | Leave a comment

Cardiocerebral resuscitation

Posted on March 8, 2010 by Cliff Reid

An emergency medical service introduced a cardiocerebral resuscitation protocol and compared outcomes with a standard ACLS protocol.

Cardiocerebral resuscitation (CCR) was defined as:

  1. initiation of 200 immediate, uninterrupted chest compressions at a rate of 100 compressions ⁄ min
  2. analyzing the rhythm and delivering a single defibrillator shock, if indicated
  3. 200 more chest compressions before the first pulse check or rhythm reanalysis
  4. epinephrine (1 mg intravenous or intraosseous) as soon as possible or with each 200 compression cycle
  5. endotracheal intubation delayed until after three cycles of chest compressions

Data was analysed from a registry including data on 3515 patients from 62 EMS agencies, some of which instituted CCR (in a total of 1024 patients). Outcome predictors were identified using logistic regression analysis and

Individuals who received CCR had better outcomes across age groups. The increase in survival for the subgroup with a witnessed Vfib was most prominent on those <40 years of age (3.7% for standard ALS patients vs. 19% for CCR patients, odds ratio [OR] = 5.94, 95% confidence interval [CI] = 1.82 to 19.26). Neurologic outcomes were also better in the patients who received CCR (OR = 6.64, 95% CI = 1.31 to 32.8). Within the subgroup that received CCR, the factors most predictive of improved survival included witnessed arrest, initial rhythm of Vfib⁄Vtach, agonal respirations upon arrival, EMS response time, and age. Neurologic outcome was not adversely affected by age.

Cardiocerebral Resuscitation Is Associated With Improved Survival and Neurologic Outcome from Out-of-hospital Cardiac Arrest in Elders
Academic Emergency Medicine 2010;17(3):269 – 275

Posted in General PH&RM | Tagged , | Leave a comment

Pre-hospital thoracotomy and aortic clamping in blunt trauma

Posted on February 14, 2010 by Cliff Reid

This is one of those ‘wow they really do that!?‘ papers…Patients undergoing thoracotomy and aortic clamping for pre-hospital blunt traumatic arrest either in the field or in the ED were evaluated for the outcome of survival to ICU admission. None of the 81 patients who underwent this intervention survived to discharge.

Field thoracotomy resulted in shorter times from arrival of the emergency medical team to performance of the thoracotomy (19.2 vs 30.7 mins). Patients who arrested in front of the team had a greater ICU admission rate than those who were already in cardiac arrest when the team arrived (70% vs 8%).

One may argue against an intervention that seems to have resulted in no benefit to the patient. However a counterargument might be that an ICU admission allows for better end-of-life management for grieving families, and for the possibility of organ donation.

Interestingly, there were some neurologically intact survivors of emergency thoracotomy for blunt trauma by this service, although they were excluded from the study for either (i) receiving the field thoracotomy before full arrest or (ii) arresting after arrival in the ED.

Role of resuscitative emergency field thoracotomy in the Japanese helicopter emergency medical service system
Resuscitation. 2009 Nov;80(11):1270-4

Posted in General PH&RM | Tagged , , , , , , , , | Leave a comment

Self-extrication with a collar on

Posted on February 9, 2010 by Cliff Reid

Using a sophisticated infrared six camera motion capture system, investigators demonstrated decreased cervical spine movement when collared volunteers self-extricated from a mock smashed up Toyota Corolla, when compared with extrication by paramedics using a backboard.

The authors conclude that in ambulatory subjects who do not complain of back pain, the least motion of the cervical spine may occur when the subject is allowed to exit the car in a c-collar without backboard immobilisation.

Cervical spine motion during extrication: a pilot study
West J Emerg Med. 2009 May;10(2):74-8

Full text article

Posted in General PH&RM | Tagged , , , | Leave a comment

Standard medication kit for prehospital and retrieval physicians

Posted on February 9, 2010 by Cliff Reid

A very comprehensive (hence the title of the paper) review of medications required for pre-hospital & retrieval medicine missions was undertaken, resulting in recommendations. While the casemix seen by various services may be influenced by local geography or tasking restrictions, the list provides an excellent standard from which locally appropriate modifications can be made.

Defining a standard medication kit for prehospital and retrieval physicians: a comprehensive review.
Emerg Med J. 2010 Jan;27(1):62-71

Posted in General PH&RM | Tagged , , | Leave a comment

External jugular vein a tricky one

Posted on February 4, 2010 by Cliff Reid

Emergency medicine residents and paramedics cannulated patients who were anaesthetised. The external jugular vein (EJV) took longer to cannulate and had a higher failure rate than an antecubital vein. More than a quarter of the paramedics and a third of the doctors failed to cannulate the EJV.
Is external jugular vein cannulation feasible in emergency care? A randomised study in open heart surgery patients
Resuscitation. 2009 Dec;80(12):1361-4

Posted in General PH&RM | Tagged , | Leave a comment

IO in OI

Posted on February 4, 2010 by Cliff Reid

A case report describes three failed attempts to flush or secure an intraosseous needle placed using the EZ-IO drill during cardiac arrest of an adult patient subsequently noted to have osteogenesis imperfecta (OI) type III. While not listed as a contraindication to EZ-IO use by the manufacturer, one should consider that OI may result in procedural failure.

Intraosseous access in osteogenesis imperfecta (IO in OI)
Resuscitation. 2009 Dec;80(12):1442-3

Posted in General PH&RM | Tagged | Leave a comment

HEMS paramedic intubation success

Posted on February 4, 2010 by Cliff Reid

All medical out of hospital cardiac arrests attended by the Warwickshire and Northamptonshire Air Ambulance (WNAA) over a 64-month period were reviewed. There were no significant differences in self-reported intubation failure rate, morbidity or clinical outcome between doctor-led and paramedic-led cases. The authors conclude that experienced paramedics regularly operating with physicians have a low tracheal intubation failure rate at out of hospital cardiac arrests, whether practicing independently or as part of a doctor-led team, and that this is likely due to increased and regular clinical exposure.

Can experienced paramedics perform tracheal intubation at cardiac arrests? Five years experience of a regional air ambulance service in the UK
Resuscitation. 2009 Dec;80(12):1342-5

Posted in General PH&RM | Tagged , , , | Leave a comment