The time cost of prehospital intubation and intravenous access in trauma patients

Flight to Recovery: Impact of a Rooftop Helipad Air Ambulance Service at the Emergency University Hospital of Bucharest-A Caseload Analysis of the First 3 Years After Its Implementation

OBJECTIVE

This observational study provides an overview of the implementation and impact of the helipad at the Bucharest Emergency University Hospital, Romania. The helipad, established in April 2019, is the only rooftop medical helipad in Bucharest authorized for day and night flights. Its influence extends beyond the local region, enabling the hospital to receive patients from various cities across Romania. The helipad has particularly strengthened the hospital's capabilities in cardiology, neurovascular emergencies, and neonatal care. Patients with acute myocardial infarctions or strokes can now be swiftly transported to the hospital for immediate intervention, whereas critically ill newborns can receive specialized care at the earliest stages of their lives. The objective of this article was to present a comprehensive timeline of the helipad's implementation and to demonstrate its transformative role in improving patient transportation, enhancing medical interventions, and elevating the overall efficiency of the health care facility.

METHODS

The study is a retrospective regional caseload analysis based on data gathered from the Emergency Department of the University Emergency Hospital of Bucharest database. We included all 215 air transfer missions registered between December 2019 and December 2022, exactly 3 years apart from the beginning of the program.

RESULTS

The findings provide valuable insights into patient demographics, case distribution, and trends, highlighting the importance of specialized medical interventions at the University Emergency Hospital of Bucharest. In particular, the mean age of patients treated at the hospital was 55.9 years, with a higher representation of males (156) than females (59). The average duration of hospitalization was 10.68 days. The study also examined transportation statistics, showing a decrease in the average number of transports per month over the years. Cardiologic cases accounted for the highest frequency (62.8%) among the analyzed categories followed by neurosurgery (8.8%) and neurologic cases (8.4%).

CONCLUSION

The analysis provides important insights into patient demographics, case distribution, and trends. The findings highlight the significance of specialized medical interventions, particularly in cardiology and neurosurgery, which accounted for the majority of the cases. The implementation of the helipad has greatly improved patient transportation and facilitated timely medical assistance.

Effect of timing of advanced life support on out-of-hospital cardiac arrests at home in Japan

AIM

In cases of out-of-hospital cardiac arrests (OHCA) occurring at home, Japanese emergency medical services personnel decide whether to provide treatment on the scene or during transport based on their judgment. This study aimed to evaluate the association between the timing of advanced life support (ALS) (i.e., endotracheal intubation [ETI] or adrenaline administration) for OHCA at home and prognosis.

METHOD

This retrospective cohort study used data from the Japan Utstein Registry and emergency transport data collected from patients who underwent pre-hospital ETI (n = 6806) and received adrenaline (n = 22,636) between 2016 and 2019. The timing of ETI or adrenaline administration was determined as "on the scene" or "in the ambulance." Multiple logistic regression analysis was used to estimate the association among the timing of ALS implementation, pre-hospital return of spontaneous circulation (ROSC), and survival at 1 month.

RESULT

ETI on the scene was significantly positively associated with pre-hospital ROSC (adjusted odds ratio [AOR], 1.81; 95% confidence interval [CI], 1.57-2.09) and survival at 1 month (AOR, 1.81; 95% CI, 1.47-2.23). Adrenaline administration on the scene was significantly positively associated with pre-hospital ROSC (AOR, 2.51; 95% CI, 2.33-2.70) and survival at 1 month (AOR, 2.13; 95% CI, 1.89-2.40).

CONCLUSION

Our analysis suggests performing ALS on the scene was associated with pre-hospital ROSC and survival at 1 month. Further efforts are needed to increase the rate of ALS implementation on the scene by emergency life-saving technicians.

Parenteral, Non-Intravenous Analgesia in Acute Traumatic Pain-A Narrative Review Based on a Systematic Literature Search

Traumatic pain is frequently encountered in emergency care and requires immediate analgesia. Unfortunately, most trauma patients report sustained pain upon arrival at and discharge from the Emergency Department. Obtaining intravenous access to administer analgesics can be time-consuming, leading to treatment delay. This review provides an overview of analgesics with both fast onset and parenteral, non-intravenous routes of administration, and also indicates areas where more research is required.

The effect of prehospital intravenous access in traumatic shock: a Japanese nationwide cohort study

Aim

We aimed to evaluate effect of prehospital intravenous (IV) access on mortality in traumatic shock using a large nationwide dataset.

Methods

We used the Japan Trauma Data Bank to identify adults (≥18 years) with a systolic blood pressure <90 mm Hg at the trauma scene and were directly transported to the hospital between 2010 and 2019. We compared patients who had prehospital IV access (IV (+)) or not (IV (−)), using propensity score‐matched analysis, and 1:1 nearest‐neighbor matching without replacement. Standardized mean difference was used to evaluate the match balance between the two matched groups; a standardized mean difference >0.1 was considered a significant imbalance. Primary outcome was 72‐h mortality.

Results

Propensity scores matching generated 479 pairs from 5,857 patients. No significant between group differences occurred in 72‐h mortality (7.8 versus 8.8%; difference, −1.0%; 95% confidence interval [CI]: −2.5–4.5%), 28‐day mortality (11.8 versus 11.3%; 95% CI: −4.6–3.6%), blood transfusion administration within 24 h (55.3 versus 49.1%; 95% CI: −0.1–12.6%), prehospital time (56.3 versus 53.0 min; 95% CI: −1.8–8.4 min), and cardiopulmonary arrest on hospital arrival (1.3 versus 1.3%; 95% CI: −1.4–1.4%). However, significantly higher systolic blood pressure on hospital arrival was found in the IV (+) than in the IV (−) group (104.6 versus 100.1 mm Hg; 95% CI: 0.3‐8.7 mm Hg).

Conclusion

We found no significant effect of establishing IV access in the prehospital setting on survival outcomes of patients with traumatic shock.

Utility of Glucose Testing and Treatment of Hypoglycemia in Patients with Out-of-Hospital Cardiac Arrest

Objective: Many emergency medical services (EMS) protocols for out-of-hospital cardiac arrests (OHCA) include point-of-care (POC) glucose measurement and administration of dextrose, despite limited knowledge of benefit. The objective of this study was to describe the incidence of hypoglycemia and dextrose administration by EMS in OHCA and subsequent patient outcomes.Methods: This was a retrospective analysis of OHCA in a large, regional EMS system from 2011 to 2017. Patients ≥18 years old with non-traumatic OHCA and attempted field resuscitation by paramedics were included. The primary outcomes were frequency of POC glucose measurement, hypoglycemia (glucose <60 mg/dl), and dextrose/glucagon administration (treatment group). The secondary outcomes included field return of spontaneous circulation (ROSC), survival to hospital discharge (SHD), and survival with good neurologic outcome.Results: There were 46,211 OHCAs during the study period of which 33,851 (73%) had a POC glucose test performed. Glucose levels were documented in 32,780 (97%), of whom 2,335 (7%) were hypoglycemic. Among hypoglycemic patients, 41% (959) received dextrose and/or glucagon. Field ROSC was achieved in 30% (286) of hypoglycemic patients who received treatment. Final outcome was determined for 1,714 (73%) of the hypoglycemic cases, of whom 120 (7%) had SHD and 66 (55%) had a good neurologic outcome. Of the 32,780 patients with a documented POC glucose result who were identified as hypoglycemic, only 27 (0.08%) received field treatment, and survived to discharge with good neurologic outcome. 48 (6%) of patients in the treatment group had SHD vs. 72 (8%) without treatment, risk difference -2.0% (95%CI -4.4%, 0.4%), p = 0.1.Conclusion: In this EMS system, POC glucose testing was common in adult OHCA, yet survival to hospital discharge with good neurologic outcome did not differ between patients treated and untreated for hypoglycemia. These results question the common practice of measuring and treating hypoglycemia in OHCA patients.

Nighttime Calls, Pages, and Interruptions to the On-Call Surgery Resident

BACKGROUND

Communication is a keystone to good medical practice. At night, as physician numbers decrease, frequent, nonurgent interruptions have shown to disrupt patient care and impact resident/physician wellness. Potentially, interruptions can lead to an increase in medical errors. The frequency and activities interrupted during night calls have not been fully described.

METHODS

For a period of 44 days (August through September), all calls and pages received during the 12-hour night call session were documented. Calls were analyzed by caller, urgency, need for intervention, and resident interrupted by the communication.

RESULTS

A total of 494 communications were identified with a mean of 10 calls per shift (IQR 7-14). Communications lasted a mean of 2.7 +/- 2.9 minutes. Direct calls occurred in 78% and pages in 22% of the cases. From the non-ED calls (n = 335), most of them came from nursing staff (85%), followed by other specialties (12%). Five percent of the calls were directed to the wrong service. Communications occurred during charting (41%), patient assessment (33%), interrupted resident's sleep (12%), or during a surgical procedure (6%). Communication required no action in 47% of the cases. A physician order was needed in 41%, while bedside clinical assessment was required in 12% of the calls.

CONCLUSIONS

Communications are common at night, but most did not require clinical assessment. A large portion of communications interrupted direct patient care. An opportunity exists to eliminate nonproductive communications and improve the quality of medical education.

Relationship Between Nonconveyed Cases and On-Scene Time Intervals for Emergency Medical Services

Purpose

Emergency medical service (EMS) consumption is increasing worldwide. Some EMS cases in Saudi Arabia result in nonconveyance of patients. The aim of the present study was to determine the relationship between nonconveyed EMS cases and on-scene time intervals in Riyadh EMS centers.

Methods

Nonrandomized retrospective data obtained from EMS providers of nonconveyed emergency cases were gathered and analyzed. Data were taken from the ten busiest EMS centers in Riyadh, Saudi Arabia from January 1 to April 30, 2019. Analyses of means ± SD, bivariate comparisons, multivariate analysis, CI correlations, and regressionwere performed.

Results

Categories of nonconveyed cases were “Treatment given at the scene” V1 = 66, “Refused by patient/relative” (V2 = 876), “Patient not found” (V3 = 67), “Dead patient” (V4 = 80”, “Other (police, etc)” (V5 = 34), and NA (96). We found highly significant differences (p<0.001) among several categories of nonconveyed cases and on-scene time intervals among EMS centers.

Conclusion

This study found that there were highly significant differences among several categories of nonconveyed cases in relation to on-scene time intervals for different EMS centers. Results indicated that the probability of nonconveyance decisions was more likely to increase in the categories “Refused by patient/relative,” “Patient not found,” and “Dead patient.” The results did not reveal details of what happened on scene during or after the nonconveyance decision had been made, which needs to be investigated.

The ticking clock: does actively making an enhanced care team aware of the passage of time improve pre-hospital scene time following traumatic incidents?

Introduction

Pre-hospital enhanced care teams like Helicopter Emergency Medical Services (HEMS) are often dispatched to major trauma patients, including patients with traumatic brain injuries and those with major haemorrhage. For these patients, minimizing the time to definitive care is vital. The aim of this study was to determine whether increased awareness of elapsed on scene time produces a relevant time performance improvement for major trauma patients attended by HEMS, and weather introducing such a timer was feasible and acceptable to clinicians.

Methods

We performed a prospective cohort study of all single casualty traumatic incidents attended by Air Ambulance Kent Surrey Sussex (AAKSS) between 15 October 2016 and 23 May 2017 to test if introduction of a prompting scene timer within the service resulted in a reduction in pre-hospital scene times.

Results

The majority of the patients attended were male (74%) and sustained blunt trauma (92%). Overall, median scene time was 25.5 [IQR16.3] minutes before introduction of the scene timer and 23.0 [11.0] minutes after introduction, p = 0.13). Scene times for patients with a GCS < 8 and for patients requiring prehospital anaesthesia were significantly lower after introduction of the timer (28 [IQR 14] vs 25 [1], p = 0.017 and 34 [IQR 13] vs 28 [IQR11] minutes, p = 0.007 respectively). The majority of clinicians felt the timer made them more aware of passing time (91%) but that this had not made a difference to scene time (62%) or their practice (57%).

Conclusion

Audible scene timers may have the potential to reduce pre-hospital scene time for certain single casualty trauma patients treated by a HEMS team, particularly for those patients needing pre-hospital anaesthesia. Regular use of on-scene timers may improve outcomes by reducing time to definitive care for certain subgroups of trauma patients.

Efficacy of venous access placement at a pre-hospital scene in severe paediatric trauma patients: a retrospective cohort study

Purpose: Aside from severe traumatic brain injury, uncontrolled bleeding and corresponding haemorrhage shock are the leading causes of traumatic deaths. No established recommendations exist about venous access placement for severely injured, bleeding children at a pre-hospital scene. This study sought to evaluate the association between pre-hospital venous access placement and mortality in a paediatric trauma population by analysing the Japan Trauma Data Bank (JTDB). Methods: This epidemiologic study compared the outcomes of severe traumatic paediatric patients with or without venous access placement at a pre-hospital scene. Data were obtained from JTDB from 2004 to 2015. Results: Of 4,109 patients who met our inclusion criteria, 144 patients received venous access placement and 3,965 patients did not. The probability of survival was lower in the venous access group than in the no access group (0.90 [0.67–0.97] vs. 0.97 [0.90–0.99], p < 0.01). After multivariable logistic analysis, venous access placement did not improve survival to hospital discharge (odds ratio = 1.40, confidence interval = 0.32–6.15, p = 0.653). Conclusions: The probability of survival was lower in the venous access group than in the no access group. Survival outcome at discharge was not affected by venous access placement at a pre-hospital scene.

Does it matter who places the intravenous? An inter-professional comparison of prehospital intravenous access difficulties between physicians and paramedics

Supplemental Digital Content is available in the text.

Objectives

Depending on the specific national emergency medical systems, venous cannulations may be performed by physicians, paramedics or both alike. Difficulties in the establishment of vascular access can lead to delayed treatment and transport. Our study investigates possible inter-professional differences in the difficulties of prehospital venous cannulation.

Methods

Paramedics were interviewed for their personal attitudes towards and experiences in venous access. We analysed 47 candidate predictor variables in terms of cannulation failure and exceedance of a 2 min time threshold. Multivariable logistic regression models were fitted for variables of potential predictive value (P<0.25) and evaluated by the area under the curve (AUC>0.60) of their respective receiver operating characteristic curve. Results were compared with previously published data from emergency physicians.

Results

A total of 552 cannulations were included in our study. All 146 participants voted that paramedics should be eligible to perform venous catheterizations. Despite ample experience in the task, almost half of them considered prehospital venous cannulations more difficult than those performed in hospital. However, the multivariable logistic regression found only patient-related and puncture site factors to be predictive of cannulation failure (patient age, vein palpability with tourniquet, insufficient ambient lighting: model AUC: 0.72) or cannulation delay (vein palpability with tourniquet: model AUC: 0.60).

Conclusion

Our study shows that venous cannulation is well established among paramedics. It presents itself with similar difficulties across medical professions. Not the numerous specific circumstances of prehospital emergency care, but universal factors inherent to the task will influence the success at venous catheterization.

The Association of Prehospital Intravenous Fluids and Mortality in Patients with Penetrating Trauma

BACKGROUND

The optimal approach to prehospital care of trauma patients is controversial, and thought to require balancing advanced field interventions with rapid transport to definitive care.

OBJECTIVE

We sought principally to examine any association between the amount of prehospital IV fluid (IVF) administered and mortality.

METHODS

We conducted a retrospective cohort analysis of trauma registry data patients who sustained penetrating trauma between January 2008 and February 2011, as identified in the Pennsylvania Trauma Systems Foundation registry with corresponding prehospital records from the Philadelphia Fire Department. Analyses were conducted with logistic regression models and instrumental variable analysis, adjusted for injury severity using scene vital signs before the intervention was delivered.

RESULTS

There were 1966 patients identified. Overall mortality was 22.60%. Approximately two-thirds received fluids and one-third did not. Both cohorts had similar Trauma and Injury Severity Score-predicted mortality. Mortality was similar in those who received IVF (23.43%) and those who did not (21.30%) (p = 0.212). Patients who received IVF had longer mean scene times (10.82 min) than those who did not (9.18 min) (p < 0.0001), although call times were similar in those who received IVF (24.14 min) and those who did not (23.83 min) (p = 0.637). Adjusted analysis of 1722 patients demonstrated no benefit or harm associated with prehospital fluid (odds ratio [OR] 0.905, 95% confidence interval [CI] 0.47-1.75). Instrumental variable analysis utilizing variations in use of IVF across different Emergency Medical Services (EMS) units also found no association between the unit's percentage of patients that were provided fluids and mortality (OR 1.02, 95% CI 0.96-1.08).

CONCLUSIONS

We found no significant difference in mortality or EMS call time between patients who did or did not receive prehospital IVF after penetrating trauma.

Factors influencing on-scene time in a rural Norwegian helicopter emergency medical service: a retrospective observational study

Background

Critically ill patients need to be immediately identified, properly managed, and rapidly transported to definitive care. Extensive prehospital times may increase mortality in selected patient groups. The on-scene time is a part of the prehospital interval that can be decreased, as transport times are determined mostly by the distance to the hospital. Identifying factors that affect on-scene time can improve training, protocols, and decision making. Our objectives were to assess on-scene time in the Helicopter Emergency Medical Service (HEMS) in our region and selected factors that may affect it in specific and severe conditions.

Methods

This retrospective cohort study evaluated on-scene time and factors that may affect it for 9757 emergency primary missions by the three HEMSs in western Norway between 2009 and 2013, using graphics and descriptive statistics.

Results

The overall median on-scene time was 10 minutes (IQR 5–16). The median on-scene time in patients with penetrating torso injuries was 5 minutes (IQR 3–10), whereas in cardiac arrest patients it was 20 minutes (IQR 13–28). Based on multivariate linear regression analysis, the severity of the patient’s condition, advanced interventions performed, mode of transport, and trauma missions increased the on-scene time. Endotracheal intubation increased the OST by almost 10 minutes. Treatment prior to HEMS arrival reduced the on-scene time in patients suffering from acute myocardial infarction.

Discussion

We found a short OST in preselected conditions compared to other studies. For the various patient subgroups, the strength of association between factors and OST varied. The time spent on-scene and its influencing factors were dependent on the patient’s condition. Our results provide a basis for efforts to improve decision making and reduce OST for selected patient groups.

Conclusions

The most important factors associated with increased on-scene time were the severity of the patient’s condition, the need for intubation or intravenous analgesic, helicopter transport, and trauma missions.

Electronic supplementary material

The online version of this article (10.1186/s13049-017-0442-5) contains supplementary material, which is available to authorized users.

Identifying pre-hospital factors associated with outcome for major trauma patients in a regional trauma network: an exploratory study

BACKGROUND

Major trauma is often life threatening and the leading cause of death in the United Kingdom (UK) for adults aged less than 45 years old. This study aimed to identify pre-hospital factors associated with patient outcomes for major trauma within one Regional Trauma Network.

METHOD

Secondary analysis of pre-hospital audit data and patient outcome data from the Trauma Audit Research Network (TARN) was undertaken. The primary outcome used in analysis was 'Status at Discharge' (alive/deceased). Independent variables considered included 'Casualty Characteristics' such as mechanism of injury (MOI), age, and physiological measurements, as well as 'Response Characteristics' such as response timings and skill mix. Binary Logistic Regression analysis using the 'forward stepwise' method was undertaken for physiological measures taken at the scene.

RESULTS

The study analysed 1033 major trauma records (mean age of 38.5 years, SD 21.5, 95% CI 37-40). Adults comprised 82.6% of the sample (n = 853), whilst 12.9% of the sample were children (n = 133). Men comprised 68.5% of the sample (n = 708) in comparison to 28.8% women (n = 298). Glasgow Coma Score (GCS) (p < 0.000), Respiration Rate (p < 0.001) and Age (p < 0.000), were all significant when associated with the outcome 'Status at Discharge' (alive/deceased). Isolated bivariate associations provided tentative support for response characteristics such as existing dispatching practices and the value of rapid crew arrival. However, these measurements appear to be of limited utility in predictive modelling of outcomes.

DISCUSSION

The complexity of physiological indices potentially complicate their predictive utility e.g. whilst a Systolic Blood Pressure (SBP) of < 90 mmHg serves as a trigger for bypass to a Major Trauma Centre, the utility of this observation is nullified in cases of Traumatic Brain Injury. Analysis suggested that as people age, outcomes from major trauma significantly worsened. This finding is consistent with existing research highlighting the relationship between trauma in elderly patients and poorer outcomes.

CONCLUSION

Findings lend further validity to GCS, Respiration Rate and Age as predictive triggers for transport to a Major Trauma Centre. Analysis of interactions between response times, skill mix and triage demand further exploration but tentatively support the 'Golden Hour' concept and suggest a potential 'load and go and play on the way' approach.

The prehospital intravenous access assessment: a prospective study on intravenous access failure and access delay in prehospital emergency medicine

OBJECTIVES

Intravenous access in prehospital emergency care allows for early administration of medication and extended measures such as anaesthesia. Cannulation may, however, be difficult, and failure and resulting delay in treatment and transport may have negative effects on the patient. Therefore, our study aims to perform a concise assessment of the difficulties of prehospital venous cannulation.

METHODS

We analysed 23 candidate predictor variables on peripheral venous cannulations in terms of cannulation failure and exceedance of a 2 min time threshold. Multivariate logistic regression models were fitted for variables of predictive value (P<0.25) and evaluated by the area under the curve (AUC>0.6) of their respective receiver operating characteristic curve.

RESULTS

A total of 762 intravenous cannulations were enroled. In all, 22% of punctures failed on the first attempt and 13% of punctures exceeded 2 min. Model selection yielded a three-factor model (vein visibility without tourniquet, vein palpability with tourniquet and insufficient ambient lighting) of fair accuracy for the prediction of puncture failure (AUC=0.76) and a structurally congruent model of four factors (failure model factors plus vein visibility with tourniquet) for the exceedance of the 2 min threshold (AUC=0.80).

CONCLUSION

Our study offers a simple assessment to identify cases of difficult intravenous access in prehospital emergency care. Of the numerous factors subjectively perceived as possibly exerting influences on cannulation, only the universal - not exclusive to emergency care - factors of lighting, vein visibility and palpability proved to be valid predictors of cannulation failure and exceedance of a 2 min threshold.

Not all prehospital time is equal: Influence of scene time on mortality

BACKGROUND

Trauma is time sensitive, and minimizing prehospital (PH) time is appealing. However, most studies have not linked increasing PH time with worse outcomes because raw PH times are highly variable. It is unclear whether specific PH time patterns affect outcomes. Our objective was to evaluate the association of PH time interval distribution with mortality.

METHODS

Patients transported by emergency medical services in the Pennsylvania trauma registry from 2000 to 2013 with a total PH time (TPT) of 20 minutes or longer were included. TPT was divided into three PH time intervals: response, scene, and transport time. The number of minutes in each PH time interval was divided by TPT to determine the relative proportion each interval contributed to TPT. A prolonged interval was defined as any one PH interval contributing equal to or greater than 50% of TPT. Patients were classified by prolonged PH interval or no prolonged PH interval (all intervals < 50% of TPT). Patients were matched for TPT, and conditional logistic regression determined the association of mortality with PH time pattern, controlling for confounders. PH interventions were explored as potential mediators, and PH triage criteria used identify patients with time-sensitive injuries.

RESULTS

There were 164,471 patients included. Patients with prolonged scene time had increased odds of mortality (odds ratio, 1.21; 95% confidence interval, 1.02-1.44; p = 0.03). Prolonged response, transport, and no prolonged interval were not associated with mortality. When adjusting for mediators including extrication and PH intubation, prolonged scene time was no longer associated with mortality (odds ratio, 1.06; 95% confidence interval, 0.90-1.25; p = 0.50). Together, these factors mediated 61% of the effect between prolonged scene time and mortality. Mortality remained associated with prolonged scene time in patients with hypotension, penetrating injury, and flail chest.

CONCLUSION

Prolonged scene time is associated with increased mortality. PH interventions partially mediate this association. Further study should evaluate whether these interventions drive increased mortality because they prolong scene time or by another mechanism, as reducing scene time may be a target for intervention.

LEVEL OF EVIDENCE

Prognostic/epidemiologic study, level III.

Field intubation in civilian patients with hemorrhagic shock is associated with higher mortality

BACKGROUND

Field intubation (FI) by emergency medical service personnel on severely injured trauma patients remains a contentious practice. Clinical studies suggest an association between FI and adverse outcomes in patients with traumatic brain injury. Military tactical emergency casualty care recommends deferring intubation and providing supplemental oxygenation until reaching a more equipped destination. In addition, animal models with penetrating hemorrhagic shock demonstrate increased acidosis with intubation before resuscitation. The purpose of this study was to evaluate the impact of FI on outcomes in trauma patients with hemorrhagic shock requiring massive transfusion.

METHODS

The Los Angeles County Trauma System Database was retrospectively queried for all trauma patients 16 years or older with hemorrhagic shock requiring massive transfusion (≥6 U packed red blood cells in the first 24 hours) between January 1, 2012, and June 30, 2014. Demographics, clinical and transfusion data, and outcomes were compared between patients who received FI and those who did not (NO-FI). Multivariate regression analysis was used to adjust for confounders.

RESULTS

Of 552 trauma patients meeting inclusion criteria, 63 (11%) received FI, and the remaining 489 (89%) were NO-FI. Age, sex, and incidence of blunt injury were similar between the FI and the NO-FI group. The FI cohort presented with a lower median Glasgow Coma Scale (GCS) score (3 vs. 14, p < 0.001), a lower median systolic blood pressure (86 mm Hg vs. 104 mm Hg, p < 0.001), and a higher median Injury Severity Score (ISS) (41 vs. 29, p < 0.001). Mortality was significantly higher in FI patients (83% vs. 43%, p < 0.001). Transfusion patterns and total field times were similar in both groups. After adjusting for confounders, FI patients had increased odds of mortality (adjusted odds ratio, 2.89; 95% confidence interval, 1.08-7.78; p = 0.035). In addition, FI was identified as an independent predictor of mortality (adjusted odds ratio, 3.41; 95% confidence interval, 1.35-8.59; p = 0.009).

CONCLUSION

FI may be associated with higher mortality in trauma patients with hemorrhagic shock requiring massive transfusion. Less invasive airway interventions and rapid transport might improve outcomes for these patients.

LEVEL OF EVIDENCE

Therapeutic study, level IV; epidemiologic study, level III.

Characteristics of Patients Transported by a Paramedic-staffed Helicopter Emergency Medical Service in Victoria, Australia

OBJECTIVE

The optimal staffing of helicopter emergency medical services (HEMS) is uncertain. An intensive care paramedic-staffed HEMS has operated in the state of Victoria, Australia for over 28 years, with paramedics capable of performing advanced procedures, including rapid sequence intubation, decompression of tension pneumothorax, and cricothyroidotomy. Administration of a wide range of vasoactive, anesthetic, and analgesic medications is also permitted. We sought to explore the characteristics of patients transported by HEMS in Victoria, and describe paramedic utilization of their skill set in the prehospital environment.

METHODS

A retrospective data review was conducted of patients transported by the HEMS between 1 July 2012 and 30 June 2013. Data were sourced from the Ambulance Victoria data warehouse and the Victorian State Trauma Registry. Interhospital transfers were excluded.

RESULTS

HEMS attended 1,519 cases during the study period. A total of 825 primary transport cases were included in analyses. Most patients were male (69.5%) and the majority of cases involved trauma (86.1%). Rapid sequence intubation (RSI) was performed in 36.8% of pediatric and 29.9% of adult major trauma patients, with a procedural success rate of 100%. Ketamine was administered to 18.5% of all trauma patients. The proportion of patients with a severe pain score (≥7) decreased from 33.8 to 3.2% (p < 0.001) between initial and final paramedic assessments. A clinically significant pain reduction of ≥2 points was achieved by 87.0% (95% CI 82.9-90.4%) of adult trauma patients who had an initial pain score >2 points and a valid final pain score. In-hospital mortality following major-trauma was 7.6% (95% CI 5.0-11.0%).

CONCLUSIONS

The skill set of HEMS intensive care paramedics in Victoria is broad, including a large number of prehospital critical care procedures commonly utilized by physician-staffed HEMS in other jurisdictions. A high RSI procedural success rate was observed across the study period, as were significant improvements in patient physiological parameters and pain scores.

Prehospital Care and In-hospital Mortality of Trauma Patients in Iran

INTRODUCTION

The aim of this study was to determine the effect of prehospital time and advanced trauma life support interventions for trauma patients transported to an Iranian Trauma Center.

METHODS

This study was a retrospective study of trauma victims presenting to a trauma center in central Iran by Emergency Medical Services (EMS) and hospitalized more than 24 hours. Demographic and injury characteristics were obtained, including accident location, damaged organs, injury mechanism, injury severity score, prehospital times (response, scene, and transport), interventions and in-hospital outcome.

RESULTS

Two thousand patients were studied with an average age of 36.3 (SD = 20.8) years; 83.1% were male. One hundred twenty patients (6.1%) died during hospitalization. The mean response time, at scene time and transport time were 6.6 (SD = 3), 11.1 (SD = 5.2) and 12.8 (SD = 9.4), respectively. There was a significant association of longer transport time to worse outcome (P = .02). There was a trend for patients with transport times >10 minutes to die (OR: 0.8; 95% CI, 0.1-6.59). Advanced Life Support (ALS) interventions were applied for patients with severe injuries (Revised Trauma Score ⩽7) and ALS intervention was associated with more time on scene. There was a positive association of survival with ALS interventions applied in suburban areas (P = .001).

CONCLUSION

In-hospital trauma mortality was more common for patients with severe injuries and long prehospital transport times. While more severely injured patients received ALS interventions and died, these interventions were associated with positive survival trends when conducted in suburban and out-of-city road locations with long transport times.

Severity-adjusted mortality in trauma patients transported by police

STUDY OBJECTIVE

Two decades ago, Philadelphia began allowing police transport of patients with penetrating trauma. We conduct a large, multiyear, citywide analysis of this policy. We examine the association between mode of out-of-hospital transport (police department versus emergency medical services [EMS]) and mortality among patients with penetrating trauma in Philadelphia.

METHODS

This is a retrospective cohort study of trauma registry data. Patients who sustained any proximal penetrating trauma and presented to any Level I or II trauma center in Philadelphia between January 1, 2003, and December 31, 2007, were included. Analyses were conducted with logistic regression models and were adjusted for injury severity with the Trauma and Injury Severity Score and for case mix with a modified Charlson index.

RESULTS

Four thousand one hundred twenty-two subjects were identified. Overall mortality was 27.4%. In unadjusted analyses, patients transported by police were more likely to die than patients transported by ambulance (29.8% versus 26.5%; OR 1.18; 95% confidence interval [CI] 1.00 to 1.39). In adjusted models, no significant difference was observed in overall mortality between the police department and EMS groups (odds ratio [OR] 0.78; 95% CI 0.61 to 1.01). In subgroup analysis, patients with severe injury (Injury Severity Score >15) (OR 0.73; 95% CI 0.59 to 0.90), patients with gunshot wounds (OR 0.70; 95% CI 0.53 to 0.94), and patients with stab wounds (OR 0.19; 95% CI 0.08 to 0.45) were more likely to survive if transported by police.

CONCLUSION

We found no significant overall difference in adjusted mortality between patients transported by the police department compared with EMS but found increased adjusted survival among 3 key subgroups of patients transported by police. This practice may augment traditional care.

IV access in bleeding trauma patients: a performance review

BACKGROUND

Exsanguinating haemorrhage is a leading cause of death in severely injured trauma patients. Management includes achieving haemostasis, replacing lost intravascular volume with fluids and blood, and treating coagulopathy. The provision of fluids and blood products is contingent on obtaining adequate vascular access to the patient's venous system. We sought to examine the nature and timing of achieving adequate intravenous (IV) access in trauma patients requiring uncrossmatched blood in the trauma bay.

METHODS

We performed a retrospective chart review of all patients admitted to our trauma centre from 2005 to 2009 who were transfused uncrossmatched blood in the trauma bay. We examined the impact of IV access on prehospital times and time to first PRBC transfusion.

RESULTS

Of 208 study patients, 168 (81%) received prehospital IV access, and the on-scene time for these patients was 5 min longer (16.1 vs 11.4, p<0.01). Time to achieving adequate IV access in those without any prehospital IVs occurred on average 21 min (6.6-30.5) after arrival to the trauma bay. A central venous catheter was placed in 92 (44%) of patients. Time to first blood transfusion correlated most strongly with time to achieving central venous access (Pearson correlation coefficient 0.94, p<0.001) as opposed to time to achieving adequate peripheral IV access (Pearson correlation coefficient 0.19, p=0.12).

CONCLUSIONS

We found that most bleeding patients received a prehospital IV; however, we also found that obtaining prehospital IVs was associated with longer EMS on-scene times and longer prehospital times. Interestingly, we found that obtaining a prehospital IV was not associated with more rapid initiation of blood product transfusion. Obtaining optimal IV access and subsequent blood transfusion in severely injured patients continues to present a challenge.

Withholding and termination of resuscitation of adult cardiopulmonary arrest secondary to trauma: resource document to the joint NAEMSP-ACSCOT position statements

In the setting of traumatic cardiopulmonary arrest, protocols that direct emergency medical service (EMS) providers to withhold or terminate resuscitation, when clinically indicated, have the potential to decrease unnecessary use of warning lights and sirens and save valuable public health resources. Protocols to withhold resuscitation should be based on the determination that there are no obvious signs of life, the injuries are obviously incompatible with life, there is evidence of prolonged arrest, and there is a lack of organized electrocardiographic activity. Termination of resuscitation is indicated when there are no signs of life and no return of spontaneous circulation despite appropriate field EMS treatment that includes minimally interrupted cardiopulmonary resuscitation. Further research is needed to determine the appropriate duration of cardiopulmonary resuscitation before termination of resuscitation and the proper role of direct medical oversight in termination of resuscitation protocols. This article is the resource document to the position statements, jointly endorsed by the National Association of EMS Physicians and the American College of Surgeons' Committee on Trauma, on withholding and termination of resuscitation in traumatic cardiopulmonary arrest.

Prehospital interventions for penetrating trauma victims: a prospective comparison between Advanced Life Support and Basic Life Support

BACKGROUND

Advanced Life Support (ALS) providers may perform more invasive prehospital procedures, while Basic Life Support (BLS) providers offer stabilisation care and often "scoop and run". We hypothesised that prehospital interventions by urban ALS providers prolong prehospital time and decrease survival in penetrating trauma victims.

STUDY DESIGN

We prospectively analysed 236 consecutive ambulance-transported, penetrating trauma patients an our urban Level-1 trauma centre (6/2008-12/2009). Inclusion criteria included ICU admission, length of stay >/=2 days, or in-hospital death. Demographics, clinical characteristics, and outcomes were compared between ALS and BLS patients. Single and multiple variable logistic regression analysis determined predictors of hospital survival.

RESULTS

Of 236 patients, 71% were transported by ALS and 29% by BLS. When ALS and BLS patients were compared, no differences in age, penetrating mechanism, scene GCS score, Injury Severity Score, or need for emergency surgery were detected (p>0.05). Patients transported by ALS units more often underwent prehospital interventions (97% vs. 17%; p<0.01), including endotracheal intubation, needle thoracostomy, cervical collar, IV placement, and crystalloid resuscitation. While ALS ambulance on-scene time was significantly longer than that of BLS (p<0.01), total prehospital time was not (p=0.98) despite these prehospital interventions (1.8 ± 1.0 per ALS patient vs. 0.2 ± 0.5 per BLS patient; p<0.01). Overall, 69.5% ALS patients and 88.4% of BLS patients (p<0.01) survived to hospital discharge.

CONCLUSION

Prehospital resuscitative interventions by ALS units performed on penetrating trauma patients may lengthen on-scene time but do not significantly increase total prehospital time. Regardless, these interventions did not appear to benefit our rapidly transported, urban penetrating trauma patients.

Severe sepsis in pre-hospital emergency care: analysis of incidence, care, and outcome

RATIONALE

Severe sepsis is common and highly morbid, yet the epidemiology of severe sepsis at the frontier of the health care system-pre-hospital emergency care-is unknown.

OBJECTIVES

We examined the epidemiology of pre-hospital severe sepsis among emergency medical services (EMS) encounters, relative to acute myocardial infarction and stroke.

METHODS

Retrospective study using a community-based cohort of all nonarrest, nontrauma King County EMS encounters from 2000 to 2009 who were transported to a hospital.

MEASUREMENTS AND MAIN RESULTS

Overall incidence rate of hospitalization with severe sepsis among EMS encounters, as well as pre-hospital characteristics, admission diagnosis, and outcomes. Among 407,176 EMS encounters, we identified 13,249 hospitalizations for severe sepsis, of whom 2,596 died in the hospital (19.6%). The crude incidence rate of severe sepsis was 3.3 per 100 EMS encounters, greater than for acute myocardial infarction or stroke (2.3 per 100 and 2.2 per 100 EMS encounters, respectively). More than 40% of all severe sepsis hospitalizations arrived at the emergency department after EMS transport, and 80% of cases were diagnosed on admission. Pre-hospital care intervals, on average, exceeded 45 minutes for those hospitalized with severe sepsis. One-half or fewer of patients with severe sepsis were transported by paramedics (n = 7,114; 54%) or received pre-hospital intravenous access (n = 4,842; 37%).

CONCLUSIONS

EMS personnel care for a substantial and increasing number of patients with severe sepsis, and spend considerable time on scene and during transport. Given the emphasis on rapid diagnosis and intervention for sepsis, the pre-hospital interval may represent an important opportunity for recognition and care of sepsis.

The effect of Helicopter Emergency Medical Services on trauma patient mortality in the Netherlands

INTRODUCTION

Object of this study was to evaluate the effect of the Helicopter Emergency Medical Services (HEMS) on trauma patient mortality and the effect of prehospital time on the association between HEMS and mortality.

MATERIALS AND METHODS

Trauma patients admitted to a level 1 trauma centre and treated on-scene by the HEMS and Emergency Medical Services (EMS) between 2003 and 2008 were included (n = 186). A control group treated by EMS only (n = 186) was created by matching on ISS, age and severe traumatic brain injury (TBI). Mortality was compared by calculating odds ratios (OR) and numbers needed to treat (NNT), with adjustment for prehospital coded Revised Trauma Score. The effect of prehospital time mortality was tested by a logistic regression. Analyses were made for patients with and without TBI.

RESULTS

The OR of early trauma fatality for the HEMS/EMS versus EMS-only groups was 0.8 for patients both with TBI (95% CI 0.4-1.7; NNT: 22) and without TBI (95% CI 0.2-3.3; NNT: 273). The risk of in-hospital mortality was non-significantly higher for patients with TBI in the HEMS/EMS group (OR = 1.3; 95% CI 0.6-2.7; NNT: -15) compared to the EMS-only group and non-significantly lower for patients without TBI (OR = 0.9; 95% CI 0.3-2.5; NNT: 129). After adjustment for prehospital time, the risk of early trauma fatality for patients with TBI treated by the HEMS decreased (OR = 0.6; 95% CI 0.3-1.6). The risk of in-hospital mortality for these patients decreased from 1.3 to 0.8 (95% CI 0.4-2.0). The effect of the HEMS on patients without TBI did not change after adjustment for prehospital time.

DISCUSSION

HEMS treatment is associated with a non-significantly higher risk of in-hospital mortality for patients with TBI and a non-significantly lower risk for patients without TBI. This increased risk of mortality in TBI patients is attributable to the increased prehospital time. These results indicate that HEMS does not have a positive impact on survival.

The use of emergency department thoracotomy for traumatic cardiopulmonary arrest

Despite the establishment of evidence-based guidelines for the resuscitation of critically injured patients who have sustained cardiopulmonary arrest, rapid decisions regarding patient salvageability in these situations remain difficult even for experienced physicians. Regardless, survival is limited after traumatic cardiopulmonary arrest. One applicable, well-described resuscitative technique is the emergency department thoracotomy-a procedure that, when applied correctly, is effective in saving small but significant numbers of critically injured patients. By understanding the indications, technical details, and predictors of survival along with the inherent risks and costs of emergency department thoracotomy, the physician is better equipped to make rapid futile versus salvageable decisions for this most severely injured subset of patients.

Abnormal end-tidal carbon dioxide levels on emergency department arrival in adult and pediatric intubated patients

BACKGROUND

The utility of prehospital intubation is controversial, as uncontrolled studies in trauma patients suggest adverse outcomes with prehospital intubation, perhaps secondary to inappropriate ventilation once intubation is accomplished.

OBJECTIVES

The objectives were 1) to establish, immediately upon arrival to the emergency department (ED), the prevalence of abnormal end-tidal carbon dioxide (ETCO(2)) levels in patients with prehospital intubation and 2) to describe the relationship between abnormal ETCO(2) levels on ED arrival and mortality.

METHODS

This was a prospective, observational cohort study of patients with prehospital intubation. Patients were excluded if they underwent prehospital cardiopulmonary resuscitation (CPR). On ED arrival, the initial ETCO(2) measurement from the patient's endotracheal tube was immediately obtained prior to purposeful intervention in the patient's ventilation by using an Oridion Surestream Sure VentLine H Set with a Welch Allyn Propaq CS monitor. For each patient, the treating physician documented the ETCO(2) measurement, patient demographics, and details of the transport. The primary outcome was an abnormal ETCO(2) value (<30 mmHg or >45 mmHg). The secondary outcome was mortality.

RESULTS

One hundred eligible patients were enrolled, with a median age of 30 years (interquartile range [IQR] 15, 48 years). Esophageal intubations were identified in four cases, and those cases were excluded from further analysis. Mechanisms included trauma, 74; medical, 12; and burn, 10. The median ETCO(2) value was 32 mmHg (IQR 27, 38 mmHg), range 18-80 mmHg. Forty-six of 96 (48%, 95% confidence interval [CI] 38%, 58%) patients had abnormal ETCO(2) values, including 37 (39%, 95% CI 29%, 49%) with low ETCO(2) levels and nine (9%, 95% CI 4%, 17%) with high ETCO(2) levels. Death was higher in those trauma patients with abnormal ETCO(2) levels (10/33, 30%, 95% CI 16%, 49%) than in those with normal ETCO(2) levels (2/41, 5%, 95% CI 0.6%, 17%), relative risk = 6.2 (95% CI 1.5, 26.4), p = 0.004.

CONCLUSION

Nearly half of all patients transported by prehospital providers had abnormal ETCO(2) measurements on initial ED presentation, suggesting an area for potential improvement. Trauma patients with abnormal initial ETCO(2) levels were more likely to die.

Intravenous access during out-of-hospital emergency care of noninjured patients: a population-based outcome study

STUDY OBJECTIVE

Advanced, out-of-hospital procedures such as intravenous access are commonly performed by emergency medical services (EMS) personnel, yet little evidence supports their use among noninjured patients. We evaluate the association between out-of-hospital, intravenous access and mortality among noninjured, non-cardiac arrest patients.

METHODS

We analyzed a population-based cohort of adult (aged ≥18 years) noninjured, non-cardiac arrest patients transported by 4 advanced life support agencies to one of 16 hospitals from January 1, 2002, until December 31, 2006. We linked eligible EMS records to hospital administrative data and used multivariable logistic regression to determine the risk-adjusted association between out-of-hospital intravenous access and hospital mortality. We also tested whether this association differed by patient acuity by using a previously published, out-of-hospital triage score.

RESULTS

Among 56,332 eligible patients, half (N=28,078; 50%) received out-of-hospital intravenous access from EMS personnel. Overall hospital mortality for patients who did and did not receive intravenous access was 3%. However, in multivariable analyses, the placement of out-of-hospital, intravenous access was associated with an overall reduction in odds of hospital mortality (odds ratio=0.68; 95% confidence interval [CI] 0.56 to 0.81). The beneficial association of intravenous access appeared to depend on patient acuity (P=.13 for interaction). For example, the odds ratio of mortality associated with intravenous access was 1.38 (95% CI 0.28 to 7.0) among patients with lowest acuity (score=0). In contrast, the odds ratio of mortality associated with intravenous access was 0.38 (95% CI 0.17 to 0.9) among patients with highest acuity (score ≥6).

CONCLUSION

In this population-based cohort, out-of-hospital efforts to establish intravenous access were associated with a reduction in hospital mortality among noninjured, non-cardiac arrest patients with the highest acuity. Reasons why this occurred (cause and effect) could not be determined in this model.

Vascular access on the 21st century military battlefield

Timely and appropriate access to the vascular circulation is critical in the management of 21st century battlefield trauma. It allows the administration of emergency drugs, analgesics and rapid replacement of blood volume. Methods used to gain access can include; the cannulation of peripheral and central veins, venous cut-down and intraosseus devices. This article reviews the current literature on the benefits and complications of each vascular access method. We conclude that intraosseus devices are best for quick access to the circulation, with central venous access via the subclavian route for large volume resuscitation and low complication rates. Military clinicians involved with the care of trauma patients either in Role 2 and 3 or as part of the medical emergency response team (MERT), must have the skill set to use these vascular access techniques by incorporating them into their core medical training.

Should trauma patients with a Glasgow Coma Scale score of 3 be intubated prior to hospital arrival?

INTRODUCTION

Previous studies of heterogeneous populations (Glasgow Coma Scale (GCS) scores<9) suggest that endotracheal intubation of trauma patients prior to hospital arrival (i.e., prehospital intubated) is associated with an increased mortality compared to those patients not intubated in the prehospital setting. Deeply comatose patients (GCS=3) represent a unique population of severely traumatized patients and may benefit from intubation in the prehospital setting. The objective of this study was to compare mortality rates of severely comatose patients (scene GCS=3) with prehospital endotracheal intubation to those intubated at the hospital.

METHODS

Using the National Trauma Data Bank (V. 6.2), the following variables were analyzed retrospectively: (1) age; (2) injury type (blunt or penetrating); (3) Injury Severity Score (ISS); (4) scene GCS=3 (scored prior to intubation/without sedation); (5) emergency department GCS score; (6) arrival emergency department intubation status; (7) first systolic blood pressure in the emergency department (>0); (8) discharge status (alive or dead); (9) Abbreviated Injury Scale Score (AIS); and (10) AIS body region.

RESULTS

Of the 10,948 patients analyzed, 23% (2,491/10,948) were endotracheally intubated in a prehospital setting. Mortality rate for those hospital intubated was 35% vs. 62% for those with prehospital intubation (p<0.0001); mean ISS scores 24.2±16.0 vs. 31.6±16.2, respectively (p<0.0001). Using logistic regression, controlling for first systolic blood pressure, ISS, emergency department GCS, age, and type of trauma, those with prehospital intubation were more likely to die (OR=1.9, 95% CI=1.7-2.2). For patients with only head AIS scores (no other body region injury, n=1,504), logistic regression (controlling for all other variables) indicated that those with prehospital intubation were still more likely to die (OR=2.0. 95% CI=1.4-2.9).

CONCLUSIONS

Prehospital endotracheal intubation is associated with an increased mortality in completely comatose trauma patients (GCS = 3). Although the exact reasons for this remain unclear, these results support other studies and suggest the need for future research and re-appraisal of current policies for prehospital intubation in these severely traumatized patients.

Injury-adjusted mortality of patients transported by police following penetrating trauma

BACKGROUND

More than a decade ago, the city of Philadelphia began allowing police transport of penetrating trauma patients.

OBJECTIVES

  The objective was to determine the relation between prehospital mode of transport (police department [PD] vs. Philadelphia Fire Department (PFD) emergency medical services [EMS]) and survival in subjects with proximal penetrating trauma.

METHODS

The authors performed a retrospective cohort study of prospectively collected trauma registry data. All subjects who sustained proximal penetrating trauma and who presented to a Level I urban trauma center over a 5-year period (January 1, 2003, to December 31, 2007) were included. Mortality for subjects presenting by EMS was compared to that of those who arrived by PD transport in unadjusted and adjusted analyses. Unadjusted analyses were performed using the chi-square test, Wilcoxon rank sum test, and Student's t-test. Adjusted analyses were performed using logistic regression using the Trauma Injury Severity Score (TRISS) methodology. Data are presented as percentages, odds ratios (ORs), and 95% confidence intervals (CIs). Total hospital length of stay was examined as a secondary outcome.

RESULTS

Of the 2,127 subjects, 26.8% were transported to the emergency department (ED) by PD, and 73.2% by EMS. The mean(±standard deviation [SD]) age of PD subjects was 26.3 (±9.1) years and 92% were male versus EMS subjects whose mean (±SD) age was 31.5 (±11.8) years and of whom 87% were male. Overall, 70.8% sustained a gunshot wound (GSW), and 29.2% sustained a stab wound (SW). Overall Injury Severity Score (ISS) was 11.21 (ISS for PD, 14.2±17.5; for EMS, 10.1±14.5; p<0.001), and 16.6% of the subjects died (PD, 21.4±0.41%; EMS, 14.8±0.36%; p<0.001). In unadjusted analyses, PD subjects were more likely to die than EMS subjects (OR=1.6, 95% CI=1.2 to 2.0; p<0.001). When adjusting for injury severity using TRISS, there was no difference in survival between PD and EMS subjects (OR=1.01, 95% CI=0.63 to 1.61). Median length of hospital stay was 1 day and did not differ according to mode of prehospital transport (p=0.159).

CONCLUSIONS

Although unadjusted mortality appears to be higher in PD subjects, these findings are explained by the more severely injured population transported by PD. The current practice of permitting police officers to transport penetrating trauma patients should be continued.

Association Between Prehospital Time Intervals and ST-Elevation Myocardial Infarction System Performance

Background—

Among individuals experiencing an ST segment–elevation myocardial infarction, current guidelines recommend that the interval from first medical contact to percutaneous coronary intervention be ≤90 minutes. The objective of this study was to determine whether prehospital time intervals were associated with ST-elevation myocardial infarction system performance, defined as first medical contact to percutaneous coronary intervention.

Methods and Results—

Study patients presented with an acute ST-elevation myocardial infarction diagnosed by prehospital ECG between May 2007 and March 2009. Prehospital time intervals were as follows: 9-1-1 call receipt to ambulance on scene ≤10 minutes, ambulance on scene to 12-lead ECG acquisition ≤8 minutes, on-scene time ≤15 minutes, prehospital ECG acquisition to ST-elevation myocardial infarction team notification ≤10 minutes, and scene departure to patient on cardiac catheterization laboratory table ≤30 minutes. Time intervals were derived and analyzed with descriptive statistics and logistic regression. There were 181 prehospital patients who received percutaneous coronary intervention, with 165 (91.1) having complete data. Logistic regression indicated that table time, response time, and on-scene time were the benchmark time intervals with the greatest influence on the probability of achieving percutaneous coronary intervention in ≤90 minutes. Individuals with a time from scene departure to arrival on cardiac catheterization laboratory table of ≤30 minutes were 11.1 times (3.4 to 36.0) more likely to achieve percutaneous coronary intervention in ≤90 minutes than those with extended table times.

Conclusions—

In this patient population, prehospital timing benchmarks were associated with system performance. Although meeting all 5 benchmarks may be an ideal goal, this model may be more useful for identifying areas for system improvement that will have the greatest clinical impact.

Landing sites and intubation may influence helicopter emergency medical services on-scene time

BACKGROUND

Reduced transport time of patients from the scene of an accident to definitive surgical treatment is one important reason to employ ambulance helicopters on trauma missions. However, if the helicopter is unable to land close to the scene, the transport time may be increased compared to transport with ground ambulance, due to time-consuming transfer of the patient between vehicles.

OBJECTIVE

The objective of this study was to evaluate how the landing site, as determined by distance from the scene, and rapid sequence intubation (RSI) affected on-scene time (OST).

METHODS

This was a prospective observational study performed during a 12-month period in a mixed urban and rural anesthesiologist-staffed Helicopter Emergency Medical Service in Norway. Data regarding the landing sites, the accident, and patient treatment were recorded.

RESULTS

A total of 252 primary trauma missions were included in the study. In 75% of the missions, the aircraft landed<50 meters from the scene, and in 7% the distance exceeded 200 meters. Mean OST when the patient was not intubated was 14.5 min (median 14 min). When an RSI was performed, the mean OST was significantly higher (22.7 min, median 20 min; p<0.001).

CONCLUSION

Usually, a helicopter can land close to the accident scene and the location of the landing site does not contribute to a delay in arrival of the patient at the hospital. The OST is significantly higher, however, in those patients who receive endotracheal intubation before take-off. This reflects the time needed for intubation, as well as the increased complexity and workload when the patient is severely injured.

Population density and racial differences in the performance of emergency medical services

This paper analyzes the existence and scope of possible racial differences/disparities in the provision of emergency medical services (EMS) response capability (time from dispatch to arrival at the scene and level of training of the responding team) using data on approximately 120,000 cardiac incidents in the state of Mississippi during 1995-2004. The conceptual framework and empirical analysis focus on the likely effects of population density on the efficient production of EMS as a local public good subject to congestion, and on the need to control adequately for population density to avoid bias in testing for racial differences. Models that control for aggregate population density at the county-level indicate "reverse" disparities: faster estimated response times for African-Americans than for whites. When a refined county-level measure of population density is used that incorporates differences in African-American and white population density by Census tract, the reverse disparity in response times disappears. There also is little or no evidence of race-related differences in the certification level of EMS responders. However, there is evidence that, controlling for response time, African-Americans on average were significantly more likely to be deceased than whites upon EMS arrival at the scene. The overall results are germane to the debate over the scope of conditioning variables that should be included when testing for racial disparities in health care.

Out-of-hospital fluid in severe sepsis: effect on early resuscitation in the emergency department

BACKGROUND

Early identification and treatment of patients with severe sepsis improves outcome, yet the role of out-of-hospital intravenous (IV) fluid is unknown.

OBJECTIVE

To determine if the delivery of out-of-hospital fluid in patients with severe sepsis is associated with reduced time to achievement of goal-oriented resuscitation in the emergency department (ED).

METHODS

We performed a secondary data analysis of a retrospective cohort study in a metropolitan, tertiary care, university-based medical center supported by a two-tiered system of out-of-hospital emergency medical services (EMS) providers. We studied the association between delivery of out-of-hospital fluid by advanced life support (ALS) providers and the achievement of resuscitation endpoints (central venous pressure [CVP] > or =8 mmHg, mean arterial pressure [MAP] > or =65 mmHg, and central venous oxygen saturation [ScvO(2)] > or =70%) within six hours after triage during early goal-directed therapy (EGDT) in the ED.

RESULTS

Twenty five (48%) of 52 patients transported by ALS with severe sepsis received out-of-hospital fluid. Data for age, gender, source of sepsis, and presence of comorbidities were similar between patients who did and did not receive out-of-hospital fluid. Patients receiving out-of-hospital fluid had lower out-of-hospital mean (+/- standard deviation) systolic blood pressure (95 +/- 40 mmHg vs. 117 +/- 29 mmHg; p = 0.03) and higher median (interquartile range) Sequential Organ Failure Assessment (SOFA) scores in the ED (7 [5-8] vs. 4 [4-6]; p = 0.01) than patients not receiving out-of-hospital fluid. Despite greater severity of illness, patients receiving out-of-hospital fluid approached but did not attain a statistically significant increase in the likelihood of achieving MAP > or =65 mmHg within six hours after ED triage (70% vs. 44%, p = 0.09). On average, patients receiving out-of-hospital fluid received twice the fluid volume within one hour after ED triage (1.1 L [1.0-2.0 L] vs. 0.6 L [0.3-1.0 L]; p = 0.01). No difference in achievement of goal CVP (72% vs. 60%; p = 0.6) or goal ScvO(2) (54% vs. 36%; p = 0.25) was observed between groups.

CONCLUSIONS

Less than half of patients with severe sepsis transported by ALS received out-of-hospital fluid. Patients receiving out-of-hospital IV access and fluids approached but did not attain a statistically significant increase in the likelihood of achieving goal MAP during EGDT. These preliminary findings require additional investigation to evaluate the optimal role of out-of-hospital resuscitation in treating patients with severe sepsis.

Transfer delay and in-hospital mortality of trauma patients in Pakistan

BACKGROUND

Mortality and morbidity in trauma remain a major problem in developing countries. Organized emergency response systems for transfer of trauma patients to hospitals are absent and the consequent delays could cause significant complications.

AIMS

This study assessed the outcomes as a result of hospital transfer and delays in trauma patients.

METHODS

The study was based on trauma patients presenting to the Aga Khan University Hospital (AKUH), Karachi, Pakistan from 1998 to 2005, meeting the trauma team activation criteria. Data were collected and entered in a Trauma Registry. The study focused on analyzing the outcomes of injury to delay in definitive treatment and survival.

RESULTS

Out of 978 patients, only 303 (30.9%) patients reached the emergency room (ER) within an hour. The mean time from injury occurrence to arrival in the ER was 4.7h. There was no significant difference in mortality between all patients presenting early and those with more than 1h delay (OR=0.9, 95% CI: 0.6, 1.5).

CONCLUSIONS

Transfer and delay in admission to a tertiary care center does not affect in-hospital mortality of trauma patients in a setting with no emergency response system. This may be due to self selection of patients who survive long enough to reach the hospital.