Prehospital FAST reduces time to admission and operative treatment: a prospective, randomized, multicenter trial

BACKGROUND

The focused assessment with sonography in trauma (FAST) exam is an established trauma care diagnostic procedure. Ultrasound performed during prehospital care can improve early treatment and management of the patients. In this prospective randomized clinical trial, we wanted to assess whether a pre-hospital FAST (p-FAST) influences pre-hospital strategy and the time to operative treatment.

METHODS

We studied 296 trauma victims in a prehospital setting. Inclusion criteria were potential abdominal injuries identified either by clinical examination or suggested by the mechanism of injury. Physician-staffed helicopters and emergency ambulances were equipped with portable ultrasound devices. According to a scheme related to calendar weeks, a clinical exam only (CEX) or a clinical exam together with a p-FAST (CEX-p-FAST) was conducted. Outcome variables were prehospital diagnosis and strategy, the time to admission to the trauma room and to operation theater. The study was approved by the university ethical committee (REB#: 46/06).

RESULTS

CEX-p-FAST showed a high sensitivity (94.7%) and specificity (97.6%) in detection of free fluid compared to CEX-only (80.0%, 84.4%). The median time to admission was reduced significantly by 13 min and to operative treatment by 15 min after CEX-p-FAST. We observed a cross-over rate of 30.8% of p-FAST (n = 36) to CEX-p-FAST during the CEX-only weeks.

CONCLUSION

According to the experience of the principal investigators, CEX-p-FAST was superior to CEX-only. Despite the time needed for p-FAST, the relevant admission time was significantly shorter. Thus, p-FAST is recommended in addition to CEX if possible for decision-making in prehospital trauma care.

TRIAL REGISTRATION

German Clinical Trials Register #DRKS00022117-Registered 10 July 2020-Retrospectively registered, https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00022117 .

Quality of focused thoracic ultrasound performed by emergency medical technicians and paramedics in a prehospital setting: a feasibility study

BACKGROUND

In a prehospital setting, the severity of respiratory symptoms in patients calling for an ambulance differ. The initial evaluation, diagnosing, and thereby management can be challenging because respiratory symptoms can be caused by disease in many organs. Ultrasound examinations can contribute with important information and support the clinical decision-making. However, ultrasound is user-dependent and requires sufficient knowledge and training. The aim of this study was to explore the quality of thoracic ultrasound examinations performed on patients by emergency medical technicians and paramedics in a prehospital, clinical setting.

METHODS

From November 2018 - April 2020, Danish emergency medical technicians and paramedics (n = 100) performed thoracic ultrasound examinations on patients with respiratory symptoms using a portable ultrasound device. The ultrasound examinations were stored and retrospectively assessed by a reviewer blinded to the patients' symptoms and history, as well as the emergency medical technicians' and paramedics' findings. The image quality was scored from 1 to 5. The findings determined by the reviewer was then correlated with a questionnaire filled out by the emergency medical technicians and paramedics regarding ultrasonic findings and potential change in treatment or management of the patient. The agreement in percentage and as Cohen's kappa was explored.

RESULTS

A total of 590 ultrasound examinations were assessed, resulting in a median image quality score of 3 (IQ1 = 4, IQ3 = 3). The overall agreement in percentage between the emergency medical technicians and paramedics and reviewer was high (87.7% for a normal scan, 89.9% for interstitial syndrome, 97.3% for possible pneumothorax, and 96.3% for pleural effusion). Cohen's kappa varied from 0.01 for possible pneumothorax to 0.69 for pleural effusion. Based on the questionnaires (n = 406), the ultrasound examination entailed a change in treatment or visitation in 48 cases (11.7%) which in this study population encompasses a number-needed-to-scan of 8.5.

CONCLUSION

Emergency medical technicians and paramedics perform focused thoracic ultrasound examinations with adequate image quality sufficient to determine if pathology is present or not. The emergency medical technicians' and paramedics' assessment correlates to some extent with an experienced reviewer and their findings are most reliable for the inclusion of a normal scan or inclusion of pleural effusion. Implementation could possibly impact the number of patients receiving correct prehospital treatment and optimal choice of receiving facility.

Feasibility of using ultrasound in ambulances in Saudi Arabia

BACKGROUND

In developed countries, the economic feasibility of using ultrasound in ambulances before arriving at the hospital has been achieved through comprehensive studies, and this of course does not apply to Arab countries, as there are no current studies to support this. Therefore, this study is a preliminary measure of the economic feasibility of using ultrasound in ambulances in Saudi Arabia.

AIM

To measure the demand for ultrasound equipment in ambulances in Saudi Arabia.

METHODS

A cross-sectional study of five different groups of participants including radiation technologists, emergency physicians, paramedics, Red Crescent managers and the public. Email and social media were used to deliver a questionnaire to these groups. The questionnaire included specific questions to measure the purpose of ultrasound use in each group of participants.

RESULTS

Each group had some knowledge on ultrasound and its benefits. More than 50% in each study group supported the availability of ultrasound in ambulances. Additionally, 60% of emergency physicians reported that they had difficulties in venous access, checking the presence of internal bleeding, recognizing pregnancy in trauma cases, and inserting endotracheal tubes, and the majority of them confirmed the effective role of ultrasound in achieving such tasks. Almost all paramedics (93.33%), physicians (98.89%), and Saudi Red Crescent managers (96.3%) emphasized the importance of communication between ambulance staff and emergency departments. Moreover, most physicians (77.78%), and technologists (82.73%) supported the presence of paramedics in ambulances to operate ultrasound in order to improve patient outcomes.

CONCLUSION

Most of the study groups evaluated had knowledge on ultrasound and supported the presence of ultrasound devices in ambulances.

Pre-hospital assessment with ultrasound in emergencies: implementation in the field

BACKGROUND

Point-of-care ultrasound (US) is a proven diagnostic imaging tool in the emergency department (ED). Modern US devices are now more compact, affordable and portable, which has led to increased usage in austere environments. However, studies supporting the use of US in the prehospital setting are limited. The primary outcome of this pilot study was to determine if paramedics could perform cardiac ultrasound in the field and obtain images that were adequate for interpretation. A secondary outcome was whether paramedics could correctly identify cardiac activity or the lack thereof in cardiac arrest patients.

METHODS

We performed a prospective educational study using a convenience sample of professional paramedics without ultrasound experience. Eligible paramedics participated in a 3-hour session on point-of-care US. The paramedics then used US during emergency calls and saved the scans for possible cardiac complaints including: chest pain, dyspnea, loss of consciousness, trauma, or cardiac arrest.

RESULTS

Four paramedics from two distinct fire stations enrolled a total of 19 unique patients, of whom 17 were deemed adequate for clinical decision making (89%, 95%CI 67%-99%). Paramedics accurately recorded 17 cases of cardiac activity (100%, 95%CI 84%-100%) and 2 cases of cardiac standstill (100%, 95%CI 22%-100%).

CONCLUSION

Our pilot study suggests that with minimal training, paramedics can use US to obtain cardiac images that are adequate for interpretation and diagnose cardiac standstill. Further large-scale clinical trials are needed to determine if prehospital US can be used to guide care for patients with cardiac complaints.