When can an enhanced critical care team add value to equestrian related incidents? A retrospective observational study

BACKGROUND

Helicopter Emergency Medical Services (HEMS) may be tasked to equestrian related incidents. Previous studies have suggested that majority of patients do not require HEMS specific interventions. No data has been published since 2015 so this article aims to establish the current incidence of equestrian incidents attended by one UK HEMS and identify trends that would aid the dispatch of HEMS to the patients who most need it.

METHODS

A retrospective review of the computerised record system for one UK HEMS was performed between 1st January 2015-30th June 2022. Demographic data, timings, suspected injury pattern and HEMS specific intervention details were extracted. The 20 patients with the highest confirmed injury burden were reviewed in detail.

RESULTS

257 patients (229 female) were treated by HEMS (0.02% of all HEMS dispatches). Of those 124 dispatches were due to interrogation of the 999 calls by a clinician on the dispatch desk. Only 52% were conveyed to hospital by the HEMS team; 51% had no HEMS specific intervention. Of the 20 most severely injured patients their pathology included splenic, liver, spinal cord and traumatic brain injuries.

CONCLUSION

Whilst HEMS dispatches to equestrian incidents remain a small percentage, there are four mechanisms that may benefit due to potential injury burden: fall onto head with suggestion of hyper-extension or hyper-flexion injury; kick to the torso; horse fallen or repetitively rolled onto patient and, no movement of patient since incident. In addition, age >50 years should be considered as higher risk.

Predictive clinical utility of pre-hospital point of care lactate for transfusion of blood product in patients with suspected traumatic haemorrhage: derivation of a decision-support tool

INTRODUCTION

Pre-hospital emergency medical teams can transfuse blood products to patients with suspected major traumatic haemorrhage. Common transfusion triggers based on physiological parameters have several disadvantages and are largely unvalidated in guiding pre-hospital transfusion. The addition of pre-hospital lactate (P-LACT) may overcome these challenges. To date, the clinical utility of P-LACT to guide pre-hospital blood transfusion is unclear.

METHODS

A retrospective analysis of patients with suspected major traumatic haemorrhage attended by Air Ambulance Charity Kent Surrey Sussex (KSS) between 8 July 2017 and 31 December 2019. The primary endpoint was the accuracy of P-LACT to predict the requirement for any in-hospital (continued) transfusion of blood product.

RESULTS

During the study period, 306 patients with suspected major traumatic haemorrhage were attended by KSS. P-LACT was obtained in 194 patients. In the cohort 103 (34%) patients were declared Code Red. A pre-hospital transfusion was commenced in 124 patients (41%) and in-hospital transfusion was continued in 100 (81%) of these patients, in 24 (19%) patients it was ceased. Predictive probabilities of various lactate cut-off points for requirement of in-hospital transfusion are documented. The highest overall proportion correctly classified patients were found for a P-LACT cut-point of 5.4 mmol/L (76.50% correctly classified). Based on the calculated predictive probabilities, optimal cut-off points were derived for both the exclusion- and inclusion of the need for in-hospital transfusion. A P-LACT < 2.5 mmol/L had a sensitivity of 80.28% and a negative likelihood ratio [LR-] of 0.37 for the prediction of in-hospital transfusion requirement, whereas a P-LACT of 6.0 mmol/L had a specificity of 99.22%, [LR-] = 0.78.

CONCLUSION

Pre-hospital lactate measurements can be used to predict the need for (continued) in-hospital blood products in addition to current physiological parameters. A simple decision support tool derived in this study can help the clinician interpret pre-hospital lactate results and guide pre-hospital interventions in the major trauma patient.

The Prehospital Emergency Anaesthetic in 2022

Prehospital emergency anesthesia (PHEA) is a commonly performed prehospital procedure with inherent risks. The processes and drug regimens behind PHEA are continually updated by prehospital teams across the country as part of their governance structure. Essex & Herts Air Ambulance has recently updated this practice by reviewing the entire process of performing PHEA. Through experiential learning in a high-volume service, audit, and a contemporary literature review, a new standard operating procedure has been developed to combat common problems, such as hypotension, associated with the more traditional methods of performing PHEA. The aim of this article was to summarize the literature behind this new standard operating procedure, systematically breaking down the core components of performing a PHEA and the rationale behind them. The key components identified in the review are indications for PHEA, airway assessment, peri-intubation oxygenation, preparation for PHEA, drug dosing, special circumstances, and failed intubation. One significant change is the drug dosage regimen; 1 μg/kg fentanyl, 2 mg/kg ketamine, and 2 mg/kg rocuronium is recommended as the main drug dosing regimen for both medical and trauma patients. Other changes include preoxygenation with a nasal cannula in addition to the nonrebreather mask, optimizing patients in the preparation phase by considering inopressors or fluid bolus and ensuring a "sterile cockpit" to control the surrounding environment to ensure the first intubation attempt is the best attempt.

PP27 Pre-hospital lactate monitoring: a worthy adjunct to systolic blood pressure and shock index in triggering blood product administration in patients with suspected traumatic haemorrhage?

Introduction

Pre-hospital identification of patients with suspected occult traumatic haemorrhage is problematic. Physiological parameters and clinical gestalt are inadequate surrogates for ongoing haemorrhage. Lactate monitoring may hold stronger predictive clinical utility to identify patients with suspected traumatic haemorrhage above other physiological parameters.

Methods

A single centre, service evaluation of pre-hospital lactate monitoring. A point of care test was introduced into a Helicopter Emergency Medical Service in the United Kingdom. Clinicians adhered to strict education and governance, supported by standard operating procedure. Systolic blood pressure (SBP) and shock index (SI) was measured in patients that received pre-hospital transfusion therapy. A predetermined ‘cut off’ value of lactate >2.5 mmol was acknowledged. In-hospital follow up established further transfusion therapy.

Results

Wilcoxon rank sum compared pre-lactate (n=22) and post-lactate (n=6) groups. Monte Carlo permutations were used to obtain exact probabilities. No statistically significant differences were found between groups for: SBP, p=0.955; and, SI, p=0.401. Univariate logistic regression identified the odds ratio (OR) and confidence interval (CI) for each continuous variable as: SBP, 0.97 (CI 0.94 to 1.01); SI, 26.91 (CI 1.11 to 652.48) and lactate >2.5 mmol, 2.33 (CI 0.23 to 23.91). Multivariate logistic regression identified OR as: SBP, 0.99 (CI 0.95 to 1.04); SI, 22.98 (CI 0.56 to 946.44); and lactate >2.5 mmol, 3.05 (CI 0.14 to 65.86).

Conclusion

Lactate monitoring has been successfully introduced into an enhanced care service. The Results confirm SBP is not predictive of further transfusion. The OR for SI shows greater predictive power. Limited by a small dataset, the Results are hypothesis-generating only.

Mortality of civilian patients with suspected traumatic haemorrhage receiving pre-hospital transfusion of packed red blood cells compared to pre-hospital crystalloid

Background

Major haemorrhage is a leading cause of mortality following major trauma. Increasingly, Helicopter Emergency Medical Services (HEMS) in the United Kingdom provide pre-hospital transfusion with blood products, although the evidence to support this is equivocal. This study compares mortality for patients with suspected traumatic haemorrhage transfused with pre-hospital packed red blood cells (PRBC) compared to crystalloid.

Methods

A single centre retrospective observational cohort study between 1 January 2010 and 1 February 2015. Patients triggering a pre-hospital Code Red activation were eligible. The primary outcome measure was all-cause mortality at 6 hours (h) and 28 days (d), including a sub-analysis of patients receiving a major and massive transfusion. Multivariable regression models predicted mortality. Multiple Imputation was employed, and logistic regression models were constructed for all imputed datasets.

Results

The crystalloid (n = 103) and PRBC (n = 92) group were comparable for demographics, Injury Severity Score (p = 0.67) and mechanism of injury (p = 0.73). Observed 6 h mortality was smaller in the PRBC group (n = 10, 10%) compared to crystalloid group (n = 19, 18%). Adjusted OR was not statistically significant (OR 0.48, CI 0.19–1.19, p = 0.11). Observed mortality at 28 days was smaller in the PRBC group (n = 21, 26%) compared to crystalloid group (n = 31, 40%), p = 0.09. Adjusted OR was not statistically significant (OR 0.66, CI 0.32–1.35, p = 0.26). A statistically significant greater proportion of the crystalloid group required a major transfusion (n = 62, 60%) compared to the PRBC group (n = 41, 40%), p = 0.02. For patients requiring a massive transfusion observed mortality was smaller in the PRBC group at 28 days (p = 0.07).

Conclusion

In a single centre UK HEMS study, in patients with suspected traumatic haemorrhage who received a PRBC transfusion there was an observed, but non-significant, reduction in mortality at 6 h and 28 days, also reflected in a massive transfusion subgroup. Patients receiving pre-hospital PRBC were significantly less likely to require an in-hospital major transfusion. Further adequately powered multi-centre prospective research is required to establish the optimum strategy for pre-hospital volume replacement in patients with traumatic haemorrhage.

[Magnetic resonance tomographic study of aortic isthmus stenosis]

We present four patients with coarctation of the aorta, whose work-up was facilitated by MRI. Magnetic resonance has the potential for displacing angiography in imaging these patients.

[CT diagnosis of cystic hygroma]

We present five patients with cystic hygroma: the CT features are presented. It occurs primarily in the region of the neck. Occasional involvement of the axilla, the chest wall and the mediastinum is possible.