Paramedic Use of Needle Thoracostomy in the Prehospital Environment

Objective. The use of prehospital needle thoracostomy (NT) is controversial as it is not without risk. Issues such as inappropriate patient selection, misplacement causing iatrogenic injury, treatment failures in obese patients, anddelaying definitive tube thoracostomy in the emergency department contribute to this controversy. The purpose of this study is to evaluate a cohort of patients undergoing NT by paramedics for tension pneumothorax andreview the indications for use, complications, andemergency department outcomes of NT. Methods. We conducted a retrospective review of patients undergoing NT in the prehospital setting andtransported directly to a Level 1 trauma center over a one-year period. Patients were transported by a single ground transport agency staffed by paramedics. All paramedics were trained to follow uniform protocols for treatment procedures. Variables included indications for NT, patient demographics, prehospital vital signs, injury mechanism, chest X-ray, andEmergency Department outcomes. Results. Paramedics responded to 20,330 advanced life support calls, and39 (0.2%) patients had a NT placed for treatment of tension pneumothorax. Twenty-two (56.4%) patients were in circulatory arrest, with 12 suffering traumatic arrest and10 patients in nontraumatic PEA arrest. The remaining 17 (43.6%) patients were treated for nonarrest causes. Conclusions. The use of NT appears to be a safe procedure when preformed by paramedics in an urban EMS system. Prehospital NT resulted in four cases of unexpected survival.     

Antenatal Emergency Care Provided by Paramedics: A One-Year Clinical Profile

Objective: To report on clinical and socio-demographic factors of a one-year caseload of women attended by a statewide ambulance service in Australia, who presented during pregnancy, prior to the commencement of labor. Methods: Retrospective clinical data collected via in-field electronic patient care record (VACIS®) by paramedics during clinical management was provided by Ambulance Victoria. Cases were electronically extracted from the Ambulance Victoria Clinical Data Warehouse via comprehensive filtering followed by case review. Results: Over a 12-month period, paramedics were called to 2,098 women with pregnancy as a primary or non-primary clinical consideration. Women's ages ranged from 14 to 48 years. The majority were multigravidas (86%). There was a greater chance that ambulance services would be required during business hours than any other time of the day. Paramedics noted pregnant women required ambulance services for a range of primary presenting symptoms both obstetric (n = 1137) and non-obstetric (n = 961). Some women had pre-existing conditions including asthma, hypertension, and diabetes potentially complicating their pregnancies. Paramedics administered analgesia to one third of the women. Paired t-tests revealed significant improvement in the pain relief and overall vital signs of the women encountered. Less than half the women (n = 986, 47%) required interventions. Conclusions: This is a unique population wide analysis of ambulance service resource use exploring the clinical profile of pregnant women requiring ambulance services in one calendar year. To manage obstetric and non-obstetric complications in this population safely and effectively, paramedics require an understanding of the unique physiological adaptions during pregnancy. This study therefore has both educational and practice implications.     

Prehospital Rapid Sequence Intubation by Intensive Care Flight Paramedics

Objective: Rapid sequence intubation (RSI) is an advanced airway procedure for critically ill or injured patients. Paramedic-performed RSI in the prehospital setting remains controversial, as unsuccessful or poorly conducted RSI is known to result in significant complications. In Victoria, intensive care flight paramedics (ICFPs) have a broad scope of practice including RSI in both the adult and pediatric population. We sought to describe the success rates and characteristics of patients undergoing RSI by ICFPs in Victoria, Australia. Methods: A retrospective data review was conducted of adult (≥ 16 years) patients who underwent RSI by an ICFP between January 1, 2011, and December 31, 2016. Data were sourced from the Ambulance Victoria data warehouse. Results: A total of 795 cases were included in analyses, with a mean age of 45 (standard deviation = 19.6) years. The majority of cases involved trauma (71.7%), and most patients were male (70.1%). Neurological pathologies were the most common clinical indication for RSI (68.3%). The first pass success rate of intubation was 89.4%, and the overall success rate was 99.4%. Of the 5 failed intubations (0.6%), all patients were safely returned to spontaneous respiration. Two patients were returned via bag/valve/mask (BVM) support alone, two with BVM and oropharyngeal airway, and one via supraglottic airway. No surgical airways were required. Overall, we observed transient cases of hypotension (5.2%), hypoxemia (1.3%), or both (0.1%) in 6.6% of cases during the RSI procedure. Conclusion: A very high RSI procedural success rate was observed across the study period. This supports the growing recognition that appropriately trained paramedics can perform RSI safely in the prehospital environment.     

Development of a Prehospital Tranexamic Acid Administration Protocol

Objective: Early administration of tranexamic acid (TXA) has been shown to reduce all-cause mortality and death secondary to trauma. Our objective was to develop a collaborative prehospital TXA administration protocol between a ground EMS and academic medical center. Methods: Physicians, pharmacists, and EMS and fire department personnel developed a prehospital TXA administration protocol between a local fire and EMS center with a Midwest tertiary care health system based on results from the CRASH-2 Trial. The protocol was initiated March 27, 2013 and the first dose of TXA was administered in September 2013. Results: Since September 2013, nineteen trauma patients received TXA. Survival rate was 89% (17/19); 2 patients expired immediately following arrival to the trauma bay. Seven patients did not receive the in-hospital maintenance dose due to the following: 3/7 (43%) due to miscommunication of pre-TXA administration; 2/7 (29%) did not meet inclusion criteria for TXA protocol; 1/7 (14%) due to protocol noncompliance; 1/7 (14%) due to a chaotic situation with an unstable patient. Conclusions: Prehospital TXA protocol based on the CRASH-2 trial is safe and feasible. The first dose of TXA administered under this protocol marks the first ground EMS administration in the USA. Conceivably, this will pose as a model to other trauma centers that receive patients from outlying areas without immediate access to care. Large multi-institutional analyses need to be performed to evaluate survival benefits of prehospital TXA administration protocol.     

多发性创伤院前救治体会

目的:分析多发性创伤的临床特点及急诊救治方法.方法:回顾性分析2009年1月-2009年12月我科收治的多发性创伤276例的院前救治临床资料.结果:276例多发性创伤患者中262例经院外急救处理后成功转运到急诊科,现场死亡8例,转运途中死亡6例.结论:多发性创伤伤情复杂,病程进展快,诊治难度大,并发症多,死亡率高,院前快速、正确、有效的现场急救对提高其抢救成功率至关重要.     

Evaluation and Comparison of Different Prehospital Triage Scores of Trauma Patients on In-Hospital Mortality

Introduction: Several prehospital major trauma patient triage scores have been developed, the triage revised trauma score (T-RTS), Vittel criteria, Mechanism/Glasgow Coma Scale/Age/Systolic blood pressure score (MGAP), and the new trauma score (NTS). These scoring schemes allow a rapid and accurate prognostic assessment of the severity of potential lesions. The aim of our study was to compare these scores with in-hospital mortality predictions in a cohort of consecutive trauma patients admitted in a Level 1 trauma center. Materials: Between 2013 and 2016, 1,112 patients were admitted to the "major trauma" spinneret of a Level 1 trauma center in the south of France. All prehospital data needed to calculate the T-RTS, Vittel criteria, the MGAP score, and the NTS were collected. The main evaluation criterion was in-hospital mortality at 30 days for all causes. The predictive performances of these scores were evaluated and compared with each other using the analysis of the receiver operating curves. Results: A total of 1,001 patients were included in the analysis, 238 (24%) females, aged 43?±?19 years with ISS 15?±?13. The area under the curve was for each score: T-RTS, AUC = 0.84, [0.82–0.87]; Vittel criteria, AUC = 0.87 [0.85–0.89]; MGAP score, AUC = 0.91 [0.89–0.92] and NTS, AUC = 0.90 [0.88–0.92]. By comparing the ROC curves of these scores, the MGAP and NTS scores were statistically higher than the T-RTS. With the current thresholds, the sensitivity, specificity, positive and negative predictive values of these scores were 91%, 35%, 10%, 98% for T-RTS, 100%, 2%, 8%, 100% for Vittel criteria, 91%, 71%, 24%, 99% for MGAP score, 82%, 86%, 33%, 98% for NTS. Only Vittel's criteria allowed undertriage below 5% as recommended by the American College of Surgeons Committee on Trauma (ACSCOT). Conclusion: The comparison of these different triage scores concluded with a superiority of the MGAP and NTS scores compared with the T-RTS. Including the calculation of MGAP or NTS scores with the Vittel criteria would reduce the risk of overtriage in the Level 1 trauma centers by further directing patients at low risk of death to a lower-level trauma facility.     

Video Laryngoscopy with the Macintosh Video Laryngoscope in Simulated Prehospital Scenarios by Paramedic Students

Objective. To investigate the effectiveness of the Karl Storz BERCI DCI Macintosh video laryngoscope (MVL) via the TELE PACK system for facilitating intubation by novice paramedic students in a simulation environment. We assessed the laryngeal view, measured by percentage of glottic opening (POGO), when intubating the SimMan manikin airway in different settings. The primary endpoint was the best POGO achieved by the student. Secondary endpoints included intubation times andsuccess rate. Method. We enrolled 25 novice paramedic students to intubate SimMan manikins. Students were randomized to use either a conventional Macintosh 3 (Mac3) blade alone or the MVL with a Mac3 blade. Students attempted their first intubation with the manikin on a stretcher in a normal neck position andreattempted intubation with the manikin's neck stiffened. The groups then crossed over using the alternate device to repeat the attempts in the manikin with a normal neck andwith a stiffened neck. The students then attempted the same sequence of four intubations with the manikin on the floor. Results. The MVL significantly improved POGO in all scenarios (p < 0.05). The MVL improved mean POGO 16% ± 6% in the manikin with a normal neck position on a stretcher and33% ± 7% in the manikin with a stiff neck on the floor. The improvement was significantly greater in simulated difficult scenarios. The intubation success rate (94%) was equal in the two groups, andthe POGO was significantly worse in the failures. In some subgroups, intubation times were longer with the MVL. Conclusion. The MVL improves the laryngeal view for novice laryngoscopists in a simulated setting, andthis improvement is greatest in simulated difficult scenarios     

Review article: Paramedic education opportunities and challenges in Australia

Paramedic education has been undergoing major development in Australia in the past 20 years, with many different educational programmes being developed across all Australian jurisdictions. This paper aims to review the current paramedic education programmes in Australia to identify the similarities and differences between the programmes, and the strengths and challenges in these programmes. A literature search was performed using six scientific databases to identify any systematic reviews, literature reviews or relevant articles on the topic. Additional searches included journal articles and text references from 1995 to 2011. The search was conducted during December 2010 and November 2011. Included in this review are a total of 28 articles, which are focused around five major issues in paramedic education: (i) principle on paramedic programmes and the involvement of industry partners; (ii) clinical placements; (iii) contemporary methods of education; (iv) needs for specific programmes within paramedic education; and (v) articles related to the accreditation process for paramedic programmes. Paramedic programmes across Australian universities vary with many different practices, especially relating to clinical placements in the field. The further advances of the paramedic education programmes should aim to respond to population change and industry development, which would enhance the paramedic profession across Australia.     

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.

Predicting Prehospital Care Students' First-Year Academic Performance

Objective. Research over the last decade has supported the use of cold intravenous (IV) fluid as a method for initiating therapeutic hypothermia in post–cardiac arrest resuscitation. However, prehospital care programs employing this treatment have encountered various difficulties. Barriers to prehospital induced hypothermia (IH) protocols include the lack of effective or economically reasonable methods to maintain cold saline in the field. Validation of a simple method could allow agencies to equip numerous rigs with cold saline. The aim of this study was to determine whether a standard commercial cooler can maintain two 1-L normal saline solution (NSS) bags below 4°C in three different environments. Methods. Environments simulating those of an ambulance compartment were created for the experiment. NSS temperatures were continuously recorded inside a standard commercial cooler under one of three scenarios: ambient room temperature (25°C) without ice packs, ambient room temperature with ice packs, and 50°C ambient temperature with ice packs. Four trials under each condition were performed. Results. In a room-temperature environment without ice packs, the NSS warmed to 4°C in a mean interval of 1 hour 21 minutes. Using room temperature with ice packs, the NSS warmed to 4°C in a mean interval of 29 hours 53 minutes. In a constant hot environment of 50°C, the NSS warmed to 4°C in a mean interval of 10 hours 50 minutes. A significant difference was found between the three environments (log-rank = 17.90, df = 2, p = 0.0001). Conclusions. Prehospital refrigeration devices are needed for current and future IH protocols. Low-technology methods in the form of a cooler and ice packs can provide cold saline storage for longer than a full 24-hour shift in a room-temperature ambulance. In extremely hot conditions, 4°C NSS can be maintained for nearly 11 hours using this method. This model exhibits an economical, easily deployable cold saline storage unit.     

合理配置院前急救资源的新思维——四川成都地区院前急救资源配置现状及剖析

目的：了解四川省成都市急诊科院前急救配置现状,并从中找到更合理的配置方式以促进院前急救的建设和发展。材料与方法：通过问卷方式采集了成都市38家二乙以上医院急诊科院前急救的有关数据,考察主要指标间的相关性,在相关的基础上计算回归模型。结果：本研究得出了关于成都市急诊科院前急救配置现状的大量描述性资料;发现了院前急救配置情况与日平均急诊量、日平均观察量、日平均危重病人数、日平均抢救病人数等指标的相关关系;得到了配置的回归模型。结论：目前成都市急诊科院前急救配置上有诸多不足之处,可以参照本研究得出的回归关系进行调整。     

Evaluation of Physiologic Alterations during Prehospital Paramedic-Performed Rapid Sequence Intubation

Objective: Physiologic alterations during rapid sequence intubation (RSI) have been studied in several emergency airway management settings, but few data exist to describe physiologic alterations during prehospital RSI performed by ground-based paramedics. To address this evidence gap and provide guidance for future quality improvement initiatives in our EMS system, we collected electronic monitoring data to evaluate peri-intubation vital signs changes occurring during prehospital RSI. Methods: Electronic patient monitor data files from cases in which paramedic RSI was attempted were prospectively collected over a 15-month study period to supplement the standard EMS patient care documentation. Cases were analyzed to identify peri-intubation changes in oxygen saturation, heart rate, and blood pressure. Results: Data from 134 RSI cases were available for analysis. Paramedic-assigned prehospital diagnostic impression categories included neurologic (42%), respiratory (26%), toxicologic (22%), trauma (9%), and cardiac (1%). The overall intubation success rate (95%) and first-attempt success rate (82%) did not differ across diagnostic impression categories. Peri-intubation desaturation (SpO₂ decrease to below 90%) occurred in 43% of cases, and 70% of desaturation episodes occurred on first-attempt success. The incidence of desaturation varied among patient categories, with a respiratory diagnostic impression associated with more frequent, more severe, and more prolonged desaturations, as well as a higher incidence of accompanying cardiovascular instability. Bradycardia (HR decrease to below 60 bpm) occurred in 13% of cases, and 60% of bradycardia episodes occurred on first-attempt success. Hypotension (systolic blood pressure decrease to below 90 mmHg) occurred in 7% of cases, and 63% of hypotension episodes occurred on first-attempt success. Peri-intubation cardiac arrest occurred in 2 cases, one of which was on first-attempt success. Only 11% of desaturations and no instances of bradycardia were reflected in the standard EMS patient care documentation. Conclusions: In this study, the majority of peri-intubation physiologic alterations occurred on first-attempt success, highlighting that first-attempt success is an incomplete and potentially deceptive measure of intubation quality. Supplementing the standard patient care documentation with electronic monitoring data can identify unrecognized physiologic instability during prehospital RSI and provide valuable guidance for quality improvement interventions.     

Prehospital use of heparin locks: A cost-effective method for intravenous access

Intravenous (IV) infusions were ordered in nearly 95% of paramedic runs called into a busy base station hospital. Most of the patients received IV lines for either prophylactic access or administration of single or multiple bolus medications. In this group of patients, the application of a heparin lock injection port directly to the IV catheter, followed by the injection of 10 units of heparin, was evaluated. Of 102 consecutive patients treated in the field, 98 (97%) were treated with heparin locks only. The total number of patients requiring an IV infusion drip (either by paramedics or in the emergency department of the receiving hospital) was 20 (20%). If all 102 patients had received conventional IV drip infusions, the total patient equipment charges would have been $4,610.40. The actual charges for all patients in this series, either with heparin locks or IV infusion sets, was $1,846.14--a 60% savings. The results of the study indicate that the heparin lock is a safe, convenient, and cost-effective method for maintaining IV access in the prehospital environment.     

Inverse intubation: An important alternative for intubation in the streets

One of the highest priorities for prehospital emergency personnel is airway management. Several rescuer positions for intubation on the ground have been published. Only recently, the inverse intubation method as an additional approach for intubation in the out-of-hospital setting has received further attention. Using four case reports, situations in which inverse intubation may be an important tool for successful airway management are discussed. Other uses of the method are listed.