Abstract

We present the case of a 10-year-old previously healthy male who suffered an out-of-hospital cardiac arrest because of abdominal trauma and survived with excellent neurologic outcomes and near complete return to baseline functional status at hospital discharge. The rapid response and efficient mobilization of resources led to an excellent patient outcome despite the severity of injuries, including intra-abdominal injuries with expected mortality, out-of-hospital traumatic arrest, coagulopathy, and an extended pediatric intensive care unit stay. This case underscores the significance of timely advanced trauma life support interventions, especially early blood product administration, efficient transport, and airway management, while sharing a remarkable case of out-of-hospital pediatric traumatic arrest with near full recovery.

A 10-year-old previously healthy male called his mother on his smartwatch saying he had crashed his bicycle while riding in their neighborhood and felt unwell. His mother called 911 who activated emergency medical services, and the local advanced life support fire department arrived at the scene to find the patient pale and lethargic with right-sided abdominal pain. Recognizing the need for immediate transport to the nearest pediatric trauma facility approximately 35 miles away, helicopter emergency medical services (HEMS) was requested per county protocol because of a shorter transport time.

Click below to read the full case report and discussion published by ScienceDirect.

The post Survival of Out-of-Hospital Pediatric Blunt Traumatic Arrest With Full Neurologic Recovery: Case Report appeared first on Air Methods.

Abstract

Objective

Rapid sequence intubation (RSI) is a critical skill commonly performed by air medical teams in the United States. To improve safety and reduce potential patient harm, checklists have been implemented by various institutions in intensive care units, emergency departments, and even prehospital air medical programs. However, the literature suggests that checklist use before RSI has not shown improvement in clinically important outcomes in the hospital. It is unclear if RSI checklist use by air medical crews in prehospital environments confers any clinically important benefit.

Methods

This institutional review board–approved project is a before-and-after observational study conducted within a large helicopter ambulance company. The RSI checklist was used by flight crewmembers (flight paramedic/nurse) for over 3 years. Data were evaluated for 8 quarters before and 8 quarters after checklist implementation, spanning December 2014 to March 2019. Data were collected, including the self-reported use of the checklist during intubation attempts, the reason for intubation, and correlation with difficult airway predictors (HEAVEN [Hypoxemia, Extremes of size, Anatomic disruption, Vomit, Exsanguination, Neck mobility/Neurologic injury] criteria), and compared with airway management before the implementation of the checklist. The primary outcome was improved first-pass success (FPS) when compared among those who received RSI before the checklist versus those who received RSI with the checklist. The secondary outcome was a definitive airway sans hypoxia improvement noted on the first pass among adult patients as measured before and after RSI checklist implementation. Post-RSI outcome scenarios were recorded to analyze and validate the effectiveness of the checklist.

Results

Ten thousand four hundred five intubations were attempted during the study. FPS was achieved in 90.9% of patients before RSI checklist implementation, and 93.3% achieved FPS postimplementation of the RSI checklist (P ≤ .001). In the preimplementation epoch, 36.2% of patients had no HEAVEN predictors versus 31.5% after RSI checklist implementation. These data showed that before RSI checklist implementation, airways were defined as less difficult than after implementation.

Conclusion

The implementation of a standardized RSI checklist provided a better identification of deterring factors, affording efficient and accurate actions promoting FPS. Our data suggest that when a difficult airway is identified, using the RSI checklist improves FPS, thereby reducing adverse events.

Click below to read the full research paper published by ScienceDirect.

The post Implementation of a Rapid Sequence Intubation Checklist Improves First-Pass Success and Reduces Peri-Intubation Hypoxia in Air Medical Transport appeared first on Air Methods.

Abstract

Objective

Hypothermia is common among trauma patients and can lead to a serious rise in morbidity and mortality. This study was performed to investigate the effect of active and passive warming measures implemented in the prehospital phase on the body temperature of trauma patients.

Methods

In a multicenter, multinational prospective observational design, the effect of active and passive warming measures on the incidence of hypothermia was investigated. Adult trauma patients who were transported by helicopter emergency medical services (HEMS) or ground emergency medical services with an HEMS physician directly from the scene of injury were included. Four HEMS/ground emergency medical services programs from Canada, the United States, and the Netherlands participated.

Results

A total of 80 patients (n = 20 per site) were included. Eleven percent had hypothermia on presentation, and the initial evaluation occurred predominantly within 60 minutes after injury. In-line fluid warmers and blankets were the most frequently used active and passive warming measures, respectively. Independent risk factors for a negative change in body temperature were transportation by ground ambulance (odds ratio = 3.20; 95% confidence interval, 1.06-11.49; P = .03) and being wet on initial presentation (odds ratio = 3.64; 95% confidence interval, 0.99-13.36; P = .05).

Conclusion

For adult patients transported from the scene of injury to a trauma center, active and passive warming measures, most notably the removal of wet clothing, were associated with a favorable outcome, whereas wet patients and ground ambulance transport were associated with an unfavorable outcome with respect to temperature.

Click below to read the full research paper published by the Air Medical Journal, 2023, ISSN 1067-991X.

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Abstract

Background

Rapid sequence intubation (RSI) may compromise perfusion because of the use of sympatholytic medications as well as subsequent positive pressure ventilation. The use of bolus vasopressor agents may reverse hypotension and prevent arrest.

Methods

This was a prospective, observational study enrolling air medical patients with critical peri-RSI hypotension (systolic blood pressure [SBP] < 90 mm Hg) to receive either arginine vasopressin (aVP), 2 U intravenously every 5 minutes, for trauma patients or phenylephrine (PE), 200 μg intravenously every 5 minutes, for nontrauma patients. The main outcome measures included an increase in SBP, a reversal of hypotension, and the occurrence of dysrhythmia or hypertension (SBP > 160 mm Hg) within 20 minutes of vasopressor administration.

Results

A total of 523 patients (344 aVP and 179 PE) were enrolled over 2 years. An increase in SBP was observed in 326 aVP patients (95%), with reversal of hypotension in 272 patients (79%). An increase in SBP was observed in 171 PE patients (96%), with reversal of hypotension in 148 patients (83%). A low rate of rebound hypertension was observed for both aVP and PE patients.

Conclusion

Both aVP and PE appear to be safe and effective for treating critical hypotension in the peri-RSI period.

Click below to read the full research paper published by the Air Medical Journal.

The post Bolus Vasopressor Use for Air Medical Rapid Sequence Intubation: The Vasopressor Intravenous Push to Enhance Resuscitation Trial appeared first on Air Methods.

Abstract

Background: 

The manual resuscitator device is the most common method of ventilating patients with respiratory failure, either with a facemask, or with an advanced airway such as an endotracheal tube (ETT). Barotrauma and gastric inflation from excessive ventilation volumes or pressure are concerning complications. Ventilating adult patients with pediatric manual resuscitator may provide more lung-protective tidal volumes based on stationary patient simulations. However, use of a pediatric manual resuscitator in mobile simulations contradictorily generates inadequate tidal volumes.

Methods: 

Sixty-two emergency medical services (EMS) clinicians in a moving ambulance ventilated a manikin using pediatric and adult manual resuscitators in conjunction with oral-pharyngeal airway, i-gel, King LTS-D, or an endotracheal tube.

Results: 

Oral-pharyngeal airway data were discarded due to EMS clinician inability to produce measurable tidal volumes. Mean ventilation volumes using the pediatric manual resuscitator were inadequate compared to those with the adult manual resuscitator on all other airway devices. In addition, i-gel, King LTS-D, and endotracheal tube volumes were statistically comparable. Paramedics ventilated larger volumes than emergency medical technicians.

Conclusions: 

Using a pediatric manual resuscitator on adult patients is not supported by our findings.

Click below to read the full research paper published Prehospital Emergency Care Volume 27, 2023 – Issue 4

The post Are Pediatric Manual Resuscitators Only Fit for Pediatric Use? A Comparison of Ventilation Volumes in a Moving Ambulance appeared first on Air Methods.

Abstract

Objectives: Early administration of blood products is associated with improved survival from traumatic injury. Helicopters have the ability to initiate infusion of blood products in the out-of-hospital environment, but the experience of air medical blood product administration is not well characterized. The objective of this analysis is to describe the experience of a large air medical service with out-of-hospital administration of blood products.

Methods: We performed a descriptive study with a secondary cohort analysis. This study was conducted over a two-year period (2019-2020) in a large air medical company. A total of 139 bases had access to blood products at some interval during the study period. Subjects for this analysis included all trauma patients receiving one or more of the following blood products in the out-of-hospital setting: packed red blood cells (PRBCs), whole blood (WB), fresh-frozen or liquid plasma (plasma), platelets. Data collected for each subject included: demographics, scene/interfacility, blood products administered, and vital signs before and after blood product administration. Data were presented descriptively. In addition, initial and final vital signs were compared to assess the effect of blood product administration. Finally, we compared scene calls to interfacility transports with regard to demographic data, blood product administration, and vital signs. Descriptive data were reported using mean or frequency with 95% confidence intervals. T-testing and chi-square analysis were used for all comparisons, with statistical significance set for p<0.05.

Results: Over the two-year study period, a total of 1587 trauma patients [1504 adult, 83 pediatric] receiving out-of-hospital blood products were identified for analysis. These included 1010 scene calls and 577 interfacility transports. A total of 1152 patients (72.6%) were male. The distribution of blood products included: 647 patients (40.8%) received PRBCs alone; 65 patients (4.1%) received WB alone; 312 patients (19.7%) received plasma alone; 544 patients (34.3%) received PRBCs/plasma; 2 patients (0.1%) received WB/PRBCs; 3 patients (0.2%) received WB/plasma; 6 patients (0.4%) received platelets alone; 5 patients (0.3%) received platelets/PRBCs; 3 patients (0.2%) received PRBCs/plasma/platelets. Interfacility transport patients were more likely than scene call patients to receive PRBCs. An increase in blood pressure (+4 mmHg) and decrease in heart rate (-8 beats/min) were observed following blood product administration. A greater improvement in blood pressure and decrease in heart rate were observed for scene call versus interfacility patients following blood administration.

Conclusions: Blood product administration appears to be an important component of air medical transport, with substantial number of trauma patients receiving some combination of PRBCs, WB, plasma, and platelets. Improvements in vital signs were observed, particularly in scene call patients. These data give valuable insight into the out-of-hospital administration of blood products by air medical providers.

Click below to read the full research paper published by the 2021 Critical Care Transport Medicine Conference Scientific Forum and the Air Medical Journal, Volume 41, 2022, Pages 23-27

The post Descriptive Analysis of Blood Product Administration in Air Medical Trauma Patients appeared first on Air Methods.

Abstract

Background: Rapid sequence intubation (RSI) is a critical procedure in the resuscitation of critically ill and injured patients but carries an important risk of oxygen desaturation. In the adult population, a target preoxygenation threshold of >93% has been defined. However, it is not known whether this is an appropriate target for pediatric patients.

Objective: To define a target preoxygenation threshold for pediatric RSI.

Methods: Our air medical agency includes 150 bases, with a flight RN/flight paramedic crew configuration. The pediatric RSI protocol includes the use of etomidate or ketamine for induction and either succinylcholine or rocuronium for paralysis. Up to 120 data elements are entered into the Institutions Airway Database for each RSI procedure. For this analysis, all pediatric patients (age <18 years) undergoing RSI between January 2015 and September 2019 were included. Separate analysis was performed for infants (0-2 years), young children (3-8 years), and older children (9-17 years). Patients were stratified by highest pre-attempt SpO2 value, with the rate of desaturation identified as the primary outcome measure. Desaturation was defined as decrease in SpO2 to <94% or a continued decrease by at least 2% if pre-attempt SpO2 value was <94%. A graphical analysis was performed to identify an inflection point below which substantially higher desaturation rates were observed. The desaturation rate for patients with pre-attempt SpO2 values above that threshold were compared to those below that threshold using chi-square analysis, with significance was set at p<0.05.

Results: A total of 1,116 patients were identified over the 57-month period (infant n=247, young children n=250, older children n=619). A clear desaturation rate inflection point was observed with pre-attempt SpO2 values of 97% or greater. For patients with pre-attempt SpO2 values of <97%, the desaturation rate was 59.2% as compared to 12.8% with pre-attempt SpO2 values of 97% or greater (OR 9.8, 95% CI 6.9-14.1, p<0.0001). These results were similar across the three age groups.

Conclusions: These data support a higher preoxygenation target of 97% or greater with pediatric RSI. Limitations include the observational nature of the analysis and the possibility that lower pre-attempt SpO2 is a surrogate for more a difficult airway.

Click below to read the full research paper published by Science Direct and the Air Medical Journal, Volume 41, Issue 1, January-February 2022, Page 26

The post The Optimal Preoxygenation Target to Avoid Desaturation During Pediatric Rapid Sequence Intubation appeared first on Air Methods.

Abstract

Background: Early blood administration is associated with improved survival from traumatic shock, but the use of whole blood (WB) versus packed red blood cells (PRBCs) remains controversial. This analysis explored the effectiveness of PRBCs versus WB in a population of air medical trauma victims.

Methods: All trauma patients administered blood products by helicopter crews from 139 bases over a 2-year period were included in this retrospective analysis. Patients receiving WB and PRBCs were compared with regard to demographics, scene/interfacility, and vital sign changes following blood administration.

Results: 1587 patients were included [67 WB, 1201 PRBC, 319 plasma/platelets only]. Both WB and PRBC patients received a mean of 1.4 units. Many PRBC patients also received plasma or platelets. similar BP and HR improvements were observed for both WB (+1 mmHg, -12 B.M. and PRBC (+4 mmHg, -9 B.M. patients)).

Conclusion: similar improvements in blood pressure and heart rate were observed following administration of both WB and PRBC to air medical trauma patients. Many PRBC patients also received plasma or platelets.

Click Below to read the full research paper published by Science Direct and the Air Medical Journal, Volume 41, Issue 1, January-February 2022, Pages 33-36

The post Air Medical Administration of Whole Blood Versus Packed Red Blood Cells for Trauma Patients appeared first on Air Methods.

Abstract

Background: Rapid sequence intubation (RSI) is performed by helicopter emergency medical services (HEMS) providers to establish airway control. Common induction agents are etomidate and ketamine, both touted to have relatively stable hemodynamic profiles. Limited data comparing these medications in the air medical setting exist.

Objective: Compare administration of ketamine and etomidate on peri-intubation hemodynamics.

Methods: A retrospective chart review of intubations by a HEMS program over 69 months was completed. Heart rate (HR) change, systolic blood pressure (SBP) change, and hypotension with etomidate or ketamine use were measured.

Results: There were 258 patients induced with etomidate and 48 with ketamine. Etomidate patients showed a +1.161% change in HR (SD ± 22.7) and -0.49% change in SBP (SD ± 25.0). Ketamine patients showed a -4.7% change in HR (SD ± 16.7) and 17.2% change in SBP (SD ± 43.4). The p-values for percentage change in HR and SBP between etomidate and ketamine were 0.0830 and 0.0018, respectively. Twenty-five episodes of postadministration hypotension occurred with etomidate, and two with ketamine (p=0.028).

Conclusion: Both ketamine and etomidate are appropriate for intubation of HEMS patients. Ketamine was preferentially selected for hypotensive patients with statistically significant improvement in SBP. Although statistically significant, both ketamine and etomidate had relative low incidences of hypotension.

Keywords: intubation; hypotension; etomidate; ketamine; prehospital; HEMS

Click below to read the full study published by The Journal of Emergency Medicine, Volume 62, Issue 2, P163-170, February 01, 2022

The post Hemodynamics in Helicopter Emergency Medical Services (HEMS) Patients Undergoing Rapid Sequence Intubation With Etomidate or Ketamine appeared first on Air Methods.

Abstract

Objectives:  To characterize prehospital air medical transport sedation practices and test the hypothesis that modifiable variables related to the monitoring and delivery of analgesia and sedation are associated with prehospital deep sedation.

Design: Multicenter, retrospective cohort study.

Setting: A nationwide, multicenter (approximately 130 bases) air medical transport provider.

Patients: Consecutive, adult mechanically ventilated air medical transport patients treated in the prehospital environment (January 2015 to December 2020).

Interventions: None.

Measurements and Main Results: All data involving sedation (medications, monitoring) were recorded. Deep sedation was defined as: 1) Richmond Agitation-Sedation Scale of –3 to –5; 2) Ramsay Sedation Scale of 5 or 6; or 3) Glasgow Coma Scale of less than or equal to 9. Coma was defined as being unresponsive and based on median sedation depth: 1) Richmond Agitation-Sedation Scale of –5; 2) Ramsay of 6; or 3) Glasgow Coma Scale of 3. A total of 72,148 patients were studied. Prehospital deep sedation was observed in 63,478 patients (88.0%), and coma occurred in 42,483 patients (58.9%). Deeply sedated patients received neuromuscular blockers more frequently and were less likely to have sedation depth documented with a validated sedation depth scale (i.e., Ramsay or Richmond Agitation-Sedation Scale). After adjusting for covariates, a multivariable logistic regression model demonstrated that the use of longer-acting neuromuscular blockers (i.e., rocuronium and vecuronium) was an independent predictor of deep sedation (adjusted odds ratio, 1.28; 95% CI, 1.22–1.35; p < 0.001), while use of a validated sedation scale was associated with a lower odds of deep sedation (adjusted odds ratio, 0.29; 95% CI, 0.27–0.30; p < 0.001).

Conclusions: Deep sedation (and coma) is very common in mechanically ventilated air transport patients and associated with modifiable variables related to the monitoring and delivery of analgesia and sedation. Sedation practices in the prehospital arena and associated clinical outcomes are in need of further investigation.

Click below to read the full research paper published by Critical Care Explorations, Volume 3, Issue 12, P e0597, December, 2021

The post The AIR-SED Study: A Multicenter Cohort Study of SEDation Practices, Deep Sedation, and Coma Among Mechanically Ventilated AIR Transport Patients appeared first on Air Methods.