Prehospital non-drug assisted intubation for adult trauma patients with a Glasgow Coma Score less than 9

Emerg Med J 2013;30:935-941

© Gary Wilson/ Pre-hospital Research Forum

Prehospital airway management for adult trauma patients remains controversial. The authors sought to review the frequency that paramedic non-drug assisted intubation or attempted intubation is performed for trauma patients in Ontario, Canada, and determine its association with mortality.

Methods
The authors conducted a retrospective cohort study using the Ontario Trauma Registry’s Comprehensive Data Set for 2002–2009. Eligible patients were greater than 16 years of age, had an initial Glasgow Coma Score of less than 9 and were cared for by ground-based non-critical care paramedics. The primary outcome was mortality. Outcomes were compared between patients undergoing prehospital intubation versus basic airway management. Logistic regression analyses were used to quantify the association between prehospital intubation and mortality.

Results
Of the 2229 patients included in the analysis, 671 (30.1%) underwent prehospital intubation. Annual rates of prehospital intubation declined from 33.7% to 14.0% over the study period. Unadjusted death rates were 66.0% versus 34.8% in the intubation and basic airway groups, respectively. Intubation in the prehospital setting was associated with a heightened risk of mortality.

Conclusions
Prehospital non-drug assisted intubation for trauma is being performed less frequently in Ontario, Canada. Within the study population, paramedic non-drug assisted intubation or attempted intubation was associated with a heightened risk of mortality.

http://emj.bmj.com/content/30/11/935?etoc

Excited delirium syndrome and sudden death: Best evidence topics report

Emerg Med J 2013;30:958-960

A short-cut review was carried out to establish whether morbidity and mortality from excited delirium syndrome (EXDS) can be predicted in the emergency department (ED). Seventy-three papers were found of which 11 presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers are detailed.

The clinical bottom line is that the early recognition of EXDS remains paramount as patients may have sudden cardiovascular collapse with little warning. Several authors do describe laboured respiratory efforts before death, so prompt airway and haemodynamic control may be necessary. Patients may benefit from chemical rather than physical restraint. Acidosis and hyperthermia should also be aggressively managed. Law enforcement and prehospital personnel should also be educated regarding potential complications of EXDS.

http://emj.bmj.com/content/30/11/958.2?etoc

http://www.bestbets.org/bets/bet.php?id=2478 (link to report)

Does Use of the Recognition Of Stroke In the Emergency Room Stroke Assessment Tool Enhance Stroke Recognition by Ambulance Clinicians?

Stroke. 2013; 44: 3007-3012

© Gary Wilson/ Pre-hospital Research Forum

UK ambulance services assess patients with suspected stroke using the Face Arm Speech Test (FAST). The Recognition Of Stroke In the Emergency Room (ROSIER) tool has been shown superior to the FAST in identifying strokes in emergency departments but has not previously been tested in the ambulance setting. We investigated whether ROSIER use by ambulance clinicians can improve stroke recognition.

Methods
Ambulance clinicians used the ROSIER in place of the FAST to assess patients with suspected stroke. As the ROSIER includes all FAST elements, we calculated a FAST score from the ROSIER to enable comparisons between the two tools. Ambulance clinicians’ provisional stroke diagnoses using the ROSIER and calculated FAST were compared with stroke consultants’ diagnosis. We used stepwise logistic regression to compare the contribution of individual ROSIER and FAST items and patient demographics to the prediction of consultants’ diagnoses.

Results
Sixty-four percent of strokes and 78% of nonstrokes identified by ambulance clinicians using the ROSIER were subsequently confirmed by a stroke consultant. There was no difference in the proportion of strokes correctly detected by the ROSIER or FAST with both displaying excellent levels of sensitivity. The ROSIER detected marginally more nonstroke cases than the FAST, but both demonstrated poor specificity. Facial weakness, arm weakness, seizure activity, age, and sex predicted consultants’ diagnosis of stroke.

Conclusions
The ROSIER was not better than the FAST for prehospital recognition of stroke. A revised version of the FAST incorporating assessment of seizure activity may improve stroke identification and decision making by ambulance clinicians.

http://stroke.ahajournals.org/content/44/11/3007.abstract.html?etoc

The impact of peri-shock pause on survival from out-of-hospital shockable cardiac arrest during the Resuscitation Outcomes Consortium PRIMED trial

© Gary Wilson/ Pre-hospital Research Forum

Resuscitation. Available online 25 October 2013

Previous research has demonstrated significant relationships between peri-shock pause and survival to discharge from out-of-hospital shockable cardiac arrest (OHCA).

Objective
To determine the impact of peri-shock pause on survival from OHCA during the ROC PRIMED randomized controlled trial.

Methods
The authors included patients in the ROC PRIMED trial who suffered OHCA between June 2007 and November 2009, presented with a shockable rhythm and had CPR process data for at least one shock. We used multivariable logistic regression to determine the association between peri-shock pause duration and survival to hospital discharge.

Results
Among 2006 patients studied, the median (IQR) shock pause duration was: pre-shock pause 15 s (8, 22); post-shock pause 6 s (4, 9); and peri-shock pause 22.0 s (14, 31). After adjusting for Utstein predictors of survival as well as CPR quality measures, the odds of survival to hospital discharge were significantly higher for patients with pre-shock pause <10 s (OR: 1.52, 95% CI: 1.09, 2.11) and peri-shock pause <20 s when compared to patients with pre-shock pause ≥20 s and peri-shock pause ≥40 s. Post-shock pause was not significantly associated with survival to hospital discharge. Results for neurologically intact survival (Modified Rankin Score ≤ 3) were similar to our primary outcome.

Conclusions
In patients with cardiac arrest presenting in a shockable rhythm during the ROC PRIMED trial, shorter pre- and peri-shock pauses were significantly associated with higher odds of survival. Future cardiopulmonary education and technology should focus on minimizing all peri-shock pauses.

http://www.sciencedirect.com/science/article/pii/S0300957213008149

Vented Chest Seals for Prevention of Tension Pneumothorax in a Communicating Pneumothorax

The Journal of Emergency Medicine. Volume 45, Issue 5, Pages 686-694, November 2013

Tension pneumothorax accounts for 3%–4% of combat casualties and 10% of civilian chest trauma. Air entering a wound via a communicating pneumothorax rather than by the trachea can result in respiratory arrest and death. In such cases, the Committee on Tactical Combat Casualty Care advocates the use of unvented chest seals to prevent respiratory compromise.

Objective
A comparison of three commercially available vented chest seals was undertaken to evaluate the efficacy of tension pneumothorax prevention after seal application.

Methods
A surgical thoracostomy was created and sealed by placing a shortened 10-mL syringe barrel (with plunger in place) into the wound. Tension pneumothorax was achieved via air introduction through a Cordis to a maximum volume of 50 mL/kg. A 20% drop in mean arterial pressure or a 20% increase in heart rate confirmed hemodynamic compromise. After evacuation, one of three vented chest seals (HyFin®, n = 8; Sentinel®, n = 8, SAM®, n = 8) was applied. Air was injected to a maximum of 50 mL/kg twice, followed by a 10% autologous blood infusion, and finally, a third 50 mL/kg air bolus. Survivors completed all three interventions, and a 15-min recovery period.

Results
The introduction of 29.0 (±11.5) mL/kg of air resulted in tension physiology. All three seals effectively evacuated air and blood. Hemodynamic compromise failed to develop with a chest seal in place.

Conclusions
HyFin®, SAM®, and Sentinel® vented chest seals are equally effective in evacuating blood and air in a communicating pneumothorax model. All three prevented tension pneumothorax formation after penetrating thoracic trauma.

http://www.jem-journal.com/article/S0736-4679(13)00507-6/abstract?elsca1=etoc&elsca2=email&elsca3=0736-4679_201311_45_5&elsca4=emergency_medicine