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

Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes

© Gary Wilson/ Pre-hospital Research Forum

This Cochrane Review examines the effects of different policies for clamping the umbilical cord after birth for babies born at term. It compares early cord clamping, which usually takes place within 60 seconds of birth, versus later clamping that usually involves clamping the cord more than one minute after birth or when cord pulsation has ceased.

In the past, the umbilical cord has usually been clamped shortly following the birth of the baby, as part of the active management of the third stage of labour. This strategy might also involve the infant being placed on the mother’s abdomen, put to the breast or more closely examined on a warmed cot if resuscitation was required. However, more recent guidelines for management of the third stage of labour no longer recommend immediate cord clamping, and later clamping of the umbilical cord might take place when cord pulsation has ceased or beyond the first minute following the birth of the baby. However, there is ongoing uncertainty about the relative benefits, or harms, of the two approaches. There have been concerns that late cord clamping might increase the mother’s risk of a postpartum haemorrhage, that could outweigh potential benefits to the baby of delaying clamping which might arise from the extra time for a transfer of the fetal blood in the placenta to the infant at the time of birth. This placental transfusion can provide the infant with an additional 30% more blood volume and up to 60% more red blood cells.

Policies for timing of cord clamping vary, with early cord clamping generally carried out in the first 60 seconds after birth, whereas later cord clamping usually involves clamping the umbilical cord more than one minute after the birth or when cord pulsation has ceased. The benefits and potential harms of each policy are debated.

No studies in this review reported on maternal death or on severe maternal morbidity. There were no significant differences between early versus late cord clamping groups for the primary outcome of severe postpartum haemorrhage or for postpartum haemorrhage of 500 mL or more. There were no significant differences between subgroups depending on the use of uterotonic drugs. Mean blood loss was reported in only two trials with data for 1345 women, with no significant differences seen between groups; or for maternal haemoglobin values at 24 to 72 hours after the birth in three trials.

Neonatal outcomes: There were no significant differences between early and late clamping for the primary outcome of neonatal mortality, or for most other neonatal morbidity outcomes, such as Apgar score less than seven at five minutes or admission to the special care nursery or neonatal intensive care unit. Mean birthweight was significantly higher in the late, compared with early, cord clamping. Fewer infants in the early cord clamping group required phototherapy for jaundice than in the late cord clamping group.

Haemoglobin concentration in infants at 24 to 48 hours was significantly lower in the early cord clamping group. This difference in haemoglobin concentration was not seen at subsequent assessments. However, improvement in iron stores appeared to persist, with infants in the early cord clamping over twice as likely to be iron deficient at three to six months compared with infants whose cord clamping was delayed . In the only trial to report longer-term neurodevelopmental outcomes so far, no overall differences between early and late clamping were seen for Ages and Stages Questionnaire scores.

Authors’ conclusions
A more liberal approach to delaying clamping of the umbilical cord in healthy term infants appears to be warranted, particularly in light of growing evidence that delayed cord clamping increases early haemoglobin concentrations and iron stores in infants. Delayed cord clamping is likely to be beneficial as long as access to treatment for jaundice requiring phototherapy is available.

http://www.cochranejournalclub.com/umbilical-cord-clamping-timing-clinical/pdf/CD004074.pdf (full text)