Professor Richard Lyon MBE

Introduction

Major trauma can result in both life-threatening haemorrhage and traumatic brain injury (TBI). The pre-hospital management of these conditions, particularly in relation to the cardiovascular system, is very different. TBI can result in cardiovascular instability but the exact incidence remains poorly described. This study explores the incidence of cardiovascular instability in patients undergoing pre-hospital anaesthesia for suspected TBI.

Methods

Retrospective case series of all pre-hospital trauma patients attended by Kent, Surrey & Sussex Air Ambulance Trust (United Kingdom) trauma team during the period 1 January 2015?31 December 2016. Patients were included if they showed clinical signs of TBI, underwent pre-hospital anaesthesia and hospital computed tomography scanning subsequently confirmed an isolated TBI.

Results

Out of 121 patients with confirmed isolated TBI, 68 were cardiovascularly stable throughout the pre-anaesthesia phase, whilst 53 (44%) showed signs of instability (HR/Ã/100bpm and/or SBP/Â/100/mmHg pre-anaesthesia). Hypotension (SBP/Â/100) with or without tachycardia was present in 14 (12%) patients. 10 (8%) patients with isolated TBI received pre-hospital blood product transfusion.

Conclusion

Increased awareness that traumatic brain injury can cause significant derangement to heart rate and blood pressure, even in the absence of major haemorrhage, would allow the pre-hospital clinician to treat cardiovascular instability with the most appropriate means, such as crystalloid and vasopressors, to limit secondary brain injury.

Background

Poor communication during patient handover is recognised internationally as a root cause of a significant proportion of preventable deaths. Improving the accuracy and quality of handover may reduce associated mortality and morbidity. Although the practice of handover between Ambulance and Emergency Department clinicians has received some attention over recent years there is little evidence to support handover best practice within the prehospital domain. Further research is therefore urgently required to understand the most appropriate way to deliver clinical information exchange in the pre-hospital environment. We aimed to investigate current clinical information exchange practices, perceived challenges and the preferred handover mnemonic for use during transfer of high acuity patients between ambulance clinicians and specialist prehospital teams.

Methods

A national, cross-sectional questionnaire study. Participants were road based ambulance clinicians (RBAC) or active members of specialist prehospital teams (SPHT) based in Scotland.

Results

Over a three month study period there were 247 prehospital incidents involving specialist teams. 190 individuals completed the questionnaire; 61% [n=116] RBAC and 39% [n=74] SPHT. Median length of prehospital experience was 10 years (IQR 5-18). Overall current prehospital handover practices were perceived as being effective (Mdn 4.00; IQR 3-4 [1= very ineffective - 5 = very effective]) although SPHT clinicians rated handover effectiveness slightly lower than RBAC's (Mdn 3.00 vs 4.00, U = 1842.5, p = .03). 'ATMIST' (Age, Time of onset, Medical complaint/injury, Investigation, Signs and Treatment) was deemed the mnemonic of choice. The clinical variables perceived as essential for handover are not explicitly identified within the SBAR mnemonic. The most frequently reported method of recording and transferring information during handover was via memory (n=112 and n=120 respectively) and ?interruptions? were perceived as the most significant barrier to effective handover.

Conclusion

While, overall, current prehospital handover practice is perceived as effective this study has identified a number of areas for handover improvement. These include the development of a shared mental model through system standardisation, innovations to support information recording and delivery, and the clear identification at incidents of a handover lead. Mnemonics must be carefully selected to ensure they explicitly contain the perceived essential clinical variables required for prehospital handover; the mnemonic ATMIST meets these requirements. New theoretically informed, evidence-based interventions, must be developed and tested within existing systems of care to minimise information loss and risk to patients.

Poor communication during patient handover is recognised internationally as a root cause of a significant proportion of preventable deaths. Improving the accuracy and quality of handover may reduce associated mortality and morbidity. Although the practice of handover between Ambulance and Emergency Department clinicians has received some attention over recent years there is little evidence to support handover best practice within the prehospital domain. Further research is therefore urgently required to understand the most appropriate way to deliver clinical information exchange in the pre-hospital environment. We aimed to investigate current clinical information exchange practices, perceived challenges and the preferred handover mnemonic for use during transfer of high acuity patients between ambulance clinicians and specialist prehospital teams.

A national, cross-sectional questionnaire study. Participants were road based ambulance clinicians (RBAC) or active members of specialist prehospital teams (SPHT) based in Scotland.

Over a three month study period there were 247 prehospital incidents involving specialist teams. One hundred ninety individuals completed the questionnaire; 61% [n = 116] RBAC and 39% [n = 74] SPHT. Median length of prehospital experience was 10 years (IQR 5?18). Overall current prehospital handover practices were perceived as being effective (Mdn 4.00; IQR 3?4 [1 = very ineffective - 5 = very effective]) although SPHT clinicians rated handover effectiveness slightly lower than RBAC?s (Mdn 3.00 vs 4.00, U = 1842.5, p = .03). ?ATMIST? (Age, Time of onset, Medical complaint/injury, Investigation, Signs and Treatment) was deemed the mnemonic of choice. The clinical variables perceived as essential for handover are not explicitly identified within the SBAR mnemonic. The most frequently reported method of recording and transferring information during handover was via memory (n = 112 and n = 120 respectively) and ?interruptions? were perceived as the most significant barrier to effective handover.

While, overall, current prehospital handover practice is perceived as effective this study has identified a number of areas for improvement. These include the development of a shared mental model through system standardisation, innovations to support information recording and delivery, and the clear identification at incidents of a handover lead. Mnemonics must be carefully selected to ensure they explicitly contain the perceived essential clinical variables required for prehospital handover; the mnemonic ATMIST meets these requirements. New theoretically informed, evidence-based interventions, must be developed and tested within existing systems of care to minimise information loss and risk to patients.

Poor communication during patient handover is recognised internationally as a root cause of a significant proportion of preventable deaths. Improving the accuracy and quality of handover may reduce associated mortality and morbidity. Although the practice of handover between Ambulance and Emergency Department clinicians has received some attention over recent years there is little evidence to support handover best practice within the prehospital domain. Further research is therefore urgently required to understand the most appropriate way to deliver clinical information exchange in the pre-hospital environment. We aimed to investigate current clinical information exchange practices, perceived challenges and the preferred handover mnemonic for use during transfer of high acuity patients between ambulance clinicians and specialist prehospital teams.

A national, cross-sectional questionnaire study. Participants were road based ambulance clinicians (RBAC) or active members of specialist prehospital teams (SPHT) based in Scotland.

Over a three month study period there were 247 prehospital incidents involving specialist teams. One hundred ninety individuals completed the questionnaire; 61% [n = 116] RBAC and 39% [n = 74] SPHT. Median length of prehospital experience was 10 years (IQR 5?18). Overall current prehospital handover practices were perceived as being effective (Mdn 4.00; IQR 3?4 [1 = very ineffective - 5 = very effective]) although SPHT clinicians rated handover effectiveness slightly lower than RBAC?s (Mdn 3.00 vs 4.00, U = 1842.5, p = .03). ?ATMIST? (Age, Time of onset, Medical complaint/injury, Investigation, Signs and Treatment) was deemed the mnemonic of choice. The clinical variables perceived as essential for handover are not explicitly identified within the SBAR mnemonic. The most frequently reported method of recording and transferring information during handover was via memory (n = 112 and n = 120 respectively) and ?interruptions? were perceived as the most significant barrier to effective handover.

While, overall, current prehospital handover practice is perceived as effective this study has identified a number of areas for improvement. These include the development of a shared mental model through system standardisation, innovations to support information recording and delivery, and the clear identification at incidents of a handover lead. Mnemonics must be carefully selected to ensure they explicitly contain the perceived essential clinical variables required for prehospital handover; the mnemonic ATMIST meets these requirements. New theoretically informed, evidence-based interventions, must be developed and tested within existing systems of care to minimise information loss and risk to patients.

Objectives The aim of this study is to describe the demographics of reported traumatic cardiac arrest (TCA) victims, prehospital resuscitation and survival to hospital rate.

Setting Helicopter Emergency Medical Service (HEMS) in south-east England, covering a resident population of 4.5 million and a transient population of up to 8 million people.

Participants Patients reported on the initial 999 call to be in suspected traumatic cardiac arrest between 1 July 2016 and 31 December 2016 within the trust?s geographical region were identified. The inclusion criteria were all cases of reported TCA on receipt of the initial emergency call. Patients were subsequently excluded if a medical cause of cardiac arrest was suspected.

Outcome measures Patient records were analysed for actual presence of cardiac arrest, prehospital resuscitation procedures undertaken and for survival to hospital rates.

Results 112 patients were reported to be in TCA on receipt of the 999/112 call. 51 (46%) were found not to be in TCA on arrival of emergency medical services. Of the ?not in TCA cohort?, 34 (67%) received at least one advanced prehospital medical intervention (defined as emergency anaesthesia, thoracostomy, blood product transfusion or resuscitative thoracotomy). Of the 61 patients in actual TCA, 10 (16%) achieved return-of-spontaneous circulation. In 45 (88%) patients, the HEMS team escorted the patient to hospital.

Conclusion A significant proportion of patients reported to be in TCA on receipt of the emergency call are not in actual cardiac arrest but are critically unwell requiring advanced prehospital medical intervention. Early activation of an enhanced care team to a reported TCA call allows appropriate advanced resuscitation. Further research is warranted to determine which interventions contribute to improved TCA survival.

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 and 28 days, including a sub-analysis of patients receiving a major and massive transfusion. Multivariable regression models predicted mortality. Multiple Imputation (MI) 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= 0.74). Observed 6 hour 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, 27%) 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, 63%) compared to the PRBC group (n= 41, 46%), 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 hours 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.

The aim of this study was to establish if in patients who die at scene as a result of a traumatic cardiac arrest (TCA), their cause of death could be determined through coroners reports, and to ascertain the quality of the feedback provided.

This is a retrospective study of all patients presenting in TCA who were attended by the Kent, Surrey and Sussex Air Ambulance trust between 1 January 2015 and 30 June 2016.

In total, 159 patients were attended during the study period. PM reports could not be obtained for 37 patients, mainly due to unestablished identities at scene. Forty of the 122 reports obtained were full PM reports, 3 were inquest reports and for 79 patients only their (presumed) cause of death was provided. A specific cause of death was provided for 68 patients, whereas in the remaining 54 patients the cause of death was given as ?multiple injuries?. In 32% of the patients with a full PM report, injuries were identified during the post mortem examination that had not been noted on scene.

Feedback from coroners to pre-hospital teams after patients die as a result of a TCA is important, but currently suboptimal.

Introduction

Helicopter emergency medical services (HEMS) are often dispatched to patients in traumatic cardiac arrest (TCA) as they can provide treatments and advanced interventions in the pre-hospital environment that have the potential to contribute to an increased survival. This study, aimed to investigate the added value of HEMS in the treatment of TCA.

Methods

We performed a retrospective cohort study of all patients with a pre-hospital TCA who were attended by a non-urban HEMS (Kent, Surrey and Sussex Air Ambulance trust) between July 1st 2013 and May 1st 2018. We investigated how many patients got return of spontaneous circulation (ROSC) at scene, which HEMS specific advanced interventions were performed in these patients, and how these interventions were related to ROSC.

Results

During the study period 263 patients with a TCA were attended by HEMS with an average response time of 30/min [range 13?109]. 51 patients (20%) regained ROSC at scene (28 before- and 23 after arrival of HEMS). The HEMS specific interventions of blood product administration (OR 8.54 [2.84?25.72]), and RSI (2.95 [1.32?6.58]) were positively associated with ROSC. Most patients who had a ROSC had one or more HEMS specific interventions being performed ? RSI (n/=/19, 37%), blood product administration (n/=/32, 62%), thoracostomies (n/=/36, 71%) and thoracotomy (n/=/1, 2%). HEMS also delivered other important interventions to these patients as IV/IO access (n/=/20, 39.2%) and endotracheal intubation without drugs (n/=/9, 17.6%).

Conclusion

HEMS teams should be involved in the treatment of patients with a TCA, even in non-urban areas with prolonged response times, as they provide knowledge and skills that contribute to regaining and maintaining a sustained ROSC in this critically ill and injured cohort of patients.

Objectives Patients who sustain a head injury but maintain a Glasgow Coma Scale (GCS) of 13?15 may still be suffering from a significant brain injury. We aimed to assess the appropriateness of triage and decision to perform prehospital rapid sequence induction (RSI) in patients attended by a UK Helicopter Emergency Medical Service (HEMS) following head injury.

Design A retrospective cohort study of patients attended by Kent Surrey & Sussex Air Ambulance Trust (KSSAAT) HEMS.

Setting A mixed urban and rural area of 4.5 million people in South East England.

Participants GCS score of 13, 14 or 15 on arrival of the HEMS team and clinical findings suggesting head injury. Patients accompanied by the HEMS team to hospital (?Escorted?), and those that were ?Assisted? but conveyed by the ambulance service were reviewed. No age restrictions to inclusion were set.

Primary outcome measure Significant brain injury.

Secondary outcome measure Recognition of patients requiring prehospital anaesthesia for head injury.

Results Of 517 patients, 321 had adequate follow-up, 69% of these were Escorted, 31% Assisted. There was evidence of intracranial injury in 13.7% of patients and clinically important brain injury in 7.8%. There was no difference in the rate of clinically important brain injury between Escorted and Assisted patients (p=0.46). Nineteen patients required an RSI by the HEMS team and this patient group was significantly more likely to have clinically important brain injury (p=0.04).

Conclusion In patients attended by a UK HEMS service with a head injury and a GCS of 13?15, a small but significant proportion had a clinically important brain injury and a proportion were appropriately recognised as requiring prehospital RSI. For patients deemed not to need a HEMS intervention, differentiating between those with and without clinically important brain injury appears challenging.

Background

Early transfusion of patients with major traumatic haemorrhage may improve survival. This study aims to establish the feasibility of freeze-dried plasma transfusion in a Helicopter Emergency Medical Service in the United Kingdom.

Method

A retrospective observational study of major trauma patients attended by Kent, Surrey and Sussex Helicopter Emergency Medical Service and transfused freeze-dried plasma since it was introduced in April 2014.

Results

Of the 1873 patients attended over a 12-month period before its introduction, 79 patients received packed red blood cells (4.2%) with a total of 193 units transfused. Of 1881 patients after the introduction of freeze-dried plasma, 10 patients received packed red blood cells only and 66 received both packed red blood cells and freeze-dried plasma, with a total of 158 units of packed red blood cells transfused, representing an 18% reduction between the two 12-month periods. In the 20 months since its introduction, of 216 patients transfused with at least 1 unit of freeze-dried plasma, 116 (54.0%) patients received both freeze-dried plasma and packed red blood cells in a 1:1 ratio. Earlier transfusion was feasible, transferring the patient to hospital prior to transfusion would have incurred a delay of 71 minutes (IQR 59-90).

Conclusion

Pre-hospital freeze-dried plasma and packed red blood cell transfusion is feasible in a 1:1 ratio in patients with suspected traumatic haemorrhage. The use of freeze-dried plasma as a first line fluid bolus reduced the number of pre-hospital packed red blood cell units required and reduced the time to transfusion.

Background

Obtaining accurate information from a 112 caller is key to correct tasking of Helicopter Emergency Medical Services (HEMS). Being able to view the incident scene via video from a mobile phone may assist HEMS dispatch by providing more accurate information such as mechanism of injury and/or injuries sustained. The objective of this study is to describe the acceptability and feasibility of using live video footage from the mobile phone of a 112 caller as an HEMS dispatch aid.

Methods

Live footage is obtained via the 112 caller?s mobile phone camera through the secure GoodSAM app?s Instant-on-scene" platform. Video footage is streamed directly to the dispatcher, and not stored. During the feasibility trial period, dispatchers noted the purpose for which they used the footage and rated ease of use and any technical- and operational issues they encountered. A subjective assessment of caller acceptance to use video was conducted.

Results

Video footage from scene was attempted for 21 emergency calls. The leading reasons listed by the dispatchers to use live footage were to directly assess the patient (18/21) and to obtain information about the mechanism of injury and the scene (11/21). HEMS dispatchers rated the ease of use with a 4.95 on a 5-point scale (range 4?5). All callers gave permission to stream from their telephone camera. Video footage from scene was successfully obtained in 19 calls, and was used by the dispatcher as an aid to send (5) or stand down (14) a Helicopter Emergency Medical Services team.

Conclusion

Live video footage from a 112 caller can be used to provide dispatchers with more information from the scene of an incident and the clinical condition of the patient(s). The use of mobile phone video was readily accepted by the 112 caller and the technology robust. Further research is warranted to assess the impact video from scene could have on HEMS dispatching.

Background:

Since 2016, critical care paramedics from the South East Coast Ambulance Service have offered neuromuscular blockade to patients for ventilatory/airway control after cardiac arrest.

Aims:

To examine the first cases of paramedic-delivered neuromuscular blockade, and evaluate the prevalence of its use and safety.

Methods:

Retrospective service evaluation of patients receiving post-arrest paralysis during the study period from 1 April 2016 until 31 July 2017.

Findings:

The study included 127 patients. The mean age of administration was 63 years, mean weight was 80 kg (SD: 19 kg), dose was 1 mg/kg and median time from rocuronium administration to hospital was 32 minutes (IQR 20?43 minutes). Three patients (2.3%) experienced a minor adverse incident. There were no major airway complications, nor other significant adverse incidents. Thirty-seven patients (31%) survived to discharge.

Conclusion:

From this patient group, paramedic-administered rocuronium in intubated patients who have experienced a cardiac arrest and a return of spontaneous circulation appears to be safe, but further interventional research is required to determine whether this improves patient outcomes.

Introduction

Pre-hospital enhanced care teams like Helicopter Emergency Medical Services (HEMS) are often dispatched to major trauma patients, including patients with traumatic brain injuries and those with major haemorrhage. For these patients, minimizing the time to definitive care is vital. The aim of this study was to determine whether increased awareness of elapsed on scene time produces a relevant time performance improvement for major trauma patients attended by HEMS, and weather introducing such a timer was feasible and acceptable to clinicians.

Methods

We performed a prospective cohort study of all single casualty traumatic incidents attended by Air Ambulance Kent Surrey Sussex (AAKSS) between 15 October 2016 and 23 May 2017 to test if introduction of a prompting scene timer within the service resulted in a reduction in pre-hospital scene times.

Results

The majority of the patients attended were male (74%) and sustained blunt trauma (92%). Overall, median scene time was 25.5 [IQR16.3] minutes before introduction of the scene timer and 23.0 [11.0] minutes after introduction, p = 0.13). Scene times for patients with a GCS Â 8 and for patients requiring prehospital anaesthesia were significantly lower after introduction of the timer (28 [IQR 14] vs 25 [1], p = 0.017 and 34 [IQR 13] vs 28 [IQR11] minutes, p = 0.007 respectively). The majority of clinicians felt the timer made them more aware of passing time (91%) but that this had not made a difference to scene time (62%) or their practice (57%).

Conclusion

Audible scene timers may have the potential to reduce pre-hospital scene time for certain single casualty trauma patients treated by a HEMS team, particularly for those patients needing pre-hospital anaesthesia. Regular use of on-scene timers may improve outcomes by reducing time to definitive care for certain subgroups of trauma patients.

Objective

Prehospital rapid sequence intubation (RSI) is an important aspect of prehospital care for helicopter emergency medical services (HEMS). This study examines the feasibility of in-aircraft (aircraft on the ground) RSI in different simulated settings.

Methods

Using an AW169 aircraft cabin simulator at Air Ambulance Kent Surrey Sussex, 3 clinical scenarios were devised. All required RSI in a ?can intubate, can ventilate? (easy variant) and a ?can't intubate, can't ventilate? scenario (difficult variant). Doctor-paramedic HEMS teams were video recorded, and elapsed times for prespecified end points were analyzed.

Results

Endotracheal intubation (ETI) was achieved fastest outside the simulator for the easy variant (median/=/231 seconds, interquartile range/=/28 seconds). Time to ETI was not significantly longer for in-aircraft RSI compared with RSI outside the aircraft, both in the easy (p = .14) and difficult variant (p = .50). Wearing helmets with noise distraction did not impact the time to intubation when compared with standard in-aircraft RSI, both in the easy (p = .28) and difficult variant (p = .24).

Conclusion

In-aircraft, on-the-ground RSI had no significant impact on the time to successful completion of ETI. Future studies should prospectively examine in-cabin RSI and explore the possibilities of in-flight RSI in civilian HEMS services.

Background

For the prehospital diagnosis of raised intracranial pressure (ICP), clinicians are reliant on clinical signs such as the Glasgow Coma Score (GCS), pupillary response and/or Cushing?s triad (hypertension, bradycardia and an irregular breathing pattern). This study aimed to explore the diagnostic accuracy of these signs as indicators of a raised ICP.

Methods

We performed a retrospective cohort study of adult patients attended by a Helicopter Emergency Medical Service (Air Ambulance Kent, Surrey Sussex), who had sustained a traumatic brain injury (TBI), requiring prehospital anaesthesia between 1 January 2016 and 1 January 2018. We established optimal cut-off values for clinical signs to identify patients with a raised ICP and investigated diagnostic accuracy for combinations of these values.

Results

Outcome data for 249 patients with TBI were available, of which 87 (35%) had a raised ICP. Optimal cut-off points for systolic blood pressure (SBP), heart rate (HR) and pupil diameter to discriminate patients with a raised ICP were, respectively, Ã160 mm Hg,Â60 bpm and Ã5 mm. Cushing criteria (SBP Ã160 mm Hg and HR Â60 bpm) and pupillary response and size were complimentary in their ability to detect patients with a raised ICP. The presence of a fixed blown pupil or a Cushing?s response had a specificity of 93.2 (88.2?96.6)%, and a positive likelihood ratio (LR+) of 5.4 (2.9?10.2), whereas sensitivity and LR? were only 36.8 (26.7?47.8)% and 0.7 (0.6?0.8), respectively, (Area Under the Curve (AUC) 0.65 (0.57?0.73)). Sensitivity analysis revealed that optimal cut-off values and resultant accuracy were dependent on injury pattern.

Conclusion

Traditional clinical signs of raised ICP may under triage patients to prehospital treatment with hyperosmolar drugs. Further research should identify more accurate clinical signs or alternative non-invasive diagnostic aids in the prehospital environment.