Anne Weaver

Observational study of the success rates of intubation and failed intubation airway rescue techniques in 7256 attempted intubations of trauma patients by pre-hospital physicians

BACKGROUND Effective airway management is a priority in early trauma management. Data on physician pre-hospital tracheal intubation are limited; this study was performed to establish the success rate for tracheal intubation in a physician-led system and examine the management of failed intubation and emergency surgical cricothyroidotomy in pre-hospital trauma patients. Failed intubation rates for anaesthetists and non-anaesthetists were compared. METHODS A retrospective database review was conducted to identify trauma patients undergoing pre-hospital advanced airway management between September 1991 and December 2012. The success rate of tracheal intubation and the use and success of rescue techniques were established. Success rates of tracheal intubation by individuals and by speciality were recorded. RESULTS The doctor-paramedic team attended 28 939 patients; 7256 (25.1%) required advanced airway management. A surgical airway was performed immediately, without attempted laryngoscopy, in 46 patients (0.6%). Tracheal intubation was successful in 7158 patients (99.3%). Rescue surgical airways were performed in 42 patients, seven had successful insertion of supraglottic devices, and two patients had supraglottic device insertion and a surgical airway. One patient breathed spontaneously with bag-valve-mask support during transfer. All rescue techniques were successful. Non-anaesthetists performed 4394 intubations and failed to intubate in 41 cases (0.9%); anaesthetists performed 2587 intubations and failed in 11 (0.4%) (P=0.02). CONCLUSIONS This is the largest series of physician pre-hospital tracheal intubation; the success rate of 99.3% is consistent with other reported data. All rescue airways were successful. Non-anaesthetists were twice as likely to have to perform a rescue airway intervention than anaesthetists. Surgical airway rates reported here (0.7%) are lower than most other physician-led series (median 3.1%, range 0.1-7.7%).

Advanced airway management is necessary in prehospital trauma patients

BACKGROUND Treatment of airway compromise in trauma patients is a priority. Basic airway management is provided by all emergency personnel, but the requirement for on-scene advanced airway management is controversial. We attempted to establish the demand for on-scene advanced airway interventions. Trauma patients managed with standard UK paramedic airway interventions were assessed to determine whether airway compromise had been effectively treated or whether more advanced airway management was required. METHODS A prospective observational study was conducted to identify trauma patients requiring prehospital advanced airway management attended by a doctor-paramedic team. The team assessed and documented airway compromise on arrival, interventions performed before and after their arrival, and their impact on airway compromise. RESULTS Four hundred and seventy-two patients required advanced airway intervention and received 925 airway interventions by ground-based paramedics. Two hundred and sixty-nine patients (57%) still had airway compromise on arrival of the enhanced care team; no oxygen had been administered to 52 patients (11%). There were 45 attempted intubations by ground paramedics with a 64% success rate and 11% unrecognized oesophageal intubation rate. Doctor-paramedic teams delivering prehospital anaesthesia achieved definitive airway management for all patients. CONCLUSIONS A significant proportion of severely injured trauma patients required advanced airway interventions to effectively treat airway compromise. Standard ambulance service interventions were only effective for a proportion of patients, but might not have always been applied appropriately. Complications of advanced airway management occurred in both provider groups, but failed intubation and unrecognized oesophageal intubation were a particular problem in the paramedic intubation group.

The introduction of on-scene blood transfusion in a civilian physician-led pre-hospital trauma service

Background London’s Air Ambulance (LAA) teams attend over 2000 trauma missions per year. Ten percent of patients suffer from serious haemorrhage. Since 2008, physician-led pre-hospital teams have activated “Code Red – massive haemorrhage protocol” pre-alerts to the Major Trauma Centres in London.[1] A significant number of seriously injured patients die at the scene of the incident. Major haemorrhage contributes to a proportion of these deaths and until recently, fluid resuscitation consisted of crystalloid infusion. Studies have demonstrated dismal outcomes from hypovolaemic traumatic arrest.[2] In March 2012, LAA became the first service in the United Kingdom to routinely carry emergency O Negative blood (packed red blood cells PRBC). Indications to transfuse include traumatic arrest where hypovolaemia is a contributing factor or patients who meet Code Red criteria and require volume resuscitation prior to hospital. Our aim was to examine the impact of on-scene blood transfusion for seriously injured patients.

Pre-hospital transfusion of red blood cells in civilian trauma patients: Pre-hospital transfusion of RBC in trauma patients

The current management of severely injured patients includes damage control resuscitation strategies that minimise the use of crystalloids and emphasise earlier transfusion of red blood cells (RBC) to prevent coagulopathy. In 2012, Londons air ambulance (LAA) became the first UK civilian pre‐hospital service to routinely carry RBC to the trauma scene.

The incidence of penetrating trauma in London: have previously reported increases persisted in the last six years?

Background We have previously reported a 20.5% annual rise in penetrating trauma attended by our pre-hospital trauma service between 1991 and 2006. Data from national registries was conflicting and surprisingly difficult to obtain. We established an increasing trend and predicted a continued rise. This study was performed to establish whether this prediction was correct. Rising penetrating trauma rates have implications for emergency medical care provision and policing.

What UK pre-hospital providers use intranasal analgesia? A survey of its current and planned use by air ambulance services in the United Kingdom

Background Intranasal analgesia (INA) has been used for many years as an alternative method of delivering pain relief in-hospital, especially in paediatric populations [1,2]. London’s Air Ambulance (LAA) is considering introducing and INA standard operating procedure (SOP) to complement their current methods of delivering analgesia pre-hospital. Little data exists on the current use of pre-hospital INA in the United Kingdom (UK). We aimed to determine what prehospital providers in the United Kingdom currently use or plan to introduce INA and what agents they are using.

Pre hospital administration of prothrombin complex concentrate in the head injured patient, a service evaluation

Prothrombin complex concentrate (PCC), provides rapid reversal of warfarin anticoagulation [1] and has been shown to reduce mortality and haematoma expansion secondary to non-traumatic intracerebral haemorrhage, in warfarinised patients [2]. The measurement of international normalised ratio (INR) and administration of PCC to warfarinised patients with an INR >2 and suspected intracranial haemorrhage, are interventions currently undertaken by London’s Air Ambulance (LAA). The feasibility of these interventions is illustrated by a case study of pre hospital administration of PCC and a service evaluation of their utilisation is presented.