Benjamin Nicholson

Relationship of the distance between non-PCI hospitals and primary PCI centers, mode of transport, and reperfusion time among ground and air interhospital transfers using NCDR's ACTION Registry-GWTG: a report from the American Heart Association Mission: Lifeline Program.

Background—ST-segment myocardial infarction patients frequently present to non-percutaneous coronary intervention (PCI) hospitals and require interhospital transfer for primary PCI. The effect of distance and mode of transport to the PCI center and the frequency that recommended primary PCI times are met are not clear. Methods and Results—Data from the ACTION Registry®-GWTG™ were used to determine the distance between the Non-PCI and PCI center and first door time to balloon time based on transfer mode (ground and air) for patients having interhospital transfer for primary PCI. From July 1, 2008, to December 31, 2012, 17 052 ST-segment myocardial infarction patients were transferred to 413 PCI hospitals. The median distance from the non-PCI hospital to the primary PCI center was 31.9 miles (Q1, Q3: 19.1, 47.9; ground 25.2 miles; air 43.9 miles; P<0.001). At distances <40 miles, ground transport was the primary transport method, whereas at distances >40 miles air transport predominanted. Median first door time to balloon time time for patients transferred for primary PCI was 118 minutes (Q1, Q3: 95 152), with time for patients transported by air significantly longer (median 124 versus 113 minutes; respectively, P<0.001) than for patients transported by ground. Fifty-three percent of patients had a first door time to balloon time ⩽120 minutes, with only 20% ⩽90 minutes. A first door time to balloon time ⩽120 minutes was more likely in ground than in air transport patients (57.0% versus 45.6%; P<0.001). Conclusions—Interhospital transfer for primary PCI is associated with prolonged reperfusion times. These delays should prompt increased consideration of fibrinolytic therapy, emergency medical services hospital bypass protocols, and improved systems of care for ST-segment myocardial infarction patients requiring transfer.

Traumatic tension pneumocephalus after blunt head trauma and positive pressure ventilation.

Abstract Pneumocephalus following head trauma is relatively rare, with tension pneumocephalus occurring in an even smaller group of patients. This review presents a recent case of tension pneumocephalus following the use of a manually operated bag–valve–mask to assist ventilations prior to rapid-sequence intubation. A discussion of this case in terms of other reported cases of pneumocephalus after oxygen therapy follows. A limited number of current case reports identified in the literature indicate a connection between pneumocephalus and positive pressure ventilation following blunt trauma. Continuous positive airway pressure (CPAP) ventilation use in patients with an undiagnosed skull fracture is the most common reported cause of ventilation-related pneumocephalus. The case review presented here identifies the use of a bag–valve–mask prior to intubation as a possible contributory cause of the tension pneumocephalus. With only one prior case reported in the literature of pneumocephalus following the use of a bag–valve–mask, this case is unique and may indicate the need for additional awareness for this rare complication. The prehospital diagnosis of pneumocephalus is difficult, as the symptoms and mechanism of injury mimic those associated with intracranial hemorrhage. The use of mannitol in the prehospital treatment of this patient and subsequent improvement in pupillary response may indicate that mannitol has a role in the treatment of tension pneumocephalus when neurosurgical services are not readily available. Additional research is needed to better understand the benefits and risks associated with this treatment modality.

Pediatric Blunt Neck Trauma Causing Esophageal and Complete Tracheal Transection

ABSTRACT Background: Blunt injuries to the cervical trachea remain rare but present unique and challenging clinical scenarios for prehospital providers. These injuries depend on prehospital providers either definitively securing the injured airway or bridging the patient to a treatment facility that can mobilize the necessary resources. Case Summary: The case presented here involves a clothesline injury to a pediatric patient that resulted in complete tracheal transection and partial esophageal transection. Ground and air prehospital providers utilized a stepwise approach to this airway injury and achieved a favorable outcome. The patient was serendipitously intubated through a blind nasal approach that entered the proximal esophagus, exited through the tear and entered the distal trachea. Discussion: There is a paucity of literature describing the successful management of these devastating injuries. While some authors have advocated for early flexible fiberoptic intubation or proceeding directly to tracheostomy, these techniques are not available in the prehospital environment. This case also highlights the inherent issues with proceeding to cricothyroidotomy in patients with tracheal trauma and should give all providers pause before considering this management technique. Conclusion: Ultimately, a systematic approach to all airways will ensure that prehospital providers are best prepared for even the most challenging scenarios.

Emergency medical services (EMS) training in Kenya: Findings and recommendations from an educational assessment

Background Over the past twenty years, Kenya has been developing many important components of a prehospital emergency medical services (EMS) system. This is due to the ever-increasing demand for emergency medical care across the country. To better inform the next phase of this development, we undertook an assessment of the current state of EMS training in Kenya. Methods A group of international and Kenyan experts with relevant EMS and educational expertise conducted an observational qualitative assessment of Kenyan EMS training institutions in 2016. Three assessment techniques were utilised: semi-structured interviews, document review, and structured observations. Recommendations were reached through a consensus process amongst the assessment team. Results Key findings include: (i) No national or state-level policy exists that establishes levels of EMS providers or expected fund of knowledge and skills; (ii) Training institutions have independently created their own individual training standards; (iii) Training materials are not adapted for the local context; (iv) The foundation of basic anatomy and physiology education is weak; (v) Training does not focus on symptom- or syndrome-based complaints; (vi) Students had difficulty applying foundational classroom knowledge in simulations and clinical encounters; (vii) There is limited emphasis on complex critical thinking. Discussion Standardisation of training is needed in Kenya, including clearly defined levels of providers and expected learning outcomes. A nationally standardised EMS provider scope of practice may also help focus EMS education. Instructors must reinforce basic anatomy and physiology amongst all trainees to establish a robust foundation, then layer on field experience before trainees receive advanced training. Training graduates should be EMS providers who approach patient care with high-order symptom- or syndrome-based critical thinking. While these recommendations are specific to the Kenyan EMS environment, they may have wider applicability to other developing EMS systems in resource-limited settings.

Helicopter Transport in Regionalized Burn Care: One Program's Perspective

BACKGROUND The decision to use helicopter EMS (HEMS) for the transport of burn patients is a complex decision. This analysis sought to evaluate burn patients flown to burn centers who met predetermined criteria for patients who likely benefit from HEMS care. METHODS A retrospective transport chart review of all burn transports covering the preceding nine and a half years was conducted to evaluate for HEMS appropriate criteria defined as patients requiring advanced airway management, ventilator support, facial burns, inhalation injury, circumferential burns, electrical or chemical burn, or major burns. All ages were included. RESULTS A total of 171 cases were identified. Thirty-one (18.1%) were pediatric. Facial burns constituted the most frequent criteria met with 112 (65.5%) patients identified. Sixty-nine (40.4%) had suspected inhalation injuries. Fifty-five (32.2%) patients were intubated. Forty (28.6%) adults and twelve (38.7%) children had major burns. CONCLUSION Of the 171 burn patient transported, twenty-one (12.3%) patients did not meet any HEMS criteria. Excluding those who did not meet any criteria, 98 (57.3%) patients were flown with non-major burns. Efforts are needed to determine the risks burn patients face if slower, non-critical care transport is utilized and which patients are appropriate for HEMS.