Holly Herron

Emergency scene endotracheal intubation before and after the introduction of a rapid sequence induction protocol.

INTRODUCTION A change in airway management protocol provided the opportunity to evaluate scene airway management by air medical crew before and after the introduction of a rapid sequence induction protocol. METHODS A retrospective chart review and a descriptive study of scene trauma patients whose airway was established primarily by an air medical crew during two study periods: April 1994 through March 1995 (group 1, before rapid sequence induction) and April 1995 through March 1996 (group 2, after rapid sequence induction). Data collected included demographics, type of airway, Glasgow Coma Scale score, scene time, and outcome. The setting included a four helicopter air medical transport program using nurse/paramedic crews with a service area of 25,000 square miles in central, southeastern, and northeastern Ohio. RESULTS Group 1 patients (n = 148) averaged 31.6 years of age and were primarily male (79.7%) with blunt injuries (92.6%) with an average Glasgow Coma Scale score of 7.7. Group 2 (n = 95) was similar, averaging 31.1 years of age, primarily male (77.9%) with blunt injuries (94.7%) and a Glasgow Coma Scale score of 8.6. Groups 1 and 2 differed in oral endotracheal intubation rate (19/118 versus 36/95 [p = 0.03]) and in scene time (15.7 minutes versus 20.1 minutes [p = 0.0012]). The groups did not differ in rate of successful intubation or the rate of subsequent cricothyrotomy. CONCLUSION Rapid sequence induction added significantly to ground time without significantly increasing intubation success rate or decreasing cricothyrotomy rate. Its use at the scene of injury may not be appropriate.

Air medical transport of the injured patient: scene versus referring hospital.

INTRODUCTION In a rural service area, does the outcome of air medical patients transferred from the scene of injury differ from that of patients transferred from a primary receiving hospital? METHODS Retrospective review of all injured patients transported by air to a single trauma center during calendar year 1996. Data collected include basic patient demographics, time of injury, revised trauma score (RTS), injury severity score (ISS), probability of survival (PS), hospital length of stay (LOS), complications, disposition, and mortality. RESULTS Concerning trauma admission, 594 of 1461 (40.7%) were transported by air: 363 from the scene (24.9%) and 231 from referring hospitals (15.8%). These two groups were similar in demographics, injury severity, hospital LOS, and crude mortality: RTS, 6.61 versus 6.68 (P > 0.05); ISS, 16.0 versus 16.0 (P > 0.05); LOS = 6.9 days versus 7.3 days (P > 0.05); mortality = 11.8% versus 10.8% (P > 0.05). The groups differed significantly, however, in time from injury to definitive care (34.2 minutes versus 196.2 minutes, P < 0.001), overall complication rate (39.1% versus 57.6%, P = 0.009), and potentially preventable deaths (PS > 0.5, 11.6% versus 44%, P = 0.02). CONCLUSION Patient groups were similar, suggesting similar triage criteria. Patients transferred from a referring hospital took almost six times longer to reach definitive care and may have suffered an increased morbidity and mortality on this basis.

Helicopter transport of patients to tertiary care centers after cardiac arrest

Air transport is commonly used to transfer survivors of cardiac arrest from rural hospitals to large tertiary-care centers, presumably to improve outcome. To examine this issue, a retrospective review of patients stabilized after a cardiac arrest was conducted; 157 transports were reviewed. The mean age of patients was 37.9 +/- 27.8 yrs, with a male to female ratio of 2.2:1. Survivors were significantly older than nonsurvivors. Thirty-one of 69 patients (45%) with primary cardiac disease were discharged alive from the hospital, 75% without neurological sequelae. Only a minority of patients with noncardiac medical illness (7%), electrical injury (33%), suffocation (15%), near-drowning (15%), and inhalation (0%) were discharged alive from the hospital. Outcomes for cardiac arrest in adult patients older than 65 years (32.3% survival) were similar to those for adult patients younger than 65 years (36.2% survival) (P = .887). These results show that survivors of a primary cardiac event have a favorable outcome when transferred by air to tertiary centers when compared with historical controls that were transported by ground. On the other hand, cardiac arrests from noncardiac medical illness, suffocation, near-drowning, and inhalation have a grim prognosis. Prospective studies should clarify the role of air transport in these patients.

Trauma and nontrauma cardiopulmonary arrest: A national survey

INTRODUCTION This survey attempts to identify the current standard of care for the air medical transport of the patient in cardiopulmonary arrest. METHOD An Association of Air Medical Services/National Flight Nurses Association-approved survey by a single mailing with an anonymous response. SETTING All rotor-craft programs with current memberships in AAMS. RESULTS Fifty-three of the 178 questionnaires mailed were returned. Program demographics, crew composition and transport volumes were typical of other reported national experiences. The majority of programs (84%) had standing operational protocols for trauma and non-trauma cardiopulmonary arrests. The indications for not initiating or discontinuing CPR, the transport of the patient in cardiopulmonary arrest, triage and financial considerations varied widely between air medical programs. CONCLUSIONS This study provides some insight on the current air medical management of the patient in cardiopulmonary arrest. National practice guidelines should be developed and tested prospectively in future studies.

Clinical Clearance of Spinal Immobilization in the Air Medical Environment: A Feasibility Study

BACKGROUND Various decision algorithms have been developed for use in the prehospital setting to analyze those trauma patients who do not require spinal immobilization. The feasibility of applying these algorithms in the air medical transport environment has not been studied. METHODS All adult patients (>/=age 16) transported to three Level I trauma centers were eligible for the study. Medical crews completed a data collection sheet during transport which was later used to analyze whether the transported patient would be eligible for spinal clearance based on the absence of all of the following clinical findings: (1) abnormal level of consciousness; (2) evidence of intoxication; (3) distracting painful injury; (4) spinal tenderness or pain; or (5) abnormal neurologic examination. The outcomes were (1) the proportion of transported patients potentially eligible for spinal clearance and (2) the ability of the algorithm to predict spinal injury. RESULTS Three hundred twenty-nine patients were enrolled in the study. Forty-nine (15%) had spinal injuries with 12 (24%) considered unstable. Only 40 patients met criteria for deferring spinal immobilization; 4 of these patients had spinal fractures. The algorithm had a sensitivity of 90% and a specificity of 16%. CONCLUSION Clearance of spinal immobilization using prehospital clinical algorithms during air medical transport did not appear to be useful. These criteria were not found to be sensitive, specific, or predictive of spinal injury in this population of blunt trauma patients. Prehospital spinal immobilization clearance algorithms using existing criteria should not be adopted for patients transported by helicopter.

Prehospital decompression for suspected tension pneumothorax

Abstract Introduction: This single institutional experience with needle decompression of a tension pneumothorax in the prehospital setting was stimulated because of the paucity of information in the literature. Methods: Retrospective, descriptive review of prehospital needle decompression. Setting: Three-helicopter air medical program staffed with nurse/paramedic crew in a primarily rural service area. Results: Seventy-five of 6,112 patients transported during the study period (1.2%) required needle decompression. Patients averaged 36.7 years of age, Trauma Score averaged 4.6, Injury Severity Score averaged 37.3, and hospital length of stay for survivors averaged 7.8 days. Confirmation of the pneumothorax and clinical improvement post decompression occurred in a little over half of the study patients. The single, most accurate sign of a tension pneumothorax was increased difficulty in manually ventilating the patient. Only one complication could be related directly to needle decompression. The overall mortality was high (49 of 75 patients). Conclusions: The majority of patients died of their injuries in the prehospital setting. The procedure appeared safe and effective. Prospective study is indicated to further define the population that might most benefit from prehospital needle decompression.

Air Medical Program Merger and Stress

INTRODUCTION How does the stress of a program merger affect job stress in air medical transport? METHODS This study was an anonymous survey of 104 transport personnel in a Mid-western critical care transport program with merged air and ground components. Tools included the Social Readjustment Rating Scale (SRRS), which quantitates stressful life events on a weighted scale that allows summation as a score, and the Medical Personnel Stress Survey (MPSS), which quantitates work stress in four categories: organizational stress (OS) related to work environment, frustration/exhaustion (FE) related to patient care, job satisfaction (JS) related to decreased self-worth, and psychosomatic complaints (PC), stress manifested as personal illness. Statistical analysis was performed with a variety of tools. RESULTS Fifty of 104 personnel responded completely. The average SRRS was low at 130.9; only 20% had scores above 200. No significant differences in MPSS occurred in personnel with high and low SRRS scores. Additionally, the SRRS correlated weakly with OS (r = -0.297, P < 0.05). Within the MPSS, OS correlated with FE and JS (r = 0.493, P = 0.0005; r = -0.593, P < 0.0001) and FE correlated with JS (r = -0.36, P = 0.01). CONCLUSION The overall personnel stress levels in this air medical program with merged air and ground components were low and appeared to be unrelated to organizational stress. This finding may be a result in part of the careful attention paid to stress and the elimination of stressors during the merger process.

8.5 French peripheral intravenous access during air medical transport of the injured patient

Abstract Introduction: This study describes a simple approach to peripheral large-bore intravenous (IV) access for the injured patient. Method: Retrospective chart review of patients identified by concurrent transport registry who received peripheral 8.5 F IV access during air medical transport for injury. The transport program consists of four remote-based BK-117 helicopters staffed by a nurse/paramedic crew. A peripheral 8.5 F IV access was obtained by protocol using guidewire technique over an existing peripheral IV. Crew education consisted of a combination of didactic and hands-on experience updated periodically on an ongoing basis. Results: From July 1991 through March 1995, 23 injured patients transported to a single Level I trauma center received a peripheral 8.5 F introducer. The patients averaged 30.9 years of age and were primarily male (78.3%) with blunt injuries (87%). Initial trauma score averaged 9.8; injury severity score averaged 24.6. All patients had at least one additional IV line; 21 of 23 patients were endotracheally intubated. Ground times averaged 19 minutes, flight time averaged 22.1 minutes, and in-flight fluids averaged 2239 ml or 101 ml per minute of flight. Complications associated with prehospital IV access did not occur. Conclusion: Peripheral 8.5 F access through a guidewire technique of an existing IV provides a rapid, simple approach to large-bore IV access in the injured patient transported by air.