Matthew J. Douma

Prehospital ultrasound of the abdomen and thorax changes trauma patient management: A systematic review.

BACKGROUND Ultrasound examination of trauma patients is increasingly performed in prehospital services. It is unclear if prehospital sonographic assessments change patient management: providing prehospital diagnosis and treatment, determining choice of destination hospital, or treatment at the receiving hospital. OBJECTIVE This review aims to assess and grade the evidence that specifically examines whether prehospital ultrasound (PHUS) of the thorax and/or abdomen changes management of the trauma patient. METHODS A systematic review was conducted of trauma patients who had an ultrasound of the thorax or abdomen performed in the prehospital setting. PubMed, MEDLINE, Web of Science (CINAHL, EMBASE, Cochrane Central Register of Controlled Trials) and the reference lists of included studies were searched. Methodological quality was checked and risk of bias analysis performed, a level of evidence grade was assigned, and descriptive data analysis performed. RESULTS 992 unique citations were identified, which included eight studies that met inclusion criteria with a total of 925 patients. There are no reports of randomised controlled trials. Heterogeneity exists between the included studies which ranged from a case series to retrospective and prospective non-randomised observational studies. Three studies achieved a 2+ Scottish Intercollegiate Guidelines Networks grade for quality of evidence and the remainder demonstrated a high risk of bias. The three best studies each provided examples of prehospital ultrasound positively changing patient management. CONCLUSION There is moderate evidence that supports prehospital physician use of ultrasound for trauma patients. For some patients, management was changed based on the results of the PHUS. The benefit of ultrasound use in non-physician services is unclear.

Five-year Retrospective Review of Physician and Non-physician Performed Ultrasound in a Canadian Critical Care Helicopter Emergency Medical Service

Abstract Objective: To describe the use of prehospital ultrasonography (PHUS) to support interventions, when used by physician and non-physician air medical crew (AMC), in a Canadian helicopter emergency medical service (HEMS). Methods: A retrospective review was conducted of consecutive patients who underwent ultrasound examination during HEMS care from January 1, 2009 through March 10, 2014. An a priori created data form was used to record patient demographics, type of ultrasound scan performed, ultrasound findings, location of scan, type of interventions supported by PHUS, factors that affected PHUS completion, and quality indicator(s). Data analysis was performed through descriptive statistics, Students t-test for continuous variables, Z-test for proportions, and Mann-Whitney U Test for nonparametric data. Outcomes included interventions supported by PHUS, factors associated with incomplete scans, and quality indicators associated with PHUS use. Differences between physician and AMC groups were also assessed. Results: PHUS was used in 455 missions, 318 by AMC and 137 by physicians. In combined trauma and medical patients, in the AMC group interventions were supported by PHUS in 26% of cases (95% CI 18–34). For transport physicians the percentage support was found to be significantly greater at 45% of cases (95% CI 34–56) p = < 0.006. Incomplete PHUS scans were common and reasons included patient obesity, lack of time, patient access, and clinical reasons. Quality indicators associated with PHUS were rarely identified. Conclusions: The use of PHUS by both physicians and non-physicians was found to support interventions in select trauma and medical patients. Key words: emergency medical services; aircraft; helicopter; air ambulance; ultrasonography; emergency care, prehospital; prehospital emergency care

A Pragmatic Randomized Evaluation of a Nurse-Initiated Protocol to Improve Timeliness of Care in an Urban Emergency Department.

STUDY OBJECTIVE Emergency department (ED) crowding is a common and complicated problem challenging EDs worldwide. Nurse-initiated protocols, diagnostics, or treatments implemented by nurses before patients are treated by a physician or nurse practitioner have been suggested as a potential strategy to improve patient flow. METHODS This is a computer-randomized, pragmatic, controlled evaluation of 6 nurse-initiated protocols in a busy, crowded, inner-city ED. The primary outcomes included time to diagnostic test, time to treatment, time to consultation, or ED length of stay. RESULTS Protocols decreased the median time to acetaminophen for patients presenting with pain or fever by 186 minutes (95% confidence interval [CI] 76 to 296 minutes) and the median time to troponin for patients presenting with suspected ischemic chest pain by 79 minutes (95% CI 21 to 179 minutes). Median ED length of stay was reduced by 224 minutes (95% CI -19 to 467 minutes) by implementing a suspected fractured hip protocol. A vaginal bleeding during pregnancy protocol reduced median ED length of stay by 232 minutes (95% CI 26 to 438 minutes). CONCLUSION Targeting specific patient groups with carefully written protocols can result in improved time to test or medication and, in some cases, reduce ED length of stay. A cooperative and collaborative interdisciplinary group is essential to success.

Temporization of Penetrating Abdominal-Pelvic Trauma With Manual External Aortic Compression: A Novel Case Report

A young civilian man experienced multiple gunshots to the lower abdomen, pelvis, and thigh. These were not amenable to direct compression by a single rescuer. This report outlines the first case in the peer-reviewed literature of manual external aortic compression after severe trauma. This technique successfully temporized external bleeding for more than 10 minutes and restored consciousness to the moribund victim. Subsequently, external bleeding could not be temporized by a second smaller rescuer, or during ambulance transfer. Therefore, we also gained insights about the possible limits of bimanual compression and when alternates, such as pneumatic devices, may be required. Research is needed to test our presumption that successful bimanual compression requires larger-weight rescuers, smaller-weight victims, and a hard surface. It is therefore unclear whether manual external aortic compression is achievable by most rescuers or for most victims. However, it offers an immediate and equipment-free life-sustaining strategy when there are limited alternatives.

Optimization of indirect pressure in order to temporize life-threatening haemorrhage: A simulation study.

BACKGROUND Minimizing haemorrhage using direct pressure is intuitive and widely taught. In contrast, this study examines the use of indirect-pressure, specifically external aortic compression (EAC). Indirect pressure has great potential for temporizing bleeds not amenable to direct tamponade i.e. abdominal-pelvic, junctional, and multi-site trauma. However, it is currently unclear how to optimize this technique. METHODS We designed a model of central vessel compression using the Malbrain intra-abdominal pressure monitor and digital weigh scale. Forty participants performed simulated external aortic compression on the ground, on a stretcher mattress, and with and without a backboard. RESULTS The greater the rescuers bodyweight the greater was their mean compression (Pearsons correlation 0.93). Using one-hand, a mean of 28% participant bodyweight (95% CI, 26-30%) could be transmitted at sustainable effort, waist-height, and on a stretcher. A second compressing hand increased the percentage of rescuer bodyweight transmission 10-22% regardless of other factors (i.e. presence/absence or a backboard; rescuer position) (p<0.001). Adding a backboard increased transmission of rescuer bodyweight 7-15% (p<0.001). Lowering the patient from waist-height backboard to the floor increased transmission of rescuer bodyweight 4-9% (p<0.001). Kneeling on the model was the most efficient method and transmitted 11% more weight compared to two-handed maximal compression (p<0.001). CONCLUSIONS Efficacy is maximized with larger-weight rescuers who use both hands, position themselves atop victims, and compress on hard surfaces/backboards. Knee compression is most effective and least fatiguing, thus assisting rescuers of lower weight and lesser strength, where no hard surfaces exist (i.e. no available backboard or trauma on soft ground), or when lengthy compression is required (i.e. remote locations). Our work quantifies methods to optimize indirect pressure as a temporizing measure following life-threatening haemorrhage not amenable to direct compression, and while expediting compression devices or definitive treatment.

How intravenous nitroglycerine transit time from bag-to-bloodstream can be affected by infusion technique: a simulation study

Objective To measure the possible delays in intravenous nitroglycerine administration. Methods This was a simulation study of sham intravenous nitroglycerine using a standard nitroglycerine titration protocol. Variables studied were (i) common cannulae/needles, (ii) infusion accessories and (iii) presence of a parallel intravenous saline carrier line (or drive line) infusing at 30 mL/h. Outcomes were (i) delay from bag-to-bloodstream arrival and (ii) the dosage showing on the infusion pump when the sham drug first exits the cannula (aka the ‘presumed initial dosage’). Results There was a statistically significant difference in both (i) time-to-bloodstream arrival and (ii) the dosage showing on the infusion pump as the sham first exits the cannula with (i) different cannulae, (ii) different accessories and (iii) presence of a carrier line. The bag-to-bloodstream time varied 10-fold: 197–2062 s. The ‘presumed initial dosage’ varied sixfold: 5–30 µg/min. Adding the medication to an already flowing carrier line reduced the time for the sham to exit the cannula fourfold: from 2062 to 469 s. Conclusions Despite limitations, this study outlines the importance of cannula type, infusion accessories and carrier lines. Larger cannulae and greater priming volumes substantially delay drug delivery, whereas carrier lines/drive lines substantially accelerate drug delivery. Our study also shows how patients could be exposed to clinical delays, as well as incorrect presumptions about drug dosage. Guidelines, and education efforts, should highlight the clinical importance of factors that affect bag-to-bloodstream time.

Proximal External Aortic Compression for Life-Threatening Abdominal-Pelvic and Junctional Hemorrhage: An Ultrasonographic Study in Adult Volunteers

Abstract Introduction: Following life-threatening junctional trauma, the goal is to limit blood loss while expediting transfer to operative rescue. Unfortunately, life-threatening abdominal-pelvic or junctional hemorrhage is often not amenable to direct compression and few temporizing strategies are available beyond hemostatic dressings, hypotensive resuscitation, and balanced transfusion. Objectives: In this study, we evaluated proximal external aortic compression to arrest blood flow in healthy adult men. Methods: This was a simulation trial of proximal external aortic compression, for life-threatening abdominal-pelvic and junctional hemorrhage, in a convenience sample of healthy adult male volunteers. The primary end points were cessation of femoral blood flow as assessed by pulse wave Doppler ultrasound at the right femoral artery, caudal to the inguinal ligament. Secondary end points were discomfort and negative sequelae. Results: Aortic blood flow was arrested in 12 volunteers. Median time to blood flow cessation was 12.5 seconds. Median reported discomfort was 5 out of 10. No complications or negative sequelae were reported. Conclusion: This trial suggests that it may be reasonable to attempt temporization of major abdominal-pelvic and junctional hemorrhage using bimanual proximal external aortic compression. In the absence of immediate alternatives for this dangerous and vexing injury pattern, there appear to be few downsides to prehospital proximal external aortic compression while concomitantly expediting definite care.

Insights From a Tertiary Care Intraosseous Insertion Practice Improvement Registry: A 2-Year Descriptive Analysis

Introduction: Few practice improvement registries exist that describe opportunities to improve intraosseous (IO) use. The goal of this project was to assess the success rate of the procedure by emergency nurses and identify opportunities to improvement. Secondary goals were to assess success rates based on clinician type, age of patient, and procedural factors. Methods: Emergency nurses assigned to the resuscitation area of a tertiary care emergency department completed an education module and skill lab on IO placement. Tracking forms were completed whenever IO access was attempted, and the clinical nurse educator collated the forms. Results: Over 2 years, quality improvement forms were submitted for 17 pediatric patients (receiving 23 IO insertions) and 35 adult patients (receiving 40 intraosseous insertions). Prior to an IO attempt, the average number of IV attempts for pediatric and adult patients was 4 (range 0 to 10) and 2 (0 to 5), respectively. Successful pediatric IO insertion rate was 6/15 (40%) for physicians (both residents and attending physicians) and 6/7 (86%) for emergency nurses. Physicians were more likely to perform IO insertions in children <12 months of age and emergency nurses in patients >12 months of age. The leading cause of failed insertions in pediatrics was selecting a needle that was too short: either not reaching the intramedullary canal or quickly becoming dislodged, especially with flushing the IO cannula after insertion. For adult patients, IO insertion success rates for physicians were 13/14 (93%) and 18/20 (90%) for emergency nurses. Discussion: The registry identified opportunities to improve clinical practice on the clinical threshold for IO use in pediatric patients and the appropriate selection of IO cannula.

Comparing the socioeconomic status of critical care doctors and patients

To the Editor, Efforts have been made to increase the diversity of medical doctors, including encouraging females, visible minorities, and rural residents to pursue a career in medicine. However, socioeconomic status (SES) may have a greater impact upon clinician empathy, patientadherence, and health outcome than gender, ethnicity, or geography. Trainees from lower SES may be especially under-represented in critical care medicine (CCM) or whenever medical training is very expensive, specialisttraining is lengthy, or subspecialist employment is uncertain. For these reasons, we conducted the first study comparing income and education levels for parents of CCM trainees and parents of pediatric critically ill patients. We consented Canadian senior CCM trainees in 2010, 2011, and 2012 and reported their parents’/guardians’ education levels and best employment descriptor using the Blishen index. We compared these against the distribution of highest educational achievement published in the 2006 Canadian census. Next, we prospectively accessed similar data on pediatric intensive care unit (ICU) patients at the University of Alberta Hospital, along with parental satisfaction scores, whereby parents rated the doctors caring for their children in terms of overall care, sympathy, and parental engagement in decision-making. We obtained 134 complete responses from senior trainees (89%) and 80 from pediatric ICU parents (73%). Results are summarized in the Table. Median paternal SES was significantly higher for trainees vs patients (68 vs 41; P \ 0.001). Median maternal SES score was also significantly higher (62 vs 42; P \ 0.001). A larger proportion of CCM trainee parents had completed college, graduate, or higher education compared with pediatric parents ([ 80% vs\ 50%). More pediatric parents were ‘‘stay at home mothers’’ (60% vs 27%; P = 0.05). When compared against the 2006 Canadian census data, parents of CCM trainees were even less representative of the general population because of their higher average educational achievements. There was no correlation between SES and satisfaction scores from the parents of critically ill patients. Our data—albeit with limitations—suggest overall that critical care doctors from more advantaged backgrounds look after patients from comparatively more disadvantaged backgrounds. For some this will confirm common sense; for others it may be an uncomfortable realization. Fortunately, there was no gross evidence of lower satisfaction from the parents of patients, though with the caveat that satisfaction scoring was more tied to interactions with the attending physician than with senior trainees. We are certainly not proposing punitive redress, simply that more objective data could facilitate mature and empathic debate. Following these pilot data, we could P. G. Brindley, MD, FRCPC (&) Department of Critical Care Medicine, Department of Anesthesiology and Pain Medicine, and the Dosseter Ethics Centre, University of Alberta, Edmonton, AB, Canada e-mail: peter.brindley@albertahealthservices.ca

Time delays associated with vasoactive medication preparation and delivery in simulated patients at risk of cardiac arrest

Purpose To compare, quantify, and describe the time‐delays associated with four common methods of adrenaline administration in the simulated setting of impending cardiac arrest. Methods Using sham medication and a high‐fidelity simulator, experienced Nurses prepared, then delivered, adrenaline by: i) bolus, ii) lower‐concentration infusion iii) higher‐concentration infusion, and iv) higher‐concentration infusion plus carrier‐line. We recorded medication preparation and delivery time, plus administration errors and self‐reported competence. Results Median total delay was i) 120 s for bolus (95% CI 112–128 s); ii) 179 s for lower concentration infusion (95% CI 172–186 s); iii) 296 s for higher concentration infusion (95% CI 285–307 s); and iv) 411 s for higher concentration infusion plus carrier line (95% CI 399–423 s). Time to prepare/deliver a bolus was less than any infusion (p < 0.001). Time to prepare/deliver a lower‐concentration infusion was less than either higher‐concentration infusion (p < 0.001). No substantial equipment failures or medication errors were observed. Participants reported high‐competence. The majority of delay was from drug preparation not delivery. Conclusions We highlight potentially dangerous delays with administration of life‐saving medications by all four methods. We should prioritize boluses, and focus on improving drug preparation times and human performance, more than drug delivery and equipment. HighlightsWe compare and quantify potential delays with both the preparation and delivery of vasoactive medications by bolus, and three common infusionsThe delay was shortest with a bolus. The delay was longer with lower‐concentration infusion, then higher‐concentration infusion, then carrier line.We highlight the need to prioritize boluses, and why we should be wary of overreliance upon de novo infusions.Our study suggests greater time savings by addressing drug preparation and human factors, rather than drug delivery and equipment.This work highlights the need to prepare bolus infusions and teams ahead of time.