Michael A. Frakes

Magnesium sulfate therapy in certain emergency conditions

Intravenous magnesium has been suggested as a treatment for certain emergency conditions for more than 60 years. It is currently proposed to be beneficial in treating asthma, preeclampsia, eclampsia, myocardial infarction, and cardiac arrhythmias. The use and efficacy of the drug, however, are controversial. This article discusses the current state of magnesium sulfate research and therapy.

Endotracheal tube cuff pressures in pediatric patients intubated before aeromedical transport.

Objectives: Prolonged endotracheal tube cuff pressures (ETTCPs) greater than 30 cm H2O can cause complications. With increasing utilization of cuffed endotracheal tubes (ETTs) in pediatric patients comes the risk of overinflation. We evaluated the incidence of elevated ETTCP in pediatric patients intubated with cuffed ETTs, transported by a critical-care transport service and attempted to identify whether elevated ETTCP was associated with factors such as patient demographics, diagnostic category, and intubator credentials. Methods: In this prospective study, assessment of ETTCP was made upon transport crew arrival at the bedside. The study focused on a consecutive sample of pediatric patients undergoing transport with cuffed ETTs placed before transport team arrival. All patients had cuff pressures assessed by the same cuff manometry device. Pressures found to be greater than 30 cm H2O were corrected immediately. Results: Forty-one percent of cases met the a priori defined cutoff for elevated ETTCP of 30 cm H2O; 30% of those elevated cuff pressures were twice that cutoff (>60 cm H2O). There were no associations between high ETTCP and any of the following independent variables: demographics, physician versus nonphysician intubator, and intubation location (ie, scene vs emergency department vs intensive care unit). Conclusions: A significant number of pediatric patients transported by a critical-care transport service had elevated ETTCP. Furthermore, there was no clear risk factor for elevated cuff pressures. This is further evidence that cuff pressures should be measured in all patients. Further research should focus on the effect of educational intervention and on the possible clinical results of elevated ETTCPs.

Factors associated with unoffered trauma analgesia in critical care transport

OBJECTIVE Pain relief is a key out-of-hospital patient care outcome measure, yet many trauma patients do not receive prompt analgesia. Although specialty critical care transport (CCT) teams provide analgesia frequently, successfully, and safely, there is still a population of CCT patients to whom analgesia is not offered. We report the factors associated with non-administration of analgesia and with analgesic effect in trauma patients cared for by CCT teams. METHODS This is a retrospective review of consecutive transport records for nonintubated trauma patients with self-reported pain during specialty CCT care. Patient demographics, CCT interventions, clinical traits, and pain self-reports are measured. Means comparisons are made with a univariate analysis of variance, and odds ratios (ORs) with 95% confidence intervals (CIs) are reported for between-group comparisons. RESULTS Of the 209 enrolled patients, 169 (80.9%; 95% CI, 75.6%-86.2%) were treated (147 received analgesia and 22 offered analgesia but refused). In patients with pain scale documentation (n=145), self-reported pain on a scale from 0 to 10 decreased from 6.8+/-2.8 to 3.3+/-2.4 (P<or=.001). Three factors were associated with absence of analgesic administration: initial pain level (OR for administration, 0.13; 95% CI, 0.04-0.40), pain scale documentation (OR, 0.31; 95% CI, 0.15-0.60), and transport program (OR, 0.36; 95% CI, 0.17-0.74). No clinical factor was associated with analgesia effectiveness in treated patients. CONCLUSION The identified factors may represent opportunities for CCT teams to optimize analgesic treatment.

Flight team management of in-place endotracheal tubes

INTRODUCTION Unintended misplacement or removal of the endotracheal tube (ETT) complicates the care of up to 18% of intubated patients. This project analyzed the incidence of such complications in patients transported by a flight program. METHODS 9-month analysis of all intubated patients transported by the flight team. RESULTS 340/926 patients transported were intubated. One extubation was unplanned and no patients were delivered to the receiving hospital with an esophageal or endobronchial ETT placement. After initial examination, 19/241 ETTs placed before flight team arrival were repositioned. Rates of misplacement on arrival at the receiving hospital and of unplanned extubation were significantly lower than those reported in the EMS or critical care literature. CONCLUSION Flight teams have very low rates of unplanned extubation or undetected ETT misplacement when transporting intubated patients.

Muscle relaxant choices for rapid sequence induction.

Rapid sequence induction (RSI) for intubation using neuromuscular blockade (NMB) is the most common method of achieving emergent tracheal intubation.(1) The ideal muscle relaxant for RSI would have four characteristics: a rapid onset to minimize the risk of aspiration and hypoxia, a rapid recovery to facilitate the return of ventilation if intubation proves difficult, minimal hemodynamic effects, and minimal systemic effects.(2) However, the ideal drug has yet to be found or created, so succinylcholine has been widely used for more than 40 years as a muscle relaxant in patients with full stomachs or who require emergent intubation.(3,4) Recently, rocuronium has received consideration as an alternative.(1,4) This article discusses both agents.

On-scene Times for Inter-facility Transport of Patients with Hypoxemic Respiratory Failure.

UNLABELLED Introduction Inter-facility transport of critically ill patients is associated with a high risk of adverse events, and critical care transport (CCT) teams may spend considerable time at sending institutions preparing patients for transport. The effect of mode of transport and distance to be traveled on on-scene times (OSTs) has not been well-described. Problem Quantification of the time required to package patients and complete CCTs based on mode of transport and distance between facilities is important for hospitals and CCT teams to allocate resources effectively. METHODS This is a retrospective review of OSTs and transport times for patients with hypoxemic respiratory failure transported from October 2009 through December 2012 from sending hospitals to three tertiary care hospitals. Differences among the OSTs and transport times based on the mode of transport (ground, rotor wing, or fixed wing), distance traveled, and intra-hospital pick-up location (emergency department [ED] vs intensive care unit [ICU]) were assessed. Correlations between OSTs and transport times were performed based on mode of transport and distance traveled. RESULTS Two hundred thirty-nine charts were identified for review. Mean OST was 42.2 (SD=18.8) minutes, and mean transport time was 35.7 (SD=19.5) minutes. On-scene time was greater than en route time for 147 patients and greater than total trip time for 91. Mean transport distance was 42.2 (SD=35.1) miles. There were no differences in the OST based on mode of transport; however, total transport time was significantly shorter for rotor versus ground, (39.9 [SD=19.9] minutes vs 54.2 [SD=24.7] minutes; P <.001) and for rotor versus fixed wing (84.3 [SD=34.2] minutes; P=0.02). On-scene time in the ED was significantly shorter than the ICU (33.5 [SD=15.7] minutes vs 45.2 [SD=18.8] minutes; P <.001). For all patients, regardless of mode of transportation, there was no correlation between OST and total miles travelled; although, there was a significant correlation between the time en route and distance, as well as total trip time and distance. CONCLUSIONS In this cohort of critically ill patients with hypoxemic respiratory failure, OST was over 40 minutes and was often longer than the total trip time. On-scene time did not correlate with mode of transport or distance traveled. These data can assist in planning inter-facility transports for both the sending and receiving hospitals, as well as CCT services. Wilcox SR , Saia MS , Waden H , McGahn SJ , Frakes M , Wedel SK , Richards JB . On-scene times for inter-facility transport of patients with hypoxemic respiratory failure. Prehosp Disaster Med. 2016;31(3):267-271.

Improved Oxygenation After Transport in Patients With Hypoxemic Respiratory Failure.

OBJECTIVE The purpose of this study is to measure the rate and magnitude of changes in oxygenation that occur in patients with hypoxemic respiratory failure after transport by a critical care transport team. METHODS We performed a retrospective review of 239 transports of patients with hypoxemic respiratory failure requiring a fraction of inspired oxygen (Fio2) > 50% transported from October 2009 to December 2012 from referring hospitals to 3 tertiary care hospitals. We analyzed the change the ratio of the partial pressure of oxygen in the blood to FiO2 from the sending to the receiving hospital as well as the percentage saturation of oxygen (Spo2) before, after, and en route. RESULTS The mean change in the Pao2/Fio2 ratio from the sending to the receiving hospital was an increase of 27.62 (95% confidence interval [CI], 15.84-39.40; P = .0003). The mean change in Pao2 was an increase of 27.85 mm Hg (CI, 17.49-38.22; P < .0001). The mean Spo2 was not significantly changed at -0.12 (CI, - 1.69 to 1.45, P = .9). Despite improvement in the Pao2/Fio2 ratio and a stable Spo2 on arrival, 28.1% of patients desaturated to Spo2 < 90% in transport. CONCLUSION In patients with hypoxemic respiratory failure, Pao2/Fio2 and Pao2 increased after transport by a critical care transport team despite 28.1% of patients desaturating with hypoxemia in transit.

Management of suspected myocarditis during critical-care transport.

Myocarditis and malignant dysrhythmias are unusual presentations in pediatric patients. We report a series of 4 patients with myocarditis and arrhythmia who presented to community emergency departments and were transported to a pediatric tertiary-care center. Three of the patients required extracorporeal life support. We discuss considerations for stabilization and transport: airway and ventilation, hemodynamic support, induction and sedation medication choices, transport decisions, and the traits of an ideal receiving center.

Medication Administration in Critical Care Transport of Adult Patients with Hypoxemic Respiratory Failure

INTRODUCTION Critical care transport (CCT) teams must manage a wide array of medications before and during transport. Appreciating the medications required for transport impacts formulary development as well as staff education and training. Problem As there are few data describing the patterns of medication administration, this study quantifies medication administrations and patterns in a series of adult CCTs. METHODS This was a retrospective review of medication administration during CCTs of patients with severe hypoxemic respiratory failure from October 2009 through December 2012 from referring hospitals to three tertiary care hospitals. RESULTS Two hundred thirty-nine charts were identified for review. Medications were administered by the CCT team to 98.7% of these patients, with only three patients not receiving any medications from the team. Fifty-nine medications were administered in total with 996 instances of administration. Fifteen drugs were each administered to only one patient. The mean number of medications per patient was 4.2 (SD=1.8) with a mean of 1.9 (SD=1.1) drug infusions per patient. CONCLUSIONS These results demonstrate that, even within a relatively homogeneous population of patients transferred with hypoxemic respiratory failure, a wide range of medications were administered. The CCT teams frequently initiated, titrated, and discontinued continuous infusions, in addition to providing numerous doses of bolused medications.

Improving the incomplete infrastructure for interhospital patient transfer.

Critical Care Medicine www.ccmjournal.org e21 center, equipment and skills during the transfer, prioritization, appropriate transportation and triage to an appropriate destination. Overall, moving the right patient, at the right time, by the right means, with the right people, to the right place is essential. While the article mentions paramedic transfer, there is little further discussion of what, if any, hospital personnel would accompany a patient. Clearly, this will be dependent on local resources. In the United Kingdom, the traditional model of a “team” from the referring hospital accompanying the patient is becoming less practical as the number of trainees in district hospitals is reduced and the requirement for training in transfer skills is established (2, 3). Furthermore, patients from remote and rural areas will first arrive at health facilities with no capacity to provide critical care or a safe transfer. In such cases, “retrieval,” deploying personnel with critical care skills to resuscitate, stabilize, and transfer the patient, is appropriate. Such a service is provided to remote and rural areas of the north and west of Scotland by the Emergency Medical Retrieval Service (http://www.emrs.scot.nhs.uk [4]). To assist with the logistics of such transfers, the service has developed a smartphone application (noncommercial, further information at Web site), which includes: