Zane Perkins

Resuscitative endovascular balloon occlusion of the aorta (REBOA) in the pre-hospital setting: An additional resuscitation option for uncontrolled catastrophic haemorrhage

This report describes the first use of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in the pre-hospital setting to control catastrophic haemorrhage. The patient, who had fallen 15 meters, suffered catastrophic internal haemorrhage associated with a pelvic fracture. He was treated by Londons Air Ambulances Physician-Paramedic team. This included insertion of a REBOA balloon catheter at the scene to control likely fatal exsanguination. The patient survived transfer to hospital, emergency angio-embolization and subsequent surgery. He was discharged neurologically normal after 52 days and went on to make a full recovery. The poor prognosis in catastrophic torso haemorrhage and novel endovascular methods of haemorrhage control are discussed. Also the challenges of Pre-Hospital REBOA are discussed together with the training and governance required for a safe system.

The haemodynamic response to pre-hospital RSI in injured patients ☆

BACKGROUND Laryngoscopy and tracheal intubation provoke a marked sympathetic response, potentially harmful in patients with cerebral or cardiovascular pathology or haemorrhage. Standard pre-hospital rapid sequence induction of anaesthesia (RSI) does not incorporate agents that attenuate this response. It is not known if a clinically significant response occurs following pre-hospital RSI or what proportion of injured patients requiring the intervention are potentially at risk in this setting. METHODS We performed a retrospective analysis of 115 consecutive pre-hospital RSIs performed on trauma patients in a physician-led Helicopter Emergency Medical Service. Primary outcome was the acute haemodynamic response to the procedure. A clinically significant response was defined as a greater than 20% change from baseline recordings during laryngoscopy and intubation. RESULTS Laryngoscopy and intubation provoked a hypertensive response in 79% of cases. Almost one-in-ten patients experienced a greater than 100% increase in mean arterial pressure (MAP) and/or systolic blood pressure (SBP). The mean (95% CI) increase in SBP was 41(31-51) mmHg and MAP was 30(23-37) mmHg. Conditions leaving the patient vulnerable to secondary injury from a hypertensive response were common. CONCLUSIONS Laryngoscopy and tracheal intubation, following a standard pre-hospital RSI, commonly induced a clinically significant hypertensive response in the trauma patients studied. We believe that, although this technique is effective in securing the pre-hospital trauma airway, it is poor at attenuating adverse physiological effects that may be detrimental in this patient group.

Factors affecting response to National Early Warning Score (NEWS)

INTRODUCTION The NEWS is a physiological score, which prescribes an appropriate response for the deteriorating patient in need of urgent medical care. However, it has been suggested that compliance with early warning scoring systems for identifying patient deterioration may vary out of hours. We aimed to (1) assess the scoring accuracy and the adequacy of the prescribed clinical responses to NEWS and (2) assess whether responses were affected by time of day, day of week and score severity. METHODS We performed a prospective observational study of 370 adult patients admitted to an acute medical ward in a London District General Hospital. Patient characteristics, NEW score, time of day, day of week and clinical response data were collected for the first 24h of admission. Patients with less than a 12h hospital stay were excluded. We analysed data with univariate and multivariate logistic regression. RESULTS In 70 patients (18.9%) the NEW score was calculated incorrectly. There was a worsening of the clinical response with increasing NEW score. An appropriate clinical response to the NEWS was observed in 274 patients (74.1%). Patients admitted on the weekend were more likely to receive an inadequate response, compared to patients admitted during the week (p<0.0001). After adjusting for confounders, increasing NEWS score remained significantly associated with an inadequate clinical response. Furthermore, our results demonstrate a small increase in inadequate NEWS responses at night, however this was not clinically or statistically significant. CONCLUSION The high rate of incorrectly calculated NEW scores has implications for the prescribed actions. Clinical response to NEWS score triggers is significantly worse at weekends, highlighting an important patient safety concern.

Impact on outcome of a targeted performance improvement programme in haemodynamically unstable patients with a pelvic fracture

We describe the impact of a targeted performance improvement programme and the associated performance improvement interventions, on mortality rates, error rates and process of care for haemodynamically unstable patients with pelvic fractures. Clinical care and performance improvement data for 185 adult patients with exsanguinating pelvic trauma presenting to a United Kingdom Major Trauma Centre between January 2007 and January 2011 were analysed with univariate and multivariate regression and compared with National data. In total 62 patients (34%) died from their injuries and opportunities for improved care were identified in one third of deaths. Three major interventions were introduced during the study period in response to the findings. These were a massive haemorrhage protocol, a decision-making algorithm and employment of specialist pelvic orthopaedic surgeons. Interventions which improved performance were associated with an annual reduction in mortality (odds ratio 0.64 (95% confidence interval (CI) 0.44 to 0.93), p = 0.02), a reduction in error rates (p = 0.024) and significant improvements in the targeted processes of care. Exsanguinating patients with pelvic trauma are complex to manage and are associated with high mortality rates; implementation of a targeted performance improvement programme achieved sustained improvements in mortality, error rates and trauma care in this group of severely injured patients.

The relationship between head injury severity and hemodynamic response to tracheal intubation.

INTRODUCTION The acutely injured brain is sensitive to fluctuations in blood pressure. During tracheal intubation, airway stimulation provokes acute surges in blood pressure that have the potential to cause further harm in patients with intracranial pathology. Although reduced consciousness is thought to suppress airway reflexes, its influence on these hemodynamic reflexes is unknown. We aimed to investigate the relationship between head injury severity and hemodynamic response to laryngoscopy and intubation. METHODS This retrospective observational study included 97 consecutive patients with head injuries who underwent prehospital tracheal intubation by a physician-led helicopter emergency medical service. The primary outcome was the acute hemodynamic response to the procedure. Secondary outcomes included the incidence of serious intracranial pathology and mortality. RESULTS A hypertensive response to laryngoscopy and tracheal intubation occurred in 80% of patients. In 11% of patients, blood pressure increased by ≥100%. The hemodynamic response was attenuated with increasing head injury severity but unpredictably and not to clinically acceptable levels. The incidence of serious intracranial bleeding (61%) and raised intracranial pressure (22%) was high in patients with head injuries, requiring tracheal intubation. CONCLUSION A clinically significant hemodynamic response to laryngoscopy and intubation is common in patients with head injuries and is not effectively attenuated by increasing head injury severity. The need to attenuate the hemodynamic response should be assessed independently of head injury severity. LEVEL OF EVIDENCE Therapeutic study, level III.

Factors affecting outcome after traumatic limb amputation

Traumatic leg amputation commonly affects young, active people and leads to poor long‐term outcomes. The aim of this review was to describe common causes of disability and highlight therapeutic interventions that may optimize outcome after traumatic leg amputation.

Meta-analysis of prognostic factors for amputation following surgical repair of lower extremity vascular trauma

Lower extremity vascular trauma (LEVT) is a major cause of amputation. A clear understanding of prognostic factors for amputation is important to inform surgical decision‐making, patient counselling and risk stratification. The aim was to develop an understanding of prognostic factors for amputation following surgical repair of LEVT.

Paramedic rapid sequence induction (RSI) in a South African emergency medical service: A retrospective observational study

BACKGROUND Early access to critical care interventions may improve outcomes for severely ill and injured patients. South Africa (SA) faces the unique challenges of prolonged pre-hospital times and limited access to physicians. In 2008, the Health Professions Council of SA introduced paramedic rapid sequence induction (RSI), the gold standard critical care intervention for emergency airway management; however, the risk to benefit ratio in this context is unclear. OBJECTIVE We conducted a pilot study to identify if paramedic RSI in the SA pre-hospital care setting is effective and safe. METHODS We undertook a retrospective observational study of paramedic RSI performed by an emergency medical service, between 12 December 2009 and 12 December 2011. RESULTS Eighty-six RSIs were performed during the study period. No failed intubations were reported. Heart rate was significantly reduced from a median baseline value of 112 to 90 bpm, and oxygen saturations improved from 92% to 99% at handover following RSI. Nineteen patients (22%), however, had an adverse event (AE). Female patients (odds ratio (OR) 18.3; 95% confidence interval (CI) 3.46 - 99.38; p=0.001) and patients subsequently transported by helicopter (OR 7.24; 95% CI 1.44 - 36.32; p=0.016) remained independently associated with AEs after adjusting for confounders. CONCLUSIONS RSI performed by specially trained paramedics is effective in terms of self-reported success. However, the 1 in 5 AE rate highlights safety concerns. The importance of a robust clinical governance programme to identify problems, refine practice and improve the quality of care is underscored.

A comprehensive review of blood product use in civilian mass casualty events.

I recent decades, there has been a significant increase in the frequency of disasters and major emergencies. By definition, these mass casualty events (MCEs) result in large numbers of severely injured patients, which overwhelm available resources, thereby limiting the ability to deliver optimal care. In these casualties, hemorrhage is a leading cause of preventable mortality, accounting for almost 50% of deaths in the first 24 hours. Modern transfusion strategies recommend high ratios of blood components, such as fresh frozen plasma (FFP) to red blood cells (RBCs) from the outset as part of damage-control resuscitation (DCR). The timely availability and appropriate delivery of blood products in MCEs is essential to improve critical mortality in severely injured patients. Emergency preparedness for future MCEs must therefore include evidence-based transfusion strategies and blood bank planning. Predicting blood product requirements for MCEs is challenging. Previous studies of events, in both military and civilian settings, have been based on single-center experiences and quantified RBC requirements by units used per victim or per hospitalized patient. In civilian and military trauma, casualty blood requirements depend on factors such as injury severity and mechanism of injury (MOI). Some of this information may not be applicable or readily available in MCEs. Past experience of blood use in MCEs has indicated that held stocks of RBCs have been adequate for a hospitals’ capacity to deliver them to patients. Despite this, there are continued reports of emergency donation following MCEs suggesting stock availability in blood banks and demand requires further investigation. In conjunction with this, transfusion strategies in trauma have evolved in recent years with the advent of DCR using early high-dose coagulation therapy alongside RBCs to prevent and treat coagulopathy. This new approach has not been explored fully in the context of MCEs and the potential impact it may have on supply and demand during these events. The overall objective of this article was to determine if blood requirements necessary to adequately manage a civilian MCE are predictable based on historical data and events. The first aim of the study was to perform a review of the adequacy of reporting of blood product use across a full range of civilian MCEs. Second, we wished to determine whether a predictive relationship exists between blood use and available casualty profiles. The third aim was to determine whether any existing relationship is affected by the nature of the event itself. Finally, we wished to investigate the potential effect that current trauma transfusion practices would have had on blood demands during previous events. We conducted a comprehensive review of literature from 1911 to 2011 and compared findings with civilian blood use data from a major trauma center.

Resuscitative endovascular balloon occlusion of the aorta: promise, practice, and progress?

Purpose of reviewResuscitative endovascular balloon occlusion of the aorta (REBOA) is a minimally invasive damage control procedure for life-threatening abdominal or pelvic haemorrhage. The purpose of this review is to summarize the current understanding and experience with REBOA, outline potential future applications of this technology, and highlight priority areas for further research. Recent findingsREBOA is a feasible method of achieving temporary aortic occlusion and can be performed rapidly, with a high degree of success, in the emergency setting (including at the scene of injury) by appropriately trained clinicians. The procedure supports central perfusion, controls noncompressible haemorrhage, and may improve survival in certain profoundly shocked patient groups; but is also associated with significant risks, including ischaemic tissue damage and procedural complications. Evolutions of this strategy are being explored, with promising proof-of-concept studies in the fields of partial aortic occlusion and the combination of REBOA with extracorporeal support. SummaryNoncompressible torso haemorrhage is the leading cause of preventable trauma deaths. The majority of these deaths occur soon after injury, often before any opportunity for definitive haemorrhage control. For a meaningful reduction in trauma mortality, novel methods of rapid haemorrhage control are required.