Characteristics and outcomes of prehospital and emergency department surgical airways.

Objectives: The surgical airway is a high acuity, low occurrence procedure. Data on the complications and outcomes of surgical airways are limited. Our primary objective was to describe immediate complications, late complications, and clinical outcomes of patients who underwent a surgical airway procedure in the prehospital or emergency department (ED) setting. Methods: We conducted a retrospective chart review of patients ≥14 years at an academic medical center who underwent a surgical airway procedure in the ED, the prehospital setting, or at a referring ED prior to interfacility transfer. We identified cases from keyword searches of prehospital text pages and hospital electronic medical records from June 1, 2008 to July 1, 2022. Manual chart review was used to confirm inclusion and determine patient and procedure characteristics. Outcomes included immediate complications, delayed in-hospital complications, and neurologic disability as defined by Modified Rankin Score (mRS) at discharge. Results: We identified 63 patients (34 prehospital, 11 ED, and 18 referring ED). Immediate complications included mainstem intubation (46.0%) and bleeding that required direct pressure (23.4%). Overall, 29 patients (46%) died after arrival to the hospital. Of the patients surviving to hospital admission, 25 (48%) had an airway-related complication. Nine complications were deemed directly related to technical components of the procedure. Of the patients who survived to discharge, 18 (52.9%) had poor neurologic function (mRS 4-5). Conclusion: Procedural complications, mortality, and poor neurologic function were common following a surgical airway procedure in the prehospital or ED setting. Most patients surviving to discharge had a moderate to severe neurologic disability.

Characterizing Air Medical Transport Experiences in Emergency Medicine Residency Training Programs.

OBJECTIVE: Air medical transportation (AMT) of patients plays a critical role in the prehospital care of the ill patient. Despite its importance, there is no requirement in emergency medicine training programs to have direct experience or education on the topic, and data detailing current AMT experiences across programs are limited. METHODS: A survey detailing program characteristics, AMT experience characteristics, and curriculum factors relating to AMT experience was sent to all 275 credentialed emergency medicine residency training programs in the United States. Our outcomes were to describe the characteristics of AMT and non-AMT programs (proportions) and to evaluate associations (odds ratios with 95% confidence intervals) between program characteristics and 1) AMT experience opportunity and 2) level of resident participation among AMT programs. RESULTS: Two hundred (73%) programs responded, with 135 of 200 (68%) offering some type of AMT experience. The majority of programs offering AMT were 3 years (113 [84%]), university based (63 [47%]), and located in small urban areas (57 [42%]). When AMT was offered, most programs reported that the overall resident participation was low (≤ 20%). Programs that did not offer shift reduction or additional pay for participation in AMT were significantly more likely to have low participation than those with incentives (odds ratio = 4.8; 95% confidence interval, 1.8-15.3). Around one third of AMT experiences allowed for direct patient care. Less than half of the responding programs reported a dedicated AMT curriculum. CONCLUSION: The majority of emergency medicine residency training programs offer an AMT experience, but this experience is highly variable, and overall participation by residents is low. Given the importance of AMT in the care of emergency patients, standardization and increased access to AMT experience and education should be considered by emergency medicine training programs moving forward.

Impact of a New Helicopter Base on Transport Time and Survival in a Rural Adult Trauma Population.

BACKGROUND: Significant disparities in access to prompt helicopter transport exist among rural trauma populations. We evaluated the impact of an additional helicopter base on transport time and mortality in a rural adult trauma population. MATERIALS AND METHODS: We performed a retrospective cohort study of adult patients with trauma transported by helicopter from scene to a level one trauma center between 2014 and 2018. A new rural helicopter base added to the trauma center's catchment area in 2016 served as the transition time for an interrupted time series analysis. Patients injured in this base's county and adjoining counties were analyzed. Baseline characteristics were compared with a Student's t-test and Pearson's chi-squared test. Cox and linear regression models evaluated the new base's effect on mortality and transport time, respectively. RESULTS: A total of 332 patients were analyzed: 120 (36.1%) transported before the addition of the new helicopter base and 212 (63.9%) transported after. Patients transported after the addition of the base had higher injury severity score (13.7 versus 10.1, P < 0.001) and were more likely to receive blood en route (19.3% versus 6.7%, P = 0.005). After the addition of the base, there was a decreased hazard ratio for mortality (hazard ratio 0.26, 95% confidence interval: 0.11-0.65, P = 0.004) with no significant change in transport time (-36.7 min, P = 0.071) for the area. CONCLUSIONS: Local helicopter transport units may confer improved survival for the injured patient. This study demonstrates the important role of helicopter transport within a regional trauma system and the impact that expanded access to rapid air transport can have on mortality.

Cricothyrotomy in Helicopter Emergency Medical Service Transport.

OBJECTIVE: Airway management is a requisite skill set for helicopter emergency medical service (HEMS) providers. Cricothyrotomy is a potentially lifesaving skill that is used when other airway maneuvers fail. The authors reviewed all transports by a helicopter program in which cricothyrotomy was performed to assess the frequency, success, and technique. METHODS: This was a retrospective chart review of air medical patient records from an electronic medical record system over a 112-month period. RESULTS: During the study period, 22,434 patients were transported, 13 (.057%) of whom underwent cricothyrotomy. The typical patient was a male trauma victim with a mean Glasgow Coma Score of 5 transported from an accident scene with a mean age of 34.3 years. Six (46%) of the patients were alive at 24 hours. All patients (13/100%) received attempted endotracheal intubation; the mean number of attempts per patient was 2. The success rate was 100% with all patients ventilated via cricothyrotomy. CONCLUSION: This study shows cricothyrotomy is a rarely performed skill but that HEMS providers are able to successfully learn the skill with proper training and oversight.

Retrospective Review of Air Transportation Use for Upper Extremity Amputations at a Level-1 Trauma Center.

INTRODUCTION: Air transportation to tertiary care centers of patients with upper extremity amputations has been utilized in hopes of reducing the time to potential replantation; however, this mode of transportation is expensive and not all patients will undergo replantation. The purpose of this study is to review the appropriateness and cost of air transportation in upper extremity amputations. MATERIALS AND METHODS: Consecutive patients transported by aircraft with upper extremity amputations in a 7-year period at a level-1 trauma center were retrospectively reviewed. The distance traveled was recorded, along with the times of the injury, referral, transportation duration, arrival, and start of the operation. The results of the transfer were defined as replantation or revision amputation. RESULTS: Overall, 47 patients were identified with 43 patients going to the operating room, but only 14 patients (30%) undergoing replantation. Patients arrived at the tertiary hand surgery center with a mean time of 182.3 minutes following the injury, which includes 105.2 minutes of transportation time. The average distance traveled was 105.4 miles (range, 22-353 miles). The time before surgery of those who underwent replantation was 154.6 minutes. The average cost of transportation was $20,482. DISCUSSION: Air transportation for isolated upper extremity amputations is costly and is not usually the determining factor for replantation. The type of injury and patients' expectations often dictate the outcome, and these may be better determined at the time of referral with use of telecommunication photos, discussion with a hand surgeon, and patient counseling. LEVEL OF EVIDENCE: III.

Safety and Efficacy of Thoracostomy in the Air Medical Environment.

OBJECTIVE: The use of thoracostomy to treat tension pneumothorax is a core skill for prehospital providers. Tension pneumothoraces are potentially lethal and are often encountered in the prehospital environment. METHODS: The authors reviewed the prehospital electronic medical records of patients who had undergone finger thoracostomy (FT) or tube thoracostomy (TT) while under the care of air medical crewmembers. Demographic data were obtained along with survival and complications. RESULTS: During the 90-month data period, 250 patients (18 years of age or older) underwent FT/TT, with a total of 421 procedures performed. The mean age of patients was 44.8 years, with 78.4% being male and 21.6% being female; 98.4% of patients had traumatic injuries. Cardiopulmonary resuscitation was required in 65.2% of patients undergoing FT/TT; 34.8% did not require cardiopulmonary resuscitation. Thirty percent of patients exhibited clinical improvement such as increasing systolic blood pressure, oxygen saturation, improved lung compliance, or a release of blood or air under tension. Patients who experienced complications such as tube dislodgement or empyema made up 3.4% of the cohort. CONCLUSION: The results of this study suggest that flight crews can use FT/TT in their practice on patients with actual or potential pneumothoraces with limited complications and generate clinical improvement in a subset of patients.

Does scene physiology predict helicopter transport trauma admission?

BACKGROUND: Helicopter transport (HT) is necessary in the management of civilian trauma; however, its significant expense underscores the need to minimize overuse and inefficiency. Our objective was to determine whether on-scene physiologic criteria predict appropriate triage in HT trauma patients. METHODS: We performed a retrospective review of patients flown from the injury scene to the emergency department of a level 1 trauma center by a university HT service from January 2006 to December 2010. Demographics, mechanism of injury, scene revised trauma score (RTS), travel distance, trauma alert level, payer status, emergency department and hospital disposition, and injury severity scores were queried from the electronic medical record and Trauma Registry of the American College of Surgeons with similar data on patients admitted because of trauma by ground transport for comparison. Proper triage criteria were defined through by the American College of Surgeons Committee on Trauma. RESULTS: We identified 2522 HT patients. Of these, 1491 (59%) were properly triaged and 1031 (41%) were overtriaged. Univariate analysis revealed that the mean scene RTS was significantly higher for over- versus proper triage (7.68 ± 0.67 and 6.97 ± 1.57 respectively, P < 0.001). Neither the scene RTS nor travel distance predicted the triage criteria in a regression model (odds ratio 0.37, 95% confidence interval 0.16-0.85, and odds ratio 0.67, 95% confidence interval 0.60-0.74, respectively). Compared with ground transport, admitted HT patients had significantly more blunt trauma, lower scene RTSs, higher injury severity scores, more intensive care unit and ventilator days, a longer length of stay, and a greater travel distance and were more likely to be intubated (P < 0.001). CONCLUSIONS: The physiological criteria did not predict the triage status in HT trauma patients. Although >40% of HT patients were overtriaged, they were more severely injured and required greater institutional resources than did the ground transport patients. Overtriage by a helicopter transport program might be appropriate.

Emergency medical services transport decisions in posttraumatic circulatory arrest: are national practices congruent?

OBJECTIVE: To catalog the 9-1-1 emergency medical services (EMS) transport practices for posttraumatic circulatory arrest patients (PTCAPs) in the majority of the nation's largest municipalities and to compare those practices to guidelines recommended by the National Association of EMS Physicians (NAEMSP) and American College of Surgeons Committee on Trauma (ACSCOT). METHODS: A survey was conducted in 33 of the nation's largest cities primarily to determine whether or not individual EMS systems transport PTCAPs to hospitals and, if so, whether or not the initial electrocardiographic (ECG) rhythm or mechanism of injury affected those transport decisions. RESULTS: All 33 cities (100%) responded. Seven (21%) indicated that EMS would transport an "asystolic blunt trauma patient" emergently or "leave the transport decision to paramedic judgment" despite NAEMSP-ACSCOT guidelines to terminate resuscitation in such cases. Likewise, 15 (46%) of the 33 EMS agencies would transport "asystolic penetrating trauma patients" emergently. Similarly, 27 (82%) would transport penetrating injury patients and 20 (61%) would transport blunt trauma patients with persistent ECG activity but no palpable pulses. However, only five systems had policies that included a minimum ECG heart rate criterion for transport, and all agencies that monitor ECG (n = 32) would transport PTCAPs found with ventricular fibrillation. CONCLUSIONS: Many of the nation's highest volume EMS systems transport certain PTCAPs emergently, contrary to NAEMSP-ACSCOT guidelines to terminate resuscitative efforts in such cases. Reasons for these discrepancies should be evaluated to help better delineate applicable consensus guidelines for large urban EMS agencies.