[Entrapped motorists and air rescue services: analysis of tactical rescue approach, rescue techniques, and emergency medical services illustrated by a helicopter emergency medical service]. / Eingeklemmte Fahrzeuginsassen in der Luftrettung: Einsatztaktik, rettungstechnische und notfallmedizinische Analyse am Beispiel einer Rettungshubschrauberstation.

BACKGROUND: Analysis of the results and presentation of a treatment concept of a helicopter emergency medical service (HEMS) in prehospital acute care of entrapped motorists. METHODS: Consecutive patient data collection from primary rescue missions of a helicopter emergency medical service (HEMS) from the years 2000-2004. Evaluation based on data collected regarding emergency medical care, rescue techniques, and tactical rescue approach. RESULTS: A total of 359 cases of entrapped motorists were documented: 237 patients were male, 122 were female, and the average age was 37 (range: 2-82 years). The motor vehicle accidents (MVA) occurred in 21% of the cases on the highway, in 29% on a main road, in 43% on a rural road, and in 7% in city/urban areas. Concerning the vehicle types, 86% were automobiles, 5% vans, and 9% trucks. Drivers accounted for 86% of the patients, front seat passengers for 10.1%, and back seat passengers for 3.9%. The average length of motorist entrapment amounted to 17 min with an average on-scene time of 27 min for the HEMS. The total rescue time averaged 56 min. A Glasgow Coma Scale (GCS) score between 3 and 8 was recorded in 33.7% of the patients; in 24% of the cases the shock index was <1; a respiratory rate of <10/min or >20/min was documented in 25.2% of the patients. An NACA score between I and III was recorded in 34.2% of the cases, NACA IV in 18.9%, and NACA >/=V in 46.8%; 11.9% of the patients died before hospital admission. CONCLUSION: For both the emergency control center personnel and the emergency medical technicians (EMT), a case of motorist entrapment must be considered as a trigger mechanism of injury, activating a sophisticated and time-sensitive prehospital acute care and transportation service. In the German emergency medical service this involves primarily the HEMS. Even in cases of potentially critically injured entrapped motorists, the prehospital adherence to"the golden hour of shock" is made possible, despite the resulting higher personnel and equipment expenses.

Feasibility of preclinical cardiac output and systemic vascular resistance in HEMS in thoracic pain--the ultrasonic cardiac output monitor.

BACKGROUND: Cardiac output (CO) and systemic vascular resistance (SVR) are important hemodynamic parameters in emergency patients and for clinical early goal-directed therapy. This study evaluated the feasibility of CO and SVR determination using preclinical continuous wave Doppler ultrasound in a helicopter emergency medical service (HEMS) on emergency patients presenting with or without thoracic pain as a pilot observational study. METHODS: Forty-four consecutive medical emergency patients (62.8 +/- 22 years of age, 23 males) were classified at the scene as with (15 patients, 69 +/- 14 years of age, 40% male) or without (29 patients, 60 +/- 25 years of age, 59% male) thoracic pain by an emergency physician. Hemodynamic parameters were determined based on continuous wave Doppler noninvasively (USCOM, Sydney, Australia): stroke volume (SV), CO, cardiac index (CI), minute distance (MD), and SVR. RESULTS: Noninvasive SV, MD, CO, CI, and SVR determination is feasible using preclinical ultrasound in HEMS. Thoracic pain patients had higher SVR (2,709 +/- 891 vs 1,499 +/- 661 dyne*sec*cm-5) and lower CO/CI (3.37 +/- 1.1 vs 5.06 +/- 2.9 L/min, CI: 1.67 +/- 0.58 vs 3.18 +/- 1.34 L/min/m2) as well as a reduced aortic minute distance (11.2 +/- 3.3 m/min vs 19.1 +/- 8 m/min, P = .001) than patients without thoracic pain. Highest cardiac outputs were measured during and within 30 minutes after seizures (n = 5, 7.5 +/- 3.05 L/min). The range of CO measured in six cardiopulmonary resuscitation patients was 2.7 to 12 L/min; the level of CO was not associated with the establishing of sustained circulation. CONCLUSIONS: Determining SV, CO/CI, and SVR in different emergency situations in HEMS using rapid CW Doppler ultrasound is feasible. Thoracic pain patients have increased SVR and lower CO/CI and reduced aortic minute distance than do non-thoracic pain patients in the preclinical setting.

[Non-invasive determination of cardiac output by continuous wave Doppler in air rescue service]. / Nicht-invasive Bestimmung des Herzzeitvolumens durch einen transkutanen CW Doppler in der Luftrettung.

BACKGROUND: Determination of cardiac output (CO) enables to assess the hemodynamic situation as well as to administer optimal catecholamine therapy especially in critically compromised patients with hemodynamic instability. Invasive determination of CO is possible via a Swan-Ganz-catheter with its associated risk of implantation in the hospital. Using the Doppler technique, we evaluated the feasibility of the USCOM-system for non-invasive CO determination in preclinical emergency medicine in air rescue service. METHODS: In 32 patients (17 months to 92-years-old) cardiac output was determined non-invasively (USCOM) at the scene and during the helicopter transport at Christoph 4, based at Hannover Medical School. Simultaneously, blood pressure, ECG and oxygen saturation were determined. Non-invasive CO was assessed by a suprasternal access aiming at the aorta ascendens. 19 patients were unconscious due to cardial and non-cardial reasons, and 13 were conscious (sepsis, status epilepticus, anaphylactic reaction). 7 patients were hemodynamically unstable. In three patients the monitor was used during interhospital transfer by helicopter. RESULTS: Non-invasively determined CO via the USCOM system was 4.8 +/- 0.7 l/min with a cardiac index of 2.4 +/- 0.3 l/m (2). Highest CO values were determined in a patient with sepsis and during a grand-mal-status in epilepsy (CO 8.2 l/min). All examinations were done by the same emergency physician of the emergency helicopter Christoph 4 immediately after arrival at the scene. The examination took on average 25 seconds. During the helicopter transport, several consecutive CO measurements were performed to assess volume and catecholamine therapy with increase of stroke volume after volume load with colloidal fluids. CONCLUSIONS: Using the USCOM system it is possible to determine the beat-to-beat cardiac output in air rescue service non-invasively. The emergency physician gains additional crucial hemodynamic information to diagnose and treat adequately by administration of volume load and catecholamines at the scene and during flight conditions. Further preclinical prospective trials are mandatory to elucidate the value of this novel device in emergency medicine.

[Pediatric prehospital trauma care. A retrospective comparison of air and ground transportation]. / Die präklinische Versorgung des pädiatrischen Traumapatienten Ein retrospektiver Vergleich zwischen luft- und bodengebundener Rettung.

OBJECTIVE: In contrast to prehospital care of adult trauma victims, prehospital care providers have only limited clinical experience of pediatric trauma cases as these are relatively infrequent. Literature reports on prehospital pediatric trauma care given by paramedics are frequently found in the literature, but there are few publications analyzing the quality of prehospital trauma care provided by emergency physicians in the care of injured children. It was the goal of this study to analyze the prehospital care of the pediatric trauma victims transported to a trauma center by physician-staffed ambulances and helicopters. METHODS: The study took the form of a retrospective 5-year review of pediatric trauma patients admitted to a trauma center. The inclusion criteria were age younger than 13 years and a NACA score higher than 3. In all, 104 patients were included, and these were divided into two groups, those transported to hospital by helicopter (RTH, n=87) and those taken to hospital by road ambulance (NEF, n=17). RESULTS: With a mean NACA score of 4.6 and a mean ISS of 15, no significant differences were found between the two groups in either severity of injury or length of hospital stay. The mortality of the total patient population was 15.4%, with no evidence of preventable deaths in patients who were admitted to the trauma center with vital signs. Analysis of prehospital therapy showed no differences in the volume of intravenous fluids administered (RTH 636 ml vs NEF 476 ml) or in the proportion of children with a GCS<9 in whom endotracheal intubation was implemented (RTH 39/44 vs NEF 7/7). Placement of more than one i.v. line and endotracheal intubation were associated with longer times at the scene of the accident before patients were taken to hospital (>one i.v. corresponded to 9 min longer, and endotracheal intubation, to 10 min longer). CONCLUSIONS: Prehospital pediatric trauma care delivered by physician-staffed ambulances or rescue helicopters is associated with a high rate of i.v. line placement (92%) and high intubation rates (90%) in patients with an altered level of consciousness (GCS<9). The prehospital care provided by helicopter or ground ambulance personnel was not different and was not associated with longer stays in the intensive care unit or longer overall stays in hospital. Scene times became longer with increasing number of i.v. line placements and with endotracheal intubation, but was not prolonged by a greater severity of injury as determined by the ISS. Preventable deaths were not observed in the patient population. In summary, owing to the the local infrastructure, pediatric trauma patients are more frequently transported to the trauma center by air (87 by air vs. 17 by road per 5-year time period). However, despite being less frequently involved in the case of pediatric trauma, the quality of care provided by road ambulance staff is similar to that in air ambulances.

Prehospital airway management in the acutely injured patient: the role of surgical cricothyrotomy revisited.

BACKGROUND: Ensuring an unobstructed airway and adequate oxygenation are first priorities in the resuscitation of the trauma patient. In situations of difficult endotracheal intubation, rapid sequence protocols frequently include the use of paralytic agents and cricothyrotomy for airway management. Recent literature findings suggest that the prehospital use of cricothyrotomy is too frequent. The purpose of this study was (a) to evaluate the efficacy of a rapid sequence intubation protocol without the use of paralytic agents, and (b) to determine the need for cricothyrotomy by using this protocol in the field. METHODS: We prospectively analyzed 383 acutely injured patients who were in need of airway control. Success rates, indications, and complications of endotracheal intubation and cricothyrotomy were analyzed. RESULTS: Successful orotracheal intubation on the scene with the use of this protocol was performed in 373 of 383 patients (97%). Two patients (0.5%) arrived at the trauma center with unrecognized esophageal intubation. Eight patients underwent cricothyrotomy in the field, six without previous attempts at intubation. CONCLUSION: Experienced emergency medical services personnel can effectively perform endotracheal intubation with narcotic analgesics without the use of paralytic agents in the field. With proper training for field airway management, cricothyrotomy in the field can be reduced to a few indications with high success rates.