Serratus Anterior Plane Blocks for Early Rib Fracture Pain Management: The SABRE Randomized Clinical Trial.

Importance: Rib fractures secondary to blunt thoracic trauma typically result in severe pain that is notoriously difficult to manage. The serratus anterior plane block (SAPB) is a regional anesthesia technique that provides analgesia to most of the hemithorax; however, SAPB has limited evidence for analgesic benefits in rib fractures. Objective: To determine whether the addition of an SAPB to protocolized care bundles increases the likelihood of early favorable analgesic outcomes and reduces opioid requirements in patients with rib fractures. Design, Setting, and Participants: This multicenter, open-label, pragmatic randomized clinical trial was conducted at 8 emergency departments across metropolitan and regional New South Wales, Australia, between April 12, 2021, and January 22, 2022. Patients aged 16 years or older with clinically suspected or radiologically proven rib fractures were included in the study. Participants were excluded if they were intubated, transferred for urgent surgical intervention, or had a major concomitant nonthoracic injury. Data were analyzed from September 2022 to July 2023. Interventions: Patients were randomly assigned (1:1) to receive an SAPB in addition to usual rib fracture management or standard care alone. Main Outcomes and Measures: The primary outcome was a composite pain score measured 4 hours after enrollment. Patients met the primary outcome if they had a pain score reduction of 2 or more points and an absolute pain score of less than 4 out of 10 points. Results: A total of 588 patients were screened, of whom 210 patients (median [IQR] age, 71 [55-84] years; 131 [62%] male) were enrolled, with 105 patients randomized to receive an SAPB plus standard care and 105 patients randomized to standard care alone. In the complete-case intention-to-treat primary outcome analysis, the composite pain score outcome was reached in 38 of 92 patients (41%) in the SAPB group and 18 of 92 patients (19.6%) in the control group (relative risk [RR], 0.73; 95% CI, 0.60-0.89; P = .001). There was a clinically significant reduction in overall opioid consumption in the SAPB group compared with the control group (eg, median [IQR] total opioid requirement at 24 hours: 45 [19-118] vs 91 [34-155] milligram morphine equivalents). Rates of pneumonia (6 patients [10%] vs 7 patients [11%]), length of stay (eg, median [IQR] hospital stay, 4.2 [2.2-7.7] vs 5 [3-7.3] days), and 30-day mortality (1 patient [1%] vs 3 patients [4%]) were similar between the SAPB and control groups. Conclusions and Relevance: This randomized clinical trial found that the addition of an SAPB to standard rib fracture care significantly increased the proportion of patients who experienced a meaningful reduction in their pain score while also reducing in-hospital opioid requirements. Trial Registration: http://anzctr.org.au Identifier: ACTRN12621000040864.

Brain Injury Associated Shock: An Under-Recognized and Challenging Prehospital Phenomenon.

OBJECTIVE: Hemodynamic collapse in multi-trauma patients with severe traumatic brain injury (TBI) poses both a diagnostic and therapeutic challenge for prehospital clinicians. Brain injury associated shock (BIAS), likely resulting from catecholamine storm, can cause both ventricular dysfunction and vasoplegia but may present clinically in a manner similar to hemorrhagic shock. Despite different treatment strategies, few studies exist describing this phenomenon in the early post-injury phase. This retrospective observational study aimed to describe the frequency of shock in isolated TBI in prehospital trauma patients and to compare their clinical characteristics to those patients with hemorrhagic shock and TBI without shock. METHODS: All prehospital trauma patients intubated by prehospital medical teams from New South Wales Ambulance Aeromedical Operations (NSWA-AO) with an initial Glasgow Coma Scale (GCS) of 12 or less were investigated. Shock was defined as a pre-intubation systolic blood pressure under 90mmHg and the administration of blood products or vasopressors. Injuries were classified from in-hospital computed tomography (CT) reports. From this, three study groups were derived: BIAS, hemorrhagic shock, and isolated TBI without shock. Descriptive statistics were then produced for clinical and treatment variables. RESULTS: Of 1,292 intubated patients, 423 had an initial GCS of 12 or less, 24 patients (5.7% of the original cohort) had shock with an isolated TBI, and 39 patients had hemorrhagic shock. The hemodynamic parameters were similar amongst these groups, including values of tachycardia, hypotension, and elevated shock index. Prehospital clinical interventions including blood transfusion and total fluids administered were also similar, suggesting they were indistinguishable to prehospital clinicians. CONCLUSIONS: Hemodynamic compromise in the setting of isolated severe TBI is a rare clinical entity. Current prehospital physiological data available to clinicians do not allow for easy delineation between these patients from those with hemorrhagic shock.

Factors Associated With Desaturation in Prehospital Rapid Sequence Intubation in a Helicopter Emergency Medical Service.

OBJECTIVE: Desaturation during prehospital rapid sequence intubation (RSI) is common and is associated with patient morbidity. Past studies have identified oxygen saturations at induction, the grade of laryngoscopy, and multiple attempts to intubate as being associated with desaturation. This study aimed to investigate whether there are other factors, identifiable before RSI, associated with desaturation. METHODS: This was a study of a physician-paramedic critical care team operating as Aeromedical Operations, NSW Ambulance. Prehospital RSIs (using paralysis) were studied retrospectively via patient case notes, monitor data, and an airway database. The review occurred between April 1, 2016, and December 31, 2018. Desaturation was defined as monitor recordings of saturations ≤ 92%. Logistic regression was performed for factors likely to be associated with desaturation. RESULTS: Desaturation occurred in 67 of 350 (19.1%) RSIs. Factors significantly associated with desaturation included male sex, a chest injury, increased weight, and lower saturations pre-RSI. CONCLUSION: Increased weight, chest injuries, and lower oxygen saturations are associated with desaturation at RSI. The variable male sex may be a surrogate for other as-yet unidentified factors.

Severe Multifactorial Metabolic Alkalosis in the Emergency Department: A Case Report.

BACKGROUND: Metabolic alkalosis is an uncommon clinical entity resulting from a wide variety of underlying etiologies including gastrointestinal, renal, endocrine, and metabolic causes. It is a typically clinically silent condition; however, severe cases can be life-threatening, mandating both a systematic investigative approach and an early aggressive management strategy. CASE REPORT: We present a case of a 58-year-old man with severe, multifactorial metabolic alkalosis (pH 7.72, HCO3- 42 mmol/L, pCO2 31 mm Hg) resulting from refractory vomiting, severe hypokalemia (2.0 mmol/L), and hypoalbuminemia (albumin 20 g/L). WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Severe metabolic alkalosis is associated with significant morbidity and mortality. Clinicians need to be aware of the potential underlying causes in these cases, as well as how to delineate between chloride- and non-chloride-depleted states, which dictates initial treatment. We provide a pragmatic summary of the evaluation, pertinent investigations, and early management of these cases.

Clinical outcomes of traumatic pneumothoraces undergoing conservative management following detection by prehospital physicians.

OBJECTIVE: To describe the clinical and transport characteristics of patients diagnosed with a suspected traumatic pneumothorax and managed conservatively by prehospital medical teams including secondary deterioration during transfer and the subsequent rate of in-hospital tube thoracostomy. METHODS: Retrospective observational study of all adult trauma patients diagnosed with a suspected pneumothorax on ultrasound and managed conservatively by their treating prehospital medical team between 2018 and 2020. Descriptive analysis was performed comparing patients who did and did not receive in-hospital tube thoracostomy. RESULTS: In total, 181 patients were diagnosed with suspected traumatic pneumothoraces on prehospital ultrasound of which 75 (41.4%) were managed conservatively by their treating medical team whilst 106 (58.6%) underwent pleural decompression. There were no recorded cases of emergent pleural decompression required in transit. Of the 75 conservatively managed patients, 42 (56%) had an intercostal catheter (ICC) placed within four hours of hospital arrival and another nine (17.6%) had an ICC placed between four- and 24-hours post-hospital arrival. There was no significant difference in prehospital clinical characteristics between patients who did and did not receive an in-hospital ICC. The detection of a pneumothorax on the initial chest x-ray and larger pneumothorax volume visualised on computed tomography imaging were significantly more common in patients receiving in-hospital ICCs. Aviation factors including flight altitude and duration of flight were not associated with subsequent in-hospital tube thoracostomy. CONCLUSION: Prehospital medical teams can safely identify patients who have a traumatic pneumothorax and can be transported to hospital without pleural decompression. Patient characteristics at the time of hospital arrival combined with the size of pneumothorax identified on imaging appear most likely to influence subsequent urgent in-hospital tube thoracostomy placement.

Mixed-methods pilot study exploring the influence of the novel Paediatric Anaesthetic Drug Solution tool on clinician cognitive load during simulated paediatric rapid sequence intubation in the emergency department.

AIM: Rapid sequence intubation (RSI) in children is a low-incidence, high-risk event associated with cognitive overload and potential errors producing unfavourable outcomes. Cognitive aids, such as charts, algorithms and flow diagrams, are prompts that externalise and structure mental processes to reduce cognitive load, thereby reducing errors. The Paediatric Anaesthetic Emergency Drug Solution (PAEDS) approach combines a colour-coded chart and medication box with a simplified mathematical system of volume-based dosing; the effect of which on cognitive load during a simulated RSI has not previously been described. METHODS: A randomised, cross-over trial was conducted with 26 multi-disciplinary emergency medicine clinicians (doctors and nurses) allocated to four groups, performing four high-fidelity RSI simulations, two mandating the use of the PAEDS approach. This mixed methods study followed the pragmatic ontology using grounded theory methodology. Qualitative data were collected from nine individual interviews by a process of thematic analysis via an inductive approach, to allow for appropriate open and axial coding to occur. Quantitative data collected included cognitive loading using the raw NASA-Task Load Index as well as time to intubation and drug dosage details to assess for safety. RESULTS: Qualitative results showed that the PAEDS approach reduced cognitive loading through the use of both the labelled medication box and colour-coded medication charts. The PAEDS approach also showed improved perceived time pressure without feeling rushed, and with no recorded drug errors. Differences in the quantitative data for total cognitive load, error and time were not statistically significant, likely due to sample size. CONCLUSION: The PAEDS approach is a multifaceted system which is not inferior to current practice, with some components described as an improvement. Further research on a larger sample size needs to be conducted to assess the aspects of the PAEDS approach both collectively and independently.

The effect of ketamine and fentanyl on haemodynamics during intubation in pre-hospital and retrieval medicine.

BACKGROUND: Ketamine use for rapid sequence intubation (RSI) is frequent in pre-hospital and retrieval medicine (PHARM) and is associated with potentially deleterious haemodynamic changes, which may be ameliorated by concurrent use of fentanyl. OBJECTIVES: To describe the frequency with which fentanyl is used in conjunction with ketamine in a system where its use is discretionary, and to explore any observed changes in haemodynamics with its use. METHODS: A retrospective observational study of over 800 patients undergoing RSI with ketamine ± fentanyl in the PHARM setting between 2015 and 2019. The primary outcome was the proportion of patients in each group who had a systolic blood pressure (SBP) outside a pre-specified target range, with adjustment for baseline abnormality, within 10 min of anaesthetic induction. RESULTS: Eight hundred and seventy-six patients were anaesthetised with ketamine, of whom 804 were included in the analysis. 669 (83%, 95% CI 80%-86%) received ketamine alone, and 135 (17%, 95% CI 14%-20%) received both fentanyl and ketamine. Median fentanyl dose was 1.1 mcg/kg (IQR 0.75-1.5 mcg/kg). Systolic blood pressure (SBP) at induction was consistently associated with SBP after intubation in multivariable logistic regression, but fentanyl use was not associated with a change in odds of meeting the primary outcome (OR 1.08; 95% CI 0.72-1.60), becoming hypertensive (OR 1.35; 95% CI 0.88-2.07) or hypotensive (OR 0.76; 95% CI 0.47-1.21). CONCLUSIONS: The addition of fentanyl to ketamine for RSI was not associated with an alteration of the odds of post-induction haemodynamic stability, although the doses used were low. These findings justify further study into the optimal dosing of fentanyl during RSI in pre-hospital and retrieval medicine.

Serratus Anterior Plane Block for Clinically Suspected Rib Fractures in Prehospital and Retrieval Medicine.

Objective: To describe the use of the serratus anterior plane block (SAPB) in the prehospital and retrieval environment including the ability to accurately identify those patients with thoracic trauma and clinically suspected rib fractures who would benefit from this procedure.Methods: This is a retrospective case series of all patients with thoracic trauma and clinically suspected rib fractures who received SAPB by a prehospital and retrieval medical team in New South Wales, Australia, between 2018 and 2021. The primary outcome was to identify the proportion of patients who received appropriate blocks based on the criteria of reporting moderate pain after receiving adequate pre-block analgesia. Secondary outcomes included the proportions of patients with rib fractures identified on thoracic imaging, concomitant time-critical pathology, radiologist identification of fluid adjacent to the serratus anterior muscle, and local anesthetic systemic toxicity.Results: Of the 2004 patients who sustained thoracic trauma, only 13 received a SAPB. Nine (69.2%) met the predetermined definition of appropriate selection. Of the four patients who did not meet this criteria, three reported less than moderate pain and one did not receive adequate pre-block analgesia. There was no significant effect on median scene interval when compared to other thoracic trauma patients who did not receive a SAPB. Ten patients had rib fractures identified on in-patient imaging (chest x-ray or computed tomography (CT)) with a median (IQR) number of ribs fractured of 5 (interquartile range 2-10). Three of these patients had radiological flail segments. Prespecified time-critical pathology was identified in three patients (23.1%) on initial hospital imaging. Five out of eight patients with post-SAPB CT imaging (62.5%) available for radiologist review had fluid identified adjacent to the serratus anterior muscle. None of the 13 patients had local anesthetic systemic toxicity.Conclusion: The SAPB can be safely and successfully performed in the prehospital and retrieval environment, where clinicians can appropriately identify patients with thoracic trauma and clinically suspected rib fractures who would benefit from this technique. Further research is required to identify the ideal patient population to perform the SAPB upon and compare its performance to current analgesic options.

Characteristics, clinical findings and outcomes of acute aortic dissection: A comparison between an Australian emergency department and the International Registry of Acute Aortic Dissection.

OBJECTIVES: Acute aortic dissection (AAD) is a rare, life-threatening condition for which the International Registry of Acute Aortic Dissection (IRAD) remains the most detailed clinical resource. The present study compared the characteristics, clinical findings and outcomes of patients presenting to Liverpool Hospital, NSW, Australia (LPOOL) with AAD to those in IRAD. Secondary aims were to identify LPOOL patient variables associated with 30-day mortality and to assess the impact of transfer times in the ED on 30-day mortality. METHODS: Retrospective observational study of patients presenting to LPOOL with AAD between 2011 and 2019. Clinical records were examined and compared with IRAD data. Variables in LPOOL associated (P < 0.10) with 30-day mortality by univariable analysis were subsequently entered in a multivariable logistic regression to identify independent predictors. Mediation analysis was performed to assess the impact of ED transfer times on 30-day mortality. RESULTS: The characteristics, clinical findings and outcomes of 156 LPOOL patients were overall similar to those in IRAD. Syncope, weakness or paralysis, raised lactate and chest X-ray abnormalities were identified as independent predictors of 30-day mortality. Time from ED to ICU explained 28% of the variance in survival at 30 days. CONCLUSIONS: The characteristics, clinical features and outcomes of patients with AAD presenting to LPOOL appeared similar to those reported by IRAD. The identification of independent mortality predictors serves to improve the understanding of local AAD presentations. Reducing ED to ICU transfer times may increase 30-day survival and further interdisciplinary research should be considered.

Prospective, multicentre observational study of point-of-care ultrasound practice in emergency departments across Australia and New Zealand: The POCUS-ED Registry.

OBJECTIVES: The present study aimed to describe the characteristics, performance, accuracy and significance of point-of-care ultrasound (POCUS) use in the ED, by utilising an expanded version of the ACEM-mandated special skills placement (SSP) logbook, to develop a novel clinical quality registry. METHODS: A prospective, observational study was performed across EDs in Australia and New Zealand over a 12-month period. Trainees undertaking ACEM-approved ultrasound (US) SSPs recorded all US scan interpretations and follow-up imaging reports in an online database. RESULTS: In total, 2647 USs were recorded by 26 special skills trainees across 10 EDs in Australia or New Zealand; of these 2356 scans (89%) were clinically indicated. Overall, 2493 scans (94%) were used for diagnostic assessment, of which 1147 (43%) had abnormal findings. Basic echocardiography, extended Focused Assessment with Sonography in Trauma and right upper quadrant scans were the most commonly used modalities. There were 134 US-guided procedures logged in the registry. Approximately 36% of scans were reported to alter the original provisional diagnosis, whereas in another 37% of cases, POCUS was thought to confirm the original clinical suspicion. The majority of scans (76.5%) entered into the registry were physically reviewed by the SSP supervisor. CONCLUSIONS: This multicentred registry provides a detailed description of the current utilisation of POCUS within special skills US placements across EDs in Australia and New Zealand. This data should inform clinical leaders in emergency US to improve both POCUS education and governance around this important tool.

Prehospital activation of a coordinated multidisciplinary hospital response in preparation for patients with severe hemorrhage: A statewide data linkage study of the New South Wales "Code Crimson" pathway.

BACKGROUND: Hemorrhage is a leading cause of preventable death in trauma. Prehospital medical teams can streamline access to massive transfusion and definitive hemorrhage control by alerting in-hospital trauma teams of suspected life-threatening bleeding in unstable patients. This study reports the initial experience of an Australian "Code Crimson" (CC) pathway facilitating early multidisciplinary care for these patients. METHODS: This data-linkage study combined prehospital databases with a trauma registry of patients with an Injury Severity Score greater than 12 between 2017 and 2019. Four groups were created; prehospital CC activation with and without in-hospital links and patients with inpatient treatment consistent with CC, without one being activated. Diagnostic accuracy was estimated using capture-recapture methodology to replace the missing cell (no prehospital CC and Injury Severity Score < 12). RESULTS: Of 72 prehospital CC patients, 50 were linked with hospital data. Of 154 potentially missed patients, 42 had a prehospital link. Most CC patients were young men who sustained blunt trauma and required more prehospital interventions than non-CC patients. Code Crimson patients had more multisystem trauma, especially complex thoracic injuries (80%), while missed CC patients more frequently had single organ injuries (59%). Code Crimson patients required fewer hemorrhage control procedures (60% vs. 86%). Lower mortality was observed in CC patients despite greater hospital and intensive care unit length of stay. Despite a low sensitivity (0.49; 95% confidence interval [CI], 0.38-0.61) and good specificity (0.92; 95% CI, 0.86-0.96), the positive likelihood ratio was acceptable (6.42; 95% CI, 3.30-12.48). CONCLUSION: The initiation of a statewide CC process was highly specific for the need for hemorrhage control intervention in hospital, but further work is required to improve the sensitivity of prehospital activation. Patients who had a CC activation sustained more multisystem trauma but had lower mortality than those who did not. These results guide measures to improve this pathway. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

A multicenter evaluation of the accuracy of prehospital eFAST by a physician-staffed helicopter emergency medical service.

PURPOSE: The purpose of this study is to report the relative accuracy of prehospital extended focused assessment with sonography in trauma (eFAST) examinations performed by HEMS physicians. METHODS: Trauma patients who received prehospital eFAST by HEMS clinicians between January 2013 and December 2017 were reviewed. The clinician's interpretations of these ultrasounds were compared to gold standard references of CT imaging or operating room findings. The outcomes measured include the calculated accuracy of eFAST for detecting intraperitoneal free fluid (IPFF), pneumothorax, hemothorax, and pericardial fluid compared to available gold standard results. RESULTS: Of the 411 patients with adequate data for comparison, the median age was 39.5 years with 73% male and 98% sustaining blunt force trauma. For the detection of IPFF, eFAST had a sensitivity of 25% (95% CI 16-36%) and specificity of 96% (95% CI 93-98%). Sensitivities and specificities were calculated for pneumothorax (38% and 96% respectively), hemothorax (17% and 97% respectively), and pericardial effusion (17% and 100% respectively). These results did not change significantly when reassessed with several sensitivity analyses. CONCLUSION: Prehospital eFAST is reliable for detecting the presence of intraperitoneal free fluid. This finding should inform receiving trauma teams to prepare for early definitive care in these patients. The low sensitivities across all components of the eFAST highlight the importance of cautiously interpreting negative studies while prompting the need for further studies. TRIAL REGISTRATION: ACTRN12618001973202 (Registered on 06/12/2018).

Review article: ventricular assist devices in the emergency department.

Ventricular assist devices (VADs) have become an indispensable tool in the management of end-stage cardiac failure, both as a means of bridging to cardiac transplantation and as destination therapy for long-term quality of life improvement. Although the technology continues to advance and these devices continue to be refined, they are still associated with significant complications. This article reviews the basics of VAD function and physiology, as well as the myriad to complications that follow their implantation. This review aims to provide a systematic approach to the troubleshooting, diagnosis and management of both VAD-associated complications and the resuscitation of the decompensated VAD patient presenting to the ED.

Leech on the eye: a novel use for hypertonic saline.

Although human interaction with leeches is common in Australia, there is little documented literature on ocular injuries as a result of contact with a leech. We report a case of ocular leech attachment and a previously undocumented method of removal with hypertonic saline solution.