Cardiorespiratory consequences of attenuated fentanyl and augmented rocuronium dosing during protocolised prehospital emergency anaesthesia at a regional air ambulance service: a retrospective study.

BACKGROUND: Pre-Hospital Emergency Anaesthesia (PHEA) has undergone significant developments since its inception. However, optimal drug dosing remains a challenge for both medical and trauma patients. Many prehospital teams have adopted a drug regimen of 3 mcg/kg fentanyl, 2 mg/kg ketamine and 1 mg/kg rocuronium ('3:2:1'). At Essex and Herts Air Ambulance Trust (EHAAT) a new standard dosing regimen was introduced in August 2021: 1 mcg/kg fentanyl, 2 mg/kg ketamine and 2 mg/kg rocuronium (up to a maximum dose of 150 mg) ('1:2:2'). The aim of this study was to evaluate the cardiorespiratory consequences of a new attenuated fentanyl and augmented rocuronium dosing regimen. METHODS: A retrospective study was conducted at EHAAT as a service evaluation. Anonymized records were reviewed from an electronic database to compare the original ('3:2:1') drug dosing regimen (December 2019-July 2021) and the new ('1:2:2') dosing regimen (September 2021-May 2023). The primary outcome was the incidence of absolute hypotension within ten minutes of induction. Secondary outcomes included immediate hypertension, immediate hypoxia and first pass success (FPS) rates. RESULTS: Following exclusions (n = 121), 720 PHEA cases were analysed (360 new vs. 360 original, no statistically significant difference in demographics). There was no difference in the rate of absolute hypotension (24.4% '1:2:2' v 23.8% '3:2:1', p = 0.93). In trauma patients, there was an increased first pass success (FPS) rate with the new regimen (95.1% v 86.5%, p = 0.01) and a reduced incidence of immediate hypoxia (7.9% v 14.8%, p = 0.05). There was no increase in immediate hypertensive episodes (22.7% vs. 24.2%, p = 0.73). No safety concerns were identified. CONCLUSION: An attenuated fentanyl and augmented rocuronium dosing regimen showed no difference in absolute hypotensive episodes in a mixed cohort of medical and trauma patients. In trauma patients, the new regimen was associated with an increased FPS rate and reduced episodes of immediate hypoxia. Further research is required to understand the impact of such drug dosing in the most critically ill and injured subpopulation.

Critical hypertension in trauma patients following prehospital emergency anaesthesia: a multi-centre retrospective observational study.

BACKGROUND: Critical hypertension in major trauma patients is associated with increased mortality. Prehospital emergency anaesthesia (PHEA) is performed for 10% of the most seriously injured patients. Optimising oxygenation, ventilation, and cerebral perfusion, whilst avoiding extreme haemodynamic fluctuations are the cornerstones of reducing secondary brain injury. The aim of this study was to report the differential determinants of post-PHEA critical hypertension in a large regional dataset of trauma patients across three Helicopter Emergency Medical Service (HEMS) organisations. METHODS: A multi-centre retrospective observational study of consecutive adult trauma patients undergoing PHEA across three HEMS in the United Kingdom; 2015-2022. Critical hypertension was defined as a new systolic blood pressure (SBP) > 180mmHg within 10 min of induction of anaesthesia, or > 10% increase if the baseline SBP was > 180mmHg prior to induction. Purposeful logistical regression was used to explore variables associated with post-PHEA critical hypertension in a multivariable model. Data are reported as number (percentage), and odds ratio (OR) with 95% confidence interval (95%CI). RESULTS: 30,744 patients were attended by HEMS during the study period; 2161 received PHEA and 1355 patients were included in the final analysis. 161 (11.9%) patients had one or more new episode(s) of critical hypertension ≤ 10 min post-PHEA. Increasing age (compared with 16-34 years): 35-54 years (OR 1.76, 95%CI 1.03-3.06); 55-74 years (OR 2.00, 95%CI 1.19-3.44); ≥75 years (OR 2.38, 95%CI 1.31-4.35), pre-PHEA Glasgow Coma Scale (GCS) motor score four (OR 2.17, 95%CI 1.19-4.01) and five (OR 2.82, 95%CI 1.60-7.09), patients with a pre-PHEA SBP > 140mmHg (OR 6.72, 95%CI 4.38-10.54), and more than one intubation attempt (OR 1.75, 95%CI 1.01-2.96) were associated with post-PHEA critical hypertension. CONCLUSION: Delivery of PHEA to seriously injured trauma patients risks haemodynamic fluctuation. In adult trauma patients undergoing PHEA, 11.9% of patients experienced post-PHEA critical hypertension. Increasing age, pre-PHEA GCS motor score four and five, patients with a pre-PHEA SBP > 140mmHg, and more than intubation attempt were independently associated with post-PHEA critical hypertension.

Predictors of post-intubation hypotension in trauma patients following prehospital emergency anaesthesia: a multi-centre observational study.

BACKGROUND: Post-intubation hypotension (PIH) after prehospital emergency anaesthesia (PHEA) is prevalent and associated with increased mortality in trauma patients. The objective of this study was to compare the differential determinants of PIH in adult trauma patients undergoing PHEA. METHODS: This multi-centre retrospective observational study was performed across three Helicopter Emergency Medical Services (HEMS) in the UK. Consecutive sampling of trauma patients who underwent PHEA using a fentanyl, ketamine, rocuronium drug regime were included, 2015-2020. Hypotension was defined as a new systolic blood pressure (SBP) < 90 mmHg within 10 min of induction, or > 10% reduction if SBP was < 90 mmHg before induction. A purposeful selection logistic regression model was used to determine pre-PHEA variables associated with PIH. RESULTS: During the study period 21,848 patients were attended, and 1,583 trauma patients underwent PHEA. The final analysis included 998 patients. 218 (21.8%) patients had one or more episode(s) of hypotension ≤ 10 min of induction. Patients > 55 years old; pre-PHEA tachycardia; multi-system injuries; and intravenous crystalloid administration before arrival of the HEMS team were the variables significantly associated with PIH. Induction drug regimes in which fentanyl was omitted (0:1:1 and 0:0:1 (rocuronium-only)) were the determinants with the largest effect sizes associated with hypotension. CONCLUSION: The variables significantly associated with PIH only account for a small proportion of the observed outcome. Clinician gestalt and provider intuition is likely to be the strongest predictor of PIH, suggested by the choice of a reduced dose induction and/or the omission of fentanyl during the anaesthetic for patients perceived to be at highest risk.

When can an enhanced critical care team add value to equestrian related incidents? A retrospective observational study.

BACKGROUND: Helicopter Emergency Medical Services (HEMS) may be tasked to equestrian related incidents. Previous studies have suggested that majority of patients do not require HEMS specific interventions. No data has been published since 2015 so this article aims to establish the current incidence of equestrian incidents attended by one UK HEMS and identify trends that would aid the dispatch of HEMS to the patients who most need it. METHODS: A retrospective review of the computerised record system for one UK HEMS was performed between 1st January 2015-30th June 2022. Demographic data, timings, suspected injury pattern and HEMS specific intervention details were extracted. The 20 patients with the highest confirmed injury burden were reviewed in detail. RESULTS: 257 patients (229 female) were treated by HEMS (0.02% of all HEMS dispatches). Of those 124 dispatches were due to interrogation of the 999 calls by a clinician on the dispatch desk. Only 52% were conveyed to hospital by the HEMS team; 51% had no HEMS specific intervention. Of the 20 most severely injured patients their pathology included splenic, liver, spinal cord and traumatic brain injuries. CONCLUSION: Whilst HEMS dispatches to equestrian incidents remain a small percentage, there are four mechanisms that may benefit due to potential injury burden: fall onto head with suggestion of hyper-extension or hyper-flexion injury; kick to the torso; horse fallen or repetitively rolled onto patient and, no movement of patient since incident. In addition, age >50 years should be considered as higher risk.

The Prehospital Emergency Anaesthetic in 2022.

Prehospital emergency anesthesia (PHEA) is a commonly performed prehospital procedure with inherent risks. The processes and drug regimens behind PHEA are continually updated by prehospital teams across the country as part of their governance structure. Essex & Herts Air Ambulance has recently updated this practice by reviewing the entire process of performing PHEA. Through experiential learning in a high-volume service, audit, and a contemporary literature review, a new standard operating procedure has been developed to combat common problems, such as hypotension, associated with the more traditional methods of performing PHEA. The aim of this article was to summarize the literature behind this new standard operating procedure, systematically breaking down the core components of performing a PHEA and the rationale behind them. The key components identified in the review are indications for PHEA, airway assessment, peri-intubation oxygenation, preparation for PHEA, drug dosing, special circumstances, and failed intubation. One significant change is the drug dosage regimen; 1 µg/kg fentanyl, 2 mg/kg ketamine, and 2 mg/kg rocuronium is recommended as the main drug dosing regimen for both medical and trauma patients. Other changes include preoxygenation with a nasal cannula in addition to the nonrebreather mask, optimizing patients in the preparation phase by considering inopressors or fluid bolus and ensuring a "sterile cockpit" to control the surrounding environment to ensure the first intubation attempt is the best attempt.

Outcomes of critically ill COVID-19 patients managed in a high-volume severe respiratory failure and ECMO centre in the United Kingdom.

During the Coronavirus Disease 2019 (COVID-19) pandemic institutions have needed to develop pragmatic clinical pathways to balance the excess critical care demand and local resources. In this single-centre retrospective cohort study we describe the outcomes of COVID-19 patients admitted to Guy's and St. Thomas' NHS Foundation Trust (GSTT) critical care service. Patients were managed according to a local respiratory failure management pathway that was predicated on timely invasive ventilation when indicated and tailored ventilatory strategies according to pulmonary mechanics. Between 2 March and 25 May 2020 GSTT critical care service admitted 316 patients with confirmed COVID-19. Of the 201 patients admitted directly through the Emergency Department (ED) with a completed critical care outcome, 71.1% survived to critical care discharge. These favourable outcomes may serve to inform the wider debate on optimal organ support in COVID-19.

Cardiovascular complications of prehospital emergency anaesthesia in patients with return of spontaneous circulation following medical cardiac arrest: a retrospective comparison of ketamine-based and midazolam-based induction protocols.

BACKGROUND: Hypotension following intubation and return of spontaneous circulation (ROSC) after cardiac arrest is associated with poorer patient outcomes. In patients with a sustained ROSC requiring emergency anaesthesia, there is limited evidence to guide anaesthetic practice. At the Essex & Herts Air Ambulance Trust, a UK-based helicopter emergency medical service, we assessed the relative haemodynamic stability of two different induction agents for post-cardiac arrest medical patients requiring prehospital emergency anaesthesia (PHEA). METHODS: We performed a retrospective database review over a 5-year period between December 2014 and December 2019 comparing ketamine-based and midazolam-based anaesthesia in this patient cohort. Our primary outcome was clinically significant hypotension within 30 min of PHEA, defined as a new systolic BP less than 90 mm Hg, or a 10% drop if less than 90 mm Hg before induction. RESULTS: One hundred ninety-eight patients met inclusion criteria. Forty-eight patients received a ketamine-based induction, median dose (IQR) 1.00 (1.00-1.55) mg/kg, and a 150 midazolam-based regime, median dose 0.03 (0.02-0.04) mg/kg. Hypotension occurred in 54.2% of the ketamine group and 50.7% of the midazolam group (p=0.673). Mean maximal HRs within 30 min of PHEA were 119 beats/min and 122 beats/min, respectively (p=0.523). A shock index greater than 1.0 beats/min/mm Hg and age greater than 70 years were both associated with post-PHEA hypotension with ORs 1.96 (CI 1.02 to 3.71) and 1.99 (CI 1.01 to 3.90), respectively. Adverse event rates did not significantly differ between groups. CONCLUSION: PHEA following a medical cardiac arrest is associated with potentially significant cardiovascular derangements when measured up to 30 min after induction of anaesthesia. There was no demonstrable difference in post-induction hypotension between ketamine-based and midazolam-based PHEA. Choice of induction agent alone is insufficient to mitigate haemodynamic disturbance, and alternative strategies should be used to address this.

A survey on the practices and capabilities in the management of respiratory failure in South East England.

INTRODUCTION: The variability of acute respiratory distress syndrome management may affect the referral practice to severe respiratory failure centres. We described the management of acute respiratory distress syndrome in our catchment area. METHODS: An electronic survey was administered to 42 intensive care units in South-East England. RESULTS: Response rate was 71.4%. High-flow nasal oxygen and non-invasive ventilation were used 'often' in moderate-acute respiratory distress syndrome by 46.7% and 60%. During invasive ventilation, 90% preferred pressure control, targeting tidal volumes of 6-8 ml/kg (53.3%) or 4-6 ml/kg (46.7%). Positive end-expiratory pressure was selected by positive end-expiratory pressure/inspiratory fraction of oxygen tables (50%) or decremental positive end-expiratory pressure trials (20%). Neuro-muscular blockers were widely used, although routinely by only 3.3%. High-frequency oscillatory ventilation (10%) and inhaled nitric oxide (13.3%) were rarely used. None used oesophageal manometry. Recruitment manoeuvres were used 'often' by 26.7%. Equipment (90%) and protocols (80%) for prone position were common, with sessions mostly lasting 12-18 h. CONCLUSIONS: Although variable, practice well reflected the available evidence. Proning was widely practiced with good availability of educational resources and protocolised care.

Assessment of Right Ventricular Function With CT and Echocardiography in Patients With Severe Acute Respiratory Distress Syndrome on Extracorporeal Membrane Oxygenation.

OBJECTIVES: Changes in right ventricular size and function are frequently observed in patients with severe acute respiratory distress syndrome. The majority of patients who receive venovenous extracorporeal membrane oxygenation undergo chest CT and transthoracic echocardiography. The aims of this study were to compare the use of CT and transthoracic echocardiography to evaluate the right ventricular function and to determine the prevalence of acute cor pulmonale in this patient population. DESIGN: Observational, retrospective, single-center, cohort study. SETTING: Severe respiratory failure and extracorporeal membrane oxygenation center. PATIENTS: About 107 patients with severe acute respiratory distress syndrome managed with venovenous extracorporeal membrane oxygenation. INTERVENTIONS: Chest CT to evaluate right ventricular size and transthoracic echocardiography to evaluate right ventricular size and function. MEASUREMENTS AND MAIN RESULTS: All 107 patients had a qualitative assessment of right ventricular size and function on transthoracic echocardiography. Quantitative measurements were available in 54 patients (50%) who underwent transthoracic echocardiography and in 107 of patients (100%) who received CT. Right ventricular dilatation was defined as a right ventricle end-diastolic diameter greater than left ventricular end-diastolic diameter upon visual assessment or an right ventricle end-diastolic diameter/left ventricular end-diastolic diameter and/or right ventricle cavity area/left ventricular cavity area of greater than 0.9. Right ventricle systolic function was visually estimated as being normal or impaired (visual right ventricular systolic impairment). The right ventricle was found to be dilated in 38/107 patients (36%) and in 58/107 patients (54%), using transthoracic echocardiography or CT right ventricle end-diastolic diameter/left ventricular end-diastolic diameter, respectively. When the CT right ventricle cavity/left ventricular cavity area criterion was used, the right ventricle was dilated in 19/107 patients (18%). About 33/107 patients (31%) exhibited visual right ventricular systolic impairment. Transthoracic echocardiography right ventricle end-diastolic diameter/left ventricular end-diastolic diameter showed good agreement with CT right ventricle cavity/left ventricular cavity area (R 2 = 0.57; p < 0.01). A CT right ventricle cavity/left ventricular cavity area greater than 0.9 provided the optimal cutoff for acute cor pulmonale on transthoracic echocardiography with an AUC of 0.78. Acute cor pulmonale was defined by the presence of a right ventricle "D-shape" and quantitative right ventricle dilatation on transthoracic echocardiography or a right ventricle cavity/left ventricular cavity area greater than 0.9 on CT. A diagnosis of acute cor pulmonale was made in 9/54 (14% patients) on transthoracic echocardiography and in 19/107 (18%) on CT. CONCLUSIONS: Changes in right ventricular size and function are common in patients with severe acute respiratory distress syndrome requiring venovenous extracorporeal membrane oxygenation with up to 18% showing imaging evidence of acute cor pulmonale. A CT right ventricular cavity /left ventricular cavity area greater than 0.9 is indicative of impaired right ventricular systolic function.

Temporal Changes in Targeted Temperature Management for Out-of-Hospital Cardiac Arrest-Examining the Effect of the Targeted Temperature Management Trial: A Retrospective Cohort Study.

Targeted temperature management (TTM) is recommended after out-of-hospital cardiac arrest (OHCA). However, interpretation of the evidence and translation into clinical practice, to realize benefits to patient outcomes may be inconsistent. This study aims to compare compliance with the recommended targeted temperatures and the use of intravascular temperature management (IVTM), as well as 90-day survival, before and after publication of the TTM trial. A single-center retrospective cohort study was conducted from 2010 to 2017. All comatose patients admitted to the intensive care unit after OHCA, who survived for ≥24 hours, were included. IVTM use was measured and TTM adherence was defined as the percentage time the core temperature was (1) within the guideline-recommended temperature range (initially 32-34°C, later modified to 32-36°C) for the first 24 hours, and (2) ≤37.5°C between 24 and 72 hours following admission. Multiple logistic regression analyses were performed for the use of IVTM and survival at 90 days. Of the 302 patients identified, 136 (45%) were pre-TTM, and 166 (55%) post-TTM. Baseline characteristics were similar between the groups. IVTM use decreased significantly (77.9% vs. 51.8%, p < 0.001) after the publication of the TTM trial. Adherence to the 32-34°C and 32-36°C targets was higher pre-TTM as compared with the post-TTM cohort (33.3% [0-66.7%] vs. 0% [0-16.7%], p < 0.001 and 83.3% [50.0-100%] vs. 36.7% [16.7-66.7%], p < 0.001, respectively). Time with temperature ≥37.5°C in the first 24 hours was higher post-TTM (p = < 0.001) but not between 24 and 72 hours. Ninety-day survival was 54.4% in the pre-TTM cohort and 44.0% post-TTM, (odds ratio 1.52 [0.96-2.40], p = 0.083). Adherence with recommended TTM decreased significantly following publication of the TTM trial and this was explained by a significant decrease in IVTM use. However, this concerning trend did not result in a statistically significant difference in survival.

Veno-venous extracorporeal membrane oxygenation in coronavirus disease 2019: a case series.

BACKGROUND: The use of veno-venous extracorporeal membrane oxygenation (VV-ECMO) in severe hypoxaemic respiratory failure from coronavirus disease 2019 (COVID-19) has been described, but reported utilisation and outcomes are variable, and detailed information on patient characteristics is lacking. We aim to report clinical characteristics, management and outcomes of COVID-19 patients requiring VV-ECMO, admitted over 2 months to a high-volume centre in the UK. METHODS: Patient information, including baseline characteristics and clinical parameters, was collected retrospectively from electronic health records for COVID-19 VV-ECMO admissions between 3 March and 2 May 2020. Clinical management is described. Data are reported for survivors and nonsurvivors. RESULTS: We describe 43 consecutive patients with COVID-19 who received VV-ECMO. Median age was 46 years (interquartile range 35.5-52.5) and 76.7% were male. Median time from symptom onset to VV-ECMO was 14 days (interquartile range 11-17.5). All patients underwent computed tomography imaging, revealing extensive pulmonary consolidation in 95.3%, and pulmonary embolus in 27.9%. Overall, 79.1% received immunomodulation with methylprednisolone for persistent maladaptive hyperinflammatory state. Vasopressors were used in 86%, and 44.2% received renal replacement therapy. Median duration on VV-ECMO was 13 days (interquartile range 8-20). 14 patients died (32.6%) and 29 survived (67.4%) to hospital discharge. Nonsurvivors had significantly higher d-dimer (38.2 versus 9.5 mg·L-1, fibrinogen equivalent units; p=0.035) and creatinine (169 versus 73 µmol·L-1; p=0.022) at commencement of VV-ECMO. CONCLUSIONS: Our data support the use of VV-ECMO in selected COVID-19 patients. The cohort was characterised by high degree of alveolar consolidation, systemic inflammation and intravascular thrombosis.

COVID-19-related organ dysfunction and management strategies on the intensive care unit: a narrative review.

The coronavirus disease 2019 (COVID-19) pandemic has resulted in a significant surge of critically ill patients and an unprecedented demand on intensive care services. The rapidly evolving understanding of pathogenesis, limited disease specific evidence, and demand-resource imbalances have posed significant challenges for intensive care clinicians. COVID-19 is a complex multisystem inflammatory vasculopathy with a significant mortality implication for those admitted to intensive care. Institutional strategic preparation and meticulous intensive care support are essential to maximising outcomes during the pandemic. The significant mortality variation observed between institutions and internationally, despite a single aetiology and uniform presentation, highlights the potential influence of management strategies on outcome. Given that optimal organ support and adjunctive therapies for COVID-19 have not yet been well defined by trial-based outcomes, strategies are predicated on existing literature and experiential learning. This review outlines the relevant pathophysiology and management strategies for critically ill patients with COVID-19, and shares some of the collective learning accumulated in a high volume severe respiratory failure centre in London.

Veno-arterio-venous ECMO for septic cardiomyopathy: a single-centre experience.

INTRODUCTION: The role of extracorporeal support for patients with septic shock remains unclear. METHODS: We conducted a retrospective analysis of our single-centre experience with veno-arterio-venous extracorporeal membrane oxygenation (VAV ECMO) in adult patients with severe respiratory failure and septic cardiomyopathy. Clinical data was extracted from electronic medical records including a dedicated ECMO referral and follow-up database. RESULTS: Twelve patients were commenced on VAV ECMO for septic cardiomyopathy for a median of four days (IQR 3.0 to 5.3) between 01/2014 and 12/2017. Five patients (41.7%) had a cardiac arrest prior to initiation of ECMO support. At baseline, median left ventricular ejection fraction was 16.25% (IQR 13.13 to 17.5) and median PaO2/FiO2 ratio was 9 kPa (IQR 6.5 to 12.0) [67.50 mmHg (IQR 48.75 to 90.00)]. The survival rate to hospital discharge for VAV ECMO was 75% in this cohort. None of the surviving patients died within the follow-up period (median six month). CONCLUSION: VAV ECMO is a feasible rescue strategy for a small proportion of patients with combined respiratory and cardiac failure secondary to septic shock with septic cardiomyopathy. We provide a detailed report of our experience with this technique. Further research is required comparing the different extracorporeal strategies directly to conventional resuscitation and against each other.

The impact of major trauma network triage systems on patients with major burns.

INTRODUCTION: Trauma is a leading cause of death and disability worldwide. Patients presenting with severe trauma and burns benefit from specifically trained multidisciplinary teams. Regional trauma systems have shown improved outcomes for trauma patients. The aim of this study is to determine whether the development of major trauma systems have improved the management of patients with major burns. METHODS: A retrospective study was performed over a four-year period reviewing all major burns in adults and children received at a regional burns centre in the UK before and after the implementation of the regional trauma systems and major trauma centres (MTC). Comparisons were drawn between three areas: (1) Patients presenting before the introduction of MTC and after the introduction of MTC. (2) Patients referred from MTC and non-MTC within the region, following the introduction of MTC. (3) Patients referred using the urban trauma protocol and the rural trauma protocol. RESULTS: Following the introduction of regional trauma systems and major trauma centres (MTC), isolated burn patients seen at our regional burns centre did not show any significant improvement in transfer times, admission resuscitation parameters, organ dysfunction or survival when referred from a MTC compared to a non-MTC emergency department. There was also no significant difference in survival when comparing referrals from all hospitals pre and post establishment of the major trauma network. CONCLUSION: No significant outcome benefit was demonstrated for burns patients referred via MTCs compared to non-MTCs. We suggest further research is needed to ascertain whether burns patients benefit from prolonged transfer times to a MTC compared to those seen at their local hospitals prior to transfer to a regional burns unit for further specialist care.

Traumatic brain injury: physiological targets for clinical practice in the prehospital setting and on the Neuro-ICU.

PURPOSE OF REVIEW: Over many years, understanding of the pathophysiology in traumatic brain injury (TBI) has resulted in the development of core physiological targets and therapies to preserve cerebral oxygenation, and in doing so prevent secondary insult. The present review revisits the evidence for these targets and therapies. RECENT FINDINGS: Achieving oxygen, carbon dioxide, blood pressure, temperature and glucose targets remain a key goal of therapy in TBI, as does the role of effective prehospital care. Physician led air ambulance teams reduce mortality. Normobaric hyperoxia is dangerous to the injured brain; as are both high and low carbon dioxide levels. Hypotension is life threatening and higher targets have now been suggested in TBI. Both therapeutic normothermia and hypothermia have a role in specific groups of patients with TBI. Although consensus has not been reached on the optimal intravenous fluid for resuscitation in TBI, vigilant goal-directed fluid administration may improve outcome. Osmotherapeutic agents such as hypertonic sodium lactate solutions may also have a role alongside conventional agents. SUMMARY: Maintaining physiological targets in several areas remains part of protocol led care in the acute phase of TBI management. As evidence accumulates however, the target values and therefore therapies may be set to change.

Systemic complications of traumatic brain injury.

PURPOSE OF REVIEW: Increased understanding of the pathophysiology in traumatic brain injury (TBI) has resulted in the development of core physiological targets and therapies to preserve cerebral oxygenation, and in doing so prevent secondary insult. This review addresses the many systemic complications of TBI that make achieving these targets challenging and can influence outcome. RECENT FINDINGS: There are a wide range of systemic complications following TBI. Complications involve the cardiovascular, respiratory, immunological, haematological and endocrinological systems amongst others, and can influence early management and long-term outcomes. SUMMARY: Effective management of TBI should go beyond formulaic-based pursuit of physiological targets and requires a detailed understanding of the multisystem response of the body.

Availability and use of capnography for in-hospital cardiac arrests in the United Kingdom.

BACKGROUND: Airway complications occur more frequently outside the operating theatre and in emergency situations. Capnography remains the gold standard for confirming correct endotracheal tube placement, retaining high sensitivity and specificity in cardiac arrest. The 2010 European Resuscitation Council guidelines for adult advanced life support recommended waveform capnography in this setting. We investigated current UK practice relating to the availability and use of this technology during cardiac arrest. METHODS: Between June and November 2014, a study was conducted of all UK acute hospitals with both a level three adult intensive care unit (ICU) and an emergency department (ED). A telephone questionnaire was administered examining intubation practice and utilisation of capnography within the ED, ICU and general wards. RESULTS: Two hundred and eleven hospitals met the inclusion criteria. The response rate was 100%. Arrests were mainly attended by anaesthesia (48%) and ICU physicians (38%) of registrar grade (56%). The ability to measure end tidal carbon dioxide (ETCO2) was available in all but 4 EDs; most used in waveform devices. Most ICUs were similar. However, in 67% of hospitals surveyed, it was not possible to measure ETCO2 in general wards. Where available, 87% used capnography to confirm ETT placement with less than 50% using ETCO2 to determine CPR effectiveness and 8% to prognosticate. CONCLUSIONS: We believe this is the first study of its kind to fully investigate the availability and use of capnography during cardiac arrest throughout the hospital. Whilst equipment provision appears adequate in critical care areas, it is insufficient in general wards.

Development of a standard operating procedure and checklist for rapid sequence induction in the critically ill.

INTRODUCTION: Rapid sequence induction (RSI) of critically ill patients outside of theatres is associated with a higher risk of hypoxia, cardiovascular collapse and death. In the prehospital and military environments, there is an increasing awareness of the benefits of standardised practice and checklists. METHODS: We conducted a non-systematic review of literature pertaining to key components of RSI preparation and management. A standard operating procedure (SOP) for in-hospital RSI was developed based on this and experience from large teaching hospital anaesthesia and critical care departments. RESULTS: The SOP consists of a RSI equipment set-up sheet, pre-RSI checklist and failed airway algorithm. The SOP should improve RSI preparation, crew resource management and first pass intubation success while minimising adverse events. CONCLUSION: Based on the presented literature, we believe the evidence is sufficient to recommend adoption of the core components in the suggested SOP. This standardised approach to RSI in the critically ill may reduce the current high incidence of adverse events and hopefully improve patient outcomes.

Are physicians required during winch rescue missions in an Australian helicopter emergency medical service?

BACKGROUND: A helicopter emergency medical service (HEMS) capable of winching offers several advantages over standard rescue operations. Little is known about the benefit of physician winching in addition to a highly trained paramedic. OBJECTIVE: To analyse the mission profiles and interventions performed during rescues involving the winching of a physician in the Greater Sydney Area HEMS (GSA-HEMS). METHODS: All winch missions involving a physician from August 2009 to January 2012 were identified from the prospectively completed GSA-HEMS electronic database. A structured case sheet review for a predetermined list of demographic data and physician-only interventions (POIs) was conducted. RESULTS: We identified 130 missions involving the winching of a physician, of which 120 case sheets were available for analysis. The majority of patients were traumatically injured (90%) and male (85%) with a median age of 37 years. Seven patients were pronounced dead at the scene. A total of 63 POIs were performed on 48 patients. Administration of advanced analgesia was the most common POI making up 68.3% of interventions. Patients with abnormal RTSc(2) scores were more likely to receive a POI than those with normal RTSc(2) (84.8% vs 15.2%; p=0.03). The performance of a POI had no effect on median scene times (45 vs 43 min; p=0.51). CONCLUSIONS: Our high POI rate of 40% (48/120) coupled with long rescue times and the occasional severe injuries support the argument for winching Physicians. Not doing so would deny a significant proportion of patients time-critical interventions, advanced analgesia and procedural sedation.