Prehospital use of tranexamic acid for hemorrhagic shock in primary and secondary air medical evacuation.

INTRODUCTION: Major hemorrhage remains a leading cause of death in both military and civilian trauma. We report the use of tranexamic acid (TXA) as part of a trauma exanguination/massive transfusion protocol in the management of hemorrhagic shock in a civilian primary and secondary air medical evacuation (AME) helicopter EMS program. METHODS: TXA was introduced into our CCP flight paramedic program in June 2011. Indications for use include age > 16 years, major trauma (defined a priori based on mechanism of injury or findings on primary survey), and heart rate (HR) > 110 beats per minute (bpm) or systolic blood pressure (SBP) < 90 mmHg. Our protocol, which includes 24-hour online medical oversight, emphasizes rapid initiation of transport, permissive hypotension in select patients, early use of blood products (secondary AME only), and infusion of TXA while en route to a major trauma center. RESULTS: Over a 4-month period, our CCP flight crews used TXA a total of 13 times. Patients had an average HR of 111 bpm [95% CI 90.71-131.90], SBP of 91 mmHg [95% CI 64.48-118.60], and Glascow Coma Score of 7 [95% CI 4.65-9.96]. For primary AME, average response time was 33 minutes [95% CI 19.03-47.72], scene time 22 minutes [95% CI 20.23-24.27], and time to TXA administration 32 minutes [95% CI 25.76-38.99] from first patient contact. There were no reported complications with the administration of TXA in any patient. CONCLUSION: We report the successful integration of TXA into a primary and secondary AME program in the setting of major trauma with confirmed or suspected hemorrhagic shock. Further studies are needed to assess the effect of such a protocol in this patient population.

Code Blue Emergencies: A Team Task Analysis and Educational Initiative.

INTRODUCTION: The objective of this study was to identify factors that have a positive or negative influence on resuscitation team performance during emergencies in the operating room (OR) and post-operative recovery unit (PAR) at a major Canadian teaching hospital. This information was then used to implement a team training program for code blue emergencies. METHODS: In 2009/10, all OR and PAR nurses and 19 anesthesiologists at Vancouver General Hospital (VGH) were invited to complete an anonymous, 10 minute written questionnaire regarding their code blue experience. Survey questions were devised by 10 recovery room and operation room nurses as well as 5 anesthesiologists representing 4 different hospitals in British Columbia. Three iterations of the survey were reviewed by a pilot group of nurses and anesthesiologists and their feedback was integrated into the final version of the survey. RESULTS: Both nursing staff (n = 49) and anesthesiologists (n = 19) supported code blue training and believed that team training would improve patient outcome. Nurses noted that it was often difficult to identify the leader of the resuscitation team. Both nursing staff and anesthesiologists strongly agreed that too many people attending the code blue with no assigned role hindered team performance. CONCLUSION: Identifiable leadership and clear communication of roles were identified as keys to resuscitation team functioning. Decreasing the number of people attending code blue emergencies with no specific role, increased access to mock code blue training, and debriefing after crises were all identified as areas requiring improvement. Initial team training exercises have been well received by staff.

A comparison of a fiberoptic stylet and a bougie as adjuncts to direct laryngoscopy in a manikin-simulated difficult airway.

STUDY OBJECTIVE: We compare the effectiveness of an endotracheal tube introducer ("bougie") with a new fiberoptic stylet as an adjunct to direct laryngoscopy in facilitating simulated difficult tracheal intubation in a manikin. METHODS: Inexperienced laryngoscopists were recruited for this randomized, crossover study. After brief training, participants were randomized to first use either the bougie or fiberoptic stylet as an adjunct to direct laryngoscopy for attempted tracheal intubation of a manikin presenting a fixed, simulated, Cormack-Lehane grade IIIA view. Two attempts at tracheal intubation were allowed, each limited to 60 seconds. The participant then crossed over and used the other device. The same procedure was then repeated on a second manikin presenting a simulated Cormack-Lehane grade IIIB view. Primary outcomes were time to tracheal intubation and successful endotracheal tube placement. RESULTS: One hundred three study participants performed a total of 533 tracheal intubations for evaluation. For the Cormack-Lehane grade IIIA view, correct placement of the endotracheal tube was achieved in 101 (98%) of the fiberoptic stylet-facilitated and all 103 (100%) of the bougie-facilitated tracheal intubations. The time to successful tracheal intubation was similar for both devices (difference in mean time 1.8 seconds; 95% confidence interval [CI] -2.5 to 6.1 seconds). In the Cormack-Lehane grade IIIB view manikin, use of the fiberoptic stylet significantly increased success rate (fiberoptic stylet 98% versus bougie 9%), and a trend was observed toward a decrease in the mean time required for successful tracheal intubation compared to the bougie (fiberoptic stylet 31.0 seconds versus bougie 45.6 seconds; difference in mean time -14.6 seconds; 95% CI -31.4 to 2.3 seconds). CONCLUSION: In a manikin model, with inexperienced clinicians, both the bougie and the fiberoptic stylet were effective in facilitating tracheal intubation of a simulated Cormack-Lehane grade IIIA view. For a Cormack-Lehane IIIB view, the fiberoptic stylet was significantly more effective than the bougie in facilitating tracheal intubation. Because a manikin model eliminates some of the barriers to use of fiberoptics in patients, further validation of fiberoptic stylet use is required in human subjects with normal and difficult airways.