Retrospective evaluation of prehospital triage, presentation, interventions and outcome in paediatric drowning managed by a physician staffed helicopter emergency medical service.

BACKGROUND: Drowning patients may benefit from the advanced airway management capabilities that can be provided by physician staffed helicopter emergency medical services. The aim of this study is to describe paediatric drowning patients treated by such a service examining tasking systems, initial physiology at the incident scene, survival and neurological outcome. METHODS: Retrospective analysis of paediatric drowning victims over a 5- year period. Case identification system, patient age, site of drowning, presence or absence of cardiac output, first Glasgow Coma Scale (GCS) score and interventions were collected from prehospital notes, and survival and neurological outcomes from hospital and rehabilitation notes. RESULTS: The P-HEMS direct case identification system operating in parallel with a central control system identified all severe drowning cases but 3 of 7 cases (43%) were missed when the central control system operated in isolation. All severe drowning cases (22) identified for P-HEMS response were intubated and transported directly to a paediatric specialist centre. Intubation required adjuvant anaesthesia in 10 (45%) cases. All children with GCS greater than eight on arrival of the P-HEMS survived neurologically intact. Seven of eight children with a GCS between four and seven survived without neurological impairment and all children with a GCS greater than three survived. Four of twelve asystolic children survived including one child who at 18 months post drowning is neurologically normal. All children who survived had return of spontaneous circulation prior to arrival in the emergency department. CONCLUSIONS: P-HEMS played a significant role in the management of severe paediatric drowning in this case series. Requirement for P-HEMS only interventions were high and all identified cases were transferred directly to a paediatric specialist centre. Discontinuation of the P-HEMS direct case identication system that operated during the majority of the study period resulted in deterioration in system performance with some paediatric drowning cases subsequently not identified for P-HEMS response being transported to adult hospitals.

Paediatric aeromedical retrievals in the 'Top End' of the Northern Territory.

OBJECTIVE: The primary objective of this study was to describe the remote paediatric aeromedical population of the 'Top End' of the Northern Territory. The secondary objective was to identify children requiring high-dependency care by the transport team. DESIGN: Retrospective case review. SETTING: Aeromedical service in the remote Northern Territory. PARTICIPANTS: All patients under the age of 16 years transported over a one-year period between February 2012 and February 2013. OUTCOME MEASURES: Age, gestation if newborn, diagnosis at referral, requirement for high-dependency care and transport team members. RESULTS: Seven hundred eighty-nine children were transported with an average age of 4.4 years (range 0 days to 16 years). Nursing staff transferred 646 (82%). Respiratory problems (bronchiolitis and pneumonia) were the predominant illness type (31%). Other frequent diagnoses were trauma (11%), gastroenteritis (10%), cellulitis or abscess (9%) and the sequelae of streptococcal infection (8%). Thirty preterm infants including seven below 31 weeks gestation were transferred. Twenty-five children required high-dependency care, 15 of these on day 0 of life. Twenty-five required respiratory support, seven central venous access, four surfactant, two inotropes and one chest tubes. CONCLUSIONS: The majority of paediatric aeromedical patients have an infective cause for their illness. Respiratory disease is the most common indication for aeromedical transport. The majority of patients are transferred by a flight nurse and do not require high-dependency care. The main risk factor identified for requiring high-dependency care during transport is respiratory distress in a newborn infant.

Prehospital paediatric emergencies treated by an Australian helicopter emergency medical service.

OBJECTIVES: The aim of this study was to describe the mechanism and severity of injuries in the paediatric population treated by an Australian helicopter emergency medical service and to examine the frequency and nature of interventions performed. This information is important for planning education and continuing professional development in prehospital medicine. METHODS: The study is a retrospective cohort analysis of 349 patients under the age of 16 treated by CareFlight in Sydney, Australia, between April 2007 and April 2012. Data collected included age, type of incident, medication and fluid administered, procedures performed, receiving hospital, 24 h and 30-day mortality and injuries sustained. RESULTS: Falls (33%), motor vehicle incidents (30%), sport injury (14%) and immersion injury (12%) were the most common mechanisms. A total of 27 children died within 30 days; nontrauma cases were proportionally overrepresented in the deaths. With respect to tasking, 59% cases involved a severely or significantly injured child. Among the children, 97% with a traumatic mechanism were transferred directly to a paediatric trauma centre.In addition, 81% of children had at least one intervention by the helicopter emergency medical services team at the incident scene, most commonly intravenous cannulation (61%), crystalloid bolus (29%), intubation (21%) and intravenous analgesia administration (15%). CONCLUSION: Paediatric prehospital patients can be of high dependency, requiring urgent critical care procedures. Training in prehospital medicine should include paediatrics. It is essential that practitioners maintain skills in venous access, airway management and provision of adequate analgesia in children.

Obstetric air medical retrievals in the Australian outback.

INTRODUCTION: Women in labor or with complications of pregnancy in the remote, outback region of Australia's Northern Territory are transported to the hospital by air. The objective of this study was to describe the interventions required by obstetric and newborn patients during air medical transport and to evaluate how often these were beyond the scope of practice of a team consisting of an experienced midwife with or without a general flight doctor. METHODS: A retrospective cohort analysis of 200 consecutive women between 20 weeks gestation up to 24 hours postpartum and newborns transferred during the same time period. RESULTS: Only 1 obstetric patient required intervention beyond the scope of a midwife. Forty-eight newborn infants were transferred. Eleven (23%) required interventions within the skill range of a general flight doctor. Twenty (42%) required neonatal specialist care. Ten of 31 newborns requiring more than midwifery care were referred for transport while in utero. CONCLUSIONS: In this specific cohort, a midwife provided an appropriate level of maternal care to the majority of patients. Newborns frequently required clinical expertise beyond the practice scope of a midwife and general flight doctor. Most women in labor do not deliver during transport. The transport service has finite economic resources and logistical constraints. This study highlighted an ongoing challenge regarding when to request additional neonatal specialist care for preterm or high-risk patients referred for transport in utero.

Practical management of the shocked neonate.

The shocked neonate often causes anxiety in the ED. This article aims to provide a systematic, practical approach to recognition and initial management of these patients. Their resuscitation should follow a pattern of provision of oxygen, fluid resuscitation, blood glucose correction, inotropic support and ventilation. Practical tips for intravenous access and the rationale behind choice of inotrope and anaesthetic induction agent are discussed. The major underlying causes - sepsis, cardiac disease, metabolic disease and non-accidental injury - along with their investigation and management are considered.

A tomato mutant that shows stunting, wilting, progressive necrosis and constitutive expression of defence genes contains a recombinant Hcr9 gene encoding an autoactive protein.

The tomato Cf-9 gene confers resistance to races of the leaf mould fungus Cladosporium fulvum that carry the Avr9 avirulence gene. Cf-9 resides at a locus containing five paralogous genes and was isolated by transposon tagging using a modified maize Dissociation (Ds) element. The tagging experiment generated an allelic series of Ds-induced mutations of Cf-9, most of which were wild type in appearance. However, one mutant, designated M205, showed stunted growth, wilting, progressive leaf chlorosis and necrosis and constitutive expression of defence genes. The phenotype of M205 was caused by a semidominant, Avr9-independent mutation that co-segregated with a Ds element insertion at the Cf-9 locus. Molecular genetic analysis indicated that the Cf-9 locus of M205 had undergone recombination, generating a chimeric gene, designated Hcr9-M205, that comprised an in-frame fusion between the 5' coding region of the Cf-9 paralogue, Hcr9-9A, and the 3' coding region of Cf-9. The presence of a possible excision footprint adjacent to the junction between Hcr9-9A and Cf-9, and a Ds insertion at the homologous position in the downstream paralogue Hcr9-9D, is consistent with recombination between Hcr9-9A and Cf-9 promoted by transposition of Ds from Cf-9 into Hcr9-9D. Agrobacterium tumefaciens-mediated transient expression of Hcr9-M205 in Nicotiana tabacum caused chlorosis and the accumulation of defence gene transcripts, indicating that the protein encoded by this novel Hcr9 gene is autoactive.

Dominant-negative interference with defence signalling by truncation mutations of the tomato Cf-9 disease resistance gene.

The tomato Cf-9 gene confers resistance to races of the leaf mould fungus Cladosporium fulvum that carry the Avr9 avirulence gene. Cf-9 was isolated by transposon tagging using a modified maize Dissociation (Ds) element. This generated an allelic series of Ds-induced mutations of Cf-9, of which two were found to confer novel phenotypes in a screen for mutants affecting wild-type Cf-9 function in trans. Genetic and molecular analysis of these mutants suggested semidominant, Avr9-dependent, negative-interfering mutations involving Ds insertions in a defined subregion of Cf-9. Interference was associated with expression of the 5'-end of Cf-9 upstream of the Ds insertions in these mutants, suggesting that truncated Cf-9 proteins were the likely cause of interference. Transgenic tomato lines harbouring Cf-9 constructs with premature stop codons in positions similar to the Ds insertions also showed interference, indicating that the presence of Ds was not required for interference to occur. Interestingly, interference in these transgenic lines was completely dominant and was associated with a pronounced developmental phenotype that was dependent on co-expression of Cf-9, Avr9 and a truncated Cf-9 transgene. However, interference with a weakly autoactive Hcr9 gene was Avr9-independent and did not cause a developmental phenotype, suggesting that localized restoration of Cf-9/Avr9-dependent cell death was responsible for the developmental phenotype. The restricted region in which truncation of Cf-9 results in dominant-negative interference suggests that leucine-rich repeats (LRR) 16-19 of Cf-9 may mediate dimerization of Cf-9 and LRRs 20-23 may mediate interactions with downstream partner proteins required for Cf-9 signalling, or vice versa.

Prolonged treatment with prostaglandin in an infant born with extremely low weight.

We describe an infant with duct-dependent cardiac disease diagnosed prenatally who was born prematurely, and at extremely low weight. Treatment by infusion of prostaglandin maintained ductal patency for 66 days, permitting weight to be gained whilst under the care of a regional unit for neonatal intensive care prior to transfer for palliative cardiac surgery.