Emergency General Surgery Transfers to Definitive Care: An Assessment of Patient and Systemic Factors in Appendicitis Referrals.

Patients presenting to the emergency department (ED) with an Emergency General Surgery (EGS) problem often require transfer to a tertiary facility. Issues impacting EGS mirror the same issues trauma surgery faced prior to the implementation of current trauma guidelines. This study analyzed the cost, time, and transport resource utilization of EGS patients with acute appendicitis when transferred from network hospitals to a level II trauma center. This was a retrospective study. Patients were transferred by a critical or specialty care transport team 62% of the time, although no skills performed required a critical or specialty care provider. The median time from decision to transfer to incision was 254 minutes, with an average transport time of 27 minutes. This study suggests that there is an opportunity to improve access to the operating room and to decrease resource utilization of specialty care and critical care transport for patients.

Prehospital Administration of Cefazolin in Trauma Patients.

OBJECTIVE: A lack of research has become a barrier to the common use of prehospital antibiotics. The objective of this study is to further the limited research of prehospital antibiotics through evaluating the clinical impact, safety, and reliability of prehospital cefazolin administration in trauma patients. METHODS: We completed a retrospective evaluation of adult trauma patients who were transported by a single air and ground critical care transport program between January 1, 2014, and June 30 2017. Two hundred eighty-two patients received prehospital cefazolin for deep wounds or open fractures before their arrival at a single level 2 trauma center during the study period. Patient demographics, mechanism of injury, injury type, infection rate, and identification of allergic reactions to cefazolin were also collected. RESULTS: Of 278 patients in the final analysis, 35.3% (n = 98) were diagnosed with an open fracture and 58.6% (n = 163) had a deep tissue injury. Eighty-two percent of prehospital open fracture diagnoses were confirmed in the emergency department. The overall infection rate was 6%; 31.3% of patients received a second dose of cefazolin in the emergency department during the study period. No patients receiving prehospital cefazolin had allergic or anaphylactic reactions. The overadministration rate was 5% (n = 14). CONCLUSION: Prehospital providers reliably identified open fractures, and prehospital cefazolin administration was not associated with anaphylactic reactions. This study population's infection rate of open fractures caused by traumatic injury was found to be 6%, and there was a low inappropriate administration rate.

Prehospital Hypertonic Saline Administration After Severe Traumatic Brain Injury.

A 25-year old male paient was critically injuried in a high speed motor vehicle collision over an hour from the nearest trauma center. Paramedics diagnosed the patient with a traumatic brain injury and increasing intracranial pressure and transported the patient to a predesignated landing zone for helicopter intercept. During transport paramedics initiated a severe traumatic brain injury protocol which included the adminisration of 3% hypertonic saline. The flight crew continued 3% hypertonic saline managment which was later transferred to the receiving trauma team. Upon trauma center arrival the patient was diagnosed with a skull fracture and subdural hematoma. The patient was transitioned to a 3% hypertonic saline infusion for the next 24 h. The need for integrating systems of care is particularly important when managing patients with severe traumatic brain injury. This case report describes a patient with a severe TBI who received prehospital 3% hypertonic saline based on an integrated protocol developed between multiple prehosptial systems and a tertiary care trauma center. Severe traumatic brain injuries (TBIs) are a potentially catastrophic event, and morbidity can rise precipitously without early interventions to prevent hypoxia and hypotension and control for rising intracranial pressure. In recent years, hypertonic saline (HTS) has shown efficacy in lowering intracranial pressures for patients experiencing TBIs, the leading cause of death and disability among children and young adults in the United States.1 Integrating care between health care providers across the acute care continuum, from prehospital systems to discharge, is paramount in providing the best patient outcomes possible, especially in health care system expansions such as air medical transport. The need for integrating systems of care is particularly important when managing patients with severe TBI. Statewide prehospital care protocols vary greatly; 78% provide ventilation guidance, 77.3% have targeted end-tidal carbon dioxide levels below < 35 mm Hg, and only 1 (of 38 reviewed) includes HTS (3%).2 One barrier to consistency in protocol development is the available literature. One trial demonstrated that a prehospital bolus of 7.5% HTS in severe TBI did not improve mortality.3 However, the Brain Foundation guidelines continue to recommend the prehospital use of hyperosmolar therapy for patients with severe TBI and evidence of impending herniation.4 Hyperosmolar therapy is also recommended as an inpatient strategy for lowering increased intracranial pressure (ICP).4 One reason for this apparent disconnect is because the ideal timing of HTS administration and its concentration have not been determined.4 A meta-analysis previously determined no one prehospital fluid is superior to another in improving the outcomes of patients with severe TBI.5 However, none of the reviewed research investigated the continued use of HTS across an integrated system of care. This case report describes a patient with a severe TBI who received 3% HTS initiated in the prehospital setting with the infusion continued upon arrival at the trauma center using a system-wide integrated protocol.

Patient Care Alterations After Point-of-Care Laboratory Testing During Critical Care Transport.

OBJECTIVE: Point-of-care laboratory testing (POCT) is associated with a reduced time to testing results and critical decision making within emergency departments. POCT is an essential clinical assessment tool because laboratory data are used to support timely critical decisions regarding acute medical conditions onditions ; however, there is currently limited research to support the use of POCT in the critical care transport environment. Few studies have evaluated the changes in patient care that occur after POCT during critical care transport. This study aims to contribute to the limited data available correlating prehospital POCT and changes in patient care. METHODS: After institutional review board approval, a retrospective review of patients transported by a critical care transport team between October 1, 2013 and September 31, 2015 was completed. During the study period, 11,454 patients were transported, and 632 (5.51%) received POCT testing. RESULTS: Patient care changes were noted in 244 (38.6%) patient tests. The most frequent patient care alterations were ventilator settings (10.9%), electrolyte changes (10.4%), and unit bed upgrades (7.1%). POCT most frequently altered care for patients with post-cardiac arrest syndrome (64.7%), sepsis/septic shock (61.8%), diabetic ketoacidosis (54.5%), or pneumonia (49.3%). CONCLUSION: Patient care alterations occurred in 38.6% of patients undergoing POCT. Patient care was most frequently changed when patients were diagnosed with post-arrest, sepsis/septic shock, diabetic ketoacidosis, and pneumonia.

Hemodynamic Effects of Ketamine Versus Etomidate for Prehospital Rapid Sequence Intubation.

OBJECTIVE: Rapid sequence intubation (RSI) is often required in managing critically ill patients in the prehospital setting. Although etomidate is a commonly used induction agent for RSI, ketamine has gained new interest in prehospital management with reported neutral hemodynamic effects. Limited data exist to support ketamine as an alternative to etomidate, particularly in the prehospital setting. The purpose of this study was to evaluate hemodynamic changes after the administration of ketamine versus etomidate in prehospital RSI. METHODS: This retrospective study evaluated adult patients undergoing prehospital RSI over 13 months within a regional emergency transport medicine service. Hypotension was defined as a 20% decrease in systolic blood pressure (SBP) within 15 minutes of receiving ketamine or etomidate. Hemodynamic data were collected 15 minutes before and 15 minutes after administration or until additional sedative medications were given. Data were analyzed using SPSS software (Version 21; IBM Corp, Armonk, NY), with P < .05 considered significant. RESULTS: One hundred thirteen patients met the inclusion criteria (ketamine, n = 33; etomidate, n = 80), with the primary reasons for intubation being respiratory failure and trauma. There was no difference between the incidence of patients who experienced a 20% decrease in SBP (16% etomidate vs. 18% ketamine, P = .79). There were no significant differences in SBP pre- to postadministration between ketamine and etomidate. CONCLUSION: No hemodynamic differences occurred between patients who received ketamine versus etomidate for prehospital RSI. Neither drug was associated with an increased need for additional sedatives, and neither drug was associated with an increased first-pass intubation success rate. Larger, prospective, powered studies are required to identify patients who may benefit from either ketamine or etomidate.

Analysis of Helicopter-Transported Trauma Patients at a Regional Trauma Center.

Our medical center's regional helicopter emergency medical service (HEMS) serves southeastern North Carolina. Judicious HEMS use is vital to ensure that the resource is available for critically injured patients and to reduce morbidity and mortality by providing timely access to definitive care. We reviewed HEMS use, clinical outcomes, and overtriage rates. The data included airlifted trauma patients from January 2004 to December 2012. Of 1210 total patients, 733 were flown directly from the scene (FS) and 477 from referring hospitals (FH). The HEMS catchment area was a 100-mile radius of our trauma center. FS patients were younger and sustained more motor vehicle collisions. FH patients were older and sustained more falls. FS patients required more hospital resources including longer ventilator requirements, intensive care unit (ICU) stay, and hospital stay. For all HEMS patients, there was 92.2 per cent blunt injury, 47.5 per cent required Trauma I or II activation, 31 per cent required mechanical ventilation, and 50 per cent required ICU care. 59.5 per cent of HEMS trauma patients were critically injured (defined as requiring either immediate surgical intervention, immediate ICU admission, or immediate death). The overtriage rate was 1.8 per cent. The emergency department mortality rate was 2.3 per cent and the ultimate mortality rate was 7.5 per cent. Most of the airlifted trauma patients were critically injured, and therefore, HEMS transport was appropriate. However, overtriage was low, suggesting high incidence of undertriage. There should be a lower threshold for HEMS use for trauma patients in our region. More research is needed to determine ideal overtriage and undertriage rates.

Probability of Return of Spontaneous Circulation as a Function of Timing of Vasopressor Administration in Out-of-Hospital Cardiac Arrest.

INTRODUCTION: Vasopressors (epinephrine and vasopressin) are associated with return of spontaneous circulation (ROSC). Recent retrospective studies reported a greater likelihood of ROSC when vasopressors were administered within the first 10 minutes of arrest. However, it is unlikely that the relationship between ROSC and the timing of vasopressor administration is a binary function (i.e., ≤10 vs. >10 minutes). More likely, this relationship is a function of time measured on a continuum, with diminishing effectiveness even within the first 10 minutes of arrest, and potentially, some lingering benefit beyond 10 minutes. However, this relationship remains undefined. OBJECTIVE: To develop a model describing the likelihood of ROSC as a function of the call receipt to vasopressor interval (CRTVI) measured on a continuum. METHODS: We conducted a retrospective study of cardiac arrest using the North Carolina Prehospital Care Reporting System (PREMIS). Inclusionary criteria were all adult patients suffering a witnessed, nontraumatic arrest during January-June 2012. Chi-square and t-tests were used to analyze the relationships between ROSC and CRTVI; patient age, race, and gender; endotracheal intubation (ETI); automated external defibrillator (AED) use; presenting cardiac rhythm; and bystander cardiopulmonary resuscitation (CPR). A multivariate logistic regression model calculated the odds ratio (OR) of ROSC as a function of CRTVI while controlling for potential confounding variables. RESULTS: Of the 1,122 patients meeting inclusion criteria, 542 (48.3%) experienced ROSC. ROSC was less likely with increasing CRTVI (OR = 0.96, p < 0.01). Compared to patients with shockable rhythms, patients with asystole (OR = 0.42, p < 0.01) and pulseless electrical activity (OR = 0.52, p < 0.01) were less likely to achieve ROSC. Males (OR = 0.64, p = 0.02) and patients receiving bystander CPR (OR = 0.42, p < 0.01) were less likely to attain ROSC, although emergency medical services response times were significantly longer among patients receiving bystander CPR. Race, age, ETI, and AED were not predictors of ROSC. CONCLUSIONS: We found that time to vasopressor administration is significantly associated with ROSC, and the odds of ROSC declines by 4% for every 1-minute delay between call receipt and vasopressor administration. These results support the notion of a time-dependent function of vasopressor effectiveness across the entire range of administration delays rather than just the first 10 minutes. Large, prospective studies are needed to determine the relationship between the timing of vasopressor administration and long-term outcomes.

Busting top trauma myths. Exploring best practices for prehospital trauma care.

Evidence-based medicine will continually change the paradigm in which emergency medicine is practiced. Fifteen years ago tourniquets were a last resort and often considered a guaranteed way to lose a limb; today they are a gold standard in hemorrhage control. Believing in, and having practiced, medicine we later learn to be false doesn't make someone a bad provider, nor does it make them wrong. It simply means emergency medicine and EMS will continue to develop as a profession, and our body of evidence will continue to grow as we learn more about prehospital care. As we prepare to retire MAST, backboards and lidocaine, and realize the golden hour as a concept rather than a definitive 60 minutes, it's important to keep a critical eye out for the next intervention that truly will help patients during their prehospital care.

Surgical cricothyrotomies in prehospital care. Surgical airway placement is indicated when you cannot intubate or ventilate.

Managing the airway does not mean intubation, it means managing the airway. Allowing a patient to breathe on their own with appropriate positioning, bag-valve ventilation and blind insertion devices are all airway management options. The surgical cricothyrotomy is a rare and life-saving procedure when managing patients who are in a "can't intubate, can't ventilate" situation. These patients will die without aggressive and rapid intervention. While not all surgical cricothyrotomies provide a definitive airway, the needle cricothyrotomy is an ineffective means for ventilation and its use is discouraged. Understand the techniques used in your program and that are within your scope of practice as an EMS provider. Provide your patient the best opportunity for survival by knowing your program's surgical airway procedure thoroughly, and practice it regularly.

Aortic dissections and aneurysms. Prehospital care of these rare but life-threatening emergencies.

Aortic dissections and aneurysms are seen with low frequency and have high risk for deterioration during prehospital care. It is essential to include both dissections and aneurysms in your differential diagnoses whenever evaluating patients with chest or abdominal complaints. Often a good history is the best indication of one of these grave vascular emergencies. Consider thoracic aortic dissection in your differential diagnosis for any patient who complains of chest pain and aortic aneurysm in patients who have any sort of abdominal discomfort or syncope with an unknown etiology. When either is suspected transport rapidly to a facility with cardiothoracic and vascular surgery capability, and provide care that prepares you to manage the patient quickly should a rupture occur.