Cardiac Arrest Bundle of cARE Trial (CABARET) survey of current UK neuroprotective CPR practice.

Despite low out of hospital cardiac arrest (OOHCA) survival rates within the UK, animal studies hint at improved cerebral blood flow via a bundled neuroprotective CPR approach. The CABARET study introduces three key devices: the Head Up Position (HUP), Active Compression/Decompression (ACD) CPR, and the Impedance Threshold Device (ITD). A survey involving 27 UK pre-hospital critical care services indicated none are using these interventions widely, either alone or bundled. The CABARET team is now initiating a pilot study to investigate the feasibility of this CPR bundle, aiming to fill the prevailing evidence void in resuscitation research.

The Ability of First Aid Providers to Recognize Anaphylaxis: A Scoping Review.

Early recognition of anaphylaxis is critical to early treatment and often occurs in the first aid setting. However, the ability of first aid providers to recognize anaphylaxis is unknown. We sought to examine the evidence regarding first aid providers' ability to recognize anaphylaxis. Our scoping review was performed as part of the International Liaison Committee on Resuscitation (ILCOR) continuous evidence evaluation processes to update the 2020 ILCOR Consensus on Science with Treatment Recommendations. We searched Medline, Embase, Cochrane, and the gray literature from 2010 to September 2022. The population included adults and children experiencing anaphylaxis with a description of any specific symptom to a first aid provider. Recognition of anaphylaxis was the primary outcome. Two investigators (DM and PC) reviewed abstracts and extracted and assessed the data. Discrepancies between the reviewers were resolved by discussion and consensus with the ILCOR First Aid Task Force. Out of 957 hits, 17 studies met inclusion criteria: one review and meta-analysis, two experimental studies, and 14 observational studies. We did not identify any studies that directly addressed our PICOST (Population, Intervention, Control, Outcomes, Study Design, and Timeframe) as none were performed in the first aid setting. Articles included individuals who may be first aid providers as patients and parents (n=5), teachers, students or school staff (n=8), caregivers and patients (n= 2) or nannies (n=1). All included studies were conducted in high-income countries. Our scoping review found that signs and symptoms of anaphylaxis were not specific and did not allow for easy identification by the first aid provider. Studies focused on education (n=10) and protocols (n=2) and found that both could have a positive impact on anaphylaxis recognition and management. While we did not identify any clinical studies that directly addressed the ability of first aid providers to identify anaphylaxis, future studies examining education methods and action plans may help improve the identification of anaphylaxis by first aid providers.

The recovery position for maintenance of adequate ventilation and the prevention of cardiac arrest: A systematic review.

Aim: To conduct a systematic review of the use of the recovery position in adults and children with non-traumatic decreased levels of responsiveness changes outcomes in comparison with other positioning strategies. Methods: We searched Medline (Ovid), Embase, Cochrane Library, CINAHL, medRxiv and Google Scholar from inception to 15 March 2021 for studies involving adults and children in an out-of-hospital, first aid setting who had reduced levels of responsiveness of non-traumatic aetiology but did not require resuscitative interventions. We used the ROBINS-I tool to assess risk of bias and GRADE methodology to determine the certainty of evidence. Results: Of 17,947 citations retrieved, three prospective observational studies and four case series were included. The prone and semi-recumbent positions were associated with a decreased rate of suspected aspiration pneumonia in acute poisoning. Use of the recovery position in paediatric patients with decreased levels of responsiveness was associated with a deceased admission rate and the prone position was the position most commonly associated with sudden unexpected death in epilepsy. High risk of bias, imprecision and indirectness of evidence limited our ability to perform pooled analyses. Conclusion: We identified a limited number of observational studies and case series comparing outcomes following use of the recovery position with outcomes when other patient positions were used. There was limited evidence to support or revise existing first aid guidance; however, greater emphasis on the initial assessment of responsiveness and need for CPR, as well as the detection and management of patient deterioration of a person identified with decreased responsiveness, is recommended.

Rapid sequence induction: where did the consensus go?

BACKGROUND: Rapid Sequence Induction (RSI) was introduced to minimise the risk of aspiration of gastric contents during emergency tracheal intubation. It consisted of induction with the use of thiopentone and suxamethonium with the application of cricoid pressure. This narrative review describes how traditional RSI has been modified in the UK and elsewhere, aiming to deliver safe and effective emergency anaesthesia outside the operating room environment. Most of the key aspects of traditional RSI - training, technique, drugs and equipment have been challenged and often significantly changed since the procedure was first described. Alterations have been made to improve the safety and quality of the intervention while retaining the principles of rapidly securing a definitive airway and avoiding gastric aspiration. RSI is no longer achieved by an anaesthetist alone and can be delivered safely in a variety of settings, including in the pre-hospital environment. CONCLUSION: The conduct of RSI in current emergency practice is far removed from the original descriptions of the procedure. Despite this, the principles - rapid delivery of a definitive airway and avoiding aspiration, are still highly relevant and the indications for RSI remain relatively unchanged.

Conducting a conventional multi-casualty incident in COVID-19 personal protective equipment - a semi-structured interview.

BACKGROUND: The risk of COVID-19 transmission to healthcare professionals is likely to continue for the foreseeable future. The wearing of personal protective equipment (PPE) presents a number of potential challenges to responders that may impact upon the management of patients in a multi-casualty incident. This report describes a multi-agency multi-casualty incident. It identifies learning points specifically related to the challenges of conducting a conventional multi-casualty incident in COVID-19 PPE. CASE: The multi casualty incident in Reading, UK on the 20 June 2020 involved six stab injury victims and was attended by four pre-hospital critical care teams. This was the first conventional multi-casualty incident that pre-hospital critical care teams had attended during the COVID-19 era and it was conducted in COVID-19 PPE (1). The scene was an urban park where three patients were confirmed to be in Traumatic Cardiac Arrest (TCA) from stab wounds and another three patients had also suffered stab injuries. By the time the incident had concluded three patients were pronounced dead at the scene. Two patients were transported to the local trauma unit and one patient was transported to the regional Major Trauma Centre depending on the severity of their injuries. CONCLUSIONS: We conducted a semi structured telephone interview with the critical care clinicians who were involved in the incident. The interviews focused specifically on the challenges of responding whilst wearing COVID-19 PPE, rather than the wider challenges of responding to such an incident. The key learning points identified were: Improving the identifiability of clinicians in level 3 PPE wearing identification tabards using visible labelling on PPE suits Improving communication by radio using a belt to carry the radio using an earpiece and push to talk system. Training in conducting multi casualty incidents in level 3 PPE.

Geo-temporal provision of pre-hospital emergency anaesthesia by UK Helicopter Emergency Medical Services: an observational cohort study.

BACKGROUND: Pre-hospital emergency anaesthesia (PHEA) is frequently required for injured patients. National Institute for Health and Care Excellence (NICE) quality standards state that PHEA should be delivered within 45 min of an emergency call. We investigated whether there is geo-temporal variation in service provision to the UK population. METHODS: We retrospectivly audited the time of day when PHEA is provided by UK Helicopter Emergency Medical Services (HEMS), by recording PHEA provision on a randomly selected week and weekend day in 2018. Pre-hospital emergency anaesthesia in the United Kingdom: an observational cohort study retrospectively assessed the time from emergency call to pre-hospital emergency anaesthesia delivery by HEMS during a 1 yr period from April 2017 to March 2018. The population coverage likely to receive pre-hospital emergency anaesthesia in accord with NICE guidelines was estimated by integrating population data with the median time to PHEA, hours of service provision, geographic location, and transport modality. RESULTS: On a weekday 20 HEMS units (comprising from four to 31 enhanced care teams) were estimated to be able to meet NICE guidelines for delivery of PHEA to a poulation of 6.6-35.2 million individuals (at times of minimum and maximal staffing, respectively). At the weekend, 17 HEMS units (comprising from 5 to 28 enhanced care teams) were estimated to be able to meet NICE guidelines for PHEA deliveryto a population of 6.8-34.1 million individuals (minimum and maximal staffing, respectively). CONCLUSIONS: There is marked geo-temporal variation in the ability of HEMS organisations to deliver pre-hospital emergency anaesthesia in the UK.

Pre-hospital emergency anaesthesia in the United Kingdom: an observational cohort study.

BACKGROUND: Up to one in eight trauma patients arrive at a hospital with a partially or completely obstructed airway. The UK National Institute for health and Care Excellence (NICE) practice guidelines recommend that trauma patients requiring anaesthesia for definitive airway management receive this care within 45 min of an emergency call, preferably at the incident scene. How frequently this target is achieved remains unclear. We assessed the recorded time to pre-hospital emergency anaesthesia after trauma across UK helicopter emergency medical service (HEMS) units. METHODS: We retrospectively recorded time to pre-hospital emergency anaesthesia across all 20 eligible UK HEMS units (comprising 52 enhanced care teams) from April 1, 2017 to March 31, 2018. Times recorded for emergency notification, dispatch, arrival, and neuromuscular blocking agent administration were analysed. RESULTS: HEMS undertook 1755 pre-hospital emergency anaesthetics for trauma across the UK during the study period. There were 1176/1755 (67%) episodes undertaken by helicopter response teams during daylight hours. The median time to pre-hospital emergency anaesthesia was 55 min (inter-quartile range: 45-70); anaesthesia within 45 min of the initial emergency call was achieved in 25% cases. Delayed dispatch time (>9 min) was associated with fewer patients receiving pre-hospital anaesthesia within 45 min (odds ratio: 7.7 [95% confidence intervals: 5.8-10.1]; P<0.0001). CONCLUSIONS: The time to achieve pre-hospital emergency anaesthesia by UK HEMS frequently exceeds the recommended 45 min target. Reducing the time to dispatch of emergency medical teams may impact on the delivery of pre-hospital emergency anaesthesia.

Developing clinical performance indicators for pre-hospital blood transfusion: The Thames Valley Air Ambulance approach.

OBJECTIVE: In this article, we describe how we developed and validated key performance indicators (KPIs) for pre-hospital blood transfusion and offer suggestions for other organisations wishing to develop performance metrics. BACKGROUND: KPIs are metrics that compare actual care against an ideal structure, process or outcome standard. An increasing number of UK-based pre-hospital critical care services now carry blood components to enable pre-hospital blood transfusion. METHODS: A working group of pre-hospital physicians and paramedics was formed to create and validate performance indicators that reflected a high-quality pre-hospital transfusion. This was performed by literature searching and reviewing consensus documents that guide the best practice and then adjusting the indicators as the process evolved. RESULTS: Throughout the year, the performance against the domains was monitored monthly and outputs communicated within the clinical staff of the organisation; at the end of the year, the domains were amended. The final list of performance indicators was as follows: (a) rationale for transfusion documented in the notes; (b) rationale for transfusion in line with Thames Valley Air Ambulance blood transfusion guideline; (c) aggressive management of hypothermia; (d) tranexamic acid administered within an hour of injury; (e) evidence of bleeding in hospital; (f) monitoring of adverse effects of blood transfusion; (g) overall-was the use of blood justified; and (h) no units wasted this month. CONCLUSIONS: This study has shown that it is feasible to devise and implement clinical performance indicators for pre-hospital blood transfusion and that their use has increased the focus on this important area.

Key performance indicators for pre hospital emergency Anaesthesia - a suggested approach for implementation.

BACKGROUND: Pre-hospital Emergency Anaesthesia (PHEA) is regarded as one of the highest risk interventions that pre-hospital providers perform. AAGBI guidance from 2017 suggests the use of Key Performance Indicators (KPIs) to audit PHEA quality. The aim of this study was to develop KPIs for use in our service and evaluate their impact. METHODS: Using the AAGBI 2017 document as a guide we developed a list of ten auditable domains. Data for each case was extracted from the Electronic Patient Record (EPR) and a score assigned to each of the domains; one if the domain is achieved and zero if the domain is not achieved or if data is missing, giving a total score out of ten. This analysis is then presented as a colour-coded matrix alongside the score. Data were analysed monthly at our case review and governance meeting. The process was refined during the year and after 12 months a formal review of the KPI process occurred. RESULTS: Eighty-two cases were analysed. Domains with the highest percentage of achievement were: Indication 96%; Tube position confirmed 94% and Full AAGBI monitoring and Grade of view < 3 both 89%. The amount of missing data declined throughout the year. The results of the clinician survey showed that almost all respondents found the TVAA PHEA review process useful. CONCLUSION: The KPI process has demonstrated areas of good quality practice and led to improvements in equipment, processes and documentation and therefore patient care. We offer suggestions to other organisations considering implementing KPIs for PHEA.

What fluids are given during air ambulance treatment of patients with trauma in the UK, and what might this mean for the future? Results from the RESCUER observational cohort study.

OBJECTIVES: We investigated how often intravenous fluids have been delivered during physician-led prehospital treatment of patients with hypotensive trauma in the UK and which fluids were given. These data were used to estimate the potential national requirement for prehospital blood products (PHBP) if evidence from ongoing trials were to report clinical superiority. SETTING: The Regional Exploration of Standard Care during Evacuation Resuscitation (RESCUER) retrospective observational study was a collaboration between 11 UK air ambulance services. Each was invited to provide up to 5 years of data and total number of taskings during the same period. PARTICIPANTS: Patients with hypotensive trauma (systolic blood pressure <90 mm Hg or absent radial pulse) attended by a doctor. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was the number of patients with hypotensive trauma given prehospital fluids. Secondary outcomes were types and volumes of fluids. These data were combined with published data to estimate potential national eligibility for PHBP. RESULTS: Of 29 037 taskings, 729 (2.5%) were for patients with hypotensive trauma attended by a physician. Half were aged 21-50 years; 73.4% were male. A total of 537 out of 729 (73.7%) were given fluids. Five hundred and ten patients were given a single type of fluid; 27 received >1 type. The most common fluid was 0.9% saline, given to 486/537 (90.5%) of patients who received fluids, at a median volume of 750 (IQR 300-1500) mL. Three per cent of patients received PHBP. Estimated projections for patients eligible for PHBP at these 11 services and in the whole UK were 313 and 794 patients per year, respectively. CONCLUSIONS: One in 40 air ambulance taskings were manned by physicians to retrievepatients with hypotensive trauma. The most common fluid delivered was 0.9% saline. If evidence justifies universal provision of PHBP, approximately 800 patients/year would be eligible in the UK, based on our data combined with others published. Prospective investigations are required to confirm or adjust these estimations.

Angiotensin-converting enzyme genotype and successful ascent to extreme high altitude.

Interindividual variation in acclimatization to altitude suggests a genetic component, and several candidate genes have been proposed. One such candidate is a polymorphism in the angiotensin converting enzyme (ACE) gene, where the insertion (I-allele), rather than the deletion (D-allele), of a 287 base pair sequence has been associated with lower circulating and tissue ACE activity and has a greater than normal frequency among elite endurance athletes and, in a single study, among elite high altitude mountaineers. We tested the hypothesis that the I-allele is associated with successful ascent to the extreme high altitude of 8000 m. 141 mountaineers who had participated in expeditions attempting to climb an 8000-m peak completed a questionnaire and provided a buccal swab for ACE I/D genotyping. ACE genotype was determined in 139 mountaineers. ACE genotype distribution differed significantly between those who had successfully climbed beyond 8000 m and those who had not (p = 0.003), with a relative overrepresentation of the I-allele among the successful group (0.55 vs. 0.36 in successful vs. unsuccessful, respectively). The I-allele was associated with increased maximum altitudes achieved: 8079 +/- 947 m for DDs, 8107 +/- 653 m for IDs, and 8559 +/- 565 m for IIs (p = 0.007). There was no statistical difference in ACE genotype frequency between those who climbed to over 8000 m using supplementary oxygen and those who did not (p = 0.267). This study demonstrates an association between the ACE I-allele and successful ascent to over 8000 m.