Papers by Domhnall O'Dochartaigh
Bi-manual proximal external aortic compression after major abdominal-pelvic trauma and during amb... more Bi-manual proximal external aortic compression after major abdominal-pelvic trauma and during ambulance transfer: A simulation study
Article in Injury · November 2016
DOI: 10.1016/j.injury.2016.11.003
1st Matthew Douma
19.96 · Royal Alexandra Hospital
2nd Domhnall O'Dochartaigh
15.7 · Shock Trauma Air Rescue Society / Alberta Health Services
3rd P.G. Brindley
Abstract
Background: Applying manual pressure after hemorrhage is intuitive, cost-free, and logistically-simple. When direct abdominal-pelvic compression fails, clinicians can attempt indirect proximal-external-aortic-compression (PEAC), while expediting transfer and definitive rescue. This study quantifies the sustainability of simulated bi-manual PEAC both immediately on scene and during subsequent ambulance transfer. The goal is to understand when bi-manual PEAC might be clinically-useful, and when to prioritize compression-devices or endovascular-occlusion. Methods: We developed a simulated central vessel compression model utilizing a digital scale and Malbrain intra-abdominal pressure monitor inside a cardiopulmonary resuscitation mannequin. Twenty prehospital health care professionals (HCPs) performed simulated bimanual PEAC i) while stationary and ii) inside an 80km/h ambulance on a closed driving-track. Participants compressed at "the maximal effort they could maintain for 20min". Results were measured in mmHg applied-pressure and kilograms compressive-weight. The Borg scale of perceived-exertion was used to assess sustainability, with <16 regarded as acceptable. Results: While stationary all participants could maintain 20min of compressive pressure/weight: within five-percent of their starting effort, and with a Borg-score <16. Participants applied 88-300mmHg compression pressure; (mean 180mmHg), 14-55kg compression-weight (mean 33kg), and 37-66% of their bodyweight (mean 43%). In contrast, participants could not apply consistent or sustained compression in a moving ambulance: Borg Score exceeded 16 in all cases. Conclusions: Survival following major abdominal-pelvic hemorrhage requires expedited operative/interventional rescue. Firstly, however, we must temporize pre-hospital exsanguination both on scene and during transfer. Despite limitations, our work suggests PEAC is feasible while waiting for, but not during, ambulance-transfer. Accordingly, we propose a chain-of-survival that cautions against over-reliance on manual PEAC, while supporting pre-hospital devices, endovascular occlusion, and expeditious but safe hospital-transfer.
Bi-manual proximal external aortic compression after major abdominal-pelvic trauma and during ambulance transfer: A simulation study. Available from: https://www.researchgate.net/publication/309724294_Bi-manual_proximal_external_aortic_compression_after_major_abdominal-pelvic_trauma_and_during_ambulance_transfer_A_simulation_study [accessed Apr 22, 2017].
Article in Injury · November 2016; DOI: 10.1016/j.injury.2016.11.003
Purpose: To compare, quantify, and describe the time-delays associated with four common methods o... more Purpose: To compare, quantify, and describe the time-delays associated with four common methods of adrenaline administration in the simulated setting of impending cardiac arrest. Methods: Using sham medication and a high-fidelity simulator, experienced Nurses prepared, then delivered, adrenaline by: i) bolus, ii) lower-concentration infusion iii) higher-concentration infusion, and iv) higher-concentration infusion plus carrier-line. We recorded medication preparation and delivery time, plus administration errors and self-reported competence. Results: Median total delay was i) 120s for bolus (95% CI 112-128s); ii) 179s for lower concentration infusion (95% CI 172-186s); iii) 296s for higher concentration infusion (95% CI 285-307s); and iv) 411s for higher concentration infusion plus carrier line (95% CI 399-423s). Time to prepare/deliver a bolus was less than any infusion (p<0.001). Time to prepare/deliver a lower-concentration infusion was less than either higher-concentration infusion (p<0.001). No substantial equipment failures or medication errors were observed. Participants reported high-competence. The majority of delay was from drug preparation not delivery. Conclusions: We highlight potentially dangerous delays with administration of life-saving medications by all four methods. We should prioritize boluses, and focus on improving drug preparation times and human performance, more than drug delivery and equipment.
Article in Journal of critical care 40 · April 2017
DOI: 10.1016/j.jcrc.2017.04.003
Objective: To describe the use of prehospital ultrasonography (PHUS) to support interventions, wh... more Objective: To describe the use of prehospital ultrasonography (PHUS) to support interventions, when used by physician and non-physician air medical crew (AMC), in a Canadian helicopter emergency medical service (HEMS). Methods: A retrospective review was conducted of consecutive patients who underwent ultrasound examination during HEMS care from January 1, 2009 through March 10, 2014. An a priori created data form was used to record patient demographics, type of ultrasound scan performed, ultrasound findings, location of scan, type of interventions supported by PHUS, factors that affected PHUS completion, and quality indicator(s). Data analysis was performed through descriptive statistics, Student's t-test for continuous variables, Z-test for proportions, and Mann-Whitney U Test for nonparametric data. Outcomes included interventions supported by PHUS, factors associated with incomplete scans, and quality indicators associated with PHUS use. Differences between physician and AMC groups were also assessed. Results: PHUS was used in 455 missions, 318 by AMC and 137 by physicians. In combined trauma and medical patients, in the AMC group interventions were supported by PHUS in 26% of cases (95% CI 18–34). For transport physicians the percentage support was found to be significantly greater at 45% of cases (95% CI 34–56) p = < 0.006. Incomplete PHUS scans were common and reasons included patient obesity, lack of time, patient access, and clinical reasons. Quality indicators associated with PHUS were rarely identified. Conclusions: The use of PHUS by both physicians and non-physicians was found to support interventions in select trauma and medical patients. Key words: emergency medical services; aircraft; helicopter; air ambulance; ultrasonography; emergency care, prehospital; prehospital emergency care
Journal Prehospital Emergency Care
Volume 21, 2017 - Issue 1
http://dx.doi.org/10.1080/10903127.2016.1204036
A B S T R A C T Background: Minimizing haemorrhage using direct pressure is intuitive and widely ... more A B S T R A C T Background: Minimizing haemorrhage using direct pressure is intuitive and widely taught. In contrast, this study examines the use of indirect-pressure, specifically external aortic compression (EAC). Indirect pressure has great potential for temporizing bleeds not amenable to direct tamponade i.e. abdominal-pelvic, junctional, and multi-site trauma. However, it is currently unclear how to optimize this technique. Methods: We designed a model of central vessel compression using the Malbrain intra-abdominal pressure monitor and digital weigh scale. Forty participants performed simulated external aortic compression on the ground, on a stretcher mattress, and with and without a backboard. Results: The greater the rescuer's bodyweight the greater was their mean compression (Pearson's correlation 0.93). Using one-hand, a mean of 28% participant bodyweight (95% CI, 26–30%) could be transmitted at sustainable effort, waist-height, and on a stretcher. A second compressing hand increased the percentage of rescuer bodyweight transmission 10–22% regardless of other factors (i.e. presence/ absence or a backboard; rescuer position) (p < 0.001). Adding a backboard increased transmission of rescuer bodyweight 7–15% (p < 0.001). Lowering the patient from waist-height backboard to the floor increased transmission of rescuer bodyweight 4–9% (p < 0.001). Kneeling on the model was the most efficient method and transmitted 11% more weight compared to two-handed maximal compression (p < 0.001). Conclusions: Efficacy is maximized with larger-weight rescuers who use both hands, position themselves atop victims, and compress on hard surfaces/backboards. Knee compression is most effective and least fatiguing, thus assisting rescuers of lower weight and lesser strength, where no hard surfaces exist (i.e. no available backboard or trauma on soft ground), or when lengthy compression is required (i.e. remote locations). Our work quantifies methods to optimize indirect pressure as a temporizing measure following life-threatening haemorrhage not amenable to direct compression, and while expediting compression devices or definitive treatment.
Study objective: Emergency department (ED) crowding is a common and complicated problem challengi... more Study objective: Emergency department (ED) crowding is a common and complicated problem challenging EDs worldwide. Nurse-initiated protocols, diagnostics, or treatments implemented by nurses before patients are treated by a physician or nurse practitioner have been suggested as a potential strategy to improve patient flow. Methods: This is a computer-randomized, pragmatic, controlled evaluation of 6 nurse-initiated protocols in a busy, crowded, inner-city ED. The primary outcomes included time to diagnostic test, time to treatment, time to consultation, or ED length of stay. Results: Protocols decreased the median time to acetaminophen for patients presenting with pain or fever by 186 minutes (95% confidence interval [CI] 76 to 296 minutes) and the median time to troponin for patients presenting with suspected ischemic chest pain by 79 minutes (95% CI 21 to 179 minutes). Median ED length of stay was reduced by 224 minutes (95% CI –19 to 467 minutes) by implementing a suspected fractured hip protocol. A vaginal bleeding during pregnancy protocol reduced median ED length of stay by 232 minutes (95% CI 26 to 438 minutes). Conclusion: Targeting specific patient groups with carefully written protocols can result in improved time to test or medication and, in some cases, reduce ED length of stay. A cooperative and collaborative interdisciplinary group is essential to success. [Ann Emerg Med. 2016;-:1-7.]
Douma MJ, Bara GS, O'Dochartaigh D, Brindley PG.
Abstract
INTRODUCTION:
Resuscitation can be dela... more Douma MJ, Bara GS, O'Dochartaigh D, Brindley PG.
Abstract
INTRODUCTION:
Resuscitation can be delayed, or impaired, by insufficient vascular access. This study examines whether dual-intraosseous needles, inserted into a single porcine humerus, can facilitate rapid and concomitant fluid and medication delivery.
METHODS:
After inserting one- and then two-intraosseous needles into the same porcine humerus, we determined the rate of fluid administration using (i) an infusion pump set to 999mL/h, and (ii) a standard pressure-bag set to 300mmHg. Next, we concomitantly infused blood, crystalloid and medications into the same medullary canal, using the two-needle set-up. Humeri were inspected for fluid-leakage, needle-displacement, and bone damage.
RESULTS:
Using an infusion pump, the mean normal-saline infusion-rate was significantly higher with dual-intraosseous needles compared to a single-intraosseous needle: the infusion-rate was 16mL/min using dual-needles versus 8mL/min for a single needle set-up (p<0.001). In contrast, using the pneumatic pressure-bag, the infusion rate was not statistically different when comparing dual-intraosseous needles versus single-intraosseous: the infusion-rate was 22mL/min versus 21ml/min (p=0.4) for 500mL, and 22ml/min versus 21ml/min (p=0.64) for one-litre, respectively. Blood product could be infused at a mean rate of 20mL/min through one needle while tranexamic acid was simultaneously infused through a second. There were no complications with a dual-intraosseous set-up (no fluid leakage; no needle-displacement; no high-pressure alarms, and no external bone-fractures or internal macrohistological damage) during any of our simulated resuscitation scenarios.
CONCLUSIONS:
This is the first published study evaluating dual-intraosseous needles in a single bone. Despite limitations, this preliminary study (using a porcine humerus) suggests that dual-intraosseous needles are feasible. For critically-ill patients with limited insertion sites, dual-intraosseous (a.k.a. 'double-barrelled resuscitation') may facilitate rapid and concurrent resuscitation.
Abstract
Background
Ultrasound examination of trauma patients is increasingly performed in preh... more Abstract
Background
Ultrasound examination of trauma patients is increasingly performed in prehospital services. It is unclear if prehospital sonographic assessments change patient management: providing prehospital diagnosis and treatment, determining choice of destination hospital, or treatment at the receiving hospital.
Objective
This review aims to assess and grade the evidence that specifically examines whether prehospital ultrasound (PHUS) of the thorax and/or abdomen changes management of the trauma patient.
Methods
A systematic review was conducted of trauma patients who had an ultrasound of the thorax or abdomen performed in the prehospital setting. PubMed, MEDLINE, Web of Science, (CINAHL, EMBASE, Cochrane Central Register of Controlled Trials) and the reference lists of included studies were searched. Methodological quality was checked and risk of bias analysis performed, a level of evidence grade was assigned, and descriptive data analysis performed.
Results
992 unique citations were identified, which included eight studies that met inclusion criteria with a total of 925 patients. There are no reports of randomized controlled trials. Heterogeneity exists between the included studies which ranged from a case series to retrospective and prospective non-randomized observational studies. Three studies achieved a 2+ Scottish Intercollegiate Guidelines Networks grade for quality of evidence and the remainder demonstrated a high risk of bias. The three best studies each provided examples of prehospital ultrasound positively changing patient management.
Conclusion
There is moderate evidence that supports prehospital physician use of ultrasound for trauma patients. For some patients, management was changed based on the results of the PHUS. The benefit of ultrasound use in non-physician services is unclear.
Keywords:
Ultrasound, Prehospital, Systematic Review, Sonography, Emergency Medical Services, Air medical transport, Helicopter, Trauma, FAST, EFAST
Air Med J. 2015 Jan-Feb;34(1):37-9. doi: 10.1016/j.amj.2014.09.004.
Rural trauma patients cannot ... more Air Med J. 2015 Jan-Feb;34(1):37-9. doi: 10.1016/j.amj.2014.09.004.
Rural trauma patients cannot wait: tranexamic Acid administration by helicopter emergency medical services.
Mrochuk M1, ÓDochartaigh D2, Chang E3.
Author information
Abstract
OBJECTIVE:
Tranexamic acid (TXA) administration has been shown to reduce mortality in bleeding trauma patients if given in the hospital within 3 hours of injury. Its use has been theorized to be of benefit in the prehospital environment. This study evaluates the timing of TXA administration in a critical care helicopter emergency medical service (HEMS) versus that of the destination trauma hospital.
METHODS:
We performed a retrospective chart review of consecutive trauma patients who were given TXA during HEMS transfer. The time of injury to HEMS arrival, TXA administration, and hospital arrival was collected.
RESULTS:
Twenty complete records were identified in which TXA was administered by HEMS: 11 scene calls and 9 interfacility transfers. The median time in minutes from the time of injury to HEMS arrival, TXA administration, and receiving hospital arrival was 90, 114, and 171, respectively, for scene calls and 134, 173, and 224, respectively, for interfacility transfers.
CONCLUSION:
TXA must be administered before arrival at a trauma hospital to meet the recommendation of administration within 3 hours of injury for all patients transferred between facilities and for many patients transported from a trauma scene.
Copyright © 2015 Air Medical Journal Associates. Published by Elsevier Inc. All rights reserved.
Prehospital and disaster medicine, Jan 27, 2015
Introduction Non-invasive positive pressure ventilation (NIPPV) is used to treat severe acute res... more Introduction Non-invasive positive pressure ventilation (NIPPV) is used to treat severe acute respiratory distress. Prehospital NIPPV has been associated with a reduction in both in-hospital mortality and the need for invasive ventilation. Hypothesis/Problem The authors of this study examined factors associated with NIPPV failure and evaluated the impact of NIPPV on scene times in a critical care helicopter Emergency Medical Service (HEMS). Non-invasive positive pressure ventilation failure was defined as the need for airway intervention or alternative means of ventilatory support. A retrospective chart review of consecutive patients where NIPPV was completed in a critical care HEMS was conducted. Factors associated with NIPPV failure in univariate analyses and from published literature were included in a multivariable, logistic regression model. From a total of 44 patients, NIPPV failed in 14 (32%); a Glasgow Coma Scale (GCS) <15 at HEMS arrival was associated independently with...
Objective To measure the possible delays in intravenous nitroglycerine administration. Methods Th... more Objective To measure the possible delays in intravenous nitroglycerine administration. Methods This was a simulation study of sham intravenous nitroglycerine using a standard nitroglycerine titration protocol. Variables studied were (i) common cannulae/needles, (ii) infusion accessories and (iii) presence of a parallel intravenous saline carrier line (or drive line) infusing at 30 mL/h. Outcomes were (i) delay from bag-to-bloodstream arrival and (ii) the dosage showing on the infusion pump when the sham drug first exits the cannula (aka the 'presumed initial dosage'). Results There was a statistically significant difference in both time-to-bloodstream arrival and (ii) the dosage showing on the infusion pump as the sham first exits the cannula with (i) different cannulae, (ii) different accessories and (iii) presence of a carrier line. The bagto-bloodstream time varied 10-fold: 197-2062 s. The 'presumed initial dosage' varied sixfold: 5-30 mg/min. Adding the medication to an already flowing carrier line reduced the time for the sham to exit the cannula fourfold: from 2062 to 469 s.
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 2014
Traumatic Brain Injury in 2020 – a horizon-scanning project
Neil Roberts,corresponding author1 D... more Traumatic Brain Injury in 2020 – a horizon-scanning project
Neil Roberts,corresponding author1 Domhnall O’Dochartaigh,1 Dawid Aleksandrowicz,1 and Dean Whiting1
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4123188/
Background
Up to 62% of severe injuries in British patients include Traumatic Brain Injury (TBI) [1]. 48% of these severe TBIs have unfavourable 6-month outcome with large variations in mortality and morbidity between centres [2]. Most deaths occur from brainstem herniation [3]. This project aimed to evaluate current best-practice for gaps in knowledge, care, and research, to determine what changes could best improve TBI care, and to project optimum treatment for 2020.
Methods
Post-graduate students constructed a current optimal patient pathway following brainstorming exercises. A comprehensive literature review of current and promising new treatments was performed. A new care pathway based on the direction of current research was predicted for 2020, which we believe could improve outcomes.
Results
Best-practice TBI care is expensive and complex, requiring extensive infrastructure at all stages. Overall, there is weak evidence for much of TBI care. There are several reasons for this. TBI is often addressed as a single entity, rather than individual injury patterns with variable pathophysiology. Monitoring in the acute setting is difficult, with multiple options but no single modality with consistent evidence of benefit. Long-term outcome assessment is expensive with common tools providing little detailed information.
Conclusions
Large improvements in TBI care can be made by consistently and effectively applying treatments with known benefits. Funding is required to secure infrastructure required for optimal TBI care and evidence is required to secure this. A shift in thinking from ‘TBI’ to the assessment and treatment of individual injury patterns is important. Multimodal monitoring with computerised analysis of large registries shows promise in guiding treatment and research. Functional imaging and Patient-Reported Outcome Measurements can facilitate better evidence for aftercare. Research into tools such as novel biomarkers or drugs is important long-term, but a higher-quality evidence base is needed first as a foundation towards minimising gaps in care.
References
National Confidential Enquiry into Perioperative Death. Trauma: Who Cares? 2007. http://www.ncepod.org.uk/2007report2/Downloads/SIP_report.pdf (Last accessed October 20th 2013)
Lingsma H, Roozenbeek B, Li B, Lu J, Weir J, Butcher I. et al. Large between-center differences in outcome after moderate and severe traumatic brain injury in the international mission on prognosis and clinical trial design in traumatic brain injury (IMPACT) study. Neurosurgery. 2011;68:601–608. doi: 10.1227/NEU.0b013e318209333b. [PubMed] [Cross Ref]
Rusnak M, Janciak I, Majdan M, Wilbacher I, Mauritz W. Severe Traumatic Brain Injury in Austria VI: Effects of guideline-based management. Wien Klin Wochenschr. 2007;119:64–71. doi: 10.1007/s00508-006-0765-0. [PubMed] [Cross Ref]
Uploads
Papers by Domhnall O'Dochartaigh
Article in Injury · November 2016
DOI: 10.1016/j.injury.2016.11.003
1st Matthew Douma
19.96 · Royal Alexandra Hospital
2nd Domhnall O'Dochartaigh
15.7 · Shock Trauma Air Rescue Society / Alberta Health Services
3rd P.G. Brindley
Abstract
Background: Applying manual pressure after hemorrhage is intuitive, cost-free, and logistically-simple. When direct abdominal-pelvic compression fails, clinicians can attempt indirect proximal-external-aortic-compression (PEAC), while expediting transfer and definitive rescue. This study quantifies the sustainability of simulated bi-manual PEAC both immediately on scene and during subsequent ambulance transfer. The goal is to understand when bi-manual PEAC might be clinically-useful, and when to prioritize compression-devices or endovascular-occlusion. Methods: We developed a simulated central vessel compression model utilizing a digital scale and Malbrain intra-abdominal pressure monitor inside a cardiopulmonary resuscitation mannequin. Twenty prehospital health care professionals (HCPs) performed simulated bimanual PEAC i) while stationary and ii) inside an 80km/h ambulance on a closed driving-track. Participants compressed at "the maximal effort they could maintain for 20min". Results were measured in mmHg applied-pressure and kilograms compressive-weight. The Borg scale of perceived-exertion was used to assess sustainability, with <16 regarded as acceptable. Results: While stationary all participants could maintain 20min of compressive pressure/weight: within five-percent of their starting effort, and with a Borg-score <16. Participants applied 88-300mmHg compression pressure; (mean 180mmHg), 14-55kg compression-weight (mean 33kg), and 37-66% of their bodyweight (mean 43%). In contrast, participants could not apply consistent or sustained compression in a moving ambulance: Borg Score exceeded 16 in all cases. Conclusions: Survival following major abdominal-pelvic hemorrhage requires expedited operative/interventional rescue. Firstly, however, we must temporize pre-hospital exsanguination both on scene and during transfer. Despite limitations, our work suggests PEAC is feasible while waiting for, but not during, ambulance-transfer. Accordingly, we propose a chain-of-survival that cautions against over-reliance on manual PEAC, while supporting pre-hospital devices, endovascular occlusion, and expeditious but safe hospital-transfer.
Bi-manual proximal external aortic compression after major abdominal-pelvic trauma and during ambulance transfer: A simulation study. Available from: https://www.researchgate.net/publication/309724294_Bi-manual_proximal_external_aortic_compression_after_major_abdominal-pelvic_trauma_and_during_ambulance_transfer_A_simulation_study [accessed Apr 22, 2017].
Article in Injury · November 2016; DOI: 10.1016/j.injury.2016.11.003
Article in Journal of critical care 40 · April 2017
DOI: 10.1016/j.jcrc.2017.04.003
Journal Prehospital Emergency Care
Volume 21, 2017 - Issue 1
http://dx.doi.org/10.1080/10903127.2016.1204036
Abstract
INTRODUCTION:
Resuscitation can be delayed, or impaired, by insufficient vascular access. This study examines whether dual-intraosseous needles, inserted into a single porcine humerus, can facilitate rapid and concomitant fluid and medication delivery.
METHODS:
After inserting one- and then two-intraosseous needles into the same porcine humerus, we determined the rate of fluid administration using (i) an infusion pump set to 999mL/h, and (ii) a standard pressure-bag set to 300mmHg. Next, we concomitantly infused blood, crystalloid and medications into the same medullary canal, using the two-needle set-up. Humeri were inspected for fluid-leakage, needle-displacement, and bone damage.
RESULTS:
Using an infusion pump, the mean normal-saline infusion-rate was significantly higher with dual-intraosseous needles compared to a single-intraosseous needle: the infusion-rate was 16mL/min using dual-needles versus 8mL/min for a single needle set-up (p<0.001). In contrast, using the pneumatic pressure-bag, the infusion rate was not statistically different when comparing dual-intraosseous needles versus single-intraosseous: the infusion-rate was 22mL/min versus 21ml/min (p=0.4) for 500mL, and 22ml/min versus 21ml/min (p=0.64) for one-litre, respectively. Blood product could be infused at a mean rate of 20mL/min through one needle while tranexamic acid was simultaneously infused through a second. There were no complications with a dual-intraosseous set-up (no fluid leakage; no needle-displacement; no high-pressure alarms, and no external bone-fractures or internal macrohistological damage) during any of our simulated resuscitation scenarios.
CONCLUSIONS:
This is the first published study evaluating dual-intraosseous needles in a single bone. Despite limitations, this preliminary study (using a porcine humerus) suggests that dual-intraosseous needles are feasible. For critically-ill patients with limited insertion sites, dual-intraosseous (a.k.a. 'double-barrelled resuscitation') may facilitate rapid and concurrent resuscitation.
Background
Ultrasound examination of trauma patients is increasingly performed in prehospital services. It is unclear if prehospital sonographic assessments change patient management: providing prehospital diagnosis and treatment, determining choice of destination hospital, or treatment at the receiving hospital.
Objective
This review aims to assess and grade the evidence that specifically examines whether prehospital ultrasound (PHUS) of the thorax and/or abdomen changes management of the trauma patient.
Methods
A systematic review was conducted of trauma patients who had an ultrasound of the thorax or abdomen performed in the prehospital setting. PubMed, MEDLINE, Web of Science, (CINAHL, EMBASE, Cochrane Central Register of Controlled Trials) and the reference lists of included studies were searched. Methodological quality was checked and risk of bias analysis performed, a level of evidence grade was assigned, and descriptive data analysis performed.
Results
992 unique citations were identified, which included eight studies that met inclusion criteria with a total of 925 patients. There are no reports of randomized controlled trials. Heterogeneity exists between the included studies which ranged from a case series to retrospective and prospective non-randomized observational studies. Three studies achieved a 2+ Scottish Intercollegiate Guidelines Networks grade for quality of evidence and the remainder demonstrated a high risk of bias. The three best studies each provided examples of prehospital ultrasound positively changing patient management.
Conclusion
There is moderate evidence that supports prehospital physician use of ultrasound for trauma patients. For some patients, management was changed based on the results of the PHUS. The benefit of ultrasound use in non-physician services is unclear.
Keywords:
Ultrasound, Prehospital, Systematic Review, Sonography, Emergency Medical Services, Air medical transport, Helicopter, Trauma, FAST, EFAST
Rural trauma patients cannot wait: tranexamic Acid administration by helicopter emergency medical services.
Mrochuk M1, ÓDochartaigh D2, Chang E3.
Author information
Abstract
OBJECTIVE:
Tranexamic acid (TXA) administration has been shown to reduce mortality in bleeding trauma patients if given in the hospital within 3 hours of injury. Its use has been theorized to be of benefit in the prehospital environment. This study evaluates the timing of TXA administration in a critical care helicopter emergency medical service (HEMS) versus that of the destination trauma hospital.
METHODS:
We performed a retrospective chart review of consecutive trauma patients who were given TXA during HEMS transfer. The time of injury to HEMS arrival, TXA administration, and hospital arrival was collected.
RESULTS:
Twenty complete records were identified in which TXA was administered by HEMS: 11 scene calls and 9 interfacility transfers. The median time in minutes from the time of injury to HEMS arrival, TXA administration, and receiving hospital arrival was 90, 114, and 171, respectively, for scene calls and 134, 173, and 224, respectively, for interfacility transfers.
CONCLUSION:
TXA must be administered before arrival at a trauma hospital to meet the recommendation of administration within 3 hours of injury for all patients transferred between facilities and for many patients transported from a trauma scene.
Copyright © 2015 Air Medical Journal Associates. Published by Elsevier Inc. All rights reserved.
Neil Roberts,corresponding author1 Domhnall O’Dochartaigh,1 Dawid Aleksandrowicz,1 and Dean Whiting1
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4123188/
Background
Up to 62% of severe injuries in British patients include Traumatic Brain Injury (TBI) [1]. 48% of these severe TBIs have unfavourable 6-month outcome with large variations in mortality and morbidity between centres [2]. Most deaths occur from brainstem herniation [3]. This project aimed to evaluate current best-practice for gaps in knowledge, care, and research, to determine what changes could best improve TBI care, and to project optimum treatment for 2020.
Methods
Post-graduate students constructed a current optimal patient pathway following brainstorming exercises. A comprehensive literature review of current and promising new treatments was performed. A new care pathway based on the direction of current research was predicted for 2020, which we believe could improve outcomes.
Results
Best-practice TBI care is expensive and complex, requiring extensive infrastructure at all stages. Overall, there is weak evidence for much of TBI care. There are several reasons for this. TBI is often addressed as a single entity, rather than individual injury patterns with variable pathophysiology. Monitoring in the acute setting is difficult, with multiple options but no single modality with consistent evidence of benefit. Long-term outcome assessment is expensive with common tools providing little detailed information.
Conclusions
Large improvements in TBI care can be made by consistently and effectively applying treatments with known benefits. Funding is required to secure infrastructure required for optimal TBI care and evidence is required to secure this. A shift in thinking from ‘TBI’ to the assessment and treatment of individual injury patterns is important. Multimodal monitoring with computerised analysis of large registries shows promise in guiding treatment and research. Functional imaging and Patient-Reported Outcome Measurements can facilitate better evidence for aftercare. Research into tools such as novel biomarkers or drugs is important long-term, but a higher-quality evidence base is needed first as a foundation towards minimising gaps in care.
References
National Confidential Enquiry into Perioperative Death. Trauma: Who Cares? 2007. http://www.ncepod.org.uk/2007report2/Downloads/SIP_report.pdf (Last accessed October 20th 2013)
Lingsma H, Roozenbeek B, Li B, Lu J, Weir J, Butcher I. et al. Large between-center differences in outcome after moderate and severe traumatic brain injury in the international mission on prognosis and clinical trial design in traumatic brain injury (IMPACT) study. Neurosurgery. 2011;68:601–608. doi: 10.1227/NEU.0b013e318209333b. [PubMed] [Cross Ref]
Rusnak M, Janciak I, Majdan M, Wilbacher I, Mauritz W. Severe Traumatic Brain Injury in Austria VI: Effects of guideline-based management. Wien Klin Wochenschr. 2007;119:64–71. doi: 10.1007/s00508-006-0765-0. [PubMed] [Cross Ref]
Article in Injury · November 2016
DOI: 10.1016/j.injury.2016.11.003
1st Matthew Douma
19.96 · Royal Alexandra Hospital
2nd Domhnall O'Dochartaigh
15.7 · Shock Trauma Air Rescue Society / Alberta Health Services
3rd P.G. Brindley
Abstract
Background: Applying manual pressure after hemorrhage is intuitive, cost-free, and logistically-simple. When direct abdominal-pelvic compression fails, clinicians can attempt indirect proximal-external-aortic-compression (PEAC), while expediting transfer and definitive rescue. This study quantifies the sustainability of simulated bi-manual PEAC both immediately on scene and during subsequent ambulance transfer. The goal is to understand when bi-manual PEAC might be clinically-useful, and when to prioritize compression-devices or endovascular-occlusion. Methods: We developed a simulated central vessel compression model utilizing a digital scale and Malbrain intra-abdominal pressure monitor inside a cardiopulmonary resuscitation mannequin. Twenty prehospital health care professionals (HCPs) performed simulated bimanual PEAC i) while stationary and ii) inside an 80km/h ambulance on a closed driving-track. Participants compressed at "the maximal effort they could maintain for 20min". Results were measured in mmHg applied-pressure and kilograms compressive-weight. The Borg scale of perceived-exertion was used to assess sustainability, with <16 regarded as acceptable. Results: While stationary all participants could maintain 20min of compressive pressure/weight: within five-percent of their starting effort, and with a Borg-score <16. Participants applied 88-300mmHg compression pressure; (mean 180mmHg), 14-55kg compression-weight (mean 33kg), and 37-66% of their bodyweight (mean 43%). In contrast, participants could not apply consistent or sustained compression in a moving ambulance: Borg Score exceeded 16 in all cases. Conclusions: Survival following major abdominal-pelvic hemorrhage requires expedited operative/interventional rescue. Firstly, however, we must temporize pre-hospital exsanguination both on scene and during transfer. Despite limitations, our work suggests PEAC is feasible while waiting for, but not during, ambulance-transfer. Accordingly, we propose a chain-of-survival that cautions against over-reliance on manual PEAC, while supporting pre-hospital devices, endovascular occlusion, and expeditious but safe hospital-transfer.
Bi-manual proximal external aortic compression after major abdominal-pelvic trauma and during ambulance transfer: A simulation study. Available from: https://www.researchgate.net/publication/309724294_Bi-manual_proximal_external_aortic_compression_after_major_abdominal-pelvic_trauma_and_during_ambulance_transfer_A_simulation_study [accessed Apr 22, 2017].
Article in Injury · November 2016; DOI: 10.1016/j.injury.2016.11.003
Article in Journal of critical care 40 · April 2017
DOI: 10.1016/j.jcrc.2017.04.003
Journal Prehospital Emergency Care
Volume 21, 2017 - Issue 1
http://dx.doi.org/10.1080/10903127.2016.1204036
Abstract
INTRODUCTION:
Resuscitation can be delayed, or impaired, by insufficient vascular access. This study examines whether dual-intraosseous needles, inserted into a single porcine humerus, can facilitate rapid and concomitant fluid and medication delivery.
METHODS:
After inserting one- and then two-intraosseous needles into the same porcine humerus, we determined the rate of fluid administration using (i) an infusion pump set to 999mL/h, and (ii) a standard pressure-bag set to 300mmHg. Next, we concomitantly infused blood, crystalloid and medications into the same medullary canal, using the two-needle set-up. Humeri were inspected for fluid-leakage, needle-displacement, and bone damage.
RESULTS:
Using an infusion pump, the mean normal-saline infusion-rate was significantly higher with dual-intraosseous needles compared to a single-intraosseous needle: the infusion-rate was 16mL/min using dual-needles versus 8mL/min for a single needle set-up (p<0.001). In contrast, using the pneumatic pressure-bag, the infusion rate was not statistically different when comparing dual-intraosseous needles versus single-intraosseous: the infusion-rate was 22mL/min versus 21ml/min (p=0.4) for 500mL, and 22ml/min versus 21ml/min (p=0.64) for one-litre, respectively. Blood product could be infused at a mean rate of 20mL/min through one needle while tranexamic acid was simultaneously infused through a second. There were no complications with a dual-intraosseous set-up (no fluid leakage; no needle-displacement; no high-pressure alarms, and no external bone-fractures or internal macrohistological damage) during any of our simulated resuscitation scenarios.
CONCLUSIONS:
This is the first published study evaluating dual-intraosseous needles in a single bone. Despite limitations, this preliminary study (using a porcine humerus) suggests that dual-intraosseous needles are feasible. For critically-ill patients with limited insertion sites, dual-intraosseous (a.k.a. 'double-barrelled resuscitation') may facilitate rapid and concurrent resuscitation.
Background
Ultrasound examination of trauma patients is increasingly performed in prehospital services. It is unclear if prehospital sonographic assessments change patient management: providing prehospital diagnosis and treatment, determining choice of destination hospital, or treatment at the receiving hospital.
Objective
This review aims to assess and grade the evidence that specifically examines whether prehospital ultrasound (PHUS) of the thorax and/or abdomen changes management of the trauma patient.
Methods
A systematic review was conducted of trauma patients who had an ultrasound of the thorax or abdomen performed in the prehospital setting. PubMed, MEDLINE, Web of Science, (CINAHL, EMBASE, Cochrane Central Register of Controlled Trials) and the reference lists of included studies were searched. Methodological quality was checked and risk of bias analysis performed, a level of evidence grade was assigned, and descriptive data analysis performed.
Results
992 unique citations were identified, which included eight studies that met inclusion criteria with a total of 925 patients. There are no reports of randomized controlled trials. Heterogeneity exists between the included studies which ranged from a case series to retrospective and prospective non-randomized observational studies. Three studies achieved a 2+ Scottish Intercollegiate Guidelines Networks grade for quality of evidence and the remainder demonstrated a high risk of bias. The three best studies each provided examples of prehospital ultrasound positively changing patient management.
Conclusion
There is moderate evidence that supports prehospital physician use of ultrasound for trauma patients. For some patients, management was changed based on the results of the PHUS. The benefit of ultrasound use in non-physician services is unclear.
Keywords:
Ultrasound, Prehospital, Systematic Review, Sonography, Emergency Medical Services, Air medical transport, Helicopter, Trauma, FAST, EFAST
Rural trauma patients cannot wait: tranexamic Acid administration by helicopter emergency medical services.
Mrochuk M1, ÓDochartaigh D2, Chang E3.
Author information
Abstract
OBJECTIVE:
Tranexamic acid (TXA) administration has been shown to reduce mortality in bleeding trauma patients if given in the hospital within 3 hours of injury. Its use has been theorized to be of benefit in the prehospital environment. This study evaluates the timing of TXA administration in a critical care helicopter emergency medical service (HEMS) versus that of the destination trauma hospital.
METHODS:
We performed a retrospective chart review of consecutive trauma patients who were given TXA during HEMS transfer. The time of injury to HEMS arrival, TXA administration, and hospital arrival was collected.
RESULTS:
Twenty complete records were identified in which TXA was administered by HEMS: 11 scene calls and 9 interfacility transfers. The median time in minutes from the time of injury to HEMS arrival, TXA administration, and receiving hospital arrival was 90, 114, and 171, respectively, for scene calls and 134, 173, and 224, respectively, for interfacility transfers.
CONCLUSION:
TXA must be administered before arrival at a trauma hospital to meet the recommendation of administration within 3 hours of injury for all patients transferred between facilities and for many patients transported from a trauma scene.
Copyright © 2015 Air Medical Journal Associates. Published by Elsevier Inc. All rights reserved.
Neil Roberts,corresponding author1 Domhnall O’Dochartaigh,1 Dawid Aleksandrowicz,1 and Dean Whiting1
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4123188/
Background
Up to 62% of severe injuries in British patients include Traumatic Brain Injury (TBI) [1]. 48% of these severe TBIs have unfavourable 6-month outcome with large variations in mortality and morbidity between centres [2]. Most deaths occur from brainstem herniation [3]. This project aimed to evaluate current best-practice for gaps in knowledge, care, and research, to determine what changes could best improve TBI care, and to project optimum treatment for 2020.
Methods
Post-graduate students constructed a current optimal patient pathway following brainstorming exercises. A comprehensive literature review of current and promising new treatments was performed. A new care pathway based on the direction of current research was predicted for 2020, which we believe could improve outcomes.
Results
Best-practice TBI care is expensive and complex, requiring extensive infrastructure at all stages. Overall, there is weak evidence for much of TBI care. There are several reasons for this. TBI is often addressed as a single entity, rather than individual injury patterns with variable pathophysiology. Monitoring in the acute setting is difficult, with multiple options but no single modality with consistent evidence of benefit. Long-term outcome assessment is expensive with common tools providing little detailed information.
Conclusions
Large improvements in TBI care can be made by consistently and effectively applying treatments with known benefits. Funding is required to secure infrastructure required for optimal TBI care and evidence is required to secure this. A shift in thinking from ‘TBI’ to the assessment and treatment of individual injury patterns is important. Multimodal monitoring with computerised analysis of large registries shows promise in guiding treatment and research. Functional imaging and Patient-Reported Outcome Measurements can facilitate better evidence for aftercare. Research into tools such as novel biomarkers or drugs is important long-term, but a higher-quality evidence base is needed first as a foundation towards minimising gaps in care.
References
National Confidential Enquiry into Perioperative Death. Trauma: Who Cares? 2007. http://www.ncepod.org.uk/2007report2/Downloads/SIP_report.pdf (Last accessed October 20th 2013)
Lingsma H, Roozenbeek B, Li B, Lu J, Weir J, Butcher I. et al. Large between-center differences in outcome after moderate and severe traumatic brain injury in the international mission on prognosis and clinical trial design in traumatic brain injury (IMPACT) study. Neurosurgery. 2011;68:601–608. doi: 10.1227/NEU.0b013e318209333b. [PubMed] [Cross Ref]
Rusnak M, Janciak I, Majdan M, Wilbacher I, Mauritz W. Severe Traumatic Brain Injury in Austria VI: Effects of guideline-based management. Wien Klin Wochenschr. 2007;119:64–71. doi: 10.1007/s00508-006-0765-0. [PubMed] [Cross Ref]