Rapid sequence induction: where did the consensus go? Avery, Pascale; Morton, Sarah; Raitt, James ...
Scandinavian journal of trauma, resuscitation and emergency medicine,
05/2021, Letnik:
29, Številka:
1
Journal Article
Recenzirano
Odprti dostop
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.
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.
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.
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.
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.
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.
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 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.
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.
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.
Introduction
Thames Valley Air Ambulance have carried two units of red blood cells on board both the aircraft and rapid response car since 2014.
Methods
A retrospective database narrative review of ...patients receiving blood was carried out.
Results
Data were analysed for 63 patients, the age range was 13 years to 89 years and 74.6% were male. Blunt trauma was the mechanism of injury in 84%. Overall, 16% of patients died at scene, 32% died either in the Emergency Department or as a hospital inpatient and 52% survived to discharge. There were no survivors from traumatic cardiac arrest who received blood products. Injury Severity Scores (ISS) ranged from 4 to 75, and 95% of the patients for whom data were available had an Injury Severity Scores greater than 15.
Discussion
Patients who received pre-hospital blood transfusions were overwhelmingly those with high Injury Severity Scores and the majority who survived to hospital received additional blood products on arrival. This suggests that our pre-hospital blood transfusions were correctly targeted to severely injured patients who had a need for blood transfusion in hospital.
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.
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.
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.
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.
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.
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.
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).
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.
BackgroundBlood pressure monitoring is important in the pre-hospital management of critically ill patients. Non-invasive blood pressure (NIBP) measurements are commonly used but the accuracy of ...standard oscillometric cuff devices may be affected by extremes of physiology and adverse conditions (e.g. vibration) during transport. This study aimed to quantify the accuracy of NIBP measurements amongst patients requiring pre-hospital critical care.MethodsA retrospective cohort study was undertaken using data from patients treated by a pre-hospital critical team between 1st May 2020 and 30th April 2023 that had NIBP measured concurrently with invasive blood pressure (IBP) arterial manometry. An acceptable difference was determined a priori to be < 20mmHg for systolic blood pressure (SBP) and diastolic blood pressure (DBP), and < 10mmHg for mean arterial pressure (MAP). The primary outcome was “pairwise agreement”, i.e. the proportion of paired observations that fell within this range of acceptability. Bland-Altman plots were constructed together with 95% limits of agreement to visualise differences between pairs of data. Associations with patient age, reason for critical care, transport status, haemodynamic shock, severe hypertension, and arterial catheter position were explored in univariate analyses and by fitting multivariable logistic regression models.ResultsThere were 2,359 paired measurements from 221 individual patients with a median age of 57. The most frequent reason for transport was cardiac arrest (79, 35.7%). Bland-Altman analyses suggested unacceptably wide limits of agreement with NIBP overestimating both SBP and MAP during hypotension and underestimating these values during hypertension. Haemodynamic shock (SBP < 90mmHg) was independently associated with reduced pairwise agreement for SBP (adjusted odds ratio aOR 0.52, 95% CI 0.35 to 0.77), DBP (aOR 0.65, 95% CI 0.42 to 0.99) and MAP (aOR 0.53, 95% CI 0.36 to 0.78) and severe hypertension (SBP > 160mmHg) with reduced pairwise agreement for SBP (aOR 0.17, 95% CI 0.11 to 0.27). There was no association between patient transport and agreement between the methods for SBP, DBP, or MAP.ConclusionsNon-invasive blood pressure measurements are often inaccurate in the pre-hospital critical care setting, particularly in patients with haemodynamic instability. Clinicians should be cautious when interpreting NIBP measurements and consider direct arterial pressure monitoring when circumstances allow.
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.
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.
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).
There is marked geo-temporal variation in the ability of HEMS organisations to deliver pre-hospital emergency anaesthesia in the UK.
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