Emergency medical dispatch recognition, clinical intervention and outcome of patients in traumatic cardiac arrest from major trauma : an observational study

© Author(s) (or their employer(s)) 2018. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.OBJECTIVES: The aim of this study is to describe the demographics of reported traumatic cardiac arrest (TCA) victims, prehospital resuscitation and survival to hospital rate. SETTING: Helicopter Emergency Medical Service (HEMS) in south-east England, covering a resident population of 4.5 million and a transient population of up to 8 million people. PARTICIPANTS: Patients reported on the initial 999 call to be in suspected traumatic cardiac arrest between 1 July 2016 and 31 December 2016 within the trust's geographical region were identified. The inclusion criteria were all cases of reported TCA on receipt of the initial emergency call. Patients were subsequently excluded if a medical cause of cardiac arrest was suspected. OUTCOME MEASURES: Patient records were analysed for actual presence of cardiac arrest, prehospital resuscitation procedures undertaken and for survival to hospital rates. RESULTS: 112 patients were reported to be in TCA on receipt of the 999/112 call. 51 (46%) were found not to be in TCA on arrival of emergency medical services. Of the 'not in TCA cohort', 34 (67%) received at least one advanced prehospital medical intervention (defined as emergency anaesthesia, thoracostomy, blood product transfusion or resuscitative thoracotomy). Of the 61 patients in actual TCA, 10 (16%) achieved return-of-spontaneous circulation. In 45 (88%) patients, the HEMS team escorted the patient to hospital. CONCLUSION: A significant proportion of patients reported to be in TCA on receipt of the emergency call are not in actual cardiac arrest but are critically unwell requiring advanced prehospital medical intervention. Early activation of an enhanced care team to a reported TCA call allows appropriate advanced resuscitation. Further research is warranted to determine which interventions contribute to improved TCA survival.Peer reviewedFinal Published versio

A novel method of non-clinical dispatch is associated with a higher rate of critical Helicopter Emergency Medical Service intervention

Background - Helicopter Emergency Medical Services (HEMS) are a scarce resource that can provide advanced emergency medical care to unwell or injured patients. Accurate tasking of HEMS is required to incidents where advanced pre-hospital clinical care is needed. We sought to evaluate any association between non-clinically trained dispatchers, following a bespoke algorithm, compared with HEMS paramedic dispatchers with respect to incidents requiring a critical HEMS intervention. Methods - Retrospective analysis of prospectively collected data from two 12-month periods was performed (Period one: 1st April 2014 – 1st April 2015; Period two: 1st April 2016 – 1st April 2017). Period 1 was a Paramedic-led dispatch process. Period 2 was a non-clinical HEMS dispatcher assisted by a bespoke algorithm. Kent, Surrey & Sussex HEMS (KSS HEMS) is tasked to approximately 2500 cases annually and operates 24/7 across south-east England. The primary outcome measure was incidence of a HEMS intervention.Results - A total of 4703 incidents were included; 2510 in period one and 2184 in period two. Variation in tasking was reduced by introducing non-clinical dispatchers. There was no difference in median time from 999 call to HEMS activation between period one and two (period one; median 7 min (IQR 4–17) vs period two; median 7 min (IQR 4–18). Non-clinical dispatch improved accuracy of HEMS tasking to a mission where a critical care intervention was required (OR 1.25, 95% CI 1.04–1.51, p = 0.02).Conclusion - The introduction of non-clinical, HEMS-specific dispatch, aided by a bespoke algorithm improved accuracy of HEMS tasking. Further research is warranted to explore where this model could be effective in other HEMS services.Peer reviewedFinal Published versio

Prehospital critical care is associated with increased survival in adult trauma patients in Scotland

Background Scotland has three prehospital critical care teams (PHCCTs) providing enhanced care support to a usually paramedic-delivered ambulance service. The effect of the PHCCTs on patient survival following trauma in Scotland is not currently known nationally. Methods National registry-based retrospective cohort study using 2011-2016 data from the Scottish Trauma Audit Group. 30-day mortality was compared between groups after multivariate analysis to account for confounding variables. Results Our data set comprised 17 157 patients, with a mean age of 54.7 years and 8206 (57.5%) of male gender. 2877 patients in the registry were excluded due to incomplete data on their level of prehospital care, leaving an eligible group of 14 280. 13 504 injured adults who received care from ambulance clinicians (paramedics or technicians) were compared with 776 whose care included input from a PHCCT. The median Injury Severity Score (ISS) across all eligible patients was 9; 3076 patients (21.5%) met the ISS>15 criterion for major trauma. Patients in the PHCCT cohort were statistically significantly (all p < 0.01) more likely to be male; be transported to a prospective Major Trauma Centre; have suffered major trauma; have suffered a severe head injury; be transported by air and be intubated prior to arrival in hospital. Following multivariate analysis, the OR for 30-day mortality for patients seen by a PHCCT was 0.56 (95% CI 0.36 to 0.86, p=0.01). Conclusion Prehospital care provided by a physician-led critical care team was associated with an increased chance of survival at 30 days when compared with care provided by ambulance clinicians

The inaugural European emergency medical dispatch conference – a synopsis of proceedings

The inaugural European Emergency Medical Dispatch conference was held in Stockholm, Sweden, in May 2013. We provide a synopsis of the conference proceedings, highlight key topic areas of emergency medical dispatch and suggest future research priorities

Coherent state transfer between an electron- and nuclear spin in 15N@C60

Electron spin qubits in molecular systems offer high reproducibility and the ability to self assemble into larger architectures. However, interactions between neighbouring qubits are 'always-on' and although the electron spin coherence times can be several hundred microseconds, these are still much shorter than typical times for nuclear spins. Here we implement an electron-nuclear hybrid scheme which uses coherent transfer between electron and nuclear spin degrees of freedom in order to both controllably turn on/off dipolar interactions between neighbouring spins and benefit from the long nuclear spin decoherence times (T2n). We transfer qubit states between the electron and 15N nuclear spin in 15N@C60 with a two-way process fidelity of 88%, using a series of tuned microwave and radiofrequency pulses and measure a nuclear spin coherence lifetime of over 100 ms.Comment: 5 pages, 3 figures with supplementary material (8 pages

Feasibility of Exoplanet Coronagraphy with the Hubble Space Telescope

Herein we report on a preliminary study to assess the use of the Hubble Space Telescope (HST) for the direct detection and spectroscopic characterization of exoplanets and debris disks - an application for which HST was not originally designed. Coronagraphic advances may enable the design of a science instrument that could achieve limiting contrasts approx.10deg beyond 275 milli-arcseconds (4 lambda/D at 800 nm) inner working angle, thereby enabling detection and characterization of several known jovian planets and imaging of debris disks. Advantages of using HST are that it already exists in orbit, it's primary mirror is thermally stable and it is the most characterized space telescope yet flown. However there is drift of the HST telescope, likely due to thermal effects crossing the terminator. The drift, however, is well characterized and consists of a larger deterministic components and a smaller stochastic component. It is the effect of this drift versus the sensing and control bandwidth of the instrument that would likely limit HST coronagraphic performance. Herein we discuss the science case, quantifY the limiting factors and assess the feasibility of using HST for exoplanet discovery using a hypothetical new instrument. Keywords: Hubble Space Telescope, coronagraphy, exoplanets, telescope

Feasibility of Prehospital Emergency Anesthesia in the Cabin of an AW169 Helicopter Wearing Personal Protective Equipment During Coronavirus Disease 2019

OBJECTIVE: Pre-hospital emergency anaesthesia in the form of rapid sequence intubation (RSI) is a critical intervention delivered by advanced pre-hospital critical care teams. Our previous simulation study determined the feasibility of in-aircraft RSI. We now examine whether this feasibility is preserved in a simulated setting, when clinicians wear personal protective equipment (PPE) for aerosol-generating procedures (AGP) for in-aircraft, on-the-ground RSI. METHODS: Air Ambulance Kent Surrey Sussex is a Helicopter Emergency Medical Service (HEMS) which utilises an AW169 cabin simulator. Wearing full AGP PPE (eye protection, FFP3 mask, gown, gloves), 10 doctor-paramedic teams performed RSI in a standard “can intubate, can ventilate” scenario and a “can't intubate, can't oxygenate” (CICO) scenario. Pre-specified timings were reported, and participant feedback was sought by questionnaire. RESULTS: RSI was most commonly performed by direct laryngoscopy and was successfully achieved in all scenarios. Time to completed endotracheal intubation (ETI) was fastest (287s) in the standard scenario and slower (370s, p=.01) in the CICO scenario. Time to ETI was not significantly delayed by wearing PPE in the standard (p=.19) or CICO variant (p=.97). Communication challenges, equipment complications and PPE difficulties were reported, but ways to mitigate these also reported. CONCLUSION: In-aircraft RSI (aircraft on-the-ground) whilst wearing PPE for AGPs had no significant impact on time to successful completion of ETI in a simulated setting. Patient safety is paramount in civilian HEMS, but the adoption of in-aircraft RSI could confer significant patient benefit in terms of pre-hospital time saving and further research is warranted

Hypoxia and hypotension in patients intubated by physician staffed helicopter emergency medical services - a prospective observational multi-centre study

Background The effective treatment of airway compromise in trauma and non-trauma patients is important. Hypoxia and hypotension are predictors of negative patient outcomes and increased mortality, and may be important quality indicators of care provided by emergency medical services. Excluding cardiac arrests, critical trauma and non-trauma patients remain the two major groups to which helicopter emergency medical services (HEMS) are dispatched. Several studies describe the impact of pre-hospital hypoxia or hypotension on trauma patients, but few studies compare this in trauma and non-trauma patients. The primary aim was to describe the incidence of pre-hospital hypoxia and hypotension in the two groups receiving pre-hospital tracheal intubation (TI) by physician-staffed HEMS. Methods Data were collected prospectively over a 12-month period, using a uniform Utstein-style airway template. Twenty-one physician-staffed HEMS in Europe and Australia participated. We compared peripheral oxygen saturation and systolic blood pressure before and after definitive airway management. Data were analysed using Cochran–Mantel–Haenszel methods and mixed-effects models. Results Eight hundred forty three trauma patients and 422 non-trauma patients receiving pre-hospital TI were included. Non-trauma patients had significantly lower predicted mean pre-intervention SpO2 compared to trauma patients. Post-intervention and admission SpO2 for the two groups were comparable. However, 3% in both groups were still hypoxic at admission. For hypotension, the differences between the groups were less prominent. However, 9% of trauma and 10% of non-trauma patients were still hypotensive at admission. There was no difference in short-term survival between trauma (97%) and non-trauma patients (95%). Decreased level of consciousness was the most frequent indication for TI, and was associated with increased survival to hospital (cOR 2.8; 95% CI: 1.4–5.4). Conclusions Our results showed that non-trauma patients had a higher incidence of hypoxia before TI than trauma patients, but few were hypoxic at admission. The difference for hypotension was less prominent, but one in ten patients were still hypotensive at admission. Further investigations are needed to identify reversible causes that may be corrected to improve haemodynamics in the pre-hospital setting. We found high survival rates to hospital in both groups, suggesting that physician-staffed HEMS provide high-quality emergency airway management in trauma and non-trauma patients.publishedVersio

Variance of transmitted power in multichannel dissipative ergodic structures invariant under time reversal

We use random matrix theory (RMT) to study the first two moments of the wave power transmitted in time reversal invariant systems having ergodic motion. Dissipation is modeled by a number of loss channels of variable coupling strength. To make a connection with ultrasonic experiments on ergodic elastodynamic billiards, the channels injecting and collecting the waves are assumed to be negligibly coupled to the medium, and to contribute essentially no dissipation. Within the RMT model we calculate the quantities of interest exactly, employing the supersymmetry technique. This approach is found to be more accurate than another method based on simplifying naive assumptions for the statistics of the eigenfrequencies and the eigenfunctions. The results of the supersymmetric method are confirmed by Monte Carlo numerical simulation and are used to reveal a possible source of the disagreement between the predictions of the naive theory and ultrasonic measurements.Comment: 10 pages, 2 figure