|
1
|
Sen JPB, Emerson J, Franklin J. Diagnostic accuracy of prehospital ultrasound in detecting lung injury in patients with trauma: a systematic review and meta-analysis. Emerg Med J 2025; 42:256-263. [PMID: 39746800 DOI: 10.1136/emermed-2023-213647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 12/11/2024] [Indexed: 01/04/2025]
Abstract
BACKGROUND Ultrasound is now readily available in the prehospital setting and its use has been highlighted as one of the top research priorities in prehospital care. Clinical examination remains the standard care for diagnosing lung injury in the prehospital setting, yet this can be challenging and has poor diagnostic accuracy. This review evaluates the accuracy of prehospital ultrasound for the diagnoses of pneumothorax, haemothorax and pulmonary contusions in patients with trauma. METHODS A systematic review and meta-analysis was conducted. MEDLINE/PubMed, CINAHL, Embase and the Cochrane Library were searched. Only papers reporting on the diagnostic accuracy of lung ultrasound for traumatic pneumothorax, haemothorax or pulmonary contusions; in a prehospital or helicopter emergency medical service setting; and with CT or operative findings as a reference standard, were included. Non-English studies or articles that reported on animal studies were excluded. The Quality Assessment of Diagnostic Accuracy Studies-2 was used to assess the methodological quality of the included studies. RESULTS Six observational studies, four with low risk of bias and two with some concerns, reporting on 1908 thoracic ultrasound examinations in patients with trauma, were included. For pneumothorax, meta-analysis yielded pooled sensitivity of 29% (95% CI 22% to 37%, I2=0%) and pooled specificity of 98% (95% CI 97% to 99%, I2=0%). Insufficient data were reported for a reliable meta-analysis on the presence of haemothorax. Only one study reported on the presence of pulmonary contusions and therefore no analysis was conducted. CONCLUSION Prehospital ultrasound is highly specific but has a lower sensitivity for the presence of pneumothorax when compared with hospital studies. Further research is required, alongside education and training of prehospital providers, to further explore the factors that account for the differences observed in this review. PROSPERO REGISTRATION NUMBER CRD42023365034.
Collapse
Affiliation(s)
- James Paul Benjamin Sen
- Intensive Care, Leeds Teaching Hospitals NHS Trust, Leeds, UK
- The Air Ambulance Service, Rugby, UK
| | - Jonathan Emerson
- School of Health & Social Care, Teesside University, Middlesbrough, North Yorkshire, UK
| | - John Franklin
- School of Health & Social Care, Teesside University, Middlesbrough, North Yorkshire, UK
| |
Collapse
|
|
2
|
Tikvesa D, Vogler C, Balen F, Le Dortz M, Grandpierre RG, Le Conte P, Bobbia X, Markarian T. Diagnostic performance of prehospital EFAST in predicting CT scan injuries in severe trauma patients: a multicenter cohort study. Eur J Trauma Emerg Surg 2025; 51:4. [PMID: 39789295 DOI: 10.1007/s00068-024-02693-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2024] [Accepted: 11/10/2024] [Indexed: 01/12/2025]
Abstract
BACKGROUND The early mortality of trauma patients, mainly from hemorrhagic shock, raises interest in detecting the presence of non-exteriorized bleeding. Intra-hospital EFAST (Extended Focused Assessment with Sonography for Trauma) has demonstrated its utility in the assessment and management of severe trauma patients (STP). However, there is a lack of data regarding the diagnostic performance of prehospital EFAST (pEFAST). The main objective of our study was to evaluate the pEFAST performance to predict a positive CT scan in STP. METHODS This was a retrospective, multicenter, database-driven study. All severe trauma patients managed by a prehospital medical team were included. The results of pEFAST were compared with the admission CT scan. RESULTS Data from 495 patients were included. The pEFAST had sensitivity of 27% (95% CI 22; 32) and specificity of 94% (95% CI 90; 97) for predicting the presence of a lesion on CT scan at hospital admission. The area under the curve (AUC) was 0.66 (95% CI 0.57; 0.63), the positive predictive value 84% (95% CI 75; 87), the negative predictive value was 51% (95% CI 44; 66), the positive likelihood ratio was 4.24 (95% CI 2.46; 7.3) and the negative likelihood ratio 0.78 (95% CI 0.72; 0.85). CONCLUSION Prehospital EFAST has an excellent specificity but a poor sensitivity for predicting a positive CT scan on hospital admission. We do not know whether this low sensitivity is secondary to the delay between the two examinations or to the poor performance of pEFAST. Therefore, a negative pEFAST should not be reassuring. A positive pEFAST is highly informative, as it predicts a lesion and enables hospital management to be prepared accordingly.
Collapse
Affiliation(s)
- Dino Tikvesa
- Emergency Department, Montpellier University, Montpellier University Hospital, Montpellier, France.
| | - Camille Vogler
- Emergency Department, Montpellier University, Montpellier University Hospital, Montpellier, France
| | - Frederic Balen
- Emergency Department, Toulouse University, Toulouse University Hospital, Toulouse, France
- CERPOP - EQUITY, INSERM, University Toulouse III, Toulouse, France
| | - Marianne Le Dortz
- Emergency Department, Montpellier University, Montpellier University Hospital, Montpellier, France
| | | | - Philippe Le Conte
- Emergency Department, Nantes University, University Hospital of Nantes, Nantes, France
| | - Xavier Bobbia
- UR UM 103 IMAGINE, Emergency Department, Montpellier University, Montpellier University Hospital, Montpellier, France
| | - Thibaut Markarian
- Department of Emergency Medicine, Assistance publique des hôpitaux de Marseille (APHM), Marseille University, Timone University Hospital, Marseille, France
- UMR 1263 Center of Cardiovascular and Nutrition Research (C2VN), Aix-Marseille University, INSERM, INRAE, Marseille, France
| |
Collapse
|
|
3
|
Moro F, Chiarini V, Scquizzato T, Brogi E, Tartaglione M. Variables for reporting studies on extended - focused assessment with sonography for trauma (E-FAST): An international delphi consensus study. Injury 2025; 56:111931. [PMID: 39438161 DOI: 10.1016/j.injury.2024.111931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2024] [Revised: 08/21/2024] [Accepted: 09/25/2024] [Indexed: 10/25/2024]
Abstract
BACKGROUND The Extended Focused Assessment with Sonography for Trauma (E-FAST) is a diagnostic ultrasound technique used in hospital and pre-hospital settings for patients with torso trauma. While E-FAST is common in emergency departments, its pre-hospital use is less routine. This study aims to establish a set of variables for designing studies on pre-hospital E-FAST through a Delphi consensus process involving international experts. METHODS A Delphi consensus process was utilized, involving four rounds of e-mail to the experts. The experts proposed variables for each category, assessed them using a 5-point Likert scale, and voted on whether they should be included in the final template. RESULTS Out of 14 invited experts, 9 participated in the study. In total, the experts proposed 247 variables. After four rounds, a final list of 32 variables was approved by all experts. These variables related to the system, patient, process, training, imaging, outcome, and others. CONCLUSIONS This Delphi consensus study presents a list of 32 variables for future research studies concerning the use of E-FAST ultrasound in pre-hospital settings. The results of this study are significant as they provide a standardized set of variables that will facilitate the comparison of data obtained from various studies. This will ultimately contribute to the advancement of pre-hospital E-FAST research and practice.
Collapse
Affiliation(s)
- Federico Moro
- Department of Anesthesia, Intensive Care and Prehospital Emergency, Ospedale Maggiore Carlo Alberto Pizzardi, Bologna, Italy.
| | - Valentina Chiarini
- Department of Anesthesia, Intensive Care and Prehospital Emergency, Ospedale Maggiore Carlo Alberto Pizzardi, Bologna, Italy
| | - Tommaso Scquizzato
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Etrusca Brogi
- Department of Anesthesia and Intensive Care, ASST Grande Ospedale Metropolitano Niguarda, Piazza dell'Ospedale Maggiore, Milan, Italy
| | - Marco Tartaglione
- Department of Anesthesia, Intensive Care and Prehospital Emergency, Ospedale Maggiore Carlo Alberto Pizzardi, Bologna, Italy
| |
Collapse
|
|
4
|
Williams J, Lammers DT, Francis AD, Prey BJ, Pumiglia LI, Eckert MJ, Liu Y, Bingham JR, McClellan JM. Who Says You can't go FAST at Night? Use of a Novel Ultrasound-Capable Night Vision Device for Prehospital Medical Personnel to Identify Noncompressible Truncal Hemorrhage. Surg Innov 2024; 31:577-582. [PMID: 39151929 DOI: 10.1177/15533506241275288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/19/2024]
Abstract
BACKGROUND Early detection of abdominal hemorrhage via ultrasound has life-saving implications for military and civilian trauma. However, strict adherence to light discipline may prohibit the use of ultrasound devices in the deployed setting. Additionally, current night vision devices remain noncompatible with ultrasound technology. This study sought to assess an innovative night vision device with ultrasound capable picture-in-picture display via a intraabdominal hemorrhage model to identify noncompressible truncal hemorrhage in blackout conditions. METHODS 8 post mortem fetal porcine specimens were used and divided into 2 groups: intrabdominal hemorrhage (n = 4) vs no hemorrhage (n = 4). Intrabdominal hemorrhage was modeled via direct injection of 200 mL of normal saline into the peritoneal cavity. Under blackout conditions, 5 participants performed a focused assessment with sonography for trauma (FAST) exam on each model using the prototype ultrasound-capable night vision device. RESULTS Of the 40 FAST exams performed, 95% (N = 38) resulted in the correct identification of intraabdominal hemorrhage. Of the incorrectly identified exams, both were false positives resulting in a 100% sensitivity, 90% specificity, 91% positive predictive value, and a 100% negative predictive value. All participants noted the novel device was easy to use and provided superior visualization for performing FAST exams under blackout conditions. CONCLUSION The ultrasound-enabled night vision prototype demonstrated promising results in identifying noncompressible truncal hemorrhage while maintaining strict light discipline in blackout conditions. Further research efforts should be directed at assessing the ability of providers to perform procedures in blackout conditions using the ultrasound-enabled prototype night vision device.
Collapse
Affiliation(s)
| | | | | | - Beau J Prey
- Madigan Army Medical Center, Tacoma, WA, USA
| | | | | | - Yang Liu
- Unify Medical Inc, Cleveland, OH, USA
- University of Iowa, Iowa City, IA, USA
| | | | | |
Collapse
|
|
5
|
Waydhas C, Prediger B, Kamp O, Kleber C, Nohl A, Schulz-Drost S, Schreyer C, Schwab R, Struck MF, Breuing J, Trentzsch H. Prehospital management of chest injuries in severely injured patients-a systematic review and clinical practice guideline update. Eur J Trauma Emerg Surg 2024; 50:1367-1380. [PMID: 38308661 PMCID: PMC11458653 DOI: 10.1007/s00068-024-02457-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 01/22/2024] [Indexed: 02/05/2024]
Abstract
PURPOSE Our aim was to review and update the existing evidence-based and consensus-based recommendations for the management of chest injuries in patients with multiple and/or severe injuries in the prehospital setting. This guideline topic is part of the 2022 update of the German Guideline on the Treatment of Patients with Multiple and/or Severe Injuries. METHODS MEDLINE and Embase were systematically searched to May 2021. Further literature reports were obtained from clinical experts. Randomised controlled trials, prospective cohort studies, cross-sectional studies, and comparative registry studies were included if they compared interventions for the detection and management of chest injuries in severely injured patients in the prehospital setting. We considered patient-relevant clinical outcomes such as mortality and diagnostic test accuracy. Risk of bias was assessed using NICE 2012 checklists. The evidence was synthesised narratively, and expert consensus was used to develop recommendations and determine their strength. RESULTS Two new studies were identified, both investigating the accuracy of in-flight ultrasound in the detection of pneumothorax. Two new recommendations were developed, one recommendation was modified. One of the two new recommendations and the modified recommendation address the use of ultrasound for detecting traumatic pneumothorax. One new good (clinical) practice point (GPP) recommends the use of an appropriate vented dressing in the management of open pneumothorax. Eleven recommendations were confirmed as unchanged because no new high-level evidence was found to support a change. CONCLUSION Some evidence suggests that ultrasound should be considered to identify pneumothorax in the prehospital setting. Otherwise, the recommendations from 2016 remained unchanged.
Collapse
Affiliation(s)
- Christian Waydhas
- Department of Trauma, Hand and Reconstructive Surgery, Essen University Hospital, Essen, Germany.
- Department of Surgery, BG Bergmannsheil University Hospital, Bochum, Germany.
| | - Barbara Prediger
- Institute for Research in Operative Medicine, Witten/Herdecke University, Cologne, Germany
| | - Oliver Kamp
- Department of Trauma, Hand and Reconstructive Surgery, Essen University Hospital, Essen, Germany
| | - Christian Kleber
- Department of Orthopaedics, Trauma Surgery and Plastic Surgery, Leipzig University Hospital, Leipzig, Germany
| | - André Nohl
- Centre of Emergency Medicine, BG Duisburg Hospital, Duisburg, Germany
| | - Stefan Schulz-Drost
- Zentrum für Bewegungs- und Altersmedizin, Helios Kliniken Schwerin, Schwerin, Germany
- Department für Unfall- und Orthopädische Chirurgie, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Christof Schreyer
- Department of General, Visceral and Thoracic Surgery, Bundeswehr Central Hospital, Koblenz, Germany
| | - Robert Schwab
- Department of General, Visceral and Thoracic Surgery, Bundeswehr Central Hospital, Koblenz, Germany
| | - Manuel Florian Struck
- Department of Anaesthesiology and Intensive Care Medicine, Leipzig University Hospital, Leipzig, Germany
| | - Jessica Breuing
- Institute for Research in Operative Medicine, Witten/Herdecke University, Cologne, Germany
| | - Heiko Trentzsch
- Institute of Emergency Medicine and Medical Management, LMU Munich University Hospital, Munich, Germany
| |
Collapse
|
|
6
|
Biasucci DG, Cina A, Sandroni C, Moscato U, Dauri M, Vetrugno L, Cavaliere F. Influence of intercostal muscles contraction on sonographic evaluation of lung sliding: a physiological study on healthy subjects. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE 2024; 4:31. [PMID: 38711161 DOI: 10.1186/s44158-024-00168-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Accepted: 04/30/2024] [Indexed: 05/08/2024]
Abstract
OBJECTIVES To investigate the following: (a) effects of intercostal muscle contraction on sonographic assessment of lung sliding and (b) inter-rater and intra-observer agreement on sonographic detection of lung sliding and lung pulse. METHODS We used Valsalva and Muller maneuvers as experimental models in which closed glottis and clipped nose prevent air from entering the lungs, despite sustained intercostal muscles contraction. Twenty-one healthy volunteers underwent bilateral lung ultrasound during tidal breathing, apnea, hyperventilation, and Muller and Valsalva maneuvers. The same expert recorded 420 B-mode clips and 420 M-mode images, independently evaluated for the presence or absence of lung sliding and lung pulse by three raters unaware of the respiratory activity corresponding to each imaging. RESULTS During Muller and Valsalva maneuvers, lung sliding was certainly recognized in up to 73.0% and up to 68.7% of imaging, respectively, with a slight to fair inter-rater agreement for Muller maneuver and slight to moderate for Valsalva. Lung sliding was unrecognized in up to 42.0% of tidal breathing imaging, and up to 12.5% of hyperventilation imaging, with a slight to fair inter-rater agreement for both. During apnea, interpretation errors for sliding were irrelevant and inter-rater agreement moderate to perfect. Even if intra-observer agreement varied among raters and throughout respiratory patterns, we found it to be higher than inter-rater reliability. CONCLUSIONS Intercostal muscles contraction produces sonographic artifacts that may simulate lung sliding. Clinical studies are needed to confirm this hypothesis. We found slight to moderate inter-rater agreement and globally moderate to almost perfect intra-observer agreement for lung sliding and lung pulse. TRIAL REGISTRATION ClinicalTrials.gov registration number. NCT02386696.
Collapse
Affiliation(s)
- Daniele Guerino Biasucci
- Department of Clinical Sciences and Translational Medicine, "Tor Vergata" University of Rome, Rome, Italy.
- Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy.
| | - Alessandro Cina
- Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Claudio Sandroni
- Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
- Catholic University of the Sacred Heart, Rome, Italy
| | | | - Mario Dauri
- Department of Clinical Sciences and Translational Medicine, "Tor Vergata" University of Rome, Rome, Italy
| | - Luigi Vetrugno
- Department of Medical, Oral and Biotechnological Sciences, "G. D'Annunzio" University of Chieti-Pescara, Chieti, Italy
| | - Franco Cavaliere
- Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
- Catholic University of the Sacred Heart, Rome, Italy
| |
Collapse
|
|
7
|
Smith B, Willner D, Roper W, McGrath C. Prehospital Extended FAST Exams Improve Clinical Decision Making by Helicopter EMS Crews: A Retrospective Case Series. PREHOSP EMERG CARE 2024; 28:727-734. [PMID: 38363335 DOI: 10.1080/10903127.2024.2320746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 01/20/2024] [Indexed: 02/17/2024]
Abstract
Point of Care Ultrasound (POCUS) has seen increasing use in the prehospital environment over the last decade, primarily with the extended focused assessment with sonography in trauma (eFAST) exam. Previous studies have shown prehospital eFAST exams are feasible in the helicopter transport environment but have yet to demonstrate effects on clinical care. This retrospective case series identified 655 patients with blunt thoraco-abdominal trauma or concern for pneumothorax due to penetrating injury transported by a single helicopter EMS (HEMS) program over a two-year period after introducing POCUS. Of those patients, 258 received prehospital ultrasound which was reported to change clinical care in seven cases (2.7%, 95%-CI [1.1-5.5]). This was primarily through preventing unnecessary needle thoracostomy and initiating blood transfusion for treatment of hemorrhagic shock in cases where the degree of shock was unclear due to inconsistent vital signs. This study highlights the improvements in clinical care that may result from the introduction of eFAST exams in the prehospital environment.
Collapse
Affiliation(s)
- Benjamin Smith
- Department of Emergency Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Carolina Air Care, Durham, North Carolina, USA
| | - Daniel Willner
- Department of Emergency Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Carolina Air Care, Durham, North Carolina, USA
| | - William Roper
- Department of Emergency Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | | |
Collapse
|
|
8
|
Lin KT, Lin ZY, Huang CC, Yu SY, Huang JL, Lin JH, Lin YR. Prehospital ultrasound scanning for abdominal free fluid detection in trauma patients: a systematic review and meta-analysis. BMC Emerg Med 2024; 24:7. [PMID: 38185679 PMCID: PMC10773115 DOI: 10.1186/s12873-023-00919-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 12/13/2023] [Indexed: 01/09/2024] Open
Abstract
INTRODUCTION Focused assessment with sonography for trauma helps detect abdominal free fluid. Prehospital ultrasound scanning is also important because the early diagnosis of hemoperitoneum may reduce the time to definitive treatment in the hospital. This study investigated whether prehospital ultrasound scanning can help detect abdominal free fluid. MATERIALS AND METHODS In this systematic review, relevant databases were searched for studies investigating prehospital ultrasound examinations for abdominal free fluid in trauma patients. The prehospital ultrasound results were compared with computed tomography, surgery, or hospital ultrasound examination data. The pooled sensitivity and specificity values were analyzed using forest plots. The overall predictive power was calculated by the summary receiver operating characteristic curve. The quality of the included studies was assessed using the quality assessment of diagnostic accuracy studies tool. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) was performed to assess the certainty of evidence. RESULT This meta-analysis comprised six studies that included 1356 patients. The pooled sensitivity and specificity values were 0.596 (95% confidence interval [CI] = 0.345-0.822) and 0.970 (95% CI = 0.953-0.983), respectively. The pooled area under the summary receiver operating characteristic curve was 0.998. The quality assessment tool showed favorable results. In the GRADE analysis, the quality of evidence was very low for sensitivity and high for specificity when prehospital ultrasound was used for hemoperitoneum diagnosis. CONCLUSION The specificity of abdominal free fluid detection using prehospital ultrasound examinations in trauma patients was very high.
Collapse
Affiliation(s)
- Kun-Te Lin
- Department of Emergency and Critical Care Medicine, Changhua Christian Hospital, 135 Nanshsiao Street, 500, Changhua, Taiwan
| | - Zih-Yang Lin
- Department of Emergency and Critical Care Medicine, Changhua Christian Hospital, 135 Nanshsiao Street, 500, Changhua, Taiwan
| | - Cheng-Chieh Huang
- Department of Emergency and Critical Care Medicine, Changhua Christian Hospital, 135 Nanshsiao Street, 500, Changhua, Taiwan
- Department of Biological Science and Technology, National Yang Ming Chiao Tung University, Hsinchu, Taiwan
| | - Shang-Yan Yu
- Fire Bureau of Changhua County Government, Changhua, Taiwan
| | - Jing-Lan Huang
- Fire Bureau of Changhua County Government, Changhua, Taiwan
| | - Jian-Houng Lin
- Fire Bureau of Changhua County Government, Changhua, Taiwan
| | - Yan-Ren Lin
- Department of Emergency and Critical Care Medicine, Changhua Christian Hospital, 135 Nanshsiao Street, 500, Changhua, Taiwan.
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan.
- School of Medicine, Chung Shan Medical University, Taichung, Taiwan.
| |
Collapse
|
|
9
|
Stralec G, Fontaine C, Arras S, Omnes K, Ghomrani H, Lecaros P, Le Conte P, Balen F, Bobbia X. Is a Positive Prehospital FAST Associated with Severe Bleeding? A Multicenter Retrospective Study. PREHOSP EMERG CARE 2023; 28:572-579. [PMID: 37874044 DOI: 10.1080/10903127.2023.2272196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 09/23/2023] [Indexed: 10/25/2023]
Abstract
INTRODUCTION Severe hemorrhage is the leading cause of early preventable death in severe trauma patients. Delayed diagnosis is a poor prognostic factor, and severe hemorrhage prediction is essential. The aim of our study was to investigate if there was an association between the detection of peritoneal or pleural fluid on prehospital sonography for trauma and posttraumatic severe hemorrhage. METHODS We retrospectively studied data from records of thoracic or abdominal trauma patients managed in mobile intensive care units from January 2017 to December 2021 in four centers in France. Severe hemorrhage was defined as a condition necessitating transfusion of at least four packed red blood cells or surgical intervention/radioembolization for hemostasis within the first 24 h. Using a multivariate analysis, we investigated the predictive performance of focused assessment with sonography for trauma (FAST) alone or in combination with the five Red Flags criteria validated by Hamada et al. RESULTS Among the 527 patients analyzed, 371 (71%) were men, the mean age was 41 ± 19 years, and the Injury Severity Score was 11 (Interquartile range = [5; 22]). Seventy-three (14%) patients had severe hemorrhage - of whom 28 (38%) had a positive FAST, compared to 61 (13%) without severe hemorrhage (p < 0.01). For severe hemorrhage prediction, FAST had a sensitivity of 38% (95%CI = [27%; 50%]) and a specificity of 87% (95%CI = [83%; 90%]) (AUC = 0.62, 95%CI = [0.57; 0.68]). The comparison of the other outcomes between positive and negative FAST was: hemostatic procedure, 22 (25%) vs 28 (6%), p < 0.01; intensive care unit admission 71 (80%) vs 190 (43%), p < 0.01; mean length of hospital stay 11 [4; 27] vs 4 [0; 14] days, p = 0.02; 30-day mortality 13 (15%) vs 22 (5%), p < 0.01. CONCLUSION A positive FAST performed in the prehospital setting is associated with severe hemorrhage and all prognostic criteria we studied.
Collapse
Affiliation(s)
- Grace Stralec
- University of Montpellier, Critical Care, Pain and Emergency Medicine, Nîmes University Hospital, Nîmes, France
| | - Camille Fontaine
- Emergency Department, Toulouse University Hospital, Toulouse, France
| | - Sarah Arras
- University of Montpellier, Department of Emergency Medicine, Montpellier University Hospital, Montpellier, France
| | - Keryann Omnes
- Faculté de médecine, Nantes Université & Service des urgences, CHU de Nantes, France
| | - Hamza Ghomrani
- University of Montpellier, Department of Emergency Medicine, Montpellier University Hospital, Montpellier, France
| | - Pablo Lecaros
- University of Montpellier, Department of Emergency Medicine, Montpellier University Hospital, Montpellier, France
| | - Philippe Le Conte
- Faculté de médecine, Nantes Université & Service des urgences, CHU de Nantes, France
| | - Frederic Balen
- Emergency Department, Toulouse University Hospital, Toulouse, France
- Emergency Department, Toulouse University Hospital, CERPOP - EQUITY, INSERM, Toulouse, France
| | - Xavier Bobbia
- University of Montpellier, UR UM 103 (IMAGINE), Department of Emergency Medicine, Montpellier University Hospital, Montpellier, France
| |
Collapse
|
|
10
|
Shi R, Rosario J. Paramedic-Performed Prehospital Tele-Ultrasound: A Powerful Technology or an Impractical Endeavor? A Scoping Review. Prehosp Disaster Med 2023; 38:645-653. [PMID: 37622570 PMCID: PMC10548023 DOI: 10.1017/s1049023x23006234] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 06/26/2023] [Accepted: 07/06/2023] [Indexed: 08/26/2023]
Abstract
Ultrasound with remote assistance (tele-ultrasound) may have potential to improve accessibility of ultrasound for prehospital patients. A review of recent literature on this topic has not been done before, and the feasibility of prehospital tele-ultrasound performed by non-physician personnel is unclear. In an effort to address this, the literature was qualitatively analyzed from January 1, 2010 - December 31, 2021 in the MEDLINE, EMBASE, and Cochrane online databases on prehospital, paramedic-acquired tele-ultrasound, and ten articles were found. There was considerable heterogeneity in the study design, technologies used, and the amount of ultrasound training for the paramedics, preventing cross-comparisons of different studies. Tele-ultrasound has potential to improve ultrasound accessibility by leveraging skills of a remote ultrasound expert, but there are still technological barriers to overcome before determinations on feasibility can be made.
Collapse
Affiliation(s)
- Rachel Shi
- University of Central Florida College of Medicine, Orlando, Florida, USA
| | - Javier Rosario
- University of Central Florida College of Medicine, Orlando, Florida, USA
| |
Collapse
|
|
11
|
Karfunkle B, Chan HK, Fisher B, Gill J, Bakunas C, Gordon R, Miller S, Huebinger R. Prehospital Ultrasound: Nationwide Incidence from the NEMSIS Database. PREHOSP EMERG CARE 2023; 28:515-530. [PMID: 37477998 DOI: 10.1080/10903127.2023.2239353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 07/17/2023] [Accepted: 07/17/2023] [Indexed: 07/23/2023]
Abstract
OBJECTIVE We sought to describe prehospital ultrasound (PHUS) use and trends in PHUS utilization over time using a national database. METHODS Using the 2018 - 2021 National Emergency Medical Services Information System databases, we identified those EMS activations where PHUS was performed. We evaluated the association between year and number of PHUS exams performed using univariable and multivariable regression analysis. Analysis was performed on the overall group and various subgroups. RESULTS In total, there were 148,709,000 EMS activations by 13,899 agencies over the 4 years. Of these, 3,291 unique activations (0.002%) involved PHUS, performed by 71 EMS agencies (0.5%). The annual rate of ultrasound evaluations per 1 million EMS activations significantly increased over the study period: 5.2 in 2018, 14.8 in 2019, 18.6 in 2020, and 38.9 in 2021 (p < 0.01). The number of agencies performing PHUS each year increased over the study period from 11 in 2018 to 54 in 2021 (p < 0.05). Each year after 2018 had an increased odds of PHUS use demonstrated with logistic regression (p < 0.01). PHUS was used in each US census region, and paramedics performed most of the PHUS exams (75.5%). We identified 1,060 out-of-hospital cardiac arrest, 820 trauma, and 427 respiratory PHUS cases. These three cohorts accounted for 70.1% of all PHUS cases. CONCLUSION Prehospital ultrasound use in the United States increased significantly over the study period, but remains exceedingly rare. The performance of PHUS was recorded throughout the United States, with paramedics performing the majority of PHUS studies included in this database.
Collapse
Affiliation(s)
- Benjamin Karfunkle
- Texas Emergency Medicine Research Center, McGovern Medical School, Houston, Texas
- Department of Emergency Medicine, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, Texas
| | - Hei Kit Chan
- Texas Emergency Medicine Research Center, McGovern Medical School, Houston, Texas
- Department of Emergency Medicine, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, Texas
| | - Benjamin Fisher
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Joseph Gill
- Texas Emergency Medicine Research Center, McGovern Medical School, Houston, Texas
- Department of Emergency Medicine, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, Texas
| | - Carrie Bakunas
- Texas Emergency Medicine Research Center, McGovern Medical School, Houston, Texas
- Department of Emergency Medicine, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, Texas
| | - Richard Gordon
- Texas Emergency Medicine Research Center, McGovern Medical School, Houston, Texas
- Department of Emergency Medicine, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, Texas
| | - Sara Miller
- Texas Emergency Medicine Research Center, McGovern Medical School, Houston, Texas
- Department of Emergency Medicine, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, Texas
| | - Ryan Huebinger
- Texas Emergency Medicine Research Center, McGovern Medical School, Houston, Texas
- Department of Emergency Medicine, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, Texas
| |
Collapse
|
|
12
|
Vianen NJ, Van Lieshout EM, Vlasveld KH, Maissan IM, Gerritsen PC, Den Hartog D, Verhofstad MH, Van Vledder MG. Impact of Point-of-Care Ultrasound on Prehospital Decision Making by HEMS Physicians in Critically Ill and Injured Patients: A Prospective Cohort Study. Prehosp Disaster Med 2023; 38:444-449. [PMID: 37458496 PMCID: PMC10445110 DOI: 10.1017/s1049023x23006003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 04/15/2023] [Accepted: 04/29/2023] [Indexed: 08/23/2023]
Abstract
INTRODUCTION Several studies have shown the additional benefit of point-of-care ultrasound (POCUS) by prehospital Emergency Medical Services (EMS). Since organization of EMS may vary significantly across countries, the value of POCUS likely depends on the prehospital system in which it is used. In order to be able to optimally implement POCUS and develop a tailored training curriculum, it is important to know how often POCUS is currently used, for which indications it is used, and how it affects decision making. The aims of this study were: (1) to determine the percentage of patients in whom POCUS was used by Dutch Helicopter Emergency Medical Services (HEMS) crews; (2) to determine how often POCUS findings led to changes in on-scene management; and (3) what these changes were. METHODS Patients who received prehospital care from December 1, 2020 through March 31, 2021 by a single HEMS crew were included in this prospective cohort study. Clinical data and specific data on POCUS examination, findings, and therapeutic consequences were collected and analyzed. RESULTS During the study period, on-scene HEMS care was provided to 612 patients, of which 211 (34.5%) patients underwent POCUS. Of these, 209 (34.2%) patients with a median age of 45 years were included. There were 131 (62.7%) trauma patients, and 70 (33.7%) of the included patients underwent cardiopulmonary resuscitation (CPR). The median reported time of POCUS examination was three (P25-P75 2-5) minutes. Median prolongation of on-scene time was zero (P25-P75 0-1) minutes. In 85 (40.7%) patients, POCUS examination had therapeutic consequence: POCUS was found to impact treatment decisions in 34 (26.0%) trauma patients and 51 (65.4%) non-trauma patients. In patients with cardiac arrest, POCUS was most often used to aid decision making with regard to terminating or continuing resuscitation (28 patients; 13.4%). CONCLUSION During the study period, POCUS examination was used in 34.5% of all prehospital HEMS patients and had a therapeutic consequence in 40.7% of patients. In trauma patients, POCUS seems to be most effective for patient triage and evaluation of treatment effectiveness. Moreover, POCUS can be of significant value in patients undergoing CPR. A tailored HEMS POCUS training curriculum should include ultrasound techniques for trauma and cardiac arrest.
Collapse
Affiliation(s)
- Niek J. Vianen
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Esther M.M. Van Lieshout
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Koen H.A. Vlasveld
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Iscander M. Maissan
- Erasmus University Medical Center Rotterdam, Department of Anesthesiology, Rotterdam, The Netherlands
| | - Patricia C. Gerritsen
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Dennis Den Hartog
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Michael H.J. Verhofstad
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Mark G. Van Vledder
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| |
Collapse
|
|
13
|
Stojek L, Bieler D, Neubert A, Ahnert T, Imach S. The potential of point-of-care diagnostics to optimise prehospital trauma triage: a systematic review of literature. Eur J Trauma Emerg Surg 2023; 49:1727-1739. [PMID: 36703080 PMCID: PMC10449679 DOI: 10.1007/s00068-023-02226-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 01/07/2023] [Indexed: 01/27/2023]
Abstract
PURPOSE In the prehospital care of potentially seriously injured patients resource allocation adapted to injury severity (triage) is a challenging. Insufficiently specified triage algorithms lead to the unnecessary activation of a trauma team (over-triage), resulting in ineffective consumption of economic and human resources. A prehospital trauma triage algorithm must reliably identify a patient bleeding or suffering from significant brain injuries. By supplementing the prehospital triage algorithm with in-hospital established point-of-care (POC) tools the sensitivity of the prehospital triage is potentially increased. Possible POC tools are lactate measurement and sonography of the thorax, the abdomen and the vena cava, the sonographic intracranial pressure measurement and the capnometry in the spontaneously breathing patient. The aim of this review was to assess the potential and to determine diagnostic cut-off values of selected instrument-based POC tools and the integration of these findings into a modified ABCDE based triage algorithm. METHODS A systemic search on MEDLINE via PubMed, LIVIVO and Embase was performed for patients in an acute setting on the topic of preclinical use of the selected POC tools to identify critical cranial and peripheral bleeding and the recognition of cerebral trauma sequelae. For the determination of the final cut-off values the selected papers were assessed with the Newcastle-Ottawa scale for determining the risk of bias and according to various quality criteria to subsequently be classified as suitable or unsuitable. PROSPERO Registration: CRD 42022339193. RESULTS 267 papers were identified as potentially relevant and processed in full text form. 61 papers were selected for the final evaluation, of which 13 papers were decisive for determining the cut-off values. Findings illustrate that a preclinical use of point-of-care diagnostic is possible. These adjuncts can provide additional information about the expected long-term clinical course of patients. Clinical outcomes like mortality, need of emergency surgery, intensive care unit stay etc. were taken into account and a hypothetic cut-off value for trauma team activation could be determined for each adjunct. The cut-off values are as follows: end-expiratory CO2: < 30 mm/hg; sonography thorax + abdomen: abnormality detected; lactate measurement: > 2 mmol/L; optic nerve diameter in sonography: > 4.7 mm. DISCUSSION A preliminary version of a modified triage algorithm with hypothetic cut-off values for a trauma team activation was created. However, further studies should be conducted to optimize the final cut-off values in the future. Furthermore, studies need to evaluate the practical application of the modified algorithm in terms of feasibility (e.g. duration of application, technique, etc.) and the effects of the new algorithm on over-triage. Limiting factors are the restriction with the search and the heterogeneity between the studies (e.g. varying measurement devices, techniques etc.).
Collapse
Affiliation(s)
- Leonard Stojek
- Department of Trauma and Orthopedic Surgery, Cologne-Merheim Medical Center (CMMC), University Witten/Herdecke, Cologne, Germany
| | - Dan Bieler
- Department of Orthopedics and Trauma Surgery, Reconstructive Surgery, Hand Surgery, Plastic Surgery and Burn Medicine, German Armed Forces Central Hospital Koblenz, Koblenz, Germany
- Department of Orthopedics and Trauma Surgery, Medical Faculty University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany
| | - Anne Neubert
- Department of Orthopedics and Trauma Surgery, Medical Faculty University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany
- TraumaEvidence @ German Society of Traumatology, Berlin, Germany
| | - Tobias Ahnert
- Department of Trauma and Orthopedic Surgery, Cologne-Merheim Medical Center (CMMC), University Witten/Herdecke, Cologne, Germany
- Helicopter Emergency Medical Service (HEMS) Christoph 3, Cologne, Germany
| | - Sebastian Imach
- Department of Trauma and Orthopedic Surgery, Cologne-Merheim Medical Center (CMMC), University Witten/Herdecke, Cologne, Germany.
- Helicopter Emergency Medical Service (HEMS) Christoph 3, Cologne, Germany.
| |
Collapse
|
|
14
|
Gamberini L, Scquizzato T, Tartaglione M, Chiarini V, Mazzoli CA, Allegri D, Lupi C, Gordini G, Coniglio C, Brogi E. Diagnostic accuracy for hemoperitoneum, influence on prehospital times and time-to-definitive treatment of prehospital FAST: A systematic review and individual participant data meta-analysis. Injury 2023:S0020-1383(23)00280-2. [PMID: 36997363 DOI: 10.1016/j.injury.2023.03.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 03/15/2023] [Accepted: 03/17/2023] [Indexed: 04/01/2023]
Abstract
BACKGROUND Focused assessment sonography for trauma (FAST) performed in the prehospital setting may improve trauma care by influencing treatment decisions and reducing time to definitive care, but its accuracy and benefits remain uncertain. This systematic review evaluated the diagnostic accuracy of prehospital FAST in detecting hemoperitoneum and its effects on prehospital time and time to definitive diagnosis or treatment. METHODS We systematically searched PubMed, Embase, and Cochrane library up to November 11th, 2022. Studies investigating prehospital FAST and reporting at least one outcome of interest for this review were considered eligible. The primary outcome was prehospital FAST diagnostic accuracy for hemoperitoneum. A random-effect meta-analysis, including individual patient data, was performed to calculate the pooled outcomes with 95% confidence intervals (CI). Quality of studies was assessed using the QUADAS-2 tool for diagnostic accuracy. RESULTS We included 21 studies enrolling 5790 patients. The pooled sensitivity and specificity of prehospital FAST for hemoperitoneum were 0.630 (0.454 - 0.777) and 0.970 (0.957-0.979), respectively. Prehospital FAST was performed in a median of 2.72 (2.12 - 3.31) minutes without increasing prehospital times (pooled median difference of 2.44 min [95% CI: -3.93 - 8.81]) compared to standard management. Prehospital FAST findings changed on-scene trauma care in 12-48% of cases, the choice of admitting hospital in 13-71%, the communication with the receiving hospital in 45-52%, and the transfer management in 52-86%. Patients with a positive prehospital FAST achieved definitive diagnosis or treatment more rapidly (severity-adjusted pooled time ratio = 0.63 [95% CI: 0.41 - 0.95]) compared with patients with a negative or not performed prehospital FAST. CONCLUSIONS Prehospital FAST had a low sensitivity but a very high specificity to identify hemoperitoneum and reduced time-to-diagnostics or interventions, without increasing prehospital times, in patients with a high probability of abdominal bleeding. Its effect on mortality is still under-investigated.
Collapse
Affiliation(s)
- Lorenzo Gamberini
- Department of Anesthesia, Intensive Care and Prehospital Emergency, Ospedale Maggiore Carlo Alberto Pizzardi, Bologna, Italy
| | - Tommaso Scquizzato
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Marco Tartaglione
- Department of Anesthesia, Intensive Care and Prehospital Emergency, Ospedale Maggiore Carlo Alberto Pizzardi, Bologna, Italy.
| | - Valentina Chiarini
- Department of Anesthesia, Intensive Care and Prehospital Emergency, Ospedale Maggiore Carlo Alberto Pizzardi, Bologna, Italy
| | - Carlo Alberto Mazzoli
- Department of Anesthesia, Intensive Care and Prehospital Emergency, Ospedale Maggiore Carlo Alberto Pizzardi, Bologna, Italy
| | - Davide Allegri
- Department of Clinical Governance and Quality, Bologna Local Healthcare Authority, Bologna, Italy
| | - Cristian Lupi
- Department of Anesthesia, Intensive Care and Prehospital Emergency, Ospedale Maggiore Carlo Alberto Pizzardi, Bologna, Italy
| | - Giovanni Gordini
- Department of Anesthesia, Intensive Care and Prehospital Emergency, Ospedale Maggiore Carlo Alberto Pizzardi, Bologna, Italy
| | - Carlo Coniglio
- Department of Anesthesia, Intensive Care and Prehospital Emergency, Ospedale Maggiore Carlo Alberto Pizzardi, Bologna, Italy
| | - Etrusca Brogi
- Department of Anesthesia and Intensive care, University of Pisa, Pisa, Italy
| |
Collapse
|
|
15
|
Hanlin E, Meyer DE, Heft N, Stilgenbauer H, Cotton B, Bourgeois M, Cabrera R, Osborn L. Prehospital Validation of the Assessment of Blood Consumption (ABC) Score. PREHOSP EMERG CARE 2023; 28:495-500. [PMID: 36649210 DOI: 10.1080/10903127.2023.2166174] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Revised: 12/29/2022] [Accepted: 01/04/2023] [Indexed: 01/18/2023]
Abstract
INTRODUCTION The Assessment of Blood Consumption (ABC) score is a previously validated scoring system designed to predict which severely injured trauma patients will require massive transfusion. When the ABC score is used in the prehospital setting to activate massive transfusion at the receiving hospital, a 23% decrease in mortality has been demonstrated. However, the ABC score was developed and validated using hospital data from the emergency department (ED). The sensitivity and specificity of the ABC score when calculated using data from the prehospital setting are unknown. We hypothesized that the sensitivity and specificity of the prehospital ABC score will be similar to the sensitivity and specificity of the ED ABC score. METHODS A 5-year retrospective analysis (2015-2019) of highest-activation adult trauma patients arriving to a quaternary Level I trauma center by hospital-based helicopter air medical service (HEMS) was performed. Demographic, prehospital, ED triage, and blood product utilization data were collected. Prehospital ABC score was calculated using the highest heart rate, lowest systolic blood pressure, and focused assessment with sonography for trauma (FAST) exam results obtained prior to arrival at the trauma center. ED ABC score was calculated using ED triage vital signs and ED FAST results. Sensitivity, specificity, positive predictive value, negative predictive value, and the area under the receiver operating characteristics (AUROC) curve were calculated for each ABC score. RESULTS 2,067 patients met inclusion criteria. Mean age 39 (±17) years, 76% male, 22% penetrating mechanism. Of these, 128 patients (6%) received massive transfusion using the definition from the original study. Prehospital ABC score at a cutoff of 2 was 51% sensitive and 85% specific for predicting massive transfusion, with 83% correctly classified and an AUROC = 0.73. ED ABC score at the same cutoff was 60% sensitive and 84% specific, with 83% correctly classified and an AUROC = 0.81. By logistic regression, the odds of massive transfusion increased by 2.76 for every 1-point increase in prehospital ABC score (95%CI 2.25-3.37, p < 0.001). CONCLUSIONS The ABC score is a useful prehospital tool for identifying who will require massive transfusion. Future studies to evaluate the effect of the prehospital ABC score on clinical care and mortality are necessary.
Collapse
Affiliation(s)
- Erin Hanlin
- Department of Surgery, Duke University, Durham, North Carolina
| | - David E Meyer
- Department of Surgery, University of Texas Health Science Center at Houston, Houston, Texas
- Life Flight®, Memorial Hermann Hospital - Texas Medical Center, Houston, Texas
| | - Nicolas Heft
- Department of Emergency Medicine, University of Texas Health Science Center at Houston, Houston, Texas
| | - Hutch Stilgenbauer
- Department of Emergency Medicine, University of Texas Health Science Center at Houston, Houston, Texas
| | - Bryan Cotton
- Department of Surgery, University of Texas Health Science Center at Houston, Houston, Texas
| | - Michele Bourgeois
- Life Flight®, Memorial Hermann Hospital - Texas Medical Center, Houston, Texas
| | - Rodolfo Cabrera
- Life Flight®, Memorial Hermann Hospital - Texas Medical Center, Houston, Texas
| | - Lesley Osborn
- Life Flight®, Memorial Hermann Hospital - Texas Medical Center, Houston, Texas
- Department of Emergency Medicine, University of Texas Health Science Center at Houston, Houston, Texas
| |
Collapse
|
|
16
|
Yates JG, Baylous D. Air Medical Ultrasound: Looking Back to See What We Have Learned for the Future. Air Med J 2022; 41:536-541. [PMID: 36494169 DOI: 10.1016/j.amj.2022.08.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 08/23/2022] [Accepted: 08/25/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE This study attempts to replicate data from a similar study performed 5 years ago by comparing point-of-care (POCUS) extended focused abdominal sonography in trauma (eFAST) examinations performed by an air medical flight crew with those performed by a trauma team at a level 1 trauma center. METHODS This prospective observational study evaluated 174 trauma patients over a 12-month period in southeastern Virginia and northeastern North Carolina. RESULTS For 101 trauma patients who had a POCUS evaluation completed by the flight crews, a positive predictive value of 100% was obtained with a negative predictive value of 96.63% for pneumothorax, hemothorax, and free abdominal fluid. This showed no significant difference in that of the trauma team's POCUS studies or that of the data from the 2017 study. Early recognition of life-threatening injury continues to be a priority during the assessment of traumatically injured patients. In conjunction with a thorough history and physical examination, POCUS is a very effective method to identify these potentially devastating injuries, especially in the air medical community. When we compared this study's results with those of our study from 2017, the data were very similar, showing that flight crews can conduct POCUS examinations effectively in the austere prehospital environment. CONCLUSION By replicating this study, we have shown the validity and continued quality, accuracy, and benefits of the POCUS eFAST examination of trauma patients in the air medical environment. The validity of our previous and now current research suggests that some current standard trauma protocol revisions are indicated (ie, the initiation of air medical trauma resuscitation with blood products, preferably whole blood, and the transport of critically injured patients with a positive POCUS examination for free abdominal fluid directly to the operating room should be closely evaluated).
Collapse
Affiliation(s)
- Jeffrey G Yates
- Eastern Virginia Medical School, School of Health Professions, Norfolk, VA.
| | - Denise Baylous
- Nightingale Regional Air Ambulance, Sentara Norfolk General Hospital, Norfolk, VA
| |
Collapse
|
|
17
|
von Foerster N, Radomski MA, Martin-Gill C. Prehospital Ultrasound: A Narrative Review. PREHOSP EMERG CARE 2022; 28:1-13. [PMID: 36194192 DOI: 10.1080/10903127.2022.2132332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Revised: 09/30/2022] [Accepted: 09/30/2022] [Indexed: 10/31/2022]
Abstract
Background: Point-of-care ultrasound is rapidly becoming more prevalent in the prehospital environment. Though considered a relatively new intervention in this setting, there is growing literature that aims to explore the use of prehospital ultrasound by EMS personnel.Methods: To better understand and report the state of the science on prehospital ultrasound, we conducted a narrative review of the literature.Results: Following a keyword search of MEDLINE in Ovid from inception to August 2, 2022, 2,564 records were identified and screened. Based on review of abstracts and full texts, with addition of seven articles via bibliography review, 193 records were included. Many included studies detail usage in air medical and other critical care transport environments. Clinicians performing prehospital ultrasound are often physicians or other advanced practice personnel who have previous ultrasound experience, which facilitates implementation in the prehospital setting. Emerging literature details training programs for prehospital personnel who are novices to ultrasound, and implementation for some study types appears feasible without prior experience. Unique use scenarios that show promise include during critical care transport, for triage in austere settings, and for thoracic evaluation of patients at risk of life-threatening pathology.Conclusion: There is a growing mostly observational body of literature describing the use of ultrasound by prehospital personnel. Prehospital ultrasound has demonstrated feasibility for specific conditions, yet interventional studies evaluating benefit to patient outcomes are absent.
Collapse
Affiliation(s)
- Nicholas von Foerster
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Marek A Radomski
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Christian Martin-Gill
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| |
Collapse
|
|
18
|
Lai J, Kuttab H, Newberry R, Stader M, Cathers A. Prehospital Ultrasound Use to Guide Resuscitative Thoracotomy in Blunt Traumatic Cardiac Arrest. Air Med J 2022; 41:494-497. [PMID: 36153149 DOI: 10.1016/j.amj.2022.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 06/08/2022] [Indexed: 06/16/2023]
Abstract
Traumatic cardiac arrest is frequently encountered in the air medical transport environment, and resuscitative thoracotomy is a procedure that is sometimes performed in an attempt to salvage these critically injured patients. Focused assessment with sonography for trauma (FAST) is a point-of-care ultrasound protocol commonly used in trauma patients to detect the presence of free fluid in the intraperitoneal and pericardial spaces. The authors present a case of an adult female victim of a motor vehicle collision whose prehospital FAST scan revealed significant hemoperitoneum without hemopericardium. When she developed cardiac arrest, these ultrasound findings aided in the decision to perform resuscitative thoracotomy and helped guide the sequence of maneuvers with prioritization given to cross-clamping the aorta. This case highlights the utility of prehospital ultrasound in yielding timely, actionable diagnostic information that can inform the performance of a high-acuity low-occurrence procedure in the air medical transport environment.
Collapse
Affiliation(s)
- Jason Lai
- UW Health Med Flight, Madison, WI; BerbeeWalsh Department of Emergency Medicine, Madison, WI.
| | - Hani Kuttab
- UW Health Med Flight, Madison, WI; BerbeeWalsh Department of Emergency Medicine, Madison, WI
| | - Ryan Newberry
- UW Health Med Flight, Madison, WI; BerbeeWalsh Department of Emergency Medicine, Madison, WI
| | | | - Andrew Cathers
- UW Health Med Flight, Madison, WI; BerbeeWalsh Department of Emergency Medicine, Madison, WI
| |
Collapse
|
|
19
|
Donovan JK, Burton SO, Jones SL, Meadley BN. Use of Point-of-Care Ultrasound by Non-Physicians to Assess Respiratory Distress in the Out-of-Hospital Environment: A Scoping Review. Prehosp Disaster Med 2022; 37:520-528. [PMID: 35506171 PMCID: PMC9280071 DOI: 10.1017/s1049023x22000711] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 02/25/2022] [Accepted: 03/06/2022] [Indexed: 01/23/2023]
Abstract
BACKGROUND The use of ultrasound in the out-of-hospital environment is increasingly feasible. The potential uses for point-of-care ultrasound (POCUS) by paramedics are many, but have historically been limited to traumatic indications. This study utilized a scoping review methodology to map the evidence for the use of POCUS by paramedics to assess respiratory distress and to gain a broader understanding of the topic. METHODS Databases Ovid MEDLINE, EMBASE, CINAHL Plus, and PUBMED were searched from January 1, 1990 through April 14, 2021. Google Scholar was searched, and reference lists of relevant papers were examined to identify additional studies. Articles were included if they reported on out-of-hospital POCUS performed by non-physicians for non-traumatic respiratory distress. RESULTS A total of 591 unique articles were identified, of which seven articles met the inclusion criteria. The articles reported various different scan protocols and, with one exception, suffered from low enrolments and low participation. Most articles reported that non-physician-performed ultrasound was feasible. Articles reported moderate to high levels of agreement between paramedics and expert reviewers for scan interpretation in most studies. CONCLUSION Paramedics and emergency medical technicians (EMTs) have demonstrated the feasibility of lung ultrasound in the out-of-hospital environment. Further research should investigate the utility of standardized education and scanning protocols in paramedic-performed lung ultrasound for the differentiation of respiratory distress and the implications for patient outcomes.
Collapse
Affiliation(s)
- Jake K. Donovan
- Ambulance Victoria, Doncaster, Victoria, Australia
- Department of Paramedicine, Monash University, Frankston, Victoria, Australia
| | - Samuel O. Burton
- Ambulance Victoria, Doncaster, Victoria, Australia
- Department of Paramedicine, Monash University, Frankston, Victoria, Australia
| | - Samuel L. Jones
- Ambulance Victoria, Doncaster, Victoria, Australia
- Department of Paramedicine, Monash University, Frankston, Victoria, Australia
| | - Benjamin N. Meadley
- Ambulance Victoria, Doncaster, Victoria, Australia
- Department of Paramedicine, Monash University, Frankston, Victoria, Australia
| |
Collapse
|
|
20
|
Semi-quantitative lung ultrasound score during ground transportation of outborn neonates with respiratory failure. Eur J Pediatr 2022; 181:3085-3092. [PMID: 35697797 DOI: 10.1007/s00431-022-04488-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 03/30/2022] [Accepted: 04/25/2022] [Indexed: 11/03/2022]
Abstract
UNLABELLED Lung ultrasound score (LUS) is increasingly diffused in neonatal critical care but scanty data are available about its use during transfer of severely ill neonates. We aimed to clarify the effect of ground transportation on LUS evolution, conformity of interpretation, and relationships with oxygenation and clinical severity. This is a single-center, blinded, observational, cross-sectional study. Neonates of any gestational age with respiratory distress appearing within 24 h from birth were transferred by a mobile unit towards neonatal intensive care unit (NICU) of a tertiary referral center. Calculation of LUS prior to the transportation (T1), in the mobile unit (T2), at the end of transportation (T3), and finally upon NICU admission. LUS in the mobile unit and in the NICU was performed by different physicians blinded to each other's results. LUS did not change overtime (T1: 6.3 (3.5), T2: 6.1 (3.5), T3: 5.8 (3.4); p = 0.479; adjusted for gestational or postnatal age or transport duration: p = 0.951, p = 0.424, and 0.266, respectively) but reliably predicted surfactant need (AUC at T1: 0.833 (95%CI: 0.72-0.92); AUC at T2: 0.82 (95%CI: 0.70-0.91); AUC at T3: 0.82 (95%CI: 0.70-0.90); p always < 0.0001). There were significant agreement (ICC = 0.912 (95%CI: 0.83-0.95); p < 0.001) and correlation (r = 0.905, p < 0.001) between LUS calculated during transportation and in the NICU. LUS during transportation was also significantly correlated with oxygenation index (r = 0.321, p = 0.026; standardized B = 0.397 (95%CI: 0.03-0.76), p = 0.048) and TRIPS-II score (r = 0.302, p = 0.008; standardized B = 0.568 (95%CI: 0.04-1.1), p = 0.037). CONCLUSION LUS during ground transportation of neonates with respiratory failure is suitable and not influenced by the transportation itself. It has a high agreement with that calculated in the NICU and correlates with patients' oxygenation and severity. WHAT IS KNOWN • Lung ultrasound is a part of the point-of-care ultrasound, which is becoming an essential tool, to manage critically ill neonates and children in an accurate, non-invasive and quick way. WHAT IS NEW • Lung ultrasound score (LUS) is suitable during transportation of critically ill neonates with respiratory failure and is not influenced by the transportation itself. • LUS has a high agreement with that calculated in the NICU and correlates with patients' oxygenation and severity of respiratory failure.
Collapse
|
|
21
|
Huang Y, Kou H, Kong Y, Shan X, Wu S, Chen X, Lin X, Zhang L, Lv F, Li Z. The effectiveness of portable ultrasound-guided resuscitative endovascular balloon occlusion of the aorta for stopping iliac artery hemorrhage during first aid pre-hospital: a randomized control animal trial. Eur J Trauma Emerg Surg 2022; 48:2841-2848. [PMID: 35412061 PMCID: PMC9360081 DOI: 10.1007/s00068-022-01895-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 01/30/2022] [Indexed: 11/06/2022]
Abstract
PURPOSE This study aimed at to comparing the effectiveness of portable ultrasound guided REBOA vs. traditional manual extracorporeal compression in stopping iliac artery hemostasis. METHODS Twelve swine were included in this study (treatment group vs. control group, 6:6). A biopsy device was used to create an iliac artery rupture and hemorrhage in each swine. After 30 s of bleeding, the treatment group received REBOA under the guidance of ultrasound, whereas the control group received traditional manual extracorporeal compression. General physiological conditions were recorded at 0 s (baseline, T1), 30 s (initiation of therapies to stop bleeding, T2), 10 min (T3) and 30 min (T4) after bleeding. Intraperitoneal and retroperitoneal hemorrhage and specimens of iliac artery were collected after all swine were euthanized. RESULTS One swine was excluded because of accidental death not related to the experiment; thus, 11 swine were analyzed in this study. The general physiological characteristics of the two groups showed no difference at T1. Hemorrhagic shock occurred in both groups. After the hemostatic procedure was performed, systolic pressure, diastolic pressure and heart rate first increased significantly between T2 and T3, and then became stable between T3 and T4; these indicators in the control group deteriorated over time. The total blood loss in the treatment group (1245.23 ± 190.07 g) was much significantly less than that in the control group (2605.63 ± 291.67 g) with p < 0.001. CONCLUSIONS Performing REBOA under the guidance of portable ultrasound is an effective way to stop bleeding. It suggests a potential alternative method for iliac artery hemostasis in the pre-hospital setting.
Collapse
Affiliation(s)
- Yuqing Huang
- Medical School of Chinese PLA, 28 Fuxing Road, Haidian District, Beijing, 100853, China
- Department of Ultrasound, The Third Medical Centre of PLA General Hospital, 69 Yongding Road, Haidian District, Beijing, 100853, China
| | - Haiyan Kou
- Department of Ultrasound, The Third Medical Centre of PLA General Hospital, 69 Yongding Road, Haidian District, Beijing, 100853, China
| | - Yuhao Kong
- Vanke School of Public Health, Tsinghua University, Beijing, 100084, China
| | - Xuexia Shan
- Department of Ultrasound, Hainan Hospital of PLA General Hospital, 80 Jianglin Road, Haitang District, Sanya, 572013, China
| | - Shengzheng Wu
- Department of Ultrasound, Hainan Hospital of PLA General Hospital, 80 Jianglin Road, Haitang District, Sanya, 572013, China
| | - Xianghui Chen
- Department of Ultrasound, Hainan Hospital of PLA General Hospital, 80 Jianglin Road, Haitang District, Sanya, 572013, China
| | - Xingxi Lin
- Department of Ultrasound, Hainan Hospital of PLA General Hospital, 80 Jianglin Road, Haitang District, Sanya, 572013, China
| | - Liye Zhang
- Department of Ultrasound, Hainan Hospital of PLA General Hospital, 80 Jianglin Road, Haitang District, Sanya, 572013, China
| | - Faqin Lv
- Medical School of Chinese PLA, 28 Fuxing Road, Haidian District, Beijing, 100853, China.
- Department of Ultrasound, The Third Medical Centre of PLA General Hospital, 69 Yongding Road, Haidian District, Beijing, 100853, China.
| | - Zhihui Li
- Vanke School of Public Health, Tsinghua University, Beijing, 100084, China.
- Institute for healthy China, Tsinghua University, Beijing, 100084, China.
| |
Collapse
|
|
22
|
Ienghong K, Cheung LW, Tiamkao S, Bhudhisawasdi V, Apiratwarakul K. The Utilization of Handheld Ultrasound Devices in a Prehospital Setting. Prehosp Disaster Med 2022; 37:355-359. [PMID: 35435155 PMCID: PMC9118051 DOI: 10.1017/s1049023x22000644] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 02/22/2022] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Prehospital ultrasounds can be considered a new form of diagnostic tool when taking into account their small structure and due to the fact that nowadays, they are used in the care of emergency patients. However, at present, there is no study regarding the advantage of ultrasound usage in prehospital settings in Thailand. STUDY OBJECTIVE This study aims to determine the sonographic characteristics recorded by handheld ultrasounds used in prehospital care and the diagnostic accuracy of ultrasounds for prehospital patients. METHODS A cross-sectional study was conducted on prehospital patients who underwent point-of-care ultrasound (POCUS) examination on Emergency Medical Service (EMS) operations at Srinagarind Hospital, Thailand from January 2021 through December 2021. The ultrasound images, the electronic emergency department medical records, and the EMS database were recorded and reviewed by a team of emergency physicians. The quality of prehospital ultrasound examinations was assessed by comparing the diagnoses at the scene with those taken at the hospital. RESULTS One hundred sixty-nine prehospital patients who received POCUS examinations were examined over a one-year period. All (100.0%) of the scans were for medical cases. No ultrasound protocol was used in the prehospital care. Two hundred eight POCUS examinations were performed in this study. The most common POCUS indication was dyspnea (45.6%), followed by hypotension/shock (30.1%), and finally syncope (8.2%). The most common area where POCUS was performed was on the lung (37.0%), followed by the inferior vena cava (30.8%), and finally for cardiac cases (26.4%). This study found that 34.9% of sonographic findings could be considered abnormal. The diagnoses of prehospital patients were confirmed by using POCUS in 66 cases (39.1%) with the accuracy of prehospital diagnosis reaching a peak of 75.8%. CONCLUSION This study shows POCUS examinations can be effectively used in prehospital care. The prehospital diagnosis given by physicians administering treatment who used POCUS examinations correlated with the in-hospital diagnosis.
Collapse
Affiliation(s)
- Kamonwon Ienghong
- Department of Emergency Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Lap Woon Cheung
- Accident & Emergency Department, Princess Margaret Hospital, Kowloon, Hong Kong
- Emergency Medicine Unit, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong
| | - Somsak Tiamkao
- Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | | | - Korakot Apiratwarakul
- Department of Emergency Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| |
Collapse
|
|
23
|
Tartaglione M, Carenzo L, Gamberini L, Lupi C, Giugni A, Mazzoli CA, Chiarini V, Cavagna S, Allegri D, Holcomb JB, Lockey D, Sbrana G, Gordini G, Coniglio C. Multicentre observational study on practice of prehospital management of hypotensive trauma patients: the SPITFIRE study protocol. BMJ Open 2022; 12:e062097. [PMID: 35636792 PMCID: PMC9152935 DOI: 10.1136/bmjopen-2022-062097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
INTRODUCTION Major haemorrhage after injury is the leading cause of preventable death for trauma patients. Recent advancements in trauma care suggest damage control resuscitation (DCR) should start in the prehospital phase following major trauma. In Italy, Helicopter Emergency Medical Services (HEMS) assist the most complex injuries and deliver the most advanced interventions including DCR. The effect size of DCR delivered prehospitally on survival remains however unclear. METHODS AND ANALYSIS This is an investigator-initiated, large, national, prospective, observational cohort study aiming to recruit >500 patients in haemorrhagic shock after major trauma. We aim at describing the current practice of hypotensive trauma management as well as propose the creation of a national registry of patients with haemorrhagic shock. PRIMARY OBJECTIVE the exploration of the effect size of the variation in clinical practice on the mortality of hypotensive trauma patients. The primary outcome measure will be 24 hours, 7-day and 30-day mortality. Secondary outcomes include: association of prehospital factors and survival from injury to hospital admission, hospital length of stay, prehospital and in-hospital complications, hospital outcomes; use of prehospital ultrasound; association of prehospital factors and volume of first 24-hours blood product administration and evaluation of the prevalence of use, appropriateness, haemodynamic, metabolic and effects on mortality of prehospital blood transfusions. INCLUSION CRITERIA age >18 years, traumatic injury attended by a HEMS team including a physician, a systolic blood pressure <90 mm Hg or weak/absent radial pulse and a confirmed or clinically likely diagnosis of major haemorrhage. Prehospital and in-hospital variables will be collected to include key times, clinical findings, examinations and interventions. Patients will be followed-up until day 30 from admission. The Glasgow Outcome Scale Extended will be collected at 30 days from admission. ETHICS AND DISSEMINATION The study has been approved by the Ethics committee 'Comitato Etico di Area Vasta Emilia Centro'. Data will be disseminated to the scientific community by abstracts submitted to international conferences and by original articles submitted to peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT04760977.
Collapse
Affiliation(s)
- Marco Tartaglione
- Department of Anesthesia, Intensive Care and Prehospital Emergency Service, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
| | - Luca Carenzo
- Department of Anesthesia and Intensive Care Medicine, IRCCS Humanitas Research Hospital, Rozzano, Milano, Italy
| | - Lorenzo Gamberini
- Department of Anesthesia, Intensive Care and Prehospital Emergency Service, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
| | - Cristian Lupi
- Department of Anesthesia, Intensive Care and Prehospital Emergency Service, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
| | - Aimone Giugni
- Department of Anesthesia, Intensive Care and Prehospital Emergency Service, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
| | - Carlo Alberto Mazzoli
- Department of Anesthesia, Intensive Care and Prehospital Emergency Service, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
| | - Valentina Chiarini
- Department of Anesthesia, Intensive Care and Prehospital Emergency Service, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
| | - Silvia Cavagna
- Department of Anesthesia, Intensive Care and Prehospital Emergency Service, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
| | - Davide Allegri
- Department of Clinical Governance and Quality, Azienda Unità Sanitaria Locale di Bologna, Bologna, Italy
| | - John B Holcomb
- Center for Injury Science, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - David Lockey
- Centre for Trauma Sciences, Queen Mary University of London, London, UK
| | - Giovanni Sbrana
- UOS 118 Gestione Territorio Area Provinciale Aretina and Grosseto HEMS, Azienda USL Toscana Sud Est, Grosseto, Italy
| | - Giovanni Gordini
- Department of Anesthesia, Intensive Care and Prehospital Emergency Service, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
| | - Carlo Coniglio
- Department of Anesthesia, Intensive Care and Prehospital Emergency Service, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
| |
Collapse
|
|
24
|
Mohrsen S, McMahon N, Corfield A, McKee S. Complications associated with pre-hospital open thoracostomies: a rapid review. Scand J Trauma Resusc Emerg Med 2021; 29:166. [PMID: 34863280 PMCID: PMC8643006 DOI: 10.1186/s13049-021-00976-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 11/04/2021] [Indexed: 02/26/2023] Open
Abstract
Background Open thoracostomies have become the standard of care in pre-hospital critical care in patients with chest injuries receiving positive pressure ventilation. The procedure has embedded itself as a rapid method to decompress air or fluid in the chest cavity since its original description in 1995, with a complication rate equal to or better than the out-of-hospital insertion of indwelling pleural catheters. A literature review was performed to explore potential negative implications of open thoracostomies and discuss its role in mechanically ventilated patients without clinical features of pneumothorax. Main findings A rapid review of key healthcare databases showed a significant rate of complications associated with pre-hospital open thoracostomies. Of 352 thoracostomies included in the final analysis, 10.6% (n = 38) led to complications of which most were related to operator error or infection (n = 26). Pneumothoraces were missed in 2.2% (n = 8) of all cases. Conclusion There is an appreciable complication rate associated with pre-hospital open thoracostomy. Based on a risk/benefit decision for individual patients, it may be appropriate to withhold intervention in the absence of clinical features, but consideration must be given to the environment where the patient will be monitored during care and transfer. Chest ultrasound can be an effective assessment adjunct to rule in pneumothorax, and may have a role in mitigating the rate of missed cases. Supplementary Information The online version contains supplementary material available at 10.1186/s13049-021-00976-1.
Collapse
Affiliation(s)
- Stian Mohrsen
- ScotSTAR, Emergency Medical Retrieval Service, 180 Abbotsinch Road, Paisley, PA2 3RY, UK. .,Faculty of Health Sciences and Sport, University of Stirling, Stirling, FK9 4LA, Scotland, UK.
| | - Niall McMahon
- ScotSTAR, Emergency Medical Retrieval Service, 180 Abbotsinch Road, Paisley, PA2 3RY, UK
| | - Alasdair Corfield
- ScotSTAR, Emergency Medical Retrieval Service, 180 Abbotsinch Road, Paisley, PA2 3RY, UK
| | - Sinéad McKee
- Department of Nursing, School of Health and Life Sciences, Glasgow Caledonian University, Cowcaddens Road, Glasgow, G4 0BA, Scotland, UK
| |
Collapse
|
|
25
|
Shekhar AC, Blumen I. A narrative review on the use of ultrasonography in critical care transport: is POCUS hocus? TRENDS IN ANAESTHESIA AND CRITICAL CARE 2021. [DOI: 10.1016/j.tacc.2021.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
|
26
|
Partyka C, Coggins A, Bliss J, Burns B, Fiorentino M, Goorkiz P, Miller M. A multicenter evaluation of the accuracy of prehospital eFAST by a physician-staffed helicopter emergency medical service. Emerg Radiol 2021; 29:299-306. [PMID: 34817706 DOI: 10.1007/s10140-021-02002-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 11/16/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE The purpose of this study is to report the relative accuracy of prehospital extended focused assessment with sonography in trauma (eFAST) examinations performed by HEMS physicians. METHODS Trauma patients who received prehospital eFAST by HEMS clinicians between January 2013 and December 2017 were reviewed. The clinician's interpretations of these ultrasounds were compared to gold standard references of CT imaging or operating room findings. The outcomes measured include the calculated accuracy of eFAST for detecting intraperitoneal free fluid (IPFF), pneumothorax, hemothorax, and pericardial fluid compared to available gold standard results. RESULTS Of the 411 patients with adequate data for comparison, the median age was 39.5 years with 73% male and 98% sustaining blunt force trauma. For the detection of IPFF, eFAST had a sensitivity of 25% (95% CI 16-36%) and specificity of 96% (95% CI 93-98%). Sensitivities and specificities were calculated for pneumothorax (38% and 96% respectively), hemothorax (17% and 97% respectively), and pericardial effusion (17% and 100% respectively). These results did not change significantly when reassessed with several sensitivity analyses. CONCLUSION Prehospital eFAST is reliable for detecting the presence of intraperitoneal free fluid. This finding should inform receiving trauma teams to prepare for early definitive care in these patients. The low sensitivities across all components of the eFAST highlight the importance of cautiously interpreting negative studies while prompting the need for further studies. TRIAL REGISTRATION ACTRN12618001973202 (Registered on 06/12/2018).
Collapse
Affiliation(s)
- Christopher Partyka
- Aeromedical Operations, NSW Ambulance, 33 Nancy Ellis Leebold Drive, Bankstown Airport, Sydney, NSW, 2200, Australia. .,Emergency Department, Liverpool Hospital, Liverpool, NSW, Australia. .,South Western Sydney Clinical School, University of New South Wales, Kensington, Australia.
| | - Andrew Coggins
- Emergency Department, Westmead Hospital, Westmead, NSW, Australia.,Western Clinical School, University of Sydney, Sydney, Australia
| | - Jimmy Bliss
- Aeromedical Operations, NSW Ambulance, 33 Nancy Ellis Leebold Drive, Bankstown Airport, Sydney, NSW, 2200, Australia.,Emergency Department, Liverpool Hospital, Liverpool, NSW, Australia.,Sydney Medical School, University of Sydney, Sydney, Australia
| | - Brian Burns
- Sydney Medical School, University of Sydney, Sydney, Australia.,GSA-HEMS, NSW Ambulance, Blacktown, NSW, Australia
| | | | - Pierre Goorkiz
- Intensive Care Unit, Liverpool Hospital, Liverpool, NSW, Australia.,School of Medicine, Western Sydney University, Sydney, Australia
| | - Matthew Miller
- Aeromedical Operations, NSW Ambulance, 33 Nancy Ellis Leebold Drive, Bankstown Airport, Sydney, NSW, 2200, Australia.,UNSW St George and Sutherland Clinical Schools, Kogarah, Australia
| |
Collapse
|
|
27
|
Griffiths E. Helicopter emergency medical services use of thoracic point of care ultrasound for pneumothorax: a systematic review and meta-analysis. Scand J Trauma Resusc Emerg Med 2021; 29:163. [PMID: 34801070 PMCID: PMC8606084 DOI: 10.1186/s13049-021-00977-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 11/04/2021] [Indexed: 02/01/2023] Open
Abstract
Background Auscultating for breath sounds to assess for pneumothorax in the helicopter emergency medical services (HEMS) settings can be extremely challenging. Thoracic point of care ultrasound (POCUS) offers a seemingly more useful visual (rather than audible) alternative. This review critically and quantitatively evaluates the use of thoracic POCUS for pneumothorax in the HEMS setting. Methods A systematic literature review with meta-analysis was conducted. Only papers reporting on patients undergoing POCUS for pneumothorax in the helicopter or pre-hospital setting were included. Primary outcome was accuracy, focusing on sensitivity and specificity. Secondary outcome was practicality. PubMed, Embase and the Cochrane Library were searched. The Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) was used to assess validity of studies. Results Twelve studies reporting on n = 1,936 images from medical and trauma patients were included in qualitative synthesis. Studies were nearly all observational designs. Most images were acquired by nurses or paramedics who were previously novices to ultrasound. The reference standard was predominantly CT. Specificity results were unanimously precise and very high, whereas sensitivity results were imprecise and extremely variable. Meta-analysis of eight studies involving n = 1,713 images yielded pooled sensitivity 61% (95% CI: 27–87%; I2 = 94%) and pooled specificity 99% (95% CI: 98–100%; I2 = 89%). Six studies involving n = 315 images reported practicality. The highest or second highest categorisation of image quality was reported in around half of those images. Conclusion Thoracic POCUS is highly specific but has extremely variable sensitivity for pneumothorax when performed in the HEMS setting. This is from purely a diagnostic (not clinical) perspective. Sensitivity increases when only clinically significant pneumothoraces are considered. Case reports reveal thoracic POCUS can appropriately alter treatment and triage decisions, but only for a small number of patients. It appears predominantly useful in mitigating against unnecessary interventions. More research reporting patient focused outcomes is required. In the meantime, thoracic POCUS appears to offer a more appropriate visual alternative to auscultation for breath sounds when assessing for pneumothorax in the HEMS setting.
Collapse
Affiliation(s)
- Edward Griffiths
- Bristow Helicopters Search and Rescue, UK Search and Rescue Helicopter Service, Aberdeen, UK. .,Queen Mary University London, London, UK.
| |
Collapse
|
|
28
|
Foster B, Kuttab HI, Damewood SC, Brazelton T, Al-Subu AM. Use of Point-of-Care Ultrasound in the Pediatric and Neonatal Emergency Transport Realm. Pediatr Ann 2021; 50:e432-e436. [PMID: 34617848 DOI: 10.3928/19382359-20210912-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Point-of-care ultrasound (POCUS) is a tool often used by clinical providers in the care of critically ill or acutely injured patients. POCUS can be used to evaluate for potentially harmful conditions during transport and to optimize downstream management. Although available literature primarily focuses on adults in the prehospital, critical care, and austere environment realm, more literature supporting POCUS use during pediatric and neonatal transport has emerged over the last few years. What is currently available is often from diverse operators and a wide variety of applications. The goal of this article is to describe current pediatric and neonatal POCUS applications and to identify its barriers and limitations in the transport realm. [Pediatr Ann. 2021;50(10):e432-e436.].
Collapse
|
|
29
|
Xiao R, Shao Q, Zhao N, Liu F, Qian KJ. Quantification analysis of pleural line movement for the diagnosis of pneumothorax. World J Clin Cases 2021; 9:5889-5899. [PMID: 34368307 PMCID: PMC8316966 DOI: 10.12998/wjcc.v9.i21.5889] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 03/19/2021] [Accepted: 06/01/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND There is no research on quantitative pleural line movement. In this study, we assume that tissue Doppler and its quantitative technology can quantify the pleural line movement and can be used to diagnose pneumothorax.
AIM To evaluate the quantitative assessment of pleural line movement measured by tissue Doppler imaging (TDI) for pneumothorax diagnosis.
METHODS Adult patients (n = 45) diagnosed with unilateral pneumothorax were included in this study. Each patient underwent TDI of both lungs. The pneumothorax side and contralateral normal lung side were compared using several indices obtained from TDI: peak pleural line velocity (PVmax), peak chest wall tissue velocity (CVmax), peak pleural line strain value (PSmax), peak chest wall tissue strain value (CSmax), PVmax/CVmax and PSmax/CSmax. The receiver operating characteristic analysis was used to evaluate the performance of these quantitative assessments for pneumothorax diagnosis.
RESULTS Various quantitative variables of the pneumothorax side were all lower than that of the non-pneumothorax side and included the PVmax (0.36 cm/s vs 0.59 cm/s, P < 0.001), PSmax (1.14% vs 1.90%, P = 0.001), PVmax/CVmax (1.06 vs 4.93, P < 0.001), and PSmax/CSmax (0.76 vs 1.74, P < 0.001). For the discrimination of pneumothorax, the cut-off values of the PVmax, PSmax, PVmax/CVmax, and PSmax/CSmax were calculated as 0.50 cm/s, 0.94%, 1.96, and 1.12, respectively. Similarly, the sensitivities and specificities of PVmax, PSmax, PVmax/CVmax, and PSmax/CSmax were 96% and 62%, 47% and 91%, 93% and 96%, and 82% and 93%, respectively. The area under the receiver operating characteristic curve were 0.84, 0.72, 0.99, and 0.91, respectively, for PVmax, PSmax, PVmax/CVmax, and PSmax/CSmax.
CONCLUSION Quantification analysis of pleural line movement using TDI is a useful tool for the diagnosis of pneumothorax.
Collapse
Affiliation(s)
- Rui Xiao
- Department of Intensive Care Medicine, First Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, China
| | - Qiang Shao
- Department of Intensive Care Medicine, First Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, China
| | - Ning Zhao
- Department of Intensive Care Medicine, First Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, China
| | - Fen Liu
- Department of Intensive Care Medicine, First Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, China
| | - Ke-Jian Qian
- Department of Intensive Care Medicine, First Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, China
| |
Collapse
|
|
30
|
Quality of abdominal ultrasound image acquisition by novice practitioners following a minimal training session on healthy volunteers. CAN J EMERG MED 2021; 22:S74-S78. [PMID: 33084552 DOI: 10.1017/cem.2020.29] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Point of care ultrasound (POCUS) is an essential tool for physicians to guide treatment decisions in both hospital and prehospital settings. Despite the potential patient care and system utilization benefits of prehospital ultrasound, the financial burden of a "hands-on" training program for large numbers of paramedics remains a barrier to implementation. In this study, we conducted a prospective, observational, double-blinded study comparing paramedics to emergency physicians in their ability to generate usable abdominal ultrasound images after a 1-hour didactic training session. METHODS Canadian aeromedical critical care paramedics were compared against emergency medicine physicians in their ability to generate adequate abdominal ultrasound images on five healthy volunteers. Quality of each scan was evaluated by a trained expert in POCUS who was blinded to the identity of the participant using a 5-point Likert scale and using the standardized QUICk Focused Assessment with Sonography in Trauma (FAST) assessment tool. RESULTS Fourteen Critical care paramedics and four emergency department (ED) physicians were voluntarily recruited. Of paramedics, 57% had never used ultrasound before, 36% has used ultrasound without formal training, and 7% had previous training. Physicians had a higher proportion of usable scans compared with paramedics (100% v. 61.4%, Δ38.6%; 95% confidence interval, 19.3-50.28). CONCLUSIONS Paramedics were not able to produce images of interpretable quality at the same frequency when compared with emergency medicine physicians. However, a 61.4% usable image rate for paramedics following a short 1-hour didactic training session is promising for future studies, which could incorporate a short hands-on tutorial while remaining cost-effective.
Collapse
|
|
31
|
Abdominal ultrasound image acquisition and interpretation by novice practitioners after minimal training on a simulated patient model. CAN J EMERG MED 2021; 22:S62-S66. [PMID: 33084554 DOI: 10.1017/cem.2019.495] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The Focused Assessment with Sonography in Trauma (FAST) exam is a rapid ultrasound test to identify evidence of hemorrhage within the abdomen. Few studies examine the accuracy of paramedic performed FAST examinations. The duration of an ultrasound training program remains controversial. This study's purpose was to assess the accuracy of paramedic FAST exam interpretation following a one hour didactic training session. METHODS The interpretation of paramedic performed FAST exams was compared to the interpretation of physician performed FAST examinations on a mannequin model containing 300ml of free fluid following a one hour didactic training course. Results were compared using the Chi-square test. Differences in accuracy rate were deemed significant if p < 0.05. RESULTS Fourteen critical care flight paramedics and four emergency physicians were voluntarily recruited. The critical care paramedics were mostly ultrasound-naive whereas the emergency physicians all had ultrasound training. The correct interpretation of FAST scans was comparable between the two groups with accuracy of 85.6% and 87.5% (∆1.79 95%CI -33.85 to 21.82, p = 0.90) for paramedics and emergency physicians respectively. CONCLUSIONS This study determined that critical care paramedics were able to use ultrasound to detect free fluid on a simulated mannequin model and interpret the FAST exam with a similar accuracy as experienced emergency physicians following a one hour training course. This suggests the potential use of prehospital ultrasound to aid in the triage and transport decisions of trauma patients while limiting the financial and logistical burden of ultrasound training.
Collapse
|
|
32
|
Buaprasert P, Sri-On J, Sukhuntee J, Asawajaroenkul R, Buanhong O, Khiaodee T, Keetawattananon W, Tiyawat G. Diagnostic Accuracy of Extended Focused Assessment with Sonography for Trauma Performed by Paramedic Students: A Simulation-Based Pilot Study. Open Access Emerg Med 2021; 13:249-256. [PMID: 34188560 PMCID: PMC8232846 DOI: 10.2147/oaem.s311376] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 06/03/2021] [Indexed: 11/23/2022] Open
Abstract
Background Training on how to perform a prehospital extended focused assessment with sonography in trauma (EFAST) has resulted in improved outcomes for trauma patients in several countries. The result of previous studies showed good accuracy despite minimal training. However, data on the diagnostic accuracy among untrained paramedic students and the course length in middle-income countries is scarce. In Thailand, the current paramedic education does not include training on prehospital ultrasounds. In the present study, we aimed to investigate the diagnostic accuracy of EFAST among ultrasound-naïve paramedic students and factors that are associated with successful posttest training. Methods Final-year paramedic students attending a 4-year university program were included in this study. A 2-h didactic training session and 1-h hands-on workshop were led by experienced emergency physicians. The diagnostic indices for EFAST interpretation were obtained pretraining and posttraining. The participants' ultrasound image acquisition was also evaluated individually on a mannequin model using a standardized assessment tool. Results In total, 47 paramedic students were voluntarily enrolled and underwent EFAST training. Of these participants, 31 (66%) reported having >1 year of experience in the prehospital field. Four were advanced emergency medical technicians before becoming paramedic students. The sensitivity, specificity, positive predictive value, and negative predictive value after training were 85.7% (95% CI, 81.5-89.3), 81.6% (95% CI, 74.2-87.6), 91.6% (95% CI, 87.9-94.4), and 71% (95% CI, 63.3-77.8), respectively. Previous prehospital experience was not associated with accuracy. Conclusion This study demonstrated that paramedic students in Thailand were able to achieve a competency comparable with that of other medical professionals in a simulated environment. The total 3 h training course was sufficient for them to acquire EFAST skills.
Collapse
Affiliation(s)
- Phudit Buaprasert
- Department of Emergency Medicine, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Jiraporn Sri-On
- Department of Emergency Medicine, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Jareeda Sukhuntee
- Department of Disaster and Emergency Medical Operation, Faculty of Science and Health Technology, Navamindradhiraj University, Bangkok, Thailand
| | - Ranu Asawajaroenkul
- Department of Disaster and Emergency Medical Operation, Faculty of Science and Health Technology, Navamindradhiraj University, Bangkok, Thailand
| | - Onchuda Buanhong
- Department of Disaster and Emergency Medical Operation, Faculty of Science and Health Technology, Navamindradhiraj University, Bangkok, Thailand
| | - Trairat Khiaodee
- Department of Disaster and Emergency Medical Operation, Faculty of Science and Health Technology, Navamindradhiraj University, Bangkok, Thailand
| | - Worrapat Keetawattananon
- Department of Disaster and Emergency Medical Operation, Faculty of Science and Health Technology, Navamindradhiraj University, Bangkok, Thailand
| | - Gawin Tiyawat
- Department of Disaster and Emergency Medical Operation, Faculty of Science and Health Technology, Navamindradhiraj University, Bangkok, Thailand
| |
Collapse
|
|
33
|
Lenz TJ, Phelan MB, Grawey T. Determining a Need for Point-of-Care Ultrasound in Helicopter Emergency Medical Services Transport. Air Med J 2021; 40:175-178. [PMID: 33933221 DOI: 10.1016/j.amj.2021.01.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Revised: 01/09/2021] [Accepted: 01/22/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Point-of care-ultrasound (PoCUS) is useful in evaluating unstable emergency department patients. The portability of this technology increases its potential use in prehospital settings, including helicopter emergency medical services (HEMS) programs. Identifying useful applications may support implementing a PoCUS program that develops sonography skills for prehospital providers. The aim of this study was to determine the HEMS patient population that would benefit from prehospital PoCUS for hypotension and how commonly the extended focused assessment with sonography in trauma (E-FAST) for trauma patients or the rapid ultrasound in shock (RUSH) for medical patients could be used by HEMS. METHODS A retrospective chart review was performed over a 1-year period of adult patients transported by a midwestern HEMS system. Charts were reviewed for episodes of hypotension. RESULTS The chart review included 216 charts, of which 3 were excluded. Of the 213 cases, 100 were trauma patients, and 113 were medical patients. Of the trauma patients, 51% experienced hypotension, as did 73 of 113 medical patients. CONCLUSION Fifty percent of HEMS patients may benefit from PoCUS to evaluate for hypotension in flight.
Collapse
Affiliation(s)
- Timothy J Lenz
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI.
| | - Mary Beth Phelan
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Tom Grawey
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI
| |
Collapse
|
|
34
|
Kalkwarf KJ, Goodman MD, Press GM, Wade CE, Cotton BA. Prehospital ABC Score Accurately Forecasts Patients Who Will Require Immediate Resource Utilization. South Med J 2021; 114:193-198. [PMID: 33787930 DOI: 10.14423/smj.0000000000001236] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Scoring systems, such as the Assessment of Blood Consumption (ABC) Score, are used to identify patients at risk for massive transfusion (MT, ≥10 U red blood cells in 24 hours). Our aeromedical transport helicopter uses ultrasound to perform the Focused Assessment with Sonography for Trauma (FAST) examination. Our objective was to evaluate the ability of the Prehospital ABC (PhABC) Score to predict blood transfusions and the need for emergent laparotomy. METHODS Post hoc analysis of a prospective observational study of trauma patients who underwent an in-flight FAST during aeromedical transport during a 7-month period. PhABC Score was positive if ≥2 of the following were present in flight: penetrating trauma, heart rate >120 bpm, systolic blood pressure <90 mm Hg, or a positive abdominal FAST. The PhABC Score was evaluated by area under the receiver operating characteristic (AUROC) curves and logistic regression. RESULTS A total of 291 trauma patients met inclusion criteria, 23 underwent emergent laparotomy, and 12 received an MT. A positive PhABC Score predicted emergent laparotomy, with a positive predictive value of 48% and a negative predictive value of 95% (sensitivity 46%, specificity 96%, AUROC curve 0.83). A positive PhABC Score also predicted receipt of an MT with a positive predictive value of 28% and a negative predictive value of 94% (sensitivity 33%, specificity 93%, AUROC curve 0.77). Multiple logistic regression identified FAST as the most powerful contributor of the PhABC Score to the prediction of both emergent laparotomy (odds ratio 8.5, P < 0.001) and MT (odds ratio 5.9, P < 0.001). CONCLUSIONS The PhABC Score effectively predicts in-hospital resource utilization. It provides an outstanding undertriage rate from the prehospital setting, and it is helpful to improve trauma team activation, mobilize blood products, and prepare the operating room.
Collapse
Affiliation(s)
- Kyle J Kalkwarf
- From the Department of Surgery, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, the Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio, the Department of Emergency Medicine, University of Texas at Austin Dell Medical School, Austin, and the Center for Translational Injury Research and the Department of Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston (UTHealth), Houston
| | - Michael D Goodman
- From the Department of Surgery, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, the Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio, the Department of Emergency Medicine, University of Texas at Austin Dell Medical School, Austin, and the Center for Translational Injury Research and the Department of Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston (UTHealth), Houston
| | - Gregory M Press
- From the Department of Surgery, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, the Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio, the Department of Emergency Medicine, University of Texas at Austin Dell Medical School, Austin, and the Center for Translational Injury Research and the Department of Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston (UTHealth), Houston
| | - Charles E Wade
- From the Department of Surgery, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, the Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio, the Department of Emergency Medicine, University of Texas at Austin Dell Medical School, Austin, and the Center for Translational Injury Research and the Department of Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston (UTHealth), Houston
| | - Bryan A Cotton
- From the Department of Surgery, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, the Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio, the Department of Emergency Medicine, University of Texas at Austin Dell Medical School, Austin, and the Center for Translational Injury Research and the Department of Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston (UTHealth), Houston
| |
Collapse
|
|
35
|
Luckey-Smith K, King B, Boyd JS. Is E-Learning Education Effective in Increasing the Ability of Nonphysician Medical Flight Crewmembers to Accurately Interpret Point-of-Care Lung and Cardiac Ultrasound Examinations? Air Med J 2021; 40:119-123. [PMID: 33637275 DOI: 10.1016/j.amj.2020.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Revised: 11/19/2020] [Accepted: 11/23/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Patients suffering from severe injury or illness can benefit from the care and transport of helicopter emergency medical services (HEMS). This may be due to the speed of transport, level of care, expertise of flight crews, and access to specialized equipment and tools. One such tool is point-of-care ultrasound (POCUS). POCUS-based lung and cardiac evaluations can positively influence the assessment and care provided to critically ill HEMS patients, but how these procedures can best be learned by nonphysician flight crewmembers has not been fully explored. METHODS In this prospective, interventional study, 26 flight crewmembers were evaluated before and after a succinct, guided educational intervention focused on the use of free open-access medical education material intended to help them acquire the knowledge needed to accurately identify and interpret POCUS assessments. RESULTS After completing the educational intervention, participants had a statistically significant improvement in their postintervention scores. CONCLUSION This study supports the use of free open-access medical education material in improving the knowledge needed for nonphysician flight crewmembers to interpret basic lung and cardiac ultrasound images. Integrating this information into educational programs may contribute to increased comfort and proficiency and serve to accelerate the adoption of this tool in the air medical environment.
Collapse
Affiliation(s)
- Kyle Luckey-Smith
- Queen Mary University of London, London, United Kingdom; Vanderbilt University Medical Center, LifeFlight, Nashville, TN.
| | - Brent King
- University of Maryland School of Medicine, Baltimore, MD
| | - Jeremy S Boyd
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN
| |
Collapse
|
|
36
|
Pietersen PI, Mikkelsen S, Lassen AT, Helmerik S, Jørgensen G, Nadim G, Christensen HM, Wittrock D, Laursen CB. Quality of focused thoracic ultrasound performed by emergency medical technicians and paramedics in a prehospital setting: a feasibility study. Scand J Trauma Resusc Emerg Med 2021; 29:40. [PMID: 33632276 PMCID: PMC7908705 DOI: 10.1186/s13049-021-00856-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 02/17/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In a prehospital setting, the severity of respiratory symptoms in patients calling for an ambulance differ. The initial evaluation, diagnosing, and thereby management can be challenging because respiratory symptoms can be caused by disease in many organs. Ultrasound examinations can contribute with important information and support the clinical decision-making. However, ultrasound is user-dependent and requires sufficient knowledge and training. The aim of this study was to explore the quality of thoracic ultrasound examinations performed on patients by emergency medical technicians and paramedics in a prehospital, clinical setting. METHODS From November 2018 - April 2020, Danish emergency medical technicians and paramedics (n = 100) performed thoracic ultrasound examinations on patients with respiratory symptoms using a portable ultrasound device. The ultrasound examinations were stored and retrospectively assessed by a reviewer blinded to the patients' symptoms and history, as well as the emergency medical technicians' and paramedics' findings. The image quality was scored from 1 to 5. The findings determined by the reviewer was then correlated with a questionnaire filled out by the emergency medical technicians and paramedics regarding ultrasonic findings and potential change in treatment or management of the patient. The agreement in percentage and as Cohen's kappa was explored. RESULTS A total of 590 ultrasound examinations were assessed, resulting in a median image quality score of 3 (IQ1 = 4, IQ3 = 3). The overall agreement in percentage between the emergency medical technicians and paramedics and reviewer was high (87.7% for a normal scan, 89.9% for interstitial syndrome, 97.3% for possible pneumothorax, and 96.3% for pleural effusion). Cohen's kappa varied from 0.01 for possible pneumothorax to 0.69 for pleural effusion. Based on the questionnaires (n = 406), the ultrasound examination entailed a change in treatment or visitation in 48 cases (11.7%) which in this study population encompasses a number-needed-to-scan of 8.5. CONCLUSION Emergency medical technicians and paramedics perform focused thoracic ultrasound examinations with adequate image quality sufficient to determine if pathology is present or not. The emergency medical technicians' and paramedics' assessment correlates to some extent with an experienced reviewer and their findings are most reliable for the inclusion of a normal scan or inclusion of pleural effusion. Implementation could possibly impact the number of patients receiving correct prehospital treatment and optimal choice of receiving facility.
Collapse
Affiliation(s)
- Pia Iben Pietersen
- Odense Respiratory Research Unit (ODIN), Department of Clinical Research, University of Southern Denmark, Sdr. Boulevard 29, entrance 87, 1st floor, 5000, Odense C, Denmark.
- Regional Center for Technical Simulation, Odense University Hospital, 5000, Odense C, Denmark.
| | - Søren Mikkelsen
- The Prehospital Research Unit, Region of Southern Denmark, Odense University Hospital, 5000, Odense C, Denmark
| | - Annmarie T Lassen
- Department of Emergency Medicine, Odense University Hospital, 5000, Odense C, Denmark
| | - Simon Helmerik
- Department of Quality & Education, Ambulance Syd, Region of Southern Denmark, 5220, Odense SØ, Denmark
| | - Gitte Jørgensen
- Ambulance Syd, Region of Southern Denmark, 5220, Odense SØ, Denmark
| | - Giti Nadim
- Department of Emergency Medicine, Odense University Hospital, 5000, Odense C, Denmark
- Department of Clinical Research, University of Southern Denmark, 5000, Odense C, Denmark
| | - Helle Marie Christensen
- Odense Respiratory Research Unit (ODIN), Department of Clinical Research, University of Southern Denmark, Sdr. Boulevard 29, entrance 87, 1st floor, 5000, Odense C, Denmark
- Department of Respiratory Medicine, Odense University Hospital, 5000, Odense C, Denmark
| | - Daniel Wittrock
- Department of Quality & Education, Ambulance Syd, Region of Southern Denmark, 5220, Odense SØ, Denmark
| | - Christian B Laursen
- Odense Respiratory Research Unit (ODIN), Department of Clinical Research, University of Southern Denmark, Sdr. Boulevard 29, entrance 87, 1st floor, 5000, Odense C, Denmark
- Department of Respiratory Medicine, Odense University Hospital, 5000, Odense C, Denmark
| |
Collapse
|
|
37
|
Kuttab HI, Flanagan E, Damewood SC, Cathers AD, Steuerwald MT. Prehospital Echocardiogram Use in Identifying Massive Pulmonary Embolism in Unidentified Respiratory Failure. Air Med J 2021; 40:73-75. [PMID: 33455632 DOI: 10.1016/j.amj.2020.10.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 10/04/2020] [Indexed: 11/17/2022]
Abstract
Medical transport teams often handle cases of complex, critically ill patients and are in need of rapid, bedside assessments to guide clinical decision making. The use of point-of-care ultrasound (POCUS) as a diagnostic indicator has gained increased acceptance in emergency medicine. Ultrasound devices have become increasingly portable, and numerous studies have demonstrated that use in the prehospital setting is feasible, accurate, and can have a dramatic impact on the care of patients. In this case report, we highlight the use of handheld ultrasound in the identification of right heart dilation in an unstable patient with respiratory failure in a rural emergency department, concerning for massive pulmonary embolism. The patient was given thrombolytic therapy with dramatic clinical improvement, ultimately surviving transport to the intensive care unit at a nearby tertiary care center.
Collapse
Affiliation(s)
- Hani I Kuttab
- UW Med Flight, Madison, WI; Department of Emergency Medicine, University of Wisconsin-Madison, Madison, WI.
| | | | - Sara C Damewood
- Department of Emergency Medicine, University of Wisconsin-Madison, Madison, WI
| | - Andrew D Cathers
- UW Med Flight, Madison, WI; Department of Emergency Medicine, University of Wisconsin-Madison, Madison, WI
| | - Michael T Steuerwald
- UW Med Flight, Madison, WI; Department of Emergency Medicine, University of Wisconsin-Madison, Madison, WI
| |
Collapse
|
|
38
|
Predictors for Direct to Operating Room Admission in Severe Trauma. J Surg Res 2021; 261:274-281. [PMID: 33460973 DOI: 10.1016/j.jss.2020.12.031] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 11/17/2020] [Accepted: 12/16/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Protocols for expediting critical trauma patients directly from the helipad to the operating room tend to vary by center, rely heavily on physician gestalt, and lack supporting evidence. We evaluated a population of severely injured trauma patients with the aim of determining objective factors associated with the need for immediate surgical intervention. METHODS All highest-activation trauma patients transported by air ambulance between 1/1/16 and 12/31/17 were enrolled retrospectively. Transfer, pediatric, isolated burn, and isolated head trauma patients were excluded. Patients who underwent emergency general surgery within 30 min of arrival without the aid of cross-sectional imaging were compared to the remainder of the cohort. RESULTS Of the 863 patients who were enrolled, 85 (10%) spent less than 30 min in the emergency department (ED) before undergoing an emergency operation. The remaining 778 patients (90%) formed the comparison group. The ED ≤ 30 min group had a higher percentage of penetrating injuries, lower blood pressure, and was more likely to have a positive FAST exam. The "Direct to Operating Room" (DTOR) score is a predictive scoring system devised to identify patients most likely to benefit from bypassing the ED. The odds ratio of emergency operation within 30 min of hospital arrival increased by 2.71 (95% confidence interval 2.23-3.29; P < 0.001) for every 1-point increase in DTOR score. CONCLUSIONS Trauma patients with profound hypotension or acidosis and positive FAST were more likely to require surgery within 30 min of hospital presentation. Use of a scoring system may allow early identification of these patients in the prehospital setting by nonphysician providers.
Collapse
|
|
39
|
Sumann G, Moens D, Brink B, Brodmann Maeder M, Greene M, Jacob M, Koirala P, Zafren K, Ayala M, Musi M, Oshiro K, Sheets A, Strapazzon G, Macias D, Paal P. Multiple trauma management in mountain environments - a scoping review : Evidence based guidelines of the International Commission for Mountain Emergency Medicine (ICAR MedCom). Intended for physicians and other advanced life support personnel. Scand J Trauma Resusc Emerg Med 2020; 28:117. [PMID: 33317595 PMCID: PMC7737289 DOI: 10.1186/s13049-020-00790-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 09/10/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Multiple trauma in mountain environments may be associated with increased morbidity and mortality compared to urban environments. OBJECTIVE To provide evidence based guidance to assist rescuers in multiple trauma management in mountain environments. ELIGIBILITY CRITERIA All articles published on or before September 30th 2019, in all languages, were included. Articles were searched with predefined search terms. SOURCES OF EVIDENCE PubMed, Cochrane Database of Systematic Reviews and hand searching of relevant studies from the reference list of included articles. CHARTING METHODS Evidence was searched according to clinically relevant topics and PICO questions. RESULTS Two-hundred forty-seven articles met the inclusion criteria. Recommendations were developed and graded according to the evidence-grading system of the American College of Chest Physicians. The manuscript was initially written and discussed by the coauthors. Then it was presented to ICAR MedCom in draft and again in final form for discussion and internal peer review. Finally, in a face-to-face discussion within ICAR MedCom consensus was reached on October 11th 2019, at the ICAR fall meeting in Zakopane, Poland. CONCLUSIONS Multiple trauma management in mountain environments can be demanding. Safety of the rescuers and the victim has priority. A crABCDE approach, with haemorrhage control first, is central, followed by basic first aid, splinting, immobilisation, analgesia, and insulation. Time for on-site medical treatment must be balanced against the need for rapid transfer to a trauma centre and should be as short as possible. Reduced on-scene times may be achieved with helicopter rescue. Advanced diagnostics (e.g. ultrasound) may be used and treatment continued during transport.
Collapse
Affiliation(s)
- G Sumann
- Austrian Society of Mountain and High Altitude Medicine, Emergency physician, Austrian Mountain and Helicopter Rescue, Altach, Austria
| | - D Moens
- Emergency Department Liège University Hospital, CMH HEMS Lead physician and medical director, Senior Lecturer at the University of Liège, Liège, Belgium
| | - B Brink
- Mountain Emergency Paramedic, AHEMS, Canadian Society of Mountain Medicine, Whistler Blackcomb Ski Patrol, Whistler, Canada
| | - M Brodmann Maeder
- Department of Emergency Medicine, University Hospital and University of Bern, Switzerland and Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy
| | - M Greene
- Medical Officer Mountain Rescue England and Wales, Wales, UK
| | - M Jacob
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Hospitallers Brothers Saint-Elisabeth-Hospital Straubing, Bavarian Mountain Rescue Service, Straubing, Germany
| | - P Koirala
- Adjunct Assistant Professor, Emergency Medicine, University of Maryland School of Medicine, Mountain Medicine Society of Nepal, Kathmandu, Nepal
| | - K Zafren
- ICAR MedCom, Department of Emergency Medicine, Stanford University Medical Center, Stanford, CA, USA
- Alaska Native Medical Center, Anchorage, AK, USA
| | - M Ayala
- University Hospital Germans Trias i Pujol, Badalona, Spain
| | - M Musi
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - K Oshiro
- Department of Cardiovascular Medicine and Director of Mountain Medicine, Research, and Survey Division, Hokkaido Ohno Memorial Hospital, Sapporo, Japan
| | - A Sheets
- Emergency Department, Boulder Community Health, Boulder, CO, USA
| | - G Strapazzon
- Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy
- The Corpo Nazionale Soccorso Alpino e Speleologico, National Medical School (CNSAS SNaMed), Milan, Italy
| | - D Macias
- Department of Emergency Medicine, International Mountain Medicine Center, University of New Mexico, Albuquerque, NM, USA
| | - P Paal
- Department of Anaesthesiology and Intensive Care Medicine, St. John of God Hospital, Paracelsus Medical University, Salzburg, Austria.
| |
Collapse
|
|
40
|
Ronaldson J, Moultrie CEJ, Corfield AR, McElhinney E. Can non-physician advanced retrieval practitioners (ARP) acquire and interpret diagnostic views of the lungs with sufficient quality to aid in the diagnosis of pneumothorax in the pre-hospital and retrieval environment? Scand J Trauma Resusc Emerg Med 2020; 28:102. [PMID: 33066800 PMCID: PMC7565770 DOI: 10.1186/s13049-020-00797-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 10/07/2020] [Indexed: 11/23/2022] Open
Abstract
Background As an adjunct to physical examination, ultrasound is a potentially attractive option for diagnosing pneumothoraces in the pre-hospital and retrieval environment – and could confer a benefit to patient safety. However, the published evidence supporting non-physicians use of ultrasound in this setting is limited. Aim We aimed to establish if Advanced Retrieval Practitioners (non-physicians) could acquire ultrasound views of the lungs and interpret them with sufficient quality to diagnose pneumothorax in the pre-hospital and retrieval environment when compared to expert review. Method The study consisted of an observational trial from April 2017 to April 2018. Twelve (12) patients bilateral lung ultrasound images (24 images) were randomly selected from 87 patients assessed using Point of Care Ultrasound (POCUS) by three Advanced Retrieval Practitioners in the Pre-hospital and Retrieval environment. Two expert reviewers’ evaluated these images to determine ARPs ability to acquire diagnostic quality images and interpret them correctly. CXR results of patients in whom lung ultrasound was undertaken were recorded as the reference standard investigation. Results Within the 22 images considered adequate by the Advanced Retrieval Practitioners, 19 (86.4%, one-tailed McNemar test p = 0.125) were considered adequate on expert review. Of the 19 images mutually considered as adequate, both the Advanced Retrieval Practitioners and the reviewers identified two pneumothoraces which were subsequently confirmed on chest x-ray (Sensitivity 100% and Specificity 100% in technically adequate images). One pneumothorax was detected on CXR in a patient with inadequate ultrasound images. Advanced Retrieval Practitioners were therefore able to both obtain adequate images and correctly diagnose pneumothorax in the pre-hospital environment with 66.6% sensitivity (95%CI 66.6–100%) and 100% specificity (95%CI 81.0–100%) compared to expert review. Conclusion Advanced Retrieval Practitioners (non-physicians) can obtain diagnostic views of the lungs of sufficient quality to diagnose the presence, or particularly the absence, of pneumothorax in the pre-hospital and retrieval environment. Although Advanced Retrieval Practitioners were less accurate than the expert reviewers at interpreting the quality of the ultrasound images, the result was not statistically significant, despite the ARPs possibly having been at a methodological disadvantage.
Collapse
Affiliation(s)
| | - Christopher E J Moultrie
- ScotSTAR, 180 Abbotsinch Road, Glasgow, PA2 3RY, USA.,Emergency Department, University Hospital Wishaw, Wishaw, UK
| | - Alasdair R Corfield
- ScotSTAR, 180 Abbotsinch Road, Glasgow, PA2 3RY, USA.,Emergency Department, Royal Alexandra Hopsital, Paisley, UK
| | - Evelyn McElhinney
- Department of Nursing & Community Health, Glasgow Caledonian University, Glasgow, UK
| |
Collapse
|
|
41
|
Puzio TJ, Kalkwarf K, Cotton BA. Predicting the need for massive transfusion in the prehospital setting. Expert Rev Hematol 2020; 13:983-989. [PMID: 32746651 DOI: 10.1080/17474086.2020.1803735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Massive transfusion (MT) prediction scores allowed for the early identification of patients with massive hemorrhage likely to require large volumes of blood products. Despite their utility, very few MT scoring systems have shown promise in the pre-hospital setting due to their complexity and resource limitations. AREAS COVERED Pub med database was utilized to identify supporting literature for this review which discusses the importance of blood-based resuscitation and highlights the utility of scoring systems to predict the need of massive transfusion. MTP scoring systems effective in the prehospital setting are specifically discussed. EXPERT OPINION Massive transfusions scores are useful in alerting hospitals to the severity of trauma patients and organizing resources necessary for appropriate patient care but should not completely replace clinical . The opportunity exists to extend their use to the pre-hospital setting to allow for even earlier notification and to triage patients to trauma centers best able to treat severely injured.
Collapse
Affiliation(s)
- Thaddeus J Puzio
- Department of Surgery and the Center for Translational Injury Research, University of Texas Health Science Center , Houston, TX, USA
| | - Kyle Kalkwarf
- Department of Surgery, University of Arkansas Medical Sciences , Little Rock, AR, USA
| | - Bryan A Cotton
- Department of Surgery and the Center for Translational Injury Research, University of Texas Health Science Center , Houston, TX, USA
| |
Collapse
|
|
42
|
Mercer CB, Ball M, Cash RE, Rivard MK, Chrzan K, Panchal AR. Ultrasound Use in the Prehospital Setting for Trauma: A Systematic Review. PREHOSP EMERG CARE 2020; 25:566-582. [PMID: 32815755 DOI: 10.1080/10903127.2020.1811815] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND Trauma is a leading cause of death in the United States. Ultrasound use in the prehospital environment has the potential to change trauma management. Although ultrasound use for prehospital trauma is increasing, the role of this modality is not clearly defined. OBJECTIVES We examined the use of prehospital ultrasound (PHUS) for trauma patients and the use by different provider types. Specific factors of interest were if prehospital ultrasound has been shown to improve providers' ability to recognize conditions that can be managed in the prehospital setting, treat these conditions, change transport destination, or improve overall mortality rates for trauma patients. METHODS We searched MEDLINE/PubMed, EBSCOhost, Cochrane Library, and Embase medical literature databases for articles that addressed our outcomes. Abstracts and articles were examined and studies that did not specifically evaluate ultrasound in the prehospital setting for trauma and duplicates were eliminated. Studies included in this comprehensive review were assessed for the use of ultrasound in the prehospital setting to aid in the diagnosis, treatment, and transport of trauma patients. We also conducted an analysis of bias in the included articles. Due to the large heterogeneity in the included studies, no meta-analysis could be performed. RESULTS Sixteen studies were identified comprising 3,317 patients. One study evaluated Emergency Medical Services (EMS) professionals as the ultrasound operator while five studies involved mixed practitioners and ten studies involved only physicians. Diagnostic accuracy was similar amongst physicians and mixed practitioners with no studies reporting PHUS accuracy for EMS providers alone. Seven studies evaluated treatment and transport impact of PHUS though the variables measured were inconsistent and results varied by protocol and outcomes measured. There were no studies that evaluated PHUS and its impact on patient mortality. CONCLUSION Ultrasound use in the prehospital setting for trauma is feasible and demonstrates potential. However, the evidence in the medical literature mainly consists of prospective observational studies of physicians utilizing ultrasound for trauma in a HEMS setting. Further scientific research must be undertaken to firmly establish the role of prehospital ultrasound in trauma management by all types of EMS providers.
Collapse
|
|
43
|
Management of Acute Aortic Dissection During Critical Care Air Medical Transport. Air Med J 2020; 39:291-295. [PMID: 32690306 DOI: 10.1016/j.amj.2020.04.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 04/27/2020] [Accepted: 04/29/2020] [Indexed: 11/23/2022]
Abstract
Acute aortic dissection is a time-critical emergency that air medical teams must be capable of transporting. Aortic dissections can manifest a myriad of complications in which prompt recognition and tailored treatments may mitigate additional physiological burden and limit dissection flap propagation. The purpose of this review is to discuss specific critical scenarios that air medical providers may be faced with and to equip them with a pathophysiological understanding of the disease and best practices for the management of acute aortic dissections.
Collapse
|
|
44
|
The Use of Ultrasonography in the Emergency Department to Screen Patients After Blunt and Penetrating Trauma: A Clinical Update for the Advanced Practice Provider. Adv Emerg Nurs J 2020; 41:290-305. [PMID: 31687993 DOI: 10.1097/tme.0000000000000267] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Use of bedside ultrasonography to identify life-threatening injuries for patients with blunt and penetrating trauma is the standard of care in the emergency department. The "FAST" examination-focused assessment with sonography for trauma-ultrasound scan of the chest and abdomen allows clinicians to assess critical regions for free fluid without use of invasive procedures as quickly and as often as needed. In addition, ultrasonography has a high degree of sensitivity and specificity and is safe during pregnancy. For patients requiring evaluation of the pleura, the "eFAST" (or extended FAST) may be conducted, which may serve to locate pleural effusions, hemothorax, and pneumothorax. However, ultrasound quality is operator dependent and is recommended with other diagnostic measures to provide a complete clinical picture of trauma patients. Ongoing development of ultrasound competency among established clinicians and nurse practitioner students is vital to maintain diagnostic accuracy and ensure quality care for trauma patients in the emergency department.
Collapse
|
|
45
|
Tomà P. Lung ultrasound in pediatric radiology - cons. Pediatr Radiol 2020; 50:314-320. [PMID: 32065267 DOI: 10.1007/s00247-019-04524-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 07/25/2019] [Accepted: 09/02/2019] [Indexed: 01/04/2023]
Abstract
In the 1990s, intensivists suggested a new type of sonography: lung ultrasound, based on artefacts that receive information even from physical acoustic phenomena not directly convertible into images of the human body. They compared the artefacts from the lung zones with no acoustic window with various computed tomography (CT) patterns. They used and still use US as a tool to evaluate patients bedside, i.e. monitoring of lung recruitment. They included Lung ultrasound in what was termed POCUS (Point-of-Care Ultrasound). Lung ultrasound has been progressively extended to paediatrics in general. The most appealing novelty has been the diagnosis of pneumothorax. Lung ultrasound was developed as a support tool for critical patients. Extrapolation with mass diffusion, in the absence of appropriate training, has led to misunderstandings and dangerous therapeutic diagnostic drifts.
Collapse
Affiliation(s)
- Paolo Tomà
- Ospedale pediatrico Bambino Gesù, IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy.
| |
Collapse
|
|
46
|
Abstract
OBJECTIVE To develop French guidelines on the management of patients with severe abdominal trauma. DESIGN A consensus committee of 20 experts from the French Society of Anaesthesiology and Critical Care Medicine (Société française d'anesthésie et de réanimation, SFAR), the French Society of Emergency Medicine (Société française de médecine d'urgence, SFMU), the French Society of Urology (Société française d'urologie, SFU) and from the French Association of Surgery (Association française de chirurgie, AFC), the Val-de-Grâce School (École du Val-De-Grâce, EVG) and the Federation for Interventional Radiology (Fédération de radiologie interventionnelle, FRI-SFR) was convened. Declaration of all conflicts of interest (COI) policy by all participants was mandatory throughout the development of the guidelines. The entire guideline process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system for assessment of the available level of evidence with particular emphasis to avoid formulating strong recommendations in the absence of high level. Some recommendations were left ungraded. METHODS The guidelines are divided in diagnostic and, therapeutic strategy and early surveillance. All questions were formulated according to Population, Intervention, Comparison, and Outcomes (PICO) format. The panel focused on three questions for diagnostic strategy: (1) What is the diagnostic performance of clinical signs to suggest abdominal injury in trauma patients? (2) Suspecting abdominal trauma, what is the diagnostic performance of prehospital FAST (Focused Abdominal Sonography for Trauma) to rule in abdominal injury and guide the prehospital triage of the patient? and (3) When suspecting abdominal trauma, does carrying out a contrast enhanced thoraco-abdominal CT scan allow identification of abdominal injuries and reduction of mortality? Four questions dealt with therapeutic strategy: (1) After severe abdominal trauma, does immediate laparotomy reduce morbidity and mortality? (2) Does a "damage control surgery" strategy decrease morbidity and mortality in patients with a severe abdominal trauma? (3) Does a laparoscopic approach in patients with abdominal trauma decrease mortality or morbidity? and (4) Does non-operative management of patients with abdominal trauma without bleeding reduce mortality and morbidity? Finally, one question was formulated regarding the early monitoring of these patients: In case of severe abdominal trauma, which kind of initial monitoring does allow to reduce the morbi-mortality? The analysis of the literature and the recommendations were conducted following the GRADE® methodology. RESULTS The SFAR/SFMU Guideline panel provided 15 statements on early management of severe abdominal trauma. After three rounds of discussion and various amendments, a strong agreement was reached for 100% of recommendations. Of these recommendations, five have a high level of evidence (Grade 1±), six have a low level of evidence (Grade 2±) and four are expert judgments. Finally, no recommendation was provided for one question. CONCLUSIONS Substantial agreement exists among experts regarding many strong recommendations for the best early management of severe abdominal trauma.
Collapse
|
|
47
|
Prehospital ultrasound use among Canadian aeromedical service providers - A cross-sectional survey. CAN J EMERG MED 2019; 22:338-341. [PMID: 31813395 DOI: 10.1017/cem.2019.451] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVES Evidence suggests that prehospital point of care ultrasound (POCUS) may change patient management. It serves as an aid in triage, physical examination, diagnosis, and patient disposition. The rate of adoption of POCUS among aeromedical services throughout Canada is unknown. The objective of this study was to describe current POCUS use among Canadian aeromedical services providers. METHODS This is a cross-sectional observational study. A survey was emailed to directors of government-funded aeromedical services bases in Canada. Data were analyzed using descriptive statistics. RESULTS The response rate was 82.3% (14/17 aeromedical services directors), representing 41 of 46 individual bases. POCUS is used by aeromedical services in British Columbia, Alberta, Saskatchewan, and Manitoba. New Brunswick, Nova Scotia, Prince Edward Island, and Yukon reported they are planning to introduce POCUS within the next year. Ontario and Newfoundland reported they are not using POCUS and are not planning to introduce it. British Columbia is the only province currently using POCUS on fixed-wing aircraft. Most commonly reported frequency of POCUS use on missions was <25%. Most useful applications are assessment for pneumothorax, abdominal free fluid, and cardiac standstill. The most common barrier to POCUS use is cost of training and maintenance of competence. CONCLUSIONS Prehospital POCUS is available in Western Canada with one third of the Canadian population having access to aeromedical services using ultrasound. The Maritimes and the Yukon Territory will further extend POCUS use on fixed-wing aircraft. While there are barriers to POCUS use, those bases that have adopted POCUS consider it valuable.
Collapse
|
|
48
|
van der Weide L, Popal Z, Terra M, Schwarte LA, Ket JCF, Kooij FO, Exadaktylos AK, Zuidema WP, Giannakopoulos GF. Prehospital ultrasound in the management of trauma patients: Systematic review of the literature. Injury 2019; 50:2167-2175. [PMID: 31627899 DOI: 10.1016/j.injury.2019.09.034] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Revised: 09/25/2019] [Accepted: 09/26/2019] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Emergency ultrasound methods such as Focused Assessment with Sonography in Trauma (FAST) are a widely used imaging method. This examination can be performed to examine the presence of several life-threatening injuries. Early diagnosis may lead to better outcome, but the effect of timely diagnosis in the prehospital setting is not yet clear. Therefore, the aim is to determine the diagnostic accuracy and the effect of prehospital ultrasound performed in (poly)trauma patients. METHODS A literature search was performed in PubMed, Embase and Cochrane's Library. Articles were included if prehospital ultrasound was performed as a diagnostic intervention in patients with trauma. The main outcome measures included diagnostic accuracy, changes in prehospital diagnosis/treatment, changes in destination hospital and in-hospital response. Case reports and case series were excluded. RESULTS After screening 3343 articles, nine studies met the inclusion criteria. These included three retrospective and six prospective observational studies, with a total number of 2,889 patients. Five studies report at least one change in polytrauma management, ranging from 6% to 48,9% of the cases. The diagnostic accuracy of prehospital ultrasound was adequate in eight (out of nine) articles. High sensitivity and high specificity were found on several endpoints (pneumothorax, free abdominal fluid, haemoperitoneum, both on site and during transport). CONCLUSION Prehospital ultrasound led to a change in polytrauma management in all studies that included this as an outcome measure. The diagnostic accuracy was described in eight studies, high sensitivity and specificity were found. Overall, the studies seem to suggest a positive influence of performing ultrasound. However, additional research with homogenous accuracy endpoints and uniformly trained prehospital care providers is recommended.
Collapse
Affiliation(s)
- Laura van der Weide
- Department of Trauma Surgery, Amsterdam University Medical Centres, location VUmc, De Boelelaan 1117, 1081 HV, the Netherlands.
| | - Zar Popal
- Department of Trauma Surgery, Amsterdam University Medical Centres, location VUmc, De Boelelaan 1117, 1081 HV, the Netherlands
| | - Maartje Terra
- Department of Trauma Surgery, Amsterdam University Medical Centres, location VUmc, De Boelelaan 1117, 1081 HV, the Netherlands
| | - Lothar A Schwarte
- Department of Anesthesiology, Amsterdam University Medical Centres, location VUmc, the Netherlands
| | | | - Fabian O Kooij
- Department of Anesthesiology, Amsterdam University Medical Centres, location AMC, the Netherlands
| | | | - Wietse P Zuidema
- Department of Trauma Surgery, Amsterdam University Medical Centres, location VUmc, De Boelelaan 1117, 1081 HV, the Netherlands
| | - Georgios F Giannakopoulos
- Department of Trauma Surgery, Amsterdam University Medical Centres, location VUmc, De Boelelaan 1117, 1081 HV, the Netherlands
| |
Collapse
|
|
49
|
Speckle tracking quantification of lung sliding for the diagnosis of pneumothorax: a multicentric observational study. Intensive Care Med 2019; 45:1212-1218. [PMID: 31359081 DOI: 10.1007/s00134-019-05710-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 07/19/2019] [Indexed: 12/23/2022]
Abstract
PURPOSE Lung ultrasound is used for the diagnosis of pneumothorax, based on lung sliding abolition which is a qualitative and operator-dependent assessment. Speckle tracking allows the quantification of structure deformation over time by analysing acoustic markers. We aimed to test the ability of speckle tracking technology to quantify lung sliding in a selected cohort of patients and to observe how the technology may help the process of pneumothorax diagnosis. METHODS We performed retrospectively a pleural speckle tracking analysis on ultrasound loops from patients with pneumothorax. We compared the values measured by two observers from pneumothorax side with contralateral normal lung side. The receiver operating characteristic (ROC) curve was constructed to evaluate the performance of maximal pleural strain to detect the lung sliding abolition. Diagnosis performance and time to diagnosis between B-Mode and speckle tracking technology were compared from a third blinded observer. RESULTS We analysed 104 ultrasound loops from 52 patients. The area under the ROC curve of the maximal pleural strain value to identify lung sliding abolition was 1.00 [95%CI 1.00; 1.00]. Specificity was 100% [95%CI 93%; 100%] and sensitivity was 100% [95%CI 93%; 100%] with the best cut-off of 4%. Over 104 ultrasound loops, the blinded observer made two errors with B-Mode and none with speckle tracking. The median diagnosis time was 3 [2-5] seconds for B-Mode versus 2 [1-2] seconds for speckle tracking (p = 0.001). CONCLUSION Speckle tracking technology allows lung sliding quantification and detection of lung sliding abolition in case of pneumothorax on selected ultrasound loops.
Collapse
|
|
50
|
A Multicenter Observational Prospective Cohort Study of Association of the Prehospital National Early Warning Score 2 and Hospital Triage with Early Mortality. Emerg Med Int 2019; 2019:5147808. [PMID: 31355000 PMCID: PMC6633971 DOI: 10.1155/2019/5147808] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Accepted: 06/09/2019] [Indexed: 11/18/2022] Open
Abstract
Aim of the Study To evaluate the ability of the prehospital National Early Warning Score 2 scale (NEWS2) to predict early mortality (within 48 hours) after the index event based on the triage priority assigned for any cause in the emergency department. Methods This is a multicenter longitudinal observational cohort study on patients attending Advanced Life Support units and transferred to the emergency department of their reference hospital. We collected demographic, physiological, and clinical variables, main diagnosis, and hospital triage level as well as mortality. The main outcome variable was mortality from any cause within two days of the index event. Results Between April 1 and November 30, 2018, a total of 1054 patients were included in our study. Early mortality within the first 48 hours after the index event affected 55 patients (5.2%), of which 23 cases (41.8%) had causes of cardiovascular origin. In the stratification by triage levels, the AUC of the NEWS2 obtained for short-term mortality varied between 0.77 (95% CI: 0.65-0.89) for level I and 0.94 (95% CI: 0.79-1) for level III. Conclusions The Prehospital Emergency Medical Services should evaluate the implementation of the NEWS2 as a routine evaluation, which, together with the structured hospital triage system, effectively serves to predict early mortality and detect high-risk patients.
Collapse
|