Prevalence of prehospital hypoxemia and oxygen use in trauma patients.
ABSTRACT: This study estimates the prevalence of injured patients requiring prehospital supplemental oxygen based on existing recommendations, and determines whether actual use exceeds those recommendations.Prehospital oxygen use and continuous peripheral oxygen saturation measurements were prospectively collected on a purposive sample of injured civilians transported to an urban level 1 trauma center by paramedics. Structured chart review determined injury characteristics and outcomes. Supplemental oxygen administration indications were hypoxemia (peripheral oxygen saturation ? 90%), hemorrhagic shock (systolic blood pressure < 100 mmHg), or paramedic suspicion of traumatic brain injury.Paramedics enrolled 224/290 screened subjects. Median (range) age was 34 (18-84) years, 48.7% were nonwhite, 75.4% were male, and Injury Severity Score was 5 (1-75). Half (54.5%) were admitted; 36.2% sustained a penetrating injury. None underwent prehospital endotracheal intubation. Hypoxemia occurred in 86 (38.4%), paramedics suspected traumatic brain injury in 22 (9.8%), and 20 (8.9%) were hypotensive. Any indication for supplemental oxygen (107/224 [47.8%, 95%CI 41.3%-54.3%]) and prehospital administration of oxygen (141/224 [62.9%, 95%CI 56.2%-69.2%]) was common. Many (35/141 [24.8%]) received oxygen without indication.On the basis of current guidelines, less than half of adult trauma patients have an indication for prehospital supplemental oxygen, yet is frequently administered in the absence of clinical indication.
Project description:It has been suggested that prehospital care teams that can provide advanced prehospital interventions may decrease the transit time through the ED to CT scan and subsequent surgery. This study is an exploratory analysis of data from the Head Injury Retrieval Trial (HIRT) examining the relationship between prehospital team type and time intervals during the prehospital and ED phases of management.Three prehospital care models were compared; road paramedics, and two physician staffed Helicopter Emergency Medical Services (HEMS) - HIRT HEMS and the Greater Sydney Area (GSA) HEMS. Data on prehospital and ED time intervals for patients who were randomised into the HIRT were extracted from the trial database. Additionally, data on interventions at the scene and in the ED, plus prehospital entrapment rate was also extracted. Subgroups of patients that were not trapped or who were intubated at the scene were also specifically examined.A total of 3125 incidents were randomised in the trial yielding 505 cases with significant injury that were treated by road paramedics, 302 patients treated by the HIRT HEMS and 45 patients treated by GSA HEMS. The total time from emergency call to CT scan was non-significantly faster in the HIRT HEMS group compared with road paramedics (medians of 1.9 hours vs. 2.1 hours P = 0.43) but the rate of prehospital intubation was 41% higher in the HIRT HEMS group (46.4% vs. 5.3% P?<?0.001). Most time intervals for the GSA HEMS were significantly longer with a regression analysis indicating that GSA HEMS scene times were 13 (95% CI, 7-18) minutes longer than the HIRT HEMS independent of injury severity, entrapment or interventions performed on scene.This study suggests that well-rehearsed and efficient interventions carried out on-scene, by a highly trained physician and paramedic team can allow earlier critical care treatment of severely injured patients without increasing the time elapsed between injury and hospital-based intervention. There is also indication that role specialisation improves time intervals in physician staffed HEMS which should be confirmed with purpose designed trials.
Project description:<h4>Background</h4>Severe hypoxemia is a major complication of chronic obstructive pulmonary disease (COPD). Long-term oxygen therapy is beneficial in hypoxemic COPD patients. However, the clinical and radiographic predictors of hypoxemia and the use of oxygen therapy are not well described. This study aimed to find the correlates of resting hypoxemia and the pattern of oxygen use in moderate to severe COPD patients.<h4>Methods</h4>Subjects with GOLD stage II or higher COPD from the first 2500 COPDGene subjects were included in this analysis. All subjects were current or ex-smokers between ages 45 and 80. Severe resting hypoxemia was defined as room air oxygen saturation (SpO(2)) ?88%. Use of supplemental oxygen therapy was determined by questionnaire.<h4>Results</h4>Eighty-two of 1060 COPD subjects (7.7%) had severe resting hypoxemia. Twenty-one of the 82 (25.6%) were not using continuous supplemental oxygen. Female sex, higher BMI, lower FEV(1), and enrollment in Denver were independent risk factors for hypoxemia; emphysema severity on quantitative chest CT scan did not predict hypoxemia. 132 of 971(13.6%) subjects without severe resting hypoxemia were using continuous supplemental oxygen. In non-hypoxemic oxygen users, Denver recruitment, higher BMI, lower FEV(1), and more severe dyspnea were associated with the use of continuous oxygen.<h4>Conclusions</h4>A large number of COPD patients without severe hypoxemia were using supplemental oxygen therapy and the pattern of oxygen use was affected by factors other than resting SpO(2) and emphysema severity. Longitudinal data will be required to reveal the effects of oxygen therapy in this subgroup.<h4>Clinical trial registration</h4>http://clinicaltrials.gov (NCT00608764).
Project description:OBJECTIVE:To test the hypothesis that environmental compared with nasal cannula oxygen decreases episodes of intermittent hypoxemia (oxygen saturations <85% for ?10 seconds) in preterm infants on supplemental oxygen by providing a more stable hypopharyngeal oxygen concentration. STUDY DESIGN:This was a single center randomized crossover trial with a 1:1 parallel allocation to order of testing. Preterm infants on supplemental oxygen via oxygen environment maintained by a servo-controlled system or nasal cannula with flow rates??1.0 L per kg per minute were crossed over every 24 hours for 96 hours. Data were collected electronically to capture real time numeric and waveform data from patient monitors. RESULTS:Twenty-five infants with gestational age of 27?±?2 weeks (mean?±?SD) and a birth weight of 933?±?328 g were studied at postnatal day 36?±?26. The number of episodes of intermittent hypoxemia per 24 hours was 117?±?77 (median, 98; range, 4-335) with oxygen environment vs 130?±?63 (median, 136; range, 16-252) with nasal cannula (P?=?.002). Infants on oxygen environment compared with nasal cannula also had decreased episodes of severe intermittent hypoxemia (P?=?.005). Infants on oxygen environment compared with nasal cannula had a lower proportion of time with oxygen saturations?<85% (.05?±?.03 vs .06?±?.03, P?<?.001), and a lower coefficient of variation of oxygen saturation (P?=?.02). CONCLUSIONS:In preterm infants receiving supplemental oxygen, servo-controlled oxygen environment decreases hypoxemia compared with nasal cannula. TRIAL REGISTRATION:ClinicalTrials.gov: NCT02794662.
Project description:In medical emergencies, supplemental oxygen is often administrated routinely. Most paramedics and physicians believe that high concentrations of oxygen are life-saving 1. Over the last century, however, a plethora of studies point to possible detrimental effects of hyperoxia induced by supplemental oxygen in a variety of medical emergencies. This viewpoint provides a historical overview and questions the safety of routine high-dose oxygen administration and is based on pathophysiology and (pre)clinical findings in various medical emergencies.
Project description:Importance:Early administration of intravenous fluids is recommended for all patients with sepsis, but the association of this treatment with mortality may depend on the patient's initial blood pressure. Objective:To test the association between early administration of intravenous fluids by paramedics and in-hospital mortality among patients with sepsis, accounting for patients' initial blood pressure. Design, Setting, and Participants:Cohort study in which multiple analyses were conducted using a 1-year (from April 1, 2015, to March 31, 2016) cohort of 1871 patients with sepsis who were transported to the hospital by paramedics from a large emergency medical services system in Alberta, Canada. Multivariable logistic regression and a propensity-matched analysis adjusting for baseline patient characteristics were used to minimize confounding by indication and test the association between early administration of intravenous fluids by paramedics and in-hospital mortality. Nonparametric additive regression was used to assess the association of early administration of intravenous fluids with prehospital and in-hospital treatment times. Exposures:Intravenous fluids administered by paramedics at the point of first contact and during transportation to the hospital. Main Outcomes and Measures:The primary outcome was in-hospital mortality. Secondary outcomes included prehospital and emergency department treatment times. Results:A total of 1871 patients with sepsis were identified (955 women and 916 men; median age, 77 years [interquartile range, 64-85 years]), with an overall in-hospital mortality of 28.2% (n?=?528). More than half of patients (1015 [54.2%]) received intravenous fluids from paramedics; the median volume provided was 400 mL (interquartile range, 250-500 mL). The association of intravenous fluids with mortality depended on the patient's initial systolic blood pressure (range, 42-222 mm Hg; P?<?.001 for interaction). For example, in a typical patient with an initial systolic blood pressure of 100 mm Hg, intravenous fluids were associated with decreased mortality (odds ratio, 0.73; 95% CI, 0.56-0.95), but for a typical patient with the median initial systolic blood pressure of 125 mm Hg, intravenous fluids were not associated with in-hospital mortality (odds ratio, 1.41; 95% CI, 0.81-2.44). Similar results were obtained in the propensity-matched analysis. The administration of intravenous fluids was associated with increased prehospital time compared with patients who did not receive intravenous fluids (median difference, 3.2 minutes; 95% CI, 1.7-4.7 minutes) but was not associated with time to assessment in the emergency department (median difference, 2.4 minutes; 95% CI, -2.4 to 7.3 minutes). Conclusions and Relevance:Intravenous fluids provided by paramedics were associated with reduced in-hospital mortality for patients with sepsis and hypotension but not for those with a higher initial systolic blood pressure.
Project description:OBJECTIVES:The aim of this study was to gather the views and experiences of paramedics who participated in a large-scale randomised controlled drug trial and to identify barriers to recruitment. DESIGN:We surveyed paramedics using a questionnaire consisting of a mix of closed and open ended questions. SETTING:The study was conducted within the London Ambulance Service, London, UK. PARTICIPANTS:150 paramedics who were trained to enrol patients into the PARAMEDIC-2 randomised controlled trial of adrenaline versus placebo in out-of-hospital cardiac arrest and who returned the questionnaire. RESULTS:98% of study participants felt prehospital research was very important, and 97.3% reported an overall positive experience of being involved in a drug trial. Only 5.3% felt uncomfortable enrolling patients into the trial without prior consent from the patient or a relative. Over one- third (39.3%) identified one or more barriers to patient recruitment, the most common being the attitudes of other staff. CONCLUSION:We found a strong appetite for involvement in prehospital research among paramedics and an understanding of the importance of research that prevailed over the complexities of the trial. This is an important finding demonstrating that potentially ethically controversial research can be undertaken successfully by paramedics in the prehospital environment.
Project description:Acute asthma is a common reason for patients to seek care from ambulance services. Although better care of acute asthma can prevent avoidable morbidity and deaths, there has been little research into ambulance clinicians' adherence to national guidelines for asthma assessment and management and how this might be improved. Our research aim was to explore paramedics' attitudes, perceptions and beliefs about prehospital management of asthma, to identify barriers and facilitators to guideline adherence.We conducted three focus group interviews of paramedics in a regional UK ambulance trust. We used framework analysis supported by NVivo 8 to code and analyse the data.Seventeen participants, including paramedics, advanced paramedics or paramedic operational managers at three geographical sites, contributed to the interviews. Analysis led to five themes: (1) guidelines should be made more relevant to ambulance service care; (2) there were barriers to assessment; (3) the approach needed to address conflicts between clinicians' and patients' expectations; (4) the complexity of ambulance service processes and equipment needed to be taken into account; (5) and finally there were opportunities for improved prehospital education, information, communication, support and care pathways for asthma.This qualitative study provides insight into paramedics' perceptions of the assessment and management of asthma, including why paramedics may not always follow guidelines for assessment or management of asthma. These findings provide opportunities to strengthen clinical support, patient communication, information transfer between professionals and pathways for prehospital care of patients with asthma.
Project description:OBJECTIVES: To examine the strength of the volume-outcome relationship among paramedics, a group of providers that has not been previously studied in this context. By identifying the effects of individual learning on performance, we also assess the value of paramedics' retention. The prehospital emergency medical services (EMS) setting allows us to interpret any volume-outcome relationship as learning by doing, uncontaminated by reputation-based referrals because ambulance units are dispatched based on proximity. DATA SOURCES: Incident-level EMS data spanning 1991 to 2005 from the Mississippi Emergency Medical Services Information System collected by the Mississippi Department of Health. RESEARCH DESIGN: Using linear and quantile methods with and without provider fixed effects, we estimate the relationship between experience accumulation and performance using the universe of trauma incidents involving injured patients (including motor vehicle crashes, falls, stabbings, and shootings). PRINCIPAL FINDINGS: We find that greater individual volume is robustly related to improved performance. In addition, we find that the benefit of learning operates through both recent and past experiences, accrues differentially across tenure groups, and operates on both mean performance and the upper quantiles of the performance distribution. CONCLUSIONS: Persistent past and current volume effects suggest that policy and managerial implications in EMS should be directed at retention efforts to take advantage of individual learning by paramedics.
Project description:Endotracheal intubation success rates in the prehospital setting are variable. Our objective was to describe the challenges encountered and corrective actions taken during the process of endotracheal intubation by paramedics.Analysis of prehospital airway management using a prospective registry that was linked to an emergency medical services administrative database.Emergency medical services system serving King County, Washington, 2006-2011. Paramedics in this system have the capability to administer neuromuscular blocking agents to facilitate intubation (i.e., rapid sequence intubation).A total of 7,523 patients more than 12 years old in whom paramedics attempted prehospital endotracheal intubation.None.An intubation attempt was defined as the introduction of the laryngoscope into the patient's mouth, and the attempt concluded when the laryngoscope was removed from the mouth. Endotracheal intubation was successful on the first attempt in 77% and ultimately successful in 99% of patients (7,433 of 7,523). Paramedics used a rapid sequence intubation strategy on 54% of first attempts. Among the subset with a failed first attempt (n = 1,715), bodily fluids obstructing the laryngeal view (50%), obesity (28%), patient positioning (17%), and facial or spinal trauma (6%) were identified as challenges to intubation. A variety of adjustments were made to achieve intubation success, including upper airway suctioning (used in 43% of attempts resulting in success), patient repositioning (38%), rescue bougie use (19%), operator change (16%), and rescue rapid sequence intubation (6%). Surgical cricothyrotomy (0.4%, n = 27) and bag-valve-mask ventilation (0.8%, n = 60) were rarely performed by paramedics as final rescue airway strategies.Airway management in the prehospital setting has substantial challenges. Success can require a collection of adjustments that involve equipment, personnel, and medication often in a simultaneous fashion.
Project description:OBJECTIVES:To explore paramedics' experience of delivering fascia iliaca compartment block (FICB) to patients with suspected hip fracture at the scene of injury. DESIGN:Focus groups within a randomised controlled trial. SETTING:Paramedics based at ambulance stations in the catchment area of one Emergency Department in South Wales, recruited and trained in a feasibility study about an alternative to routine prehospital pain management for patients with suspected hip fracture. PARTICIPANTS:11 paramedics. INTERVENTION:Paramedic-administered FICB to patients with suspected hip fracture. We randomly allocated eligible patients to FICB, a local anaesthetic injection directly into the hip region-or usual care, most commonly morphine - using audited scratch cards. OUTCOMES:Paramedics' experiences of administering FICB gathered through thematic analysis of interview transcripts by two researchers, one paramedic and one lay member. RESULTS:Respondents believed that FICB was a suitable intervention for paramedics to deliver. It aligned with routine practice and was within people's capabilities. They said it took up to 10 minutes longer than usual care to prepare and deliver, in part due to nervousness and unfamiliarity with a new procedure. They praised the training provided but said they were anxious about causing harm by injecting into the wrong location. Confidence increased after one paramedic team successfully treated a patient for local anaesthetic toxicity. Reported challenges related to the emergency context: patients often waited many hours for ambulance arrival; moving patients exacerbated their pain; family and neighbours were present as paramedics administered treatment. CONCLUSIONS:Paramedics are willing and able to administer FICB to patients with suspected hip fracture before ambulance transport to hospital. Feasibility study findings will inform further research. TRIAL REGISTRATION NUMBER:ISRCTN60065373; Pre results.