Volume 2 No. 3
Autumn 2015
Resuscitation Today A Resource for all involved in the Teaching and Practice of Resuscitation Supported by CPRO
Four things in one pack, one less thing to think about
In this issue Care Students Work in Partnership to save a life
O2
Out of Hospital Paediatric Cardiac Arrest The Management of Pre Hospital Cardiac Arrest
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CONTENTS
CONTENTS 5
EDITORS COMMENT
7
EDUCATION NEWS
12
EVIDENCE
25
EVIDENCE NEWS
29
EQUIPMENT NEWS
COVER STORY
This issue edited by: Alan Batt c/o Media Publishing Company Media House 48 High Street SWANLEY, Kent BR8 8BQ ADVERTISING & CIRCULATION: Media Publishing Company Media House, 48 High Street SWANLEY, Kent, BR8 8BQ Tel: 01322 660434 Fax: 01322 666539 E: info@mediapublishingcompany.com www.MediaPublishingCompany.com PUBLISHED BI-ANNUALLY: Spring and Autumn
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i-gel® single use supraglottic airway from Intersurgical i-gel® is the second generation supraglottic airway of choice in many hospitals in Europe and around the world. Indicated for use in resuscitation in adults, i-gel® is easy and rapid to insert and is consistently reliable – in many cases, insertion can be achieved in less than five seconds1. The device incorporates a gastric channel for improved safety, an integral bite block to reduce the possibility of airway occlusion and a buccal cavity stabiliser to aid rapid insertion and eliminate the potential for rotation. Low post-operative complications and high seal pressures provide benefits to both clinician and patient2. A number of case reports and clinical studies have highlighted the potential advantages i-gel® offers in the resuscitation scenario3,4,5,6, where seconds can make all the difference. The most recent addition to the i-gel® range is the i-gel® O2 Resus Pack. The i-gel® O2 has been specially designed to facilitate ventilation as part of standard resuscitation protocols, such as those designated by the European Resuscitation Council (ERC). However, the i-gel® O2 also incorporates a supplementary oxygen port for the delivery of passive oxygenation, or Passive Airway Management (PAMTM), as part of an appropriate Cardio Cerebral Resuscitation (CCR) protocol.
Choose Intersurgical for Quality, Innovation and Choice. Contact information: Intersurgical, Crane House, Molly Millars Lane, Wokingham, Berkshire, RG41 2RZ, England. Tel: +44 (0)118 9656 300 Fax: +44 (0)118 9656 356 Email: info@intersurgical.com Website: www.intersurgical.com References: Bamgbade OA, Macnab WR, Khalaf WM: Evaluation of the i-gel airway in 300 patients. Eur J Anaesthesiol. 2008 Oct;25(10):865-6.
1
Richez B, Saltel L, Banchereau F, Torrielli, Cros AM: A new single use supraglottic airway with a noninflatable cuff and an esophageal vent: An observational study of the i-gel: Anesth Analg. 2008 Apr;106(4):1137-9.
Gatward JJ, Thomas MJC, Nolan JP, Cook TM: Effect of chest compressions on the time taken to insert airway devices in a manikin: Br J Anaesth. 2008 Mar;100(3):351-6
3
4
Gabbott DA, Beringer R: The i-gel supraglottic airway: A potential role for resuscitation?: Resuscitation. 2007 Apr;73(1):161-2.
COPYRIGHT: Media Publishing Company Media House 48 High Street SWANLEY, Kent, BR8 8BQ PUBLISHERS STATEMENT: The views and opinions expressed in this issue are not necessarily those of the Publisher, the Editors or Media Publishing Company. Next Issue Spring 2016 Subscription Information – Autumn 2015 Resuscitation Today is a bi-annual publication published in the months of March and September. The subscription rates are as follows:UK: Individuals - £12.00 inc. postage Commercial Organisations - £30.00 inc. postage Rest of the World: Individuals - £60.00 inc. postage Commercial Organisations - £72.00 inc. postage We are also able to process your subscriptions via most major credit cards. Please ask for details. Cheques should be made payable to MEDIA PUBLISHING. Designed in the UK by Hansell Design
RESUSCITATION TODAY - AUTUMN 2015
You can find more information about the Intersurgical i-gel® range at: www.igel.com or http://www.intersurgical.com/products/airway-management/igel-supraglottic-airway
2
Resuscitation Today
Soar J: The i-gel supraglottic airway and resuscitation - some initial thoughts: Resuscitation. 2007 Jul;74(1):197.
5
6
UK Resuscitation Council Advanced Life Support Guide (5th Edition). Revised June 2008.
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EDITORS COMMENT
EDITORS COMMENT This issue of the journal is issued on the precipice of the 2015 Guidelines, which will be released next month. We eagerly await changes to resuscitation algorithms, post-resuscitation care, and general CPR and first aid advice. Many of our team are heading to Prague, we hope to see some of you there or at the AHA run science updates taking place in the USA. Yet again in this issue we continue with the themes of education, evidence and equipment. Jenny Jones, a resuscitation officer who has relocated to the Middle East reviews the ALERT course, and outlines the challenges of implementing education in a melting pot of cultures and nationalities, an issue which we can certainly relate to with our varied work in the Middle East. Tom Durham gives a medical student’s insight into management of paediatric cardiac arrest in the prehospital setting, in a reflective piece undertaken during observation shifts with London Ambulance Service. Echoing this piece, a recent study in Ontario, Canada, published in Resuscitation, showed paramedic care delivered on-scene for 10 to 35 minutes leads to better outcomes for paediatric cardiac arrests. Jean Flanagan and colleagues in Sheffield Hallam University describe their work with nursing and allied health university students and volunteering for the British Heart Foundation and Resuscitation Council UK as part of their “Save a Life” campaign, which includes training school children in CPR skills. We review the evidence behind several items in this issue, including a 2015 Dutch study by Kieboom et al which looked at outcomes after resuscitation beyond 30 minutes in drowned children with cardiac arrest and hypothermia. Lemmens et al look at the accuracy of clinical scores for predicting recurrence after TIA or stroke. Andrew Thomas and colleagues look at the current and developing practice in relation to traumatic cardiac arrest, and finally Piers Peberdy looks at the evidence surrounding prehospital Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in trauma patients. We are looking forward to upcoming conferences in such as Life Connections in October, and several in 2016, notably the smaccDUB conference which will take place in Dublin, Ireland in June 2016. Prior to this, there is a gathering of all prehospital and emergency care providers in Killarney, Ireland at the EMS Gathering. Kieran Henry gives us an outline of what to expect at the EMS Gathering in June. We’ll be attending most of these events and we hope to see some of you there too! Until next time,
Alan Batt
RESUSCITATION TODAY - AUTUMN 2015
“We are looking forward to upcoming conferences in such as Life Connections in October, and several in 2016, notably the smaccDUB conference which will take place in Dublin, Ireland in June 2016.”
5
EDUCATION
Evidence based airway management in emergency medicine and resuscitation
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RESUSCITATION TODAY - AUTUMN 2015
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Quality, innovation and choice
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EDUCATION NEWS Case Report: University Nursing and Health Care Students work in partnership to ‘Save a Life’.
at a rate of 14% and given that primary curriculum legislation in the UK
Mandy Brailsford, Jean Flanagan, and John Hutchinson.
students. We see significant benefits for all parties in this partnership
Correspondence Jean Flanagan, Assistant Dean Sheffield Hallam University S10 2BP
people with or at risk of cardiovascular disease [6] (Fig 1).
For: The British Journal of Resuscitation
Fig 1 Department of Health Outcomes Framework for Cardiovascular Disease
is unchanged the major method to achieve this target is local drive [5]. Sheffield Hallam University and local representatives from the British Heart Foundation considered (in partnership) the potential for spread of good practice through the involvement of nursing and health care above and beyond the critical outcome of improving outcomes for
1.0 Summary Cardiovascular Disease Outcomes Strategy The students and staff of one large metropolitan university in the UK wished to make a contribution to increasing bystander capacity to undertake Cardiopulmonary Resuscitation (CPR). We report how volunteering activity of university health students working with the leading heart voluntary agency British Heart Foundation, the Resuscitation Council (UK) and the community in partnership can contribute to dissemination and spread of CPR skills in bystanders.
2.0 Background It is becoming increasingly recognised that teaching of cardiopulmonary resuscitation to the general public increases survival in out of hospital cardiac arrests. Some sources stating this difference in survival by as much as 2-3 times [1]. Population comparative studies provide the best form of evidence [2] and the publication of this study lends support to the work of agencies such as the British Heart Foundation which has made significant strategic efforts to enable the public of the UK to ‘start a heart’ [3]. This nationwide study had four major findings; population=19,468 patients over a ten year period, with out-of hospital cardiac arrest:
Improving outcomes for people with or at risk of cardiovascular disease Action 7: To improve acute care: • the NHS will work with the Resuscitation Council the British Heart Foundation and other to promote AED site mapping/registration and first responder programmes by ambulance services and consider ways of increasing the numbers trained in CPR and using AEDs
3.0 Student Volunteering; ‘above and beyond’ the demands of their professional programme Nursing and health care students are busy people. Studying for a degree in nursing, physiotherapy, operating department practice or paramedic practice requires intensive periods in placement alongside study in a university and classroom with its associated rigorous assessment processes. At face value it may be thought that health and nursing students would have a sufficient burden studying at university to engage in volunteering activity but we have found this to be far from the case. Examples of students being involved in work over and above study and placement requirements include the establishment of
• rates of bystander CPR increased substantially
a university wide service for students concerned with the promotion of good sexual health, the promotion of health and wellbeing and more
• survival rates at 30 days and 1 year more than tripled
recently planning with a local hospice, for a befriending scheme for those with terminal illness. This case example provides three examples
• the number of survivors per 100,000 persons more than doubled
of volunteering activity to enhance community training of Emergency Life Support Skills (ELS). We will describe below how this strategy contributes to increasing numbers of people trained in CPR while facilitating enhanced skills in students studying for careers in healthcare.
Success stories can be seen elsewhere such as the joint initiative from the Irish Heart Foundation, Pre Hospital Emergency Care Council and the National Ambulance Service instigated in 2005. Rawlins and Hannon
[4]
4.0 ‘Training Yorkshire’ and enabling students to see University life
describe this case for an overall CPR training level involving
65,000 people per annum in the Republic of Ireland. The impact of the
Sheffield Hallam University engages in considerable activity with local
training has increased the numbers of people surviving out of hospital
schools and colleges to enable their students to gain an understanding
cardiac arrests from 1% in 2005 to 6.5% in 2012. However, the authors
of university life. In 2013 we had the opportunity to work with local
conclude that more could be done to improve public education and that
colleagues at the British Heart Foundation to really enhance these visits
CPR for Schools should be a societal priority.
while making a contribution to the training of young adults in the school and university system. We were in effect acutely mindful of the societal
The focus of the Resuscitation Council (UK) is on the training of children
priority to ‘train’ school children’ in CPR skills while recognising with
given their ability to learn new skills. Their vision of 100% of children
regret the lack of commitment from the UK government to make this
being taught Emergency Life Support (ELS) at school currently stands
compulsory in secondary school education.
RESUSCITATION TODAY - AUTUMN 2015
• rates of defibrillation by bystanders remain low.
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EDUCATION NEWS 4.1 Method: Teenagers Taking Life into their own hands: Learning lifesaving skills while considering a career at Sheffield Hallam.
Fig 2
Our approach involved 14-16 year olds from the local community in our local Schools and College’s Liaison Manager’s target area who were invited to Sheffield Hallam Universities Specialist Health and Wellbeing clinical skills facilities to learn lifesaving skills. Volunteer students from the departments of Nursing and Midwifery, Operating Department Practice, and Paramedic Practice who already had lifesaving skills attended a 2 hour preparation session in order to assist teaching staff to facilitate the supervision of skills rehearsal following their ‘expert teaching’. Volunteer teaching staff from the faculty and external partners facilitated a lifesaving skills session in four clinical skills rooms within our simulation suite consecutively. Prior to this the teenagers and their accompanying adults were seen for 1.5 hours by the Schools and Colleges Liaison Manager who, with student ambassadors, introduced them to student life, the faculty and the courses the faculty offer. During the refreshment break teenagers and their accompanying adults were exposed to recruitment information and have the opportunity to discuss courses with the Schools and College Recruitment manager. The aim was that teenagers would leave the session seeing one of the many things that the university had to offer in terms of health teaching and that they would take away with them skills that can potentially save a life. They would also take away a certificate of attendance which students felt valuable to their personal development portfolios. We also offered accompanying adults, that is teachers and parents, an opportunity to attend a lifesaving skills ‘adults group’. Students who assisted in facilitation of the sessions were provided with a participation statement for their professional portfolios. In the formal closure of the event, feedback was be taken via colour coded comments cards; one colour for the teenagers viewpoint and another from the accompanying adult perspective. The event evaluated well with the overarching feedback theme being that the school students enjoyed learning life saving skills in this practical format. The adults also focused on the practical aspects whilst commenting that the student involvement was ‘inspirational’. The Resuscitation Council (UK) participated with us by sending representation to the event. As they are currently providing all schools in the UK with a lesson plan and access to their ‘Lifesaver’ application [7]
The ‘chain of survival’ as a concept has helped understanding of the quality of response to cardiac arrest in and out of hospital [8,9,10]. The basic fact that resuscitation occurs within the community and is a key influence on the chain of survival still constitutes a radical notion to some, indeed the Resuscitation Council (UK) policy is based upon the premise that adults have learned behaviour and are difficult to change with respect to participating in bystander resuscitation. In the case described in our planning we certainly encountered attitudinal bias and experienced from some lay adults a degree of fear and concern related to potential risk and public liability. This provided an opportunity for debate discussion and education within a large public sector organisation which is entirely healthy and the resulting support received forms part of the greater public education required to make bystander participation successful in the UK. Our second event involved our nursing students attending a very large country fair in the summer of 2013. With the British Heart Foundation they engaged in public education in relation to: • The Healthy Heart
RESUSCITATION TODAY - AUTUMN 2015
their attendance supported us to promote lifesaving skills as a key skill,
• Bystander CPR
providing teachers with the opportunity to discuss the use of free open
• Other Life Support Techniques
source materials to cover lifesaving skills with their teenagers. They also
• Being a volunteer with British Heart Foundation.
provided colourful posters highlighting lifesaving skills as important.
4.2 Mass participation supported by celebrity Our collective concern was dissemination of key knowledge and skills. To assist in this process on this particular occasion the support of a celebrity figure in the form of Mr Mathew Burton from Channel 4’s “Educating Yorkshire” was particularly successful and his enthusiasm in participating in the activity was evident to all (Fig 2 photograph). Indeed it is hard to underestimate the impact of involving a ‘celebrity’ particularly in contributing to making the event more memorable for all participants and in making it an ‘event’. We trained 96 people at this event and recruited 28 train the trainers.
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4.3 Contributing to the ‘chain of survival’ university students go out into the community: Event based transition of knowledge
Thirdly we would like to report on our involvement with the record attempt to train the largest number of volunteers (June 2014) in ‘Emergency Life Support’. The images (fig 3) cannot do justice to the enormity of the event recording from the BHF 17,000 individuals trained to ‘Start a Heart’ and 46 additional train the trainers recruited from our nursing, operating department and paramedic students. Our health students had the privilege of ‘ manning a school ‘ from 1,700 secondary school students with our specialist learning disability nursing and social work students creating an impact and an ongoing link with a school whose major focus is children with a learning disability. This mass event was spectacular with a range of teaching methodologies used including the facilitators using sign language for deaf participants.
EDUCATION NEWS Fig 3
3. British Heart Campaign, help create a Nation of Lifesavers (2014) http://www.bhf.org.uk/heart-health/nation-of-lifesavers.aspx 4. Rawlins L, Hannon, M (2013), Stayin’ Alive- delivering resuscitation messages to the public. Encouraging bystander intervention. British Journal of Resuscitation, Autumn. 5. Lockey A 2013 ‘Essential Life Support’ must become part of the mandatory curriculum, Resuscitation Council and British Heart Foundation. 6. Great Britain. Department of Health (2013) Improving Cardiovascular Disease Outcomes: Strategy. London, The Stationary Office. 7. Resuscitation Council (UK) & UNIT 9. (2013) Lifesaver [mobile & desktop app] Version 1.1 8. British Heart Foundation, Resuscitation Council (UK) and NHS England (2014) Consensus Paper on Out-of-Hospital Cardiac Arrest in England. 9. Tunstall-Pedoe, H, Chamberlain D A, Marsden A K , Ward M A and
5.0 Outcomes, reflections and conclusions
Zideman D A. (1992) Survey of 3765 cardiopulmonary resuscitations
The positive outcomes of increasing bystander participation in cardiac arrest have been described above. In addition student involvement has:
results. British Medical Journal. 304(6838):1347-1351.
• provided experience for students of a number of health disciplines to work alongside different communities toward a shared objective • provided opportunities for students to practise skills and become more confident in their skills • enabled students to be involved in large scale public education • provided opportunity to work with voluntary sector staff We are also aware of less tangible potential outcomes which we would like to study further. The body of knowledge which describes the reasons individuals volunteer is reasonably substantive [11, 12]. Sivesind, Pospislovia and Pavol, [13] however, observe and describe how volunteering can cause trust. Social capital theory may have something to offer in terms of explaining the impact of public health programmes such as ‘Start a Heart’ which essentially involves mass cultural change with an acceptance for those living in a somewhat reticent British culture that it is wholly acceptable to be involved, and wholly acceptable to intervene to reverse the process of cardiac arrest. To act, and do something on another’s behalf. If we could each trust that someone would do that for us, that would be trust indeed.
1. Bottiger B (2014) Improving bystander resuscitation following cardiac arrest outside hospital could save 100,000 lives across Europe each year 49-151-551-01091 European Society of Anaesthesiology. 2. Wissenberg M, Lippert F, Folke F, Weeke P, Hansen C.M, Christensen, E.K Jans H, Hansen P.A, Lang-Jensen T, Olesen J.B, Lindharsden J, Fosbol E, Neilsen S, Gislason G.H, Kober L, TorpPederson C (2013) Association of National Initiatives to improve Cardiac Arrest management with rates of Bystander Intervention and patient Survival After Out of Hospital Cardiac Arrest, Journal of the American Medical Association, V310:13.
10. Waalewijn RA, de Vos R, Tissen JG, Koster RW (2001) Survival models for out-of-hospital cardiopulmonary resucitation from the perspectives of the bystander, the first responder and the paramedic. Resuscitation. 51 (2) 113-22 11. Chambre S, Einoff C (2011) Who volunteers? Constructing a Hybrid Theory, Baruch College Centre for Nonprofit Strategy and Management Working Papers : http://works.bepress.com/ christopher_einolf/11 12. Hustinx L, Cnaan R; Handy F Navigating Theories of Volunteering: A Hybrid Map for a Complex Phenomenon (2010) Journal for the Theory of Social Behaviour 411-434. 13. Sivesind KH; Pospislova T; PFric (2013) Does volunteering cause trust? European Societies 15.1: 106-130.
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References
in British hospitals (the BRESUS Study): methods and overall
9
EDUCATION NEWS Out-of-hospital paediatric cardiac arrest - a medical student reflects
performed better alongside discussing the emotional aspects of the case. I discovered that the emotional drain on any individual involved in a case such as this is great and the debrief sessions helped to lessen the lasting negative emotional impact. I found it
Tom Durham - first year medical student at UCL
difficult after finishing the shift that day seeing other families with young children and reconciling what I had just seen. However, by
As a first year medical student from University College London
having had the opportunity to talk helped me to move on and learn
(UCL) I am very privileged to be part of our prehospital care
from the case. I feel that without the debrief it may have taken
programme. It gives six others and I the chance to experience the
me longer to come to terms with the day. It made me question
frontline of healthcare and to be involved with many prehospital
the coping mechanisms of healthcare professionals who see
opportunities. On the 22nd December 2014 I had an experience
traumatic cases on a regular basis. The difficulties were particularly
that many others will not have for many years.
shown when the resuscitation was ended and the mother became increasingly emotional towards the medical team. This may be hard
Two hours into my second observing shift with the London
to handle for any medical professional.
Ambulance Service the call to a 2-month year old in cardiac arrest came through. I was onboard the fast response unit and we arrived
I also realized that the prehospital setting presents a unique set
in four minutes to the scene where another ambulance crew had
of emotional factors compared to an arrest in hospital. Having
arrived one minute previous. The 2-month year old was on the floor
seen a cardiac arrest once before in an A/E department I felt that
in the top room of the house and had been to hospital twice that
the prehospital arrest was in some way ‘more real’. In a hospital
week with bronchiolitis. I was struck by the calm of the paramedics
the environment is far more sanitised and devoid of the personal
as I entered the room and they began resuscitation. We left the
life of the individual. In the prehospital setting it is clear to see the
house minutes after arriving and all boarded the ambulance. On
patient in the context of their family and personal life. In my opinion
the way to Whipps Cross Hospital intraosseus drug access was
this makes it harder to move on from a case. Seeing the child, as
obtained and we arrived at Whipps Cross 12 minutes after the call
a member of a family with siblings and parents is very different
had originally come through. The Accident and Emergency team
compared to the more medicalised A/E resus experience.
took over and for the next 40 minutes resuscitation was attempted however at 12:32hours resuscitation was ended with no return of
This case also highlighted to me the importance of first aid training.
spontaneous circulation being achieved.
When we arrived no CPR had been started for at least 4 minutes. CPR is so often taught from the perspective of an adult patient
Throughout the case it became apparent to me that although
however I feel that the introduction of CPR training in pre-natal/
the primary focus should be on the child as the main patient, the
post-natal appointments and classes may be a beneficial step.
family must also be considered during what must be a horrific
The teaching may raise emotional obstacles of trying to teach
experience. In the initial moments the communication with the
parents a skill for the worst-case scenario when they have a young
family was minimal as the paramedics focused entirely on the child.
child. This may be a difficult thing for them to think about. However,
The mother of the child travelled with us on the ambulance and
I feel parents would want to learn these skills to help their child if
little could be done to comfort her. In a prehospital arrest it is very
they ever needed it. I certainly would have felt more confident in
hard to devote any time to family members, as the attention must
delivering compressions if the patient was an adult however would
be focused on the patient. On arrival at A/E a dedicated member
have been reluctant to help with a paediatric case with my level of
of staff came and sat with the mother. I feel that the role of this
basic first aid training.
member of staff was to ensure that the mother did not feel alone during the resuscitation attempt.
In conclusion, a prehospital paediatric arrest presents a unique emotional situation. The total focus of the emergency teams on
RESUSCITATION TODAY - AUTUMN 2015
10
Seeing the whole process unfold made me question if it is
the patient means that families face a very lonely time during
beneficial for a family member of the patient to be present during
what must be one of the hardest situations to face. The allocation
the resuscitation. There are two sides to the argument. For some
of a dedicated support member of staff within the emergency
individuals seeing that the medical team is trying everything
department acknowledges the fact there are more than one
they can to save the patient may help them to find closure in an
‘patient’ in these situations. Alongside the impact on the family the
unsuccessful outcome. However for others seeing the process
medical teams are presented with a challenging set of emotions
could make it harder for them in the future and potentially have
to contend with. The prehospital setting puts the patient in a very
detrimental psychological effects. I feel that families should not be
personal context. I feel that the debrief session plays a vitally
forced to witness resuscitation but think that it is overall beneficial
important role for healthcare workers to come to terms with difficult
for them to be there. Healthcare workers must be sensitive to each
situations. The case also highlighted to me the practical need for
family’s needs and the dedicated staff member helps to achieve
increased CPR training for parents. On reflection I feel that this
this.
case has been an excellent learning experience for me. Helping me to realise the emotional impact on the family and the healthcare
After the treatment was ended the ambulance crews and I sat down
workers. As well as beginning to understand how this can relate to
for a debrief session to discuss if anything could have been
optimal patient care.
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EVIDENCE
CRITICALLY EXAMINING THE THEORY AND EVIDENCE SURROUNDING PREHOSPITAL RESUSCITATIVE ENDOVASCULAR BALLOON OCCLUSION OF THE AORTA (REBOA) IN TRAUMA PATIENTS Piers James Peberdy - Paramedic
Key words:
Discussion
Reboa, Trauma, Aortic Balloon, Combat Gauze
Caroline (2008) states that hypotension without obvious external bleeding is a common sign of pelvic injury and lists other signs of symptoms of trauma to the pelvis, to include pain in the groin and
Introduction
hips as well as haematomas or contusions in the pelvic region. To this
When it comes to trauma, shock is the leading cause of
binder as the first line management to stabilise the pelvis for trauma
preventable deaths (Barash, Cullen and Stoelting et al, 2013). Patients who fall victim to high energy mechanisms of injury, such as road traffic accidents (RTC’s) or falls from height, are particularly susceptible to pelvic trauma (Dolan and Holt, 2013). Fractures to the pelvis can be complicated and of course lethal when taking into consideration surrounding
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12
end, Acharya and Forward (2014) recommend application of a pelvic patients who present with hypotension and a potential for pelvic injuries. Salamone, Pons and Guy et al. (2007) provide rationale behind this way of thinking, explaining that because some pelvic injuries are associated with an increase in abdominal volume, eg: the ‘open-book’ fracture, there becomes less tissue surrounding the pelvis to ‘tamponade’ the bleeding. Salamone, Pons and Guy et al. (2007) continue to say “Before
vasculature. It is well documented that a patient can quickly
the development of pelvic binders, patients with these injuries and
lose their entire blood volume into the pelvic cavity (Caroline,
haemodynamic instability would almost always undergo external fixation
2008), therefore clinicians must carry a high index of
of the pelvis to decrease the pelvic volume and increase the likelihood
suspicion when assessing the poly-trauma patient.
of tamponading haemorrhage.”
In the civilian prehospital arena there have been several recent
This leads to another form of management for patients with pelvic
evidence-based advances in trauma care, including the use
trauma, which is fluid resuscitation. Previous thinking has led the
of tourniquets as well as the introduction of pelvic binders and
prehospital care provider to administer fluids aggressively however
tranexamic acid in order to increase chances of survival to
more recent evidence shows “permissive hypotension” as best practice
discharge for trauma patients. Research aimed at enhancing trauma
(Durusu, Eryilmaz and Özturk et al, 2010). Acharya and Forward (2014)
care has utilised the Afghan War as its ‘springboard’ due to the
explain this further, stating that this practice stems from the ideation
high number of casualties seen in the binational hospital at Camp
that the first clot is the best clot: “permissive hypotension theoretically
Bastion, Helmand Province (NHS, 2013), and includes the long
protects the initial clot and prevents clot dislodgement.” For this, initial
debated issue of fluid management with emphasis on ‘permissive
crystalloid fluids should be used sparingly such that systolic blood
hypotension’ having found that “the first clot is the best clot”
pressure is kept between 70-80mmHg, with the exception of patients
(Acharya and Forward, 2014). An emerging topic of conversation
with head injuries (NICE, 2004).
is the utilisation of prehospital Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) a technology which, although
It is recognised however that crystalloid fluids possess no oxygen-
having existed for a number of years with a good theory base, has
carrying capability (Pante and Pollak, 2010) and therefore have
never been utilised in the acute trauma patient (Paetow, 2014).
limited benefits when it comes to the goal of replacing blood and its constituents. It could also be argued that not all pelvic ring injuries
This literature review will analyse and critique the underpinning
will benefit from compression by pelvic binders, in particular lateral
evidence surrounding prehospital REBOA. Current standards in
fractures. One could therefore question if pre-hospital management of
trauma care will be discussed and the subsequent effect on patients
pelvic trauma is substantial. Despite the opening of numerous Major
if a change in clinical practice were to occur. Protocols, guidelines
Trauma Centres (MTC’s) in April 2012, an analysis of ambulance service
other issues (eg: environmental) will be taken into consideration,
data by Morrison, Lendrum and Jansen (2013) showed that as much as
with a view to summarising the feasibility of REBOA as a ‘standard’
76.4% of patients with haemodynamic alterations suggestive of blood
in both military and civilian healthcare systems. Areas for
loss were taken to a hospital without full surgical capability, suggesting
development of research, as well as personal learning will also be
that crews fear they did not have enough time to transport that patient to
highlighted.
more definitive care at a trauma centre. With haemorrhage being the
EVIDENCE leading cause of preventable death from traumatic injury (Tien, Spencer
dressing, or no intervention at all. Morrison, Percival and Markov et
and Tremblay, 2007), the need for improved methods of haemorrhage
al. (2012) recorded rates of haemorrhage as well as mortality, which
control beyond the scope of standard paramedic practice has catalysed
showed that the group with no intervention has the fastest rate of
the start of a number of studies into the feasibility of using REBOA for
haemorrhage and suffered 100% mortality, which is to be expected.
shock as a result of trauma.
Groups that received REBOA or combat gauze dressing had drastically reduced rates of haemorrhage (822+/- 415ml/min versus 11+/-13ml/
According to Davenport (2013) REBOA is described as the insertion of
min and 0.2+/-0.4ml/min respectively) and had much improved
an end vascular balloon into the femoral artery, which is then advanced
mean arterial pressures (MAP), both 15 minutes and 180 minutes into
into the aorta and inflated in order to control haemorrhage and therefore
each procedure: 70+/-4mmHg for combat gauze, 70+/-11mmHg for
increase perfusion to the heart and brain. This is not a new technology,
REBOA versus 5 +/-13mmHg for the control group. Morrison, Percival
as Stannard, Eliason and Rasmussen (2011) explain that this procedure
and Markov et al. (2012) report no deaths in the intervention groups,
was described over 50 years ago whilst resuscitating injured Korean
although it was noted that pigs subjected to REBOA had greater fluids
soldiers, and despite a brief mention in an emergency medicine
requirements during the resuscitation phase, which one could argue is
journal in 1986, literature surrounding REBOA hasn’t been seen again
resolved easily. These results show REBOA in a promising light however
until 2011. According to Paetow (2014), the lack of traction regarding
based on this data, one might question the necessity for REBOA when
REBOA research may have been down to “sub-optimal endovascular
it has such similar results to combat gauze which is both cheaper and
technology, a poorly understood skill set or anticipated ineffectiveness.”
easier to use. This can be addressed by the simple explanation that not
Indications for REBOA include shock as a result of haemorrhage,
all haemorrhage is compressible or accessible (Salamone, Pons and
abdominal trauma (both penetrating and blunt mechanisms), pelvic
Guy et al, 2007) which renders combat gauze ineffective, or at least of
fractures causing abdominal bleeding, ruptured aortic aneurysms
limited use, should it not be placed correctly.
or “the crashing trauma patient with no obvious injury on cardiac ultrasound” (Paetow, 2014).
Morrison, Percival and Markov et al. (2012) repeated the study using pigs that had been subjected for dilutional coagulopathy. In this setting,
Stannard, Eliason and Rasmussen (2011) simplify the manoeuvre
it was found that REBOA was superior to combat gauze following a
into five steps: 1 - Femoral artery access, either by cut-down or
rate of bleeding of 20+/-7ml/min versus 229+/-295ml/min respectively.
percutaneously using ultrasound guidance, 2 - Balloon selection (those
MAP was also higher in the REBOA group, with five deaths occurring
which are soft and compliant) and positioning, either with or without
in the combat gauze group, compared to nil in the REBOA group. With
fluoroscopy 3 - Balloon inflation using a 30-60ml solution of sterile
this in mind it could be suggested that in theory, and despite greater
saline 4 - Balloon deflation, 5 - Sheath removal and closure of the artery
fluid resuscitation needs, the use of REBOA for non-compressible
once REBOA is no longer required.
haemorrhage is feasible.
For this critique, numerous databases were used to search for papers
This study is reflective of that by Martinelli, Thoni and Declety et al.
relating to the use of REBOA for trauma. These included CINHAL Plus,
(2010) who, using a constructed algorithm, selected 13 patients out of
Medline, Science Direct and Scopus. These databases were chosen
a possible 2064 that were being treated for uncontrolled haemorrhage
for their dedication to medical science and evidence based practice.
as a result of pelvic fractures. A range of mechanisms of injury were the
In order to ensure the quality and relevance of research retrieved,
cause of admission to the emergency department, including vertical
numerous parameters were employed including limiting the results to
falls and road traffic collisions (RTC’s), which one could suggest are
within the last five years. For ease, search results were limited to those
commonly seen by civilian medical services. Martinelli, Thoni and
written in English. Search terms ranged from simply “REBOA” to REBOA
Declety et al. (2010) report that all balloons were successfully placed
AND prehospital” and “REBOA AND Trauma”.
without the need for fluoroscopy, with a significant increase in systolic blood pressure being seen as a result (70mmHg). All but one of the patients became transferable to CT scan or to another department,
is significantly less research into the use of REBOA for the trauma
where angiography confirmed that 92% of the patients had arterial
patient, with research being particularly sparse on the use of REBOA
injuries, for which they received arterial embolisation (Martinelli, Thoni
in the prehospital arena. A suggested explanation for this could be
and Declety et al. 2010).
that although this is not a new procedure, changes to the settings we work in and the resulting types of injuries seen have meant a demand
A similar trial by Brenner, Moore and DuBose et al. (2013) also selected
for new ideas, whilst utilising a limited arsenal of resources as we see
trauma victims as candidates to receive REBOA for end-stage shock
ever limiting budgets. A large bulk of the research complied so far has
in a civilian trauma centre. REBOA was performed in 6 patients (4
been undertaken by Morrison J. (2012-2014), who has led retrospective
having suffered blunt trauma, 2 with penetrating trauma) with access
studies as well as those porcine model-based trials.
being obtained by either percutaneously or by direct cut-down. Brenner, Moore and DuBose et al. (2013) report a mean increase in systolic
Initial trials were focused on evaluating how efficiently REBOA
blood pressure of 55mmHg with no REBOA-related complications or
works for acute traumatic vascular injury, rather than its traditional
haemorrhage-related deaths.
use in elective surgery. Morrison, Percival and Markov et al. (2012) took a number of pigs and subjected them to forty five seconds of
Examining the results of the study by Martinelli, Thoni and Declety et al.
haemorrhage. After a 500ml intravenous colloid infusion, the pigs then
(2010), it would appear that this study suffered some bias; Unfortunately
either received intervention in the form of REBOA or combat gauze
the survival rate following the procedure was only 46%, with the vast
RESUSCITATION TODAY - AUTUMN 2015
It was found that in comparison to other trauma related topics, there
13
EVIDENCE majority of fatalities occurring in the early stages of the trial. With more
torso measurements in relation to arterial lengths could potentially differ
people surviving at the end of the trial one could argue that the study
based on gender. For this it could be recommended that a further study
was somewhat of a learning curve, rather than trialling a proven method.
would be required to include female patients.
This is further confirmed by admission by Martinelli, Thoni and Declety et al. (2010) that they found only after the event, that balloon deflation must
As previously stated, the study by Martinelli, Thoni and Declety et
be done slowly and delicately. However in the same breath the study
al. (2010) found that survival seemed to be inversely proportional
found survival was inversely related to the length of time the balloon was
to occlusion time. To probe this further, a study by Markov, Percival
inflated - something they reduced by as much as 85 minutes after the
and Morrison (2012) looked to examine the ‘physiological sequelae’
death of the 5th patient; a factor which was consistently low in the study
occurring when a REBOA system is introduced. 24 pigs were split
by Brenner, Moore and DuBose et al. (2013), whose average occlusion
equally into four groups consisting of 30 or 90 minutes of haemorrhagic
time was as low as 18 minutes. It would be unfair to suggest however
shock, and 30 or 90 minutes of REBOA. All animals prior to their
that this study was not without success, and based on REBOA being an
intervention stage underwent a haemorrhage stage which meant a
‘extreme’ measure, such a significant increase in survival rate can only
controlled haemorrhage of 35% of the blood volume of the course
be looked upon in a good light.
of twenty minutes. according to Markov, Percival and Morrison et al. (2012), the study looked to measure the changes in “mean central aortic
One might question if such low samples in both studies are reflective of
pressure (MCAP), lactate concentration and organ dysfunction”, the
the general population, in that from this data alone it is unclear if REBOA
latter of which was done by postmortem.
could be performed on all victims of pelvic trauma in a ‘one size fits all’ manner, or if the numbers of patients are vast enough to warrant the
The study found that both REBOA groups had a higher MCAP than
cost of training and equipment role-out. A study by Morrison, Ross and
that of the control groups, which we can expect given the data shown
Rasmussen et al. (2014) looked retrospectively at all trauma sustained
by the previous studies. However, the study also found that the groups
by UK military personnel as defined by the abbreviated injury scale
subjected to REBOA accumulated a high serum lactate level, which was
over the course of ten years. Morrison, Ross and Rasmussen et al.
positively correlated to the amount of time the animals were subjected
(2014) separated patients into three groups, including those who had
to REBOA (30 and 90 minutes). One could point out this could be
an indication for REBOA, those with contraindications and those with
responsible for the higher mortality rate seen in previous studies (this
no indication. 1317 patients were split into these groups with a ratio of
study saw only 2 deaths; on in the haemorrhage stage and another in
18.5%, 11.2% and 70.2% respectively.
the resuscitation phase), however Markov, Percival and Morrison et al. (2012) emphasise that the serum lactate levels were easily ameliorated
The study found nearly one fifth of all casualties in the battlefield had
during the resuscitation phase by use of blood, fluids and inotropic
potential benefit from REBOA, giving give good cause for further
support, although the amount of time required to achieve ‘controlled’
research into employing this procedure. This is further justified when
levels increased with the amount of time the pigs were subjected
Morrison, Ross and Rasmussen et al. (2014) report that of the 244 that
to REBOA (150 vs 320 minutes for the 30 and 90 minutes REBOA
had indication for REBOA, 66 died en route to hospital, with a further
respectively). Blood values combined with a postmortem examination
29 in hospital; these patients could have been saved. One might argue
also showed more renal dysfunction with some evidence of liver
that certain patients will have died at the point of injury and whilst this
necrosis in the group receiving 90 minutes REBOA compared to 90
is true, the study found that this was the case for only half of all deaths,
minutes of shock, further pressing the issue of prolonged REBOA.
with a median time to death being 75 minutes, giving ample time for REBOA to be introduced. It must be highlighted however that this data is military-based, and therefore may differ from that of civilian-based time projections. To further probe the issue of generalisability with regards to the population sample, Morrison, Stannard and Midwinter et al. (2013) RESUSCITATION TODAY - AUTUMN 2015
acknowledge the problematic nature of fluoroscopy-free REBOA placement in relation to the length of the aorta, and hence conducted a prospective study in which a convenience sample of 177 male patients, aged between 18 and 50, underwent CT imaging to measure the true length of the aorta, comparing it to the estimated length which was taken by tape measure, starting at the jugular notch down to the pubic symphysis. The study found a strong correlation between torso height and true arterial length. The relevance of this is that torso height can easily be measured in the pre-hospital setting and is therefore a reliable prediction tool for insertion length of the REBOA system. It would be erroneous however to ignore the obvious limitations of this study. Although a larger sample, 177 patients could still be put into question in terms of generalisability. Morrison, Stannard and Midwinter et al. (2013) also used only male patients in their study. Despite stating that the sample was one of convenience, it could be challenged that
14
EVIDENCE To further add to the drawbacks of REBOA, a study by Long, Houston
whether REBOA prior to transport to the ED is feasible; an increase in
and Watson et al. (2014) gives some contradicting evidence to that
the amount of time spent on scene could have detrimental effects on
found in by the study by Markov, Percival and Morrison (2012) who
patient outcomes. However a study by Roberts, Blethyn and Foreman
stated that they did not find any evidence of cerebral or spinal cord
et al. (2009) which centred around the feasibility of paramedic rapid
necrosis. A further set of 22 pigs were divided into three groups; one of
sequence intubation (RSI), found that despite introducing a complex
which receiving occlusion of the proximal aorta (n=8), another group
procedure into the extensive list of treatments required for each trauma
receiving occlusion in the distal aorta (n=8), with the third being a
patient, the mean time spent on scene increased by only one minute.
control group (n=6). Following preparation in the same manner those
The study also found that as a result, fewer patients died “on arrival at
pigs used in the trial by Markov, Percival and Morrison (2012), Long,
hospital” (Roberts, Blethyn and Foreman et al. 2009).
Houston and Watson et al. (2014) subjected the pigs to 60 minutes of REBOA followed by resuscitation and multiple examinations for spinal
This topic sparked further research into timings surrounding REBOA,
cord injury, including that by ischaemia or reperfusion, as well gait and
for which Anderson, Rehn and Oropeza-Moe et al. (2014) developed
bladder function tests. Both groups receiving REBOA had a mortality
two training methods: a gelatin model and a live model in the form of
of three (37.5%), with one of these (12.5%) being spinal cord injury
yet more pigs. After continuous training on gelatin models, a doctor-
related. Long, Houston and Watson et al. (2014) report that spinal cord
paramedic crew performed REBOA three times in a “realistic prehospital
symptoms without mortality were present in a further 12.5%, although
environment” with arrival to balloon inflation times recorded, as well as
gait scores improved with time.
skin contact to balloon inflation times. Anderson, Rehn and OropezaMoe et al. (2014) report a mean arrival to inflation time of (a very quick)
With the exception of 37.5% of the group receiving distal REBOA
4 minutes and 19 seconds), with a mean time of 3 minutes and 12
placement returning to ‘normal baseline status’, compared to the
seconds for skin contact to balloon inflation. From this it could be
proximal group (12.5%), the results above are suggestive that there is
reasonable to suggest that the introduction of REBOA in the prehospital
little difference in outcomes seen when REBOA is placed in a different
setting is not entirely dismissible, provided that the right patients are
aortic site, be it higher or lower. That said one must question again the
seen by the right people at the right time.
sample size in this study, and hence its generalisability when it comes to the general population. Also noteworthy were the results tables which
From this, one might question why we would introduce REBOA when
showed little clinical significance (p=0.6897) when it came to spinal
aortic clamping exists and is available pre-hospitally. According to
cord related mortality, and therefore it could be advised that future study
Davenport (2013), clamping can be achieved via thoracotomy by a
of a similar nature would need a far greater sample size to be clinically
doctor-paramedic crew, for which survival rates are around 18% in
relevant. Further critique may enquire why 60 minutes of REBOA was
selected patient groups. A study by White, Cannon and Stannard et al.
chosen rather than a shorter (or longer) period time, for which there
(2011) investigated this further, taking 18 pigs and dividing them into
appears to be little explanation. More importantly the suggestion that
3 groups: REBOA, Clamping or no intervention. The study found that
REBOA may led to spinal cord damage is potentially devastating for the
the group receiving balloon occlusion were less acidotic compared to
development of the procedure into mainstream civilian trauma systems.
the group who’s aorta’s were clamped (pH 7.35 vs 7.24) with a much
According to Long, Houston and Watson et al. (2014), research into
lower serum lactate and pCO2 levels (4.27 vs 6.55 and 43.5 vs 49.9
preventative methods including that of therapeutic hypothermia and
respectively). White, Cannon and Stannard et al. (2011), the group
cerebrospinal fluid drainage have long been documented in literature
who underwent REBOA rather than aortic clamping also required less
surrounding aortic clamping during cardiothoracic surgery, however it
fluid during resuscitation (667ml vs 2166). This may be due to the
could be questioned however feasible these methods are in the acute
minimally-invasive nature of REBOA compared to the maximum invasion
trauma setting.
of a thoracotomy. As with other studies, bias seems to be apparent here as one might question how transferable the results from pigs are
The acute trauma setting could be described as somewhat arduous.
to humans. From here, further research is most definitely required to
It is an uncontrolled environment in which road, vehicle or machinery
explore the potential benefits (and downfalls) of REBOA.
noise and multiple conversations between endless personnel on scene As previously stated, research by Morrison, Ross and Rasmussen et al.
well lit and prepared environment such as the emergency department
(2014) found that nearly one fifth of all trauma patients in the battlefield
(ED). Specialist equipment and expertise are often in short supply
had the potential to benefit from REBOA, had it been available at the
prehospitally, which in turn puts pressure on the clinicians on scene to
time. Nonetheless one might query if traumatic injuries sustained by
make quick yet critical decisions, with which comes risk.
civilians are so similar to those sustained by military personnel, posing the question “Will this skill be used regularly?” Willis, Hurd and Jernigan
With this in mind, it would be questionable as to whether REBOA is
(2002) list several differences between civilian and military trauma
suitable for the prehospital environment. Dependant on the method
including lower bullet velocity, lower contamination of wounds and the
used to gain arterial access, prehospital ultrasound may be required,
prevalence of comorbidites. The introduction of an advanced skill has
which according to Davenport (2013) remains a topic of controversy,
major cost issues, not just with initial training and equipment role-out,
argueing that ultrasound may delay the transfer to more definitive
but also with skill maintenance (Bernard, Nguyen and Cameron et
care in hospital. Rogers and Rittenhouse (2014) remind us of the
al. 2010). A highly publicised literature review by Deakin, King and
importance of the “golden hour” in which a patient must reach hospital
Thompson (2009) surrounding skill erosion in a civilian healthcare
within 60 minutes of time of injury, and highlight the “platinum ten
setting (of advanced airway manoeuvres in particular) showed that the
minutes” of EMS onscene time limitation, meaning that it is debatable
75.8% of all paramedics carried out one or less intubations in an
RESUSCITATION TODAY - AUTUMN 2015
mean the potential for mistakes is much higher than that in a controlled,
15
EVIDENCE entire year, which in turn put patient safety in question and the sparked
and Acute care surgery (AORTA)” led by Joseph DuBose, Brenner
the debate about withdrawal of the skill altogether. As highlighted by
and Cannon et al. (2014) at a MTC in Baltimore, USA. This study looks
Braude (2009) low volume, yet high risk procedures require the clinician
to determine outcomes following the use of aortic occlusion devices,
to be adept in the skill, something that can only be achieved by regular
specifically mortality, neurological outcomes and complications. The
hands on training and experience, a solution which is supported Adnet,
study also hopes to determine how practice patterns alter outcomes
Lapostolle and Ricard-Hibon et al. (2001), who urge cultivation rather
and therefore identify predictors of successful outcomes (DuBose,
than removal of a potentially lifesaving technique.
Brenner and Cannon et al, 2014). In June 2014, the London Air Ambulance, comprising of a doctor and
Conclusion
double paramedic team performed the worlds first prehospital REBOA,
Despite clinically proven and effective pre-hospital treatments available
Trust (LAA, 2014), is two years in the running. Further data is required
for patients sustaining traumatic pelvic injuries, such as pelvic binders and fluid management in conjunction with permissive hypotension, a consistently high mortality rate has necessitated us to look for improved methods of treatment. With REBOA being a new and very current topic, this essay has sought to analyse and critique the current literature surrounding this procedure.
as part of a trial which, led by Professor Brohi of the London Barts NHS before conclusions can be made from this study, but this step has made the feasibility of mainstream introduction of REBOA much more likely. Ultimately, REBOA is a life saving tool who’s benefits outweigh the drawbacks. It buys us more time and hence would appear well suited to both congested urban areas, as well as more rural territories where transfer to hospital time may be elongated.
After an exhaustive online database search, it has been established that the amount of published literature is still low in volume compared to more established prehospital treatments, despite being first mentioned
References
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RESUSCITATION TODAY - AUTUMN 2015
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Morrison, J., Percival, T., Markov., N., Villamaria, C., Scott, D., Saches, K., Spencer, J. and Rasmussen, T. (2012) Aortic Balloon occlusion is effective in controlling pelvic hemorrhage. Journal of Surgical Research 177(1): pp341-347
Morrison J., Ross, J., Rasmussen, T., Midwinter, M. and Jansen, J. (2014) Resuscitative endovascular balloon occlusion of the aorta: A gap analysis of severely injured UK combat casualties. Journal of Shock 41(5): pp388-393 Morrison, J., Stannard, A., Midwinter, M., Sharon, D., Eliason, J. and Rasmussen, T. (2013) Prospective evaluation of the correlation between torso height and aortic anatomy in respect of a fluoroscopy free aortic balloon occlusion system. Journal of Surgery 155(6): pp1044-1051
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Morrison, J., Ross, J., Markov, N., Scott, D., Spencer, J. and Rasmussen, T. (2013) The inflammatory sequelae of aortic balloon occlusion in hemorrhagic shock. Journal of Surgical Research 191(1): pp423-431
National Health Service (NHS) (2013) War Medical Advances [online].
17
EVIDENCE
THE MANAGEMENT OF PRE-HOSPITAL TRAUMATIC CARDIAC ARREST Flight Sergeant Andrew Thomas Academic Research Fellow (Paramedic), Royal Air Force, Department of Academic Emergency Medicine (DAEM), James Cook University Hospital. Part of Academic Department of Military Emergency Medicine (ADMEM). Warrant Officer Anthony Kyle Academic Research Fellow (Nurse), Royal Air Force, Department of Academic Emergency Medicine (DAEM), James Cook University Hospital. Part of Academic Department of Military Emergency Medicine (ADMEM). Lieutenant Colonel Simon Le Clerc Emergency Medicine Consultant (Army). James Cook University Hospital. Military Lecturer in Pre-Hospital Emergency Medicine, (RCDM), 127 Sqn, 16 Med Regt, Deputy Medical Director The Great North Air Ambulance Service. Lieutenant Colonel Mike Davison Emergency Medicine Consultant (Army). Department of Academic Emergency Medicine (DAEM), James Cook University Hospital. Part of Academic Department of Military Emergency Medicine (ADMEM). Medical Officer on The Great North Air Ambulance Service. Andy Mawson Senior Aircrew Paramedic. The Great North Air Ambulance Service Contact Info: Flight Sergeant Andrew Thomas, Department of Academic Emergency Medicine (DAEM), Academic Centre, James Cook University Hospital, Martin Road, Middlesbrough, TS4 3BW. 01642 854299 andy.thomas2@nhs.net
Abstract:
(NCEPOD 2007). This article aims to explore the management of this
This article aims to examine current and developing practice
series will challenge current protocols and provide evidence regarding a
in relation to the understanding and treatment of patients suffering Traumatic Cardiac Arrest (TCA). Current military and civilian practice is examined and consideration is given to a contemporary approach that would allow paramedics to focus on addressing the reversible causes whilst de-emphasising the need for External Chest Compressions in certain circumstances.
smaller group of OHCA with trauma aetiology. The presented case less traditional approach to the management of pre-hospital Traumatic Cardiac Arrest (TCA) involving mainly hypovolaemia as the primary cause for paramedics.
Background TCA is diagnosed when patients present unresponsive, apnoeic and
By examining the existing evidence and reviewing a selection of
have no palpable pulse. Evidence of a traumatic injury should also
case examples this article highlights that appropriate and focused
be present (Soar et al 2010). Current paramedic practice is to initiate
resuscitation of TCA patients can be successful. The attempted resuscitation of this group would have previously been deemed futile, however positive outcomes, enhanced by a new and yet simple contemporary approach. It further highlights the key role paramedics will face in future development of this area.
Key words:
Advanced Life Support (ALS) including airway management, Cardio Pulmonary Resuscitation (CPR), Intravenous fluids (crystalloids) and rapid transport to definitive care in penetrating trauma, and a vague idea that you should attempt to address the reversible causes and cease resuscitation after 20 minutes in blunt force trauma (Fisher et al 2013). The UK military has been operating a physician-lead pre-hospital care system in Afghanistan utilising a 4 person multi-disciplinary team
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Traumatic Cardiac Arrest (TCA) • Resuscitation • Medical Emergency
from 2006 to 2014. Employing Damage Control Resuscitation (DCR)
Response Team (MERT) • HEMS • Pre-Hospital • Paramedic
techniques, the team delivers ‘high end’ capability in an austere and
Introduction
difficult working environment (Kehoe et al 2011, Thomas 2014). A similar approach has been employed for a number of years by London Helicopter Emergency Medical Service (HEMS) utilising combined skills
In Europe, Out of Hospital Cardiac Arrest (OHCA) has an incidence rate
of the HEMS crew and ground based ambulance staff already at the
of approximately 66 per 100,000 (Atwood et al 2005). Extensive work has
scene (Lockey et al 2006). Both the Medical Emergency Response
gone into improving outcomes, especially when the aetiology is medical
Team (MERT) and HEMS personnel have embraced a contemporary
in nature. In 2012 the North East Cardiac Arrest Network (NECAN)
approach to TCA. This highlights the benefits of simple techniques that
produced the first annual report outside of the London Ambulance Service
may contribute to increased survival in patients where hypovolaemic
(LAS) examining OHCA. The report noted that in 2011 the North East
trauma has resulted in cardiac arrest and where these patients have
Ambulance Service (NEAS) attended 3862 calls involving cardiac arrest
traditionally been regarded as unlikely to survive “Cardiac arrest as a
with 92%(n=3541) presumed to have a cardiac aetiology, and 9%(n-164)
result of hypovolaemia is virtually always fatal” (Lockey et al 2006).
due to trauma or other causes (Kendall et al 2012). Perception exists that TCA as a result of hypovolaemia from trauma is Major trauma is the leading cause of death in people under the age
universally futile. As lessons learnt on deployed operations begin to
of 40 within the United Kingdom (UK), This equates to approximately
filter back into clinical practice in the UK, it is hoped more survivors will
5,400 deaths annually of which 2,400 occur prior to hospital admission
ensue. The instigation of early and aggressive treatment of causes
EVIDENCE of TCA by paramedics could result in the type of successes seen
activity seen on a cardiac monitor; sustained end-tidal CO2 that is
by military medics on operations. The improvements in the services
present on invasive ventilation and confirming the presence of cardiac
provided by many UK HEMS units, and specifically the carriage of blood
movement on ultrasound examination if available. It further states if
in many areas may also contribute further to outcomes.
none of these are present, resuscitation is unlikely to be successful (DCA EM 2013).
Tarmey et al (2011) published a prospective observational study of all the TCA’s brought into the UK led Role 3 hospital at Camp Bastion in
The treatment priorities are focused around identifying and treating
Helmand Province. Of the 52 patients meeting the inclusion criteria
any reversible causes of TCA. This takes precedence over performing
27% (n-14) achieved a temporary or permanent Return Of Spontaneous
ECC and the administration of adrenaline. It further emphasises the
Circulation (ROSC), with 8% (n-4) surviving to hospital discharge, all of
following 4 steps to maximise success:
which were neurologically intact. This compares with a medical OHCA overall survival rates of 7.1% (n-112) in North East Ambulance Service (Kendal et al 2012) and 10.9% (n-326) in London Ambulance Service (Watson et al 2012), which shows the potential for equal success. Tarmey et al (2011) further noted whilst the majority of patients were injured from blast and penetrating trauma, most of the survivors came from the group whose primary cause for TCA was exsanguination (75%). Although the total numbers of this study are small, it demonstrates the potential for positive outcomes of those suffering a TCA from
1. Control of catastrophic haemorrhage and restoration of circulating volume. 2. Airway patency and appropriate ventilation (with limited tidal volume and respiratory rate to minimise intra-thoracic pressure). 3. Decompression of tension pneumothorax. 4. Resuscitative thoracotomy, where indicated.
hypovolaemia or other reversible causes (each patient who survived received a resuscitative thoracotomy shortly after arriving in the
3 case studies are presented at appendix 2, as a small number of
emergency department). One patient who presented with an agonal
the many examples where ROSC has been achieved in patients who
rhythm on the ECG was resuscitated with a positive outcome. This
would previously have been labelled as unsurvivable in both the
contradicts guidance to withhold resuscitation on futility grounds issued
military and civilian pre-hospital environment. These case studies
by the National Association of Emergency Medical Service Physicians (NAEMSP) and the American College of Surgeons Committee on Trauma (ACSCOT) (Hopson et al 2003). This example, together with other case studies described by (Powell et al 2004, Pickens et al 2005 and Lockey et al 2006) demonstrates survivors who may not have been resuscitated using above guidance. This suggests that for some people resuscitation may have a positive outcome when previously deemed futile, and consideration should be given to recent military experience and practice in contributing to this group of survivors. Especially as military advances in times of conflict often lead to innovation in civilian settings (Grathwohl et al 2008).
The Medical Emergency Response Team (MERT) approach to TCA
highlight the potential for successful pre-hospital resuscitation in TCA.
Case Example 1 – Physician lead The MERT was called to an outlying Forward Operating Base (FOB) in Afghanistan to treat an Afghan soldier who had been shot in the left thigh. Despite appropriate battlefield pre-hospital interventions including; application of proximal tourniquets, compression bandages and the infusion of crystalloid, the soldier continued to deteriorate. Approximately ten minutes prior to the arrival of MERT the patient suffered a TCA. On arrival, CPR was being performed the patient was loaded and a rapid assessment confirmed a PEA arrest with an agonal rhythm on the cardiac monitor and a grossly distended abdomen. ETI without drugs was performed, ETCO2 of 1.2 was noted. Aggressive resuscitation was then commenced involving the administration of
judiciously applied horizontally to the 360 of the patient. DCR is
tranexamic acid (TXA), calcium chloride, four units of packed red
conducted by a well-trained team lead by a Consultant physician with
blood cells (RBC) and four units of fresh frozen plasma (FFP) via two
an Emergency Nurse (EN) and 2 paramedics (Thomas 2014). It is
fluid warming devices. No ECC were performed and no cardiac arrest
this approach that provides the corner stone of the Clinical Standard
drugs were given. Within five minutes the casualty had a palpable
Operating Procedure (CSOP) for TCA management (DCA EM 2013).
femoral pulse on the right side with a narrow complex tachycardia.
Aggressive resuscitation of battlefield casualties continues as they are
His ETCO2 was 3.1.
transported from the point of wounding to a Deployed hospital. Five minutes from landing the patient required paralysis and sedation The TCA CSOP (Figure 1) addresses the current areas of controversy
as he was biting down on the ETT. His pupils had become reactive
to guide resuscitation and validates the approach to TCA described
and his colour improved. His NIBP was recorded as 85mmHg and
by London HEMS. All interventions are discussed including the
his HR had dropped from 160 bpm to 120bpm. The patient bypassed
use of adrenaline, vasopressors, intubation and ventilation. The
the emergency department and underwent damage control surgery.
effectiveness of external chest compressions (ECC) and the rationale
The bullet had entered the pelvic and abdominal cavities before
for using capnography as both a measure of cardiac output and
severing the left external iliac artery. After ligation of common iliac
confirmation of endotracheal tube placement is also discussed. The
artery, haemostasis was achieved. Postoperatively, the soldier made
indications for commencing resuscitation include; witnessed cardiac
swift progress, was found to be neurologically intact and made a full
arrest that occurs during transport to hospital; organised electrical
recovery.
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The UK MERT applies damage control resuscitation (DCR),
19
EVIDENCE Case Example 2 – Paramedic lead The MERT was called to a desert location to attend two Afghan National Security Force (ANSF) patients who had been inured by a rocket propelled grenade with 1 patient suffering from an arm amputation. No other information was received from the scene. On landing at the location 29 minutes after the patient were loaded onto the aircraft. Patient 2 was managed by the double paramedic team as the doctor and nurse were dealing with the other critically wounded casualty. Initial assessment of the patient noted a proximal amputation of the left arm. In addition, multiple First Field Dressings (FFDs) applied to the patient’s pelvis and upper limbs. Primary survey noted a deformed and ‘boggy’ pelvis, with external catastrophic haemorrhage under control. The airway was clear and the patient was suffering a TCA. The airway was managed initially by oropharyngeal airway with artificial ventilation provided via a Bag Valve Mask (BVM). The second paramedic gained intraosseous (IO) access in the right humeral head, DCR was commenced and emergency transfusion of warmed blood products was initiated. ECC was not performed at this stage in view of the likely cause of profound hypovolaemia. ETI without drugs was performed using an Airtraq device. Initial ETCO2 was recorded as 0.8, with the ECG monitor showing an agonal PEA. The patient received 2 units of RBC,1 unit of FFP and TXA. ECC was commenced once other treatment priorities were completed, reversible causes addressed and 2 units of blood products had been administered. On hand over at hospital the patient showed signs of clinical improvement with an ETCO2 of 1.6 and a PEA rate of 80bpm. Within minutes of receiving further blood products in the ED the patient had a palpable carotid pulse. Primary x-ray revealed the patient had unsurvivable pelvic injuries and subsequently died.
Case example 3 – UK air ambulance physician lead The HEMS crew were called to a motorcyclist who had been involved in a head on collision with a car. The impact speed was estimated to be approximately 60mph but the bike was relatively undamaged in comparison to the car, which led the HEMS team to conclude the patient had taken the majority of the impact. HEMS arrived on scene 14
but drainage of 300-400mls of blood from both sides of the chest indicated bilateral haemothoraces. Circulatory access was secured by both intravenous (IV) and IO routes with continuous ECC performed. Blood was not available, therefore 2 litres of crystalloid was infused. Despite no signs of a significant head injury the motorcyclist was found to have fixed, unreactive pupils (3mm bilaterally). Following a rapid infusion of 1800mls of sodium chloride a rhythm check revealed profound bradycardia with single normal complex, followed by asystole. ECC was continued and a further 200mls saline was infused. The monitor then showed normal sinus rhythm with a rate of 100bpm, the patient had a strong carotid pulse and ROSC had been achieved after an 11 minutes. The patient was packaged and transferred to a Level 1 Major Trauma Centre (MTC), and a pre alert was given. The observations remained satisfactory with a BP of 80/40 and an ETCO2 of 2.8. TXA was administered. During the latter part of the flight the patient lost a femoral pulse and a further 500mls of saline was administered. The patient was handed over to the MTC with a HR of 130bpm, BP, 80/40, SPO2 99% ventilated and an ETCO2 of 3.4. 5 minutes after arriving at the MTC and whilst receiving blood products the patient re-arrested. A clamshell thoracotomy was performed which revealed T4 on T5 fracture dislocation which had ripped the azygous vein. The vein was clamped and the patient rapidly regained cardiac output. He was then transferred to the operating theatre for damage control surgery. Within 4 hours the patient’s serum lactate, Ph and biochemistry had normalised. A ‘pan CT’ scan revealed no additional injuries apart from known chest injury and femoral fracture. However over the next 4 hours, the patient’s condition deteriorated with signs of raised intracranial pressure. A further CT scan was performed, which identified massive diffuse axonal injury. The patient died 48 hours later following organ donation.
Discussion
minutes after the initial 999. The case series showed 3 patients achieving ROSC, with 1 patient
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Scene assessment revealed a male in his early 20’s lying supine, slightly
surviving to hospital discharge neurologically intact. Positive
head down in a shallow ditch with obvious deformity of right femur. The
outcomes were achieved in patients who had received pre-hospital
patient was lying 3 metres away from the car with significant intrusion to
advanced airway management, volume replacement by either
engine block and a bulls-eye on the windscreen. The crash helmet had
blood products or saline as well as aggressive but appropriate
been removed and inspection noted abrasion but no crack.
use of interventions, with systematic assessment and treatment of reversible causes. It can also be seen that the priority for ECC was
A rapid response paramedic was already on scene providing ventilation,
de-emphasised in this patient group.
a member of the public was assisting the paramedic with ECC. The patient’s cardiac rhythm was asystole. The HEMS physician noted no
Although the evidence presented is from previous level IV studies with
catastrophic external haemorrhage, with prioritisation given to airway
small sample sizes and a small case series, a valuable theme has
management and reversible cause correction.
emerged. Level I evidence is hard to ascertain especially as trauma Randomised Controlled Trials (RCT’s) often have small sample sizes,
Initially, the physician instructed the cessation of ECC to allow critical
are difficult to undertake and often suffer from baseline imbalances and
interventions to be undertaken. A SAM pelvic binder was applied
low power (Curry et al 2011). It is therefore vital that change is made in
with the airway secured by ETI without drugs, before bilateral
the absence of stronger evidence, when the limited evidence available
thoracostomies were performed. Both lungs were found to be inflated,
supports improved patient outcomes, compared to existing practice.
EVIDENCE The examples presented show the potential benefit of a contemporary approach can have on patient outcome. This however has been achieved by advanced medical teams, and often results in a significant surgical intervention. Figure 2 may empower non specialised paramedics to focus on the clinical needs of the patient and address the reversible causes within individual skill sets. The concept of Sustain, Slice and Survive will allow non-specialised paramedics to address the reversible causes within their power and hopefully sustain the patient in a viable state until advanced help arrives and performs the necessary surgical (Slice) procedure to hopefully give patients a chance to survive.
ECC on a heart that is unable to fill due to external pressure, either as a result of pericardial tamponade, or from tamponade occurring as a result of increased intra-thoracic pressure due to tension pneumothorax is also likely to be ineffective. In these cases, recognition and treatment of the underlying cause of cardiac arrest is paramount. ECC will not improve the patient condition if the underlying cause of arrest is not addressed first. This critical decision making to address the reversible cause and in some cases reduce the need for ECC may be essential to improve patient survival.
Adrenaline The International Liaison Committee of Resuscitation (ILCOR) include adrenaline in their ALS guidelines and note for the past 40 years that adrenaline has been the primary sympathomimetic drug for the management of cardiac arrest (Deakin et al 2010b). Despite there being no randomised placebo controlled trials, adrenaline continues to be the drug of choice in patients with cardiac arrest. Its alphaadrenergic effects cause systemic vasoconstriction, which increase coronary and cerebral vasoconstriction. The perceived benefits may in fact be moderated by a concomitant increase in myocardial oxygen consumption, impaired microcirculation and increased post cardiac arrest myocardial dysfunction (Deakin et al 2010b). These additional effects are often unwelcome in TCA. Consideration towards increasing circulating volume rather than a drive to increase systemic vascular resistance is adopted in military pre hospital care for a hypovolaemic casualty. Furthermore, it is considered opinion that in trauma patient’s massive surge of endogenous catecholamine has already been released as a result of any life-threatening injury. To this end, early administration of supplementary adrenaline is unlikely to be of benefit in TCA. In the absence of robust evidence supporting the benefits of adrenaline use, the risk of harm is too great to justify continued use in this specific patient group. This is supported by current evidence, which shows potentially worse outcomes of cardiac arrests when adrenaline is used (Lin et al 2014), when comparing
External Chest Compressions (ECC)
review reviewed extensive Randomised Controlled Trails (RCTs), using meta analysis and is therefore robust and strong data. Finally with the PARAMEDIC 2 trail now underway in the UK, this large multi centre, placebo, pre hospital care RCT should provide definitive evidence on patient outcomes when adrenaline is used compared to when it is not used.
Airway and ventilation Securing a definitive airway and providing adequate ventilation is standard procedure for TCA when the responder or team is proficient in its application. Paramedic-led advanced airway management using an ETT is not without controversy and is claimed to have adverse patient effects (Deakin et al 2010a, Lyon et al 2010). Discussion
Therefore the priority in hypovolaemic TCA is to replace the volume and not compress an empty heart. Furthermore ECC could cause harm in chest injuries and importantly detract resources away from addressing the reversible causes. It should be noted that if a medical cause of the cardiac arrest is suspected or unclear which has resulted in traumatic injuries ECC should be commenced whilst the origin of the arrest is established (Lockey et al 2013).
regarding the rationale, for or against paramedic intubation is beyond the scope of this paper; however, it is important to review how Intermittent Positive Pressure Ventilation (IPPV) is delivered. There is substantial evidence to show that assisted ventilation using excessive tidal volumes can be detrimental to any patient. Increases in intra-
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The importance of ECC has long been the focus of resuscitation attempts but may not always be effective in TCA. Indeed this is not a new concept as Luna et al (1989) noted that in patients suffering TCA from severe hypovolaemia, chest compressions are likely to be ineffective due to poor cardiac filling and compressing an empty heart. Recently with the use of ultrasound it has been noted that despite the lack of a palpable pulse the heart may still be contracting and producing organised electrical activity. This reduced volume and low carbon dioxide production is termed “low flow state� (Pepe et al 2005) and can be seen more commonly in the patient in a Pulseless Electrical Activity (PEA) arrest.
this to hospital discharge and neurological outcome. This systematic
thoracic pressure leads to a marked reduction in venous return to the heart as well as precipitating barotrauma to the alveoli (Ho et al 2009).
21
EVIDENCE In trauma, a critically injured patient often requires insertion of an ETT
paramedics especially relating the pelvic binder as treatment to a
when their airway is at risk, their breathing is compromised or to mitigate
reversible cause and not just a packaging device.
the secondary effects of a primary brain insult. In all of these patients it is vital the pre hospital responder considers delivering a reduction in
Airway (A) Secure airway to the most advanced skill level where
tidal volume thus maximising venous return to the heart, protecting the
possible. The use of a Supraglottic Airway device (SGA) may be most
lungs from barotrauma and reducing the risk of Systemic Inflammatory
appropriate if ETI cannot be performed confidently. Surgical airway
Response Syndrome (DCA EM 2013). Typically, HEMS clinicians follow
devices could also be considered as a last resort.
anaesthetic guidelines and aim to deliver a tidal volume equating to 6-8ml/Kg of the patient’s body weight. To this end a 70Kg patient should
Breathing (B) Ensure adequate ventilation, making sure not to over
receive between 420ml and 560ml via BVM. If a clinician is struggling
ventilate the patient. Address any additional chest injuries within your
to oxygenate patients, consideration should be given to altering the
scope of practice. This may include the application of chest seals, needle
ventilation rate (minute volume), and applying a small amount of
thoracocentesis or open thoracostomies. By decompressing the chest
extrinsic Positive End-Expiratory Pressure (PEEP) (4 to 5 cmH2O), could
of a patient in TCA, you are effectively eliminating tension pneumothorax
prevent alveolar collapse and is used in most mechanically ventilated
as a problem. Needle thoracostomy may not treat the underlying tension
patients (Manzano et al 2008). By using a mechanical ventilator
and often gives the pre-hospital practitioner a false sense of security,
you are less likely to over ventilate and therefore reduce unwanted
needles can become dislodged or kink in situ. In 50% of cases the
complications.
standard 4.4cm cannula will not make it through the chest wall to reach the pleural space (Stevens et al 2009). This may therefore require an up
Utilising ETCO2 monitoring as a minimum standard in pre hospital care
skill of paramedic training and practice for certain paramedics especially
is essential to ensure adequate ventilation of the patient (Badjatia et al
with the specialist and advanced paramedic roles.
2008). ETCO2 also allows the pre-hospital clinician to confirm correct tube placement and monitor cardiac output (a gradually declining
Circulation (C) Gain IV/IO access and commence fluid resuscitation
ETCO2 could indicate a loss of Cardiac output). It can also be used as
without delay, noting the safe use of IO access has been well proven in
a diagnostic tool to inform of disconnection or leak in the circuit and
a large military case series from Afghanistan (Lewis and Wright 2014),
provide an indication of hyper or hypoventilation. The use of ETCO2
including the use of fluids, blood products and administration of drugs.
monitoring could be vital in the low flow state patient population as an
This is likely to be normal saline until the arrival of a blood product
improved ETCO2 reading may be the first sign of clinical improvement
carrying pre- hospital care service e.g. HEMS or MERIT. The aim should
following treatment as was the case with the patient examples
be to ‘fill’ a hypovolaemic patient, rather than ‘squeeze’ them at this
presented.
stage. Skill set dependant, consider the use of Tranexamic Acid (TXA) early in the resuscitative phase although not at the expense of other
Implications for paramedic practice
priority interventions. TXA could benefit the resuscitation as this synthetic
Paramedic practice varies and is an ever growing and more complex
decreases fibrinolysis, promoting coagulation (Harvey et al, 2013).
profession. Paramedics are employed in various roles including Air Ambulance Services, NHS solo responders, offshore oil and gas industry, in remote and expeditionary settings and more recently within the military environment. Within the paramedic profession, skill sets and training vary and the level of knowledge and confidence in the TCA situation will differ. The case examples discussed in this paper have highlighted various situations in which paramedics can have a positive
derivative of the amino acid lysine (Boling & Moore, 2012), is used to
Remember, with a patient who is hypovolaemic and in TCA ECC is not a priority and at no point should detract from haemorrhage control, preventing hypoxia, treatment of respiratory failure and the initiation of fluid resuscitation.
Conclusion
impact on the outcome of a patient when operating as part of a pre-
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22
hospital team. Often however, many paramedics will be first on scene,
The traditional treatment of TCA, along with its perceived futility has
acting independently whilst waiting for additional support to arrive. It’s
been challenged in recent years by both military and civilian evidence
essential in this situation to recognise a patient suffering from TCA and
indicating that some of these patients can survive. Recent studies
prioritise time critical interventions and address the reversible cause.
now support that ROSC and hospital discharge of neurologically
Understanding the mechanism of injury and adopting the <C>ABCD
intact patients can be achieved in well-organised pre-hospital care
paradigm will maximise any potential benefit to patients. The
systems that focus on addressing the causes and aggressively
<C>ABCD paradigm was generated from military practice in the last
performing appropriate interventions where indicated. Similarly, case
decade to increase patient survival from trauma (Hodgetts 2006).
studies such as the ones discussed highlight the need for a more measured approach to resuscitation rather than a ubiquitous approach
Catastrophic Haemorrhage <C> Identify and address any external
consisting of CPR and medical ALS. The paper is designed to show that
bleeding that would result in death if no intervention was implemented.
patients can, on occasion survive and to establish debate both within
For this to be successful and to rule out occult injuries the practitioner
the paramedic profession and the growing pre-hospital care multi-
will need to undress the patient down to the skin. Treatment may
disciplinary community. The evidence presented is limited to a small
include the use of tourniquets, haemostatic dressings or compression
series of case studies and a relatively small study in Afghanistan. The
bandages and elevation. Apply a Pelvic binder at this stage if significant
need for a much larger, multicentre study examining ROSC, Hospital
pelvic injury is suspected to reduce any non-compressible pelvic
discharge and long-term outcomes is required to assess the true value
haemorrhage. This may require a mind set change amongst some
of this approach.
EVIDENCE It is clear however that lives are being saved by this contemporary method and the paramedic profession is likely to be at the forefront of any further developments within the UK. By incorporating assessment skills, identifying treatment priorities, utilising limited resources appropriately and focusing on the treatment described in this paper, it is hoped that paramedic professionals can make a difference to this small but significant population.
References Atwood C, Eisenberg M, Herlitz J and Rea T (2005) ‘Incidence of EMS treated out-of-hospital cardiac arrest in Europe’. Resuscitation. 67: 75-80. Badjatia N, Carney N, Crocco TJ et al (2006) ‘Guidelines for Pre-hospital Management of Traumatic Brain Injury’ 2nd Edition. Available at: http://informahealthcare.com/doi/ abs/10.1080/10903120701732052?journalCode=pec (Accessed 15 Mar 2015). Boling, B. & Moore, K. (2012). ‘Tranexamic acid (TXA) use in trauma’. Journal of Emergency Nursing, 38(5): 496-497. Curry, N. Hopewell, S. Doree, C. Brohi, K. and Stanworth, S (2011) ‘The acute management of trauma haemorrhage: a systematic review of randomized controlled trials’. Critical Care. 15(2): R92. Deakin, CD. Clarke, T. Nolan J et al (2010a) ‘A critical reassessment of ambulance service airway management in pre-hospital care: Joint Royal Colleges Ambulance Liasion Committee Airway Working Group’. Emergency Medicine Journal. 27:226-233. Deakin, CD. Morrison, LJ. Morley, PT et al (2010b) ‘Part 8: Advanced life support 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency cardiovascular care Science with Treatment Recommendations’. Resuscitation. 81S: e93-e174. Defence Consultant Advisor in Emergency Medicine (2013) ‘Defence Medical Services, Medical Emergency Response Team (MERT), Clinical Standard Operating Procedure: Traumatic Cardiorespiratory Arrest management’. (Internal MOD document). Fisher, JD. Brown, SN. and Cooke M et al (2013) Joint Royal Colleges Ambulance Liaison Committee: UK ambulance services clinical practice guidelines 2013. 3rd edn. UK. Class publishing Ltd. Grathwohl, KW. Venticinque, SG. Blackbourne, LH. and Jenkins, DH (2008) ‘The evolution of military trauma and critical care medicine: Applications for civilian medical care systems’. Critical Care Medicine. 36(7): S253-2254. Harvey, V. Perrone, J. & Kim, P. (2013) ‘Does the Use of Tranexamic Acid Improve Trauma Mortality?’ Annals of Emergency Medicine. 63(4): 460-2. Available at: http://www.ncbi.nlm.nih.gov/pubmed/24095056 (Accessed 12 Apr 15).
Hodgetts, TJ. Mahoney, PF. Russell, MQ. and Byers, M (2006) ‘ABC to <C>ABC: redefining the military trauma paradigm’. Emergency Medicine Journal. 23: 745-746 Hopson, LR. Hirsh, E. Delgardo, J. et al (2003) ‘Guidelines for withholding or termination of resuscitation in pre hospital traumatic cardiopulmonary arrest’. Journal of American College of Surgeons. 196: 475-481. Kehoe, A. Jones, A. Marcus, S. Nordmann, G. Pope, C. Reavley, P. and Smith, C. (2011) ‘Current Controversies in Military Pre-Hospital Critical Care’. Journal of the Royal Army Medical Corp, 157(3): S305-S309 Kendal ,S. Phillipson, A. and Wright, J (2012) ‘North East Cardiac Arrest Network (NECAN). Out of Hospital Cardiac Arrest Registry: First year of
Lewis, P. Wright, C (2014) ‘Saving the critically injured trauma patient: a retrospective analysis of 1000 uses of intraosseous access’. Emergency Medical Journal. Online. Available at: http://emj.bmj.com/content/ early/2014/06/30/emermed-2014-203588.full.pdf (Accessed on 24 Mar 15). Lin, S. Callaway, CW. Shah, PS. Wagner, JD. Beyene, J. Ziegler, CP. and Morrison, LJ (2014) ‘Adrenaline for out-of-hospital cardiac arrest resuscitation: a systematic review and meta-analysis of randomised controlled trials’. Resuscitation. 85(6): 732-40. Available at: http://www.ncbi.nlm.nih.gov/pubmed/24642404 (Accessed 13 Apr 15). Lockey, DJ. Crewdson, K. and Davies, GE (2006) ‘Traumatic Cardiac Arrest: Who are the survivors?’ Annals of Emergency Medicine. 48: 240-244. Lockey, DJ. Lyon, RM. and Davies, GE (2013) ‘Development of a simple algorithm to guide the effective management of traumatic cardiac arrest.’ Resuscitation. 84: 738-742. Luna, GK. Paulin, EG. Kirkman, J et al (1989) ‘Hemodynamic effects of external cardiac massage in traumatic shock’. J Trauma. 29:1430. Lyon, RM. Ferris, JD. Young, DM. McKeown, WD. Oglesby, AJ. and Robertson C (2010) ‘Field intubation of cardiac arrest patients: a dying art? ‘Emergency Medicine Journal. 27(4): 321-323. Manzano, F. Fernandez-Mondejar, E. Colmenero, M. et al (2008) ‘Positiveend expiratory pressure reduces incidence of ventilator-associated pneumonia in nonhypoxemic patients’. Critical Care Medicine. 36(8): 222531. Available online at : http://www.ncbi.nlm.nih.gov/pubmed/18664777 (Accessed 12 Apr 15). National Confidential Enquiry into Patient Outcome and Death (2007) Trauma: Who cares? Available at: http://www.ncepod.org.uk/2007report2/ Downloads/SIP_report.pdf (Accessed: 20 Mar 2015). Pepe, PE. Roppolo, LP. and Fowler, RL (2005) ‘The detrimental effects of ventilation during low-blood-flow states’. Current Opinion in Critical Care. 11(3): 212-218. Pickens, JJ. Copass, MK. and Bulger, EM (2005) ‘Trauma Patients receiving CPR: Predictors of survival’. Journal of Trauma. 58: 951-958. Powell, DW. Moore, EE. Cothren, CC. et al (2004) ‘Is emergency department resuscitative thoracotomy futile care for the critically injured patient requiring pre-hospital cardiopulmonary resuscitation?’ Journal of American College of Surgeons. 199: 211-215. Soar, J. Perkins, GD. Abbas, G. et al (2010) ‘European Council Guidelines for resuscitation 2010 section 8. Cardiac arrest in special circumstances: Electrolyte abnormalities, poisoning, drowning, accidental hypothermia, hyperthermia, asthma, anaphylaxis, cardiac surgery, trauma, pregnancy, electrocution’. Resuscitation. 81: 1400-1433. Stevens, RL. Rochester, AA. Busko, J. et al (2009) ‘Needle thoracostomy for tension pneumothorax: failure predicted by chest computed tomography’. Prehospital Emergency care. 13(1): 14-17. Tarmey, NT. Park, CL. Bartels, OJ. Konig, TC. Mahoney, PF. and Mellor, AJ (2011) ‘Outcomes following military traumatic cardiorespiratory arrest: A prospective observational study’. Resuscitation. 82(9). 1194-1197. Thomas, A (2014) ‘An overview of the Medical Emergency Response Team (MERT) in Afghanistan: a paramedic’s perspective’. Journal of Paramedic Practice. 6: 232-237. Watson, L. Vird, G. and Forthergill, R (2012) ‘Cardiac Arrest Annual Report:2011/12 London Ambulance Service’. Available at: http://www. londonambulance.nhs.uk/news/news_releases_and_statements/londons_
RESUSCITATION TODAY - AUTUMN 2015
Ho, AMH Graham, CA. Ng CSH et al (2009) ‘Timing of tracheal intubation in traumatic cardiac tamponade: A word of caution’. Resuscitation, 80: 272-274.
data report 2011’. Available at: http://www.networks.nhs.uk/nhs-networks/ north-east-england-cardiac-arrest-network/documents/Out%20of%20 Hospital%20Cardiac%20arrest%20registry.pdf/view (Accessed 20 Feb 15).
cardiac_arrest_suriva.aspx?lang=en-gb (Accessed 16 Mar 15).
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EVIDENCE FigureFigure 1 1 MANAGEMENT OF TRAUMATIC CARDIAC ARREST BY MERT Traumatic arrests are different to medical arrests. DO NOT just follow ALS algorithm. Assess casualty and direct treatment towards the most likely cause. See notes below for guidance on use of compressions and adrenaline. ASSESS CASUALTY FOR SPONTANEOUS VENTILATION AND CAROTID PULSE
CONFIRM TCRA (No respiratory effort and absence of carotid pulse)
LOOK FOR MOST LIKELY CAUSE
CORRECT ANY POSSIBLE REVERSIBLE CAUSES (See below) NB DO NOT ALLOW CHEST COMPRESSIONS TO PREVENT REVERSAL OF POSSIBLE CAUSES OF ARREST i.e. reverse causes and only then continue or start external cardiac compressions. Start with most likely cause, and tailor resuscitation towards correcting this. CAUSE Catastrophic haemorrhage Hypoxia
RESUSCITATION TODAY - AUTUMN 2015
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Tension Pneumothorax Hypovolaemia Cardiac Tamponade
High Spinal Cord Injury (neurogenic shock) Hyper or hypothermia
ACTION Prevent further blood loss if on-going bleeding: Apply or tighten CATs · · Celox gauze and pressure dressing Reverse airway obstruction: Secure definitive airway (ETT or surgical airway) · · Commence ventilation with BVM (minimising intra-thoracic pressure) Decompress chest with bilateral thoracostomies IV or IO access Give 1:1 Red Cells and FFP Clamshell Thoracotomy: Open pericardium, release tamponade and close · holes in heart. · Compress aorta, give internal compressions, and fill heart with warmed blood. · Lung twist if bleeding lung. ABC as per ALS guidelines. Adrenaline is given if this is the sole cause of arrest. Cool or warm as appropriate
EVIDENCE NEWS legged approach to Scarborough then to York.
NHS Clinical Commissioning Group simplifies emergency stroke care in the Whitby area
Middlesbrough is also, of course, much closer
Following hard work behind the scenes, NHS Hambleton, Richmondshire and Whitby Clinical Commissioning Group new arrangements are now in place for emergency stroke patients. As of 14 July 2015 patients are now taken directly to hospital in Middlesbrough for their treatment. You may previously have heard about changes to the way emergency stroke patients are cared for, with patients from the Whitby area first going
Thursday 22 October at The Kettering Conference Centre, Kettering, Northants.
and more accessible for visiting relatives. We are again running, in individual rooms, the “The long-term plan is to provide all stroke
following Conferences; Paramedic Practice,
rehabilitation from April 2016 onwards in
Community First Responder, Resuscitation and
Whitby, once work has been completed to
First Aid and, for those looking for something
enhance facilities.”
different, this year’s Workshops include: Paramedics in Hazardous Environments,
Life Connections 2015 Something For Everyone
Difficult Airway Course, Motorsport Medicine CPD Workshop, Cardiac Based Study on ECG Interpretation, Minor Injuries Workshop, Paediatric Workshop, NAEMT Trauma First Responder
Over 400 delegates have now registered for the various Conferences and Workshops taking place at Life Connections 2015 on Wednesday 21 and
Course and an ALSG Facilitation Course. Delegates booking on to these Workshops are also being offered a free place on our Paramedic or Resuscitation Today Conferences.
to Scarborough for initial assessment and then to York for their main treatment. This change came about because of major problems at Scarborough Hospital in recruiting replacements for stroke consultants who are due to retire this summer. However, clinicians at HRW CCG felt the journey
ILLUMINATING CPR
to Scarborough then to York was too far, and were keen that a one-journey solution should be found for patients who need emergency care. As a result HRW CCG colleagues have been working with Yorkshire Ambulance Service and
The First Manikin that helps you Visualise the effects of CPR
South Tees Hospitals to find a better solution for local people. Now, as of 14 July 2015, any stroke emergencies from Whitby town, Robin Hood’s Bay and the surrounding villages will see patients taken by emergency ambulance directly to the specialist stroke unit at James Cook University Hospital, Middlesbrough, for the main acute phase of care.
required for these patients now takes place initially in Redcar, before, longer term, people are able to return to their home. Following discharge from Redcar, patients will be either back to their normal place of residence or to Whitby hospital for the remainder of their more routine rehabilitation.
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Dr George Campbell, Whitby GP and HRW CCG Vice Chair, said: “We are really pleased we have been able to find a simpler solution for emergency stroke care in the Whitby area. Patients will be taken directly to James Cook University Hospital
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RESUSCITATION TODAY - AUTUMN 2015
Following this, the more specialist rehabilitation
for all their main treatment, rather than the two
25
EVIDENCE NEWS Once again, delegates will also have the opportunity to visit over 50 trade stands during the break out sessions and, with delegate rates starting from just £36.00 to include lunch, tea/coffee, etc., we believe Life Connections 2015 offers tremendous value for money. For full details, visit www.lifeconnections.uk.com We look forward to receiving your registration online via the above website or, by calling the Organisers on: 01322 660434.
EMS Gathering Ireland
RESUSCITATION TODAY - AUTUMN 2015
2016 promises to be a spectacular event held over two days (June 9th &10th) in the picturesque region of Killarney, Co. Kerry. There will be a packed schedule with top class national and international leaders in emergency care coming together to share their thoughts and expertise on a variety of topical subjects. We will take you out of the classroom and onto the lakes, mountains and the national park to optimize the educational experience in a most enjoyable atmosphere. Our renowned ‘learning with leisure’ sessions provide a fusion of EMS education with Killarney’s great outdoors – cutting edge topics presented in a way you will never forget! Killarney is easily accessible with Kerry International Airport close by providing direct flights from the UK, ferry ports and other forms of public transport also making a visit to the region known as ‘The Kingdom’ one to remember. The Malton Hotel, a luxurious 4 star venue
26
EVIDENCE NEWS “A highlight on next years programme will be a focus on agricultural type incidents ranging from injuries received from livestock and the potential dangers of slurry tanks to simulated specialised machinery entrapments. This will take place on a working farm and promises to be extremely informative and educational for those in attendance.” is home to EMS Gathering with special rates on offer for those attending. Located in the centre of Killarney and adjacent to the railway station, it’s also on the doorstep of the must see National Park. A highlight on next years programme will be a focus on agricultural type incidents ranging from injuries received from livestock and the potential dangers of slurry tanks to simulated specialised machinery entrapments. This will take place on a working farm and promises to be extremely
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EMS Gathering is very much a supporter of FOAMed and is delighted that SMACC (Social Media and Critical Care) an internationally renowned conference which is coming to Dublin in the days following EMS Gathering are collaborating to enhance medical education in their own
Whether responder or practitioner, hospital based or working in the ‘field’ the EMS Gathering will have something for you. We welcome all those associated in anyway with EMS from Ireland and abroad. This is a not-for-profit venture which will support your ongoing professional development. Please see www.emsgathering.com, join us on twitter @EMSgathering or Facebook for further details. Author: Kieran Henry
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EQUIPMENT NEWS What defines Success? An Open Minded View to Outcomes The Practicalities of Incorporating Intraosseous access into Emergency Education Scenarios.
Learning Objectives
healthcare practitioner who may be asked or
• Create a programme of simulation-based
expected to insert an intraosseous vascular
training allowing healthcare professionals
access device (IO VA) during clinical practice and
to participate in a “real experience” learning
combined underpinning theoretical information,
environment with guided interaction
skills practice and a variety of simulation scenarios using differing debrief methods.
• Provide an additional method of experiential learning in a safe & interactive environment
Introduction The purpose of the simulation pilot project undertaken by Teleflex in collaboration with the Health Education Yorkshire and the Humber (HEYH) Regional Clinical Skills Advisors RCSA was to determine the feasibility of incorporating simulation-based training to complement the current training package for the Arrow® EZ-IO® Intraosseous Vascular Access System. Background Teleflex is a global provider of medical devices used in critical care offered a range of training packages to support the use the Arrow® EZ-IO® Intraosseous Vascular Access System which provides immediate vascular access for the delivery of essential medications and fluids. However, Teleflex recognised the current education programme was behind the growing trend for simulation based learning. The HEYH RCSA Team not only has experience in simulation training and good working relationships with the region’s simulation centres but is responsible for ensuring that education, training, and workforce development drives patient safety and patient outcomes.
A three phase evaluation of the workshops using a self-rated Likert scale and a follow-
• Offer practitioners the opportunity to participate in clinical scenarios from a
up survey to report on the impact on
multi professional stance to support team
practice (either online or by telephone) was
decision making.
implemented. All information was collected and collated by the locality RCSA to eliminate
• Produce differing scenarios, all including a
commercial bias.
difficult vascular access situation where the
• Pre-workshop – baseline knowledge check need to consider different options of access
was required.
• Post-workshop – determine whether
content met objectives and new level
• Provide appraisal of practice through
of knowledge has been attained. Fig.3
consolidation of learning with guided
reflection in the form of debrief
demonstrates self-assessment of
knowledge and skills related to anatomy
and physiology of the bone and medullary space before and after the day’s activities. The pilot project included facilitation of four
Method
simulation-based workshops delivered at a different NHS Trust within a six-month period.
• 3 month post-workshop – to determine
A total of 49 delegates from varied healthcare
that the programme equipped the delegates
professions attended the four workshops.
with the skills & knowledge required to
(Fig2) Each workshop was aimed at any
transfer the learning into practice.
Fig.1 A+E Scenario
RESUSCITATION TODAY - AUTUMN 2015
Simulation-based medical education enables knowledge, skills and attitudes to be acquired for all healthcare professionals in a safe, educationally orientated and efficient manner (Aggarwal 2010) Simulation can recreate scenarios that are rarely experienced allowing healthcare professionals to be interactive and gain confidence with potentially challenging situations, for example, when faced with difficult vascular access challenges in critical or life-threatening emergencies (Fig.1)
Evaluation
29
EQUIPMENT NEWS Each pilot site provided an interim report and a
address an serious untoward incident or to
that may not have been realised without the pilot
collective summary of the follow-up survey. The
implement a new policy.
workshops……what initially seemed intangible was in essence a tangible outcome.
results confirmed that all 4 workshops were completed and evaluated and all the primary
As it was, significant learning took place and a
learning objectives were met. The three
realisation quite early on that success is based
Fig.4 A pilot will be a success if executed
processes evaluated i.e. theory, practical and
upon open-minded entrepreneurialism. No-
correctly and providing results that are
organisational all scored good to excellent.
one embarks on a project on this scale without
reliable (whether positive or negative). Positive
feeling passionate and optimistic about the
results prove a theory is correct. Negative
Comments on areas for improvement
outcome. Working alongside the HEYH RCSA
results are only so because they disprove the
included:
team, it was clear that they saw the value in the
initial theory. However, this ‘negativity’ can save
challenge and had the spirit and passion to
us from engaging in disastrous implementation
‘I would have liked more on A+P of medullary
grasp and support the process, regardless of
on a large scale (Bassi 2010)
space’
direction or outcome.
‘More detail on patient positioning would have
Achieving expectations can sometimes be
Aggarwal R. (2010) Training and simulation for
been useful’
tempered by the pilot aspect of a project
patient safety Quality and Safety in Health Care
and it soon became apparent that other
2010;19:i34-i43
References
‘Specific training on the use of lignocaine’
objectives which had not been considered were emerging. Networking opportunities
Bassi R. (2010) Practical guide to Pilot Projects
‘It would have been helpful to have more
and strong relationships have developed
and Large Scale Deployment of ICTs in the
practical time with the EZ-IO device’
as a consequence of the pilot scheme. The
Education Sector www.gesci.org/assets/files/
foundations of these relationships were
Knowledge%20Centre/pilot-ICT-projects.pdf
Limitations
established during the planning, delivery and
(Accessed 15/06/15)
The lack of opportunity to put the training into
on-going review processes and have continued
practice once back in the clinical environment
to flourish since. This has impacted on the
Authors
may have impacted on the individual’s follow-
scope and quality of training being delivered
Carrie Gosland RGN
up evaluation. The estimated time to plan
by Teleflex and although a programme of
Clinical Manager Immediate Care Team Teleflex
and implement the workshops took longer
simulation is still to be established, the current
than predicted – 18 months, this was due to
training has been enhanced.
some unforeseen structural changes within the
Law, PGCE, FHEA
Teleflex organisation that resulted in a period
These ‘secondary’ objectives have created a much
Regional Clinical Skills Advisor - Health
of ‘settling in’ Also, working in 4 individual NHS
longer term impact and have led to opportunities
Education Yorkshire and the Humber
sites involved working with four different teams, each of whom had internal commitments to fulfill above and beyond the pilot workshops also delayed progress somewhat. Discussion The purpose of the pilot project was to assess the viability and evaluate the potential of incorporating simulation-based training to complement the current training package for the Arrow® EZ-IO® Intraosseous Vascular RESUSCITATION TODAY - AUTUMN 2015
Access System. The pilot was a success and the intended objectives were met (Fig.4) but these became more subsidiary when compared to the unexpected outcomes and the on-going impact that still continues. The project was planned as a generic programme but prior to execution of the separate workshops, each NHS hospital had a further individual plan – their own agenda to help reduce the element of risk where possible and somehow better fulfil their organisational requirements. This may have been necessary to help justify their commitment to the pilot or to use the opportunity to address a much deeper more urgent need, for example, to
30
Jane P Nicklin CertHE ODP, MA Healthcare
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