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Cardiogenic shock (CS) represents a spectrum of hemodynamic deficits in which the cardiac output is insufficient to provide adequate tissue perfusion. The Impella (Abiomed Inc, Danvers, MA) device, a contemporary percutaneous ventricular support, is most often indicated for classic, deteriorating, and extremis Society for Coronary Angiography and Intervention stages of CS, which describe CS that is not responsive to optimal medical management and conventional treatment measures. Impella devices are an evolving field of mechanical support that is used with increasing frequency. Critical care transport medicine crews are required to transport patient support by the Impella device with increasing frequency. It is important that critical care transport medicine crews are familiar with the Impella device and are able to troubleshoot complications that may arise in the transport environment. This article reviews many aspects of the Impella device critical to the transport of this complex patient population.

Background Tranexamic acid (TXA) has been shown to reduce mortality in the treatment of traumatic hemorrhage. This effect seems most profound when given early after injury. We hypothesized that extending a protocol for TXA administration into the prehospital aeromedical setting would improve outcomes while maintaining a similar safety profile to TXA dosed in the emergency department (ED). Materials and methods We identified all trauma patients who received TXA during prehospital aeromedical transport or in the ED at our urban level I trauma center over an 18-mo period. These patients had been selected prospectively for TXA administration using a protocol that selected adult trauma patients with high-risk mechanism and concern for severe hemorrhage to receive TXA. Patient demographics, vital signs, lab values including thromboelastography, blood administration, mortality, and complications were reviewed retrospectively and analyzed. Results One hundred sixteen patients were identified (62 prehospital versus 54 ED). Prehospital TXA patients were more likely to have sustained blunt injury (76% prehospital versus 46% ED, P = 0.002). There were no differences between groups in injury severity score or initial vital signs. There were no differences in complication rates or mortality. Patients receiving TXA had higher rates of venous thromboembolic events (8.1% in prehospital and 18.5% in ED) than the overall trauma population (2.1%, P Conclusions Prehospital administration of TXA during aeromedical transport did not improve survival compared with ED administration. Treatment with TXA was associated with increased risk of venous thromboembolic events. Prehospital TXA protocols should be refined to identify patients with severe hemorrhagic shock or traumatic brain injury.

Many health systems rely on helicopter EMS (HEMS) to transfer ST-elevation myocardial infarction (STEMI) patients for percutaneous coronary intervention (PCI) to a hospital with a catheterization laboratory. Mortality rates increase with the time to reperfusion, so reducing delays is imperative. For interhospital STEMI transfers, the time spent in the initial hospital from arrival until departure (door-in to door-out interval or DIDO) should be minimized.To evaluate the impact of a series of process improvements to reduce DIDO intervals for STEMI patients transferred via a hospital based HEMS program.Changes made to the STEMI transfer protocol in March 2011 were: (a) allowing transferring facilities to request HEMS before identifying an accepting cardiologist or hospital, with one hospital serving as a default PCI center in the case of delays, (b) limiting continuous infusions to those absolutely necessary for the transfer flights and (c) training flight crews to minimize time at bedside. Trained dual abstractors conducted structured medical record reviews for all STEMI patients 18 years and older, transferred to a PCI facility by HEMS from March 2011 to December 2012. Discrepancies were adjudicated. We compared DIDO intervals to a historical control cohort from 2007. We used the Mann-Whitney U test to compare times, and calculated differences with 95% confidence intervals.Of 244 patients identified, six were excluded due to incomplete data. The historical cohort included 179 cases. Mean age was 59 (SD 14) years, 81% were white and 66% male. There were no differences in patient characteristics or door to EKG times between the cohorts. Median door-in to door-out interval decreased from 83 minutes (IQR 43) to 68 minutes (IQR 31) (difference 15 minutes, 95% CI 8 to 21, P.0001). EKG to HEMS request decreased 21 minutes (95% CI 17 to 25, P.0001), and HEMS ground time decreased 3 minutes (95% CI 2 to 4, P.0001). There was a 32% absolute increase in the proportion of patients with EKG to helicopter request interval35 minutes (83% vs 51%, difference 32%, 95% CI 24% to 41%, P.0001).HEMS-focused process improvements can significantly reduce the DIDO interval times for STEMI patients transferred for PCI.

ACADEMIC EMERGENCY MEDICINE 2012; 19:153–160 © 2012 by the Society for Academic Emergency Medicine Abstract Objectives: ST-segment elevation myocardial infarction (STEMI) care is time-dependent. Many STEMI patients require interhospital helicopter transfer for percutaneous coronary intervention (PCI) if ground emergency medical services (EMS) initially transport the patient to a non-PCI center. This investigation models potential time savings of ground EMS requests for helicopter EMS (HEMS) transport of a STEMI patient directly to a PCI center, rather than usual transport to a local hospital with subsequent transfer. Methods: Data from a multicenter retrospective chart review of STEMI patients transferred for primary PCI by a single HEMS agency over 12 months were used to model medical contact to balloon times (MCTB) for two scenarios: a direct-to-scene HEMS response and hospital rendezvous after ground EMS initiation of transfer. Results: Actual MCTB median time for 36 hospital-initiated transfers was 160 minutes (range = 116 to 321 minutes). Scene response MCTB median time was estimated as 112 minutes (range = 69 to 187 minutes). The difference in medians was 48 minutes (95% confidence interval [CI] = 33 to 62 minutes). Hospital rendezvous MCTB median time was estimated as 113 minutes (range = 74 to 187 minutes). The difference in medians was 47 minutes (95% CI = 32 to 62 minutes). No patient had an actual MCTB time of less than 90 minutes; in the scene response and hospital rendezvous scenarios, 2 of 36 (6%) and 3 of 36 (8%), respectively, would have had MCTB times under 90 minutes. Conclusions: In this setting, ground EMS initiation of HEMS transfers for STEMI patients has the potential to reduce MCTB time, but most patients will still not achieve MCTB time of less than 90 minutes.

At 2:10 pm, a 40-year-old Caucasian woman with no known medical history called 911 complaining of substernal, crushing chest pain that had started 2 to 3 hours before she called emergency medical services (EMS). EMS arrived at 2:24 pm and obtained a 12-lead electrocardiogram (ECG) diagnostic of ST-segment elevation myocardial infarction (STEMI) at 2:36 pm. University Air Care was requested by local EMS at 2:42 pm to respond directly to the cardiac scene in rural Ohio for rapid transport to a facility capable of performing percutaneous coronary intervention (PCI). The closest PCI-capable facility was approximately 35 minutes away by ground or 13 minutes by air. The closest non-PCI hospital was approximately 20 minutes away by ground (Fig. 1).

A 37-year-old man was severely burned while trying to fill a lighter with fuel while smoking. He sustained full-thickness (third-degree) burns over 60% to 70% of his body, including the oropharynx. A ground-based paramedic was unable to orotracheally intubate the patient after the administration of morphine and diazepam. The flight crew's assessment found an awake, alert man who was unable to speak because of his oral injuries. The Glasgow Coma Scale was estimated to be 10. In addition, the patient was wheelchair-bound from an undefined neuromuscular disease. The patient was successfully intubated by the flight team as in the following description.

Perhaps no patient population invokes more dread in the prehospital setting than the sick pregnant patient. Assessing the pregnant patient in shock requires identifying sources of potential shock, knowledge of the unique physiologic changes of pregnancy influencing initial therapies, and transporting in an efficient manner to maximize benefit to the patient and expedite the transfer to definitive obstetric care. Here we present a case of air medical transport of a pregnant patient in shock with a review of the relevant literature. Case Report Air medical transport was dispatched to a rural community college for a 37-year-old woman found on the floor in a restroom 35 weeks pregnant and complaining of abdominal pain. The patient denied any trauma to the abdomen or spontaneous rupture of membranes but stated that she had been having unrelenting pain in her abdomen for approximately 30 minutes. She denied contractions but described a sharp stabbing sensation extending from her xiphoid process to her pelvis. She denied any vaginal bleeding or loss of consciousness but complained of extreme dyspnea. The patient had a history of two live births via cesarean section and five miscarriages due to anti-phospholipid antibody syndrome for which she was on daily heparin injections for thrombosis prophylaxis. On examination, she was ill-appearing and tachypneic with a respiratory rate of 38 breaths/min, a pulse of 100 beats/min, and blood pressure of 76/44 mmHg. Oxygen saturation was 100% on nonrebreather mask. Her abdomen was distended, gravid, and tender to palpation without ecchymosis or palpable contractions. Her extremities were noted to be cool and pale. She was able to follow commands but was mildly confused and combative. Emergency medical services had established a 20-gauge intravenous line with normal saline. The patient continued on nonrebreather while fluids were switched to pressure infuser. She was transferred to the aircraft on a wedge under the right side. A second intravenous line was established. During the 10-minute flight, medical control arranged for transport directly to the operating room because of her persistent hypotension. On arrival the obstetrical team performed an emergent midline classical cesarean section, with the fetus noted to be free-floating outside a ruptured uterus. Approximately 3 liters of blood were evacuated. Simultaneous delivery of the infant and resuscitation of the mother occurred while the obstetric and trauma teams packed the abdominal cavity and primarily repaired the uterus. The infant was resuscitated for an hour without success. The patient had a prolonged hospitalization but ultimately recovered completely.

Study objective Early reperfusion portends better outcomes for ST-segment elevation myocardial infarction (STEMI) patients. This investigation estimates the proportions of STEMI patients transported by a hospital-based helicopter emergency medical services (EMS) system who meet the goals of 90-minute door-to-balloon time for percutaneous coronary intervention or 30-minute door-to-needle time for fibrinolysis. Methods This was a multicenter, retrospective chart review of STEMI patients flown by a hospital-based helicopter service in 2007. Included patients were transferred from an emergency department (ED) to a cardiac catheterization laboratory for primary or rescue percutaneous coronary intervention. Out-of-hospital, ED, and inpatient records were reviewed to determine door-to-balloon time and door-to-needle time. Data were abstracted with a priori definitions and criteria. Results There were 179 subjects from 16 referring and 6 receiving hospitals. Mean age was 58 years, 68% were men, and 86% were white. One hundred forty subjects were transferred for primary percutaneous coronary intervention, of whom 29 had no intervention during catheterization. For subjects with intervention, door-to-balloon time exceeded 90 minutes in 107 of 111 cases (97%). Median door-to-balloon time was 131 minutes (interquartile range 114 to 158 minutes). Thirty-nine subjects (21%) received fibrinolytics before transfer, and 19 of 39 (49%) received fibrinolytics within 30 minutes. Median door-to-needle time was 31 minutes (interquartile range 23 to 45 minutes). Conclusion In this study, STEMI patients presenting to non–percutaneous coronary intervention facilities who are transferred to a percutaneous coronary intervention–capable hospital by helicopter EMS do not commonly receive fibrinolysis and rarely achieve percutaneous coronary intervention within 90 minutes. In similar settings, primary fibrinolysis should be considered while strategies to reduce the time required for subsequent interventional care are explored.

Heart failure is a disease of epidemic proportions. Almost five million Americans suffer from heart failure and over 400,000 patients are newly diagnosed with heart failure each year. Indeed, heart failure is now the only cardiovascular disease that is increasing in incidence and prevalence. Costs related to heart failure are $18.8 billion per year and are steadily increasing. Although the outpatient management of these patients has seen substantial improvement in the last two decades, emergency department (ED) treatment of acute decompensated heart failure has remained largely unchanged since the late 1970s. Current ED therapy consists of diuretics, intravenous vasodilatators, and inotropes. Recently, the outcomes of several high-profile clinical trials evaluating intravenous nesiritide (human B-type natriuretic peptide) have suggested a benefit in select hospitalized patients. Such a therapy has potential to provide a therapeutic addition or alternative for emergency heart failure management. We discuss these trials' results, suggest their relationship to the ED population, and provide recommendations for appropriate ED use.

The following is a recount of an actual patient case involving air transport. Minor details of the case may have been changed, solely to protect the privacy of the patient. The initial presentation and treatment will be described, followed by several questions, in this issue. Readers are invited to submit responses to the questions and other thoughts or comments to David Ross, DO, at DRDR0682@aol.com . In the next issue, relevant reader responses will be published. We will conclude the case in the next issue with a discussion of how the patient was actually managed, the outcome, a review of the related medical literature, and interviews with medical/transport experts, where appropriate. We strongly encourage reader participation. If you have a case that might be suitable as a subject for Case Review, please submit the details to David Ross at the above email address.