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Objectives. This study was conducted to test out-of-hospital performance of a noninvasive radial artery tonometry device to assess blood pressure (BP), providing readings every 10-12 seconds. The primary objective was to determine the correlation between noninvasive BPs calculated with radial artery tonometry and standard oscillometric cuff methods. The secondary objective was to determine whether the difference observed between the two techniques was consistent over the range of BPs measured. Methods. This prospective trial enrolled adults transported by helicopter (n = 9 patients), fixed-wing airplane (n = 1), or ground vehicle (n = 10) of a single transport service. Patients had BP assessed simultaneously, by both standard automatic cuff and radial artery tonometry device, every 5 minutes. Data were assessed with correlation coefficients, and Bland-Altman techniques were utilized to assess for bias over the range of mean arterial pressures (MAPs) encountered. For all tests, p was set at 0.05. Results. No major problem with radial artery tonometry device field performance was noted. There were 139 pairs of MAP assessments in 20 patients. The correlation coefficient for the two assessment modalities was 0.96. Bland-Altman bias plot and Pitman's test (p = 0.11) revealed good correlation between the two assessment mechanisms over the entire range of MAPs (42 to 163 mm Hg) encountered in the study. Conclusion. The radial artery tonometry device provided MAP assessments that were highly correlated with readings from a standard oscillometric device. The radial artery tonometry device performed well in a variety of patient types and in multiple transport vehicles, and there was no sign that its performance was adversely affected by the out-of-hospital setting. [ABSTRACT FROM AUTHOR]

Introduction: We performed this study to quantify resources required by mechanically ventilated patients with hypoxemia after critical care transport (CCT) and to assess short-term clinical outcomes., Methods: We performed a retrospective review of transports of patients with severe hypoxemic respiratory failure from referring hospitals to 3 tertiary care hospitals to assess the outcomes including in-hospital mortality, ventilator days, intensive care unit length of stay (LOS), hospital LOS, disposition, and reported neurologic status on hospital discharge as well as medical interventions specific to acute respiratory failure and critical care., Results: Of 230 patients transported with hypoxemic respiratory failure, 152 survived to hospital discharge, for a mortality rate of 34.5%, despite a predicted mortality of 64% by Acute Physiology and Chronic Health Evaluation II (APACHE II) score. Twenty-five percent of patients were treated with neuromuscular blockade, 10.1% received inhaled pulmonary vasodilators, and extracorporeal membrane oxygenation was initiated in 2.6%., Conclusions: In this cohort with hypoxemic respiratory failure transported to tertiary care facilities, patients had a mortality rate comparable to patients with acute respiratory distress syndrome treated with best practices and a mortality rate lower than predicted based on APACHE-II score. The risks of CCT are outweighed by the benefits of transfer to a tertiary care facility, and pretransport hypoxemia should not be used as an absolute contraindication to transport.

Unlabelled: Introduction Inter-facility transport of critically ill patients is associated with a high risk of adverse events, and critical care transport (CCT) teams may spend considerable time at sending institutions preparing patients for transport. The effect of mode of transport and distance to be traveled on on-scene times (OSTs) has not been well-described. Problem Quantification of the time required to package patients and complete CCTs based on mode of transport and distance between facilities is important for hospitals and CCT teams to allocate resources effectively., Methods: This is a retrospective review of OSTs and transport times for patients with hypoxemic respiratory failure transported from October 2009 through December 2012 from sending hospitals to three tertiary care hospitals. Differences among the OSTs and transport times based on the mode of transport (ground, rotor wing, or fixed wing), distance traveled, and intra-hospital pick-up location (emergency department [ED] vs intensive care unit [ICU]) were assessed. Correlations between OSTs and transport times were performed based on mode of transport and distance traveled., Results: Two hundred thirty-nine charts were identified for review. Mean OST was 42.2 (SD=18.8) minutes, and mean transport time was 35.7 (SD=19.5) minutes. On-scene time was greater than en route time for 147 patients and greater than total trip time for 91. Mean transport distance was 42.2 (SD=35.1) miles. There were no differences in the OST based on mode of transport; however, total transport time was significantly shorter for rotor versus ground, (39.9 [SD=19.9] minutes vs 54.2 [SD=24.7] minutes; P <.001) and for rotor versus fixed wing (84.3 [SD=34.2] minutes; P=0.02). On-scene time in the ED was significantly shorter than the ICU (33.5 [SD=15.7] minutes vs 45.2 [SD=18.8] minutes; P <.001). For all patients, regardless of mode of transportation, there was no correlation between OST and total miles travelled; although, there was a significant correlation between the time en route and distance, as well as total trip time and distance., Conclusions: In this cohort of critically ill patients with hypoxemic respiratory failure, OST was over 40 minutes and was often longer than the total trip time. On-scene time did not correlate with mode of transport or distance traveled. These data can assist in planning inter-facility transports for both the sending and receiving hospitals, as well as CCT services. Wilcox SR , Saia MS , Waden H , McGahn SJ , Frakes M , Wedel SK , Richards JB . On-scene times for inter-facility transport of patients with hypoxemic respiratory failure. Prehosp Disaster Med. 2016;31(3):267-271.

Objective: Although the benefit of transferring patients with hypoxemic respiratory failure to tertiary care centers has been shown, transporting hypoxemic patients remains controversial, given the risk of desaturation in transit., Methods: We performed a retrospective analysis of a database of critical care transports (CCTs) of patients with hypoxemic respiratory failure to quantify the number, types, and effects of ventilator changes performed by the CCT teams. We evaluated the changes in fraction of inspired oxygen (FiO2), positive end-expiratory pressure (PEEP), tidal volume, both FiO2 and PEEP, and the administration of a neuromuscular blocking medication to assess for an association with an improvement in the arterial partial pressure of oxygen (PaO2) from the sending to the receiving hospitals., Results: Ventilator changes were made in 211 (89%) of the 237 identified transports, with significant changes in the tidal volume, PEEP, and FiO2. Analysis of variance revealed a significant relationship between changes in FiO2, PEEP, tidal volume, FiO2 and PEEP, and the administration of neuromuscular blocking agents and change in PaO2 (F5,1037 = 119.6, P < .001). Multivariable regression analyses showed a significant association between an increase in PaO2 and increasing FiO2, increasing FiO2 and PEEP, and the administration of a neuromuscular blocking medication., Conclusion: The CCT team performed multiple changes to ventilators. Complex ventilator management was associated with a higher PaO2 on arrival., (Copyright © 2016 Air Medical Journal Associates. Published by Elsevier Inc. All rights reserved.)

Objective: The purpose of this study is to measure the rate and magnitude of changes in oxygenation that occur in patients with hypoxemic respiratory failure after transport by a critical care transport team., Methods: We performed a retrospective review of 239 transports of patients with hypoxemic respiratory failure requiring a fraction of inspired oxygen (Fio2) > 50% transported from October 2009 to December 2012 from referring hospitals to 3 tertiary care hospitals. We analyzed the change the ratio of the partial pressure of oxygen in the blood to FiO2 from the sending to the receiving hospital as well as the percentage saturation of oxygen (Spo2) before, after, and en route., Results: The mean change in the Pao2/Fio2 ratio from the sending to the receiving hospital was an increase of 27.62 (95% confidence interval [CI], 15.84-39.40; P = .0003). The mean change in Pao2 was an increase of 27.85 mm Hg (CI, 17.49-38.22; P < .0001). The mean Spo2 was not significantly changed at -0.12 (CI, - 1.69 to 1.45, P = .9). Despite improvement in the Pao2/Fio2 ratio and a stable Spo2 on arrival, 28.1% of patients desaturated to Spo2 < 90% in transport., Conclusion: In patients with hypoxemic respiratory failure, Pao2/Fio2 and Pao2 increased after transport by a critical care transport team despite 28.1% of patients desaturating with hypoxemia in transit., (Copyright © 2015 Air Medical Journal Associates. Published by Elsevier Inc. All rights reserved.)

Introduction: Critical care transport (CCT) teams must manage a wide array of medications before and during transport. Appreciating the medications required for transport impacts formulary development as well as staff education and training. Problem As there are few data describing the patterns of medication administration, this study quantifies medication administrations and patterns in a series of adult CCTs., Methods: This was a retrospective review of medication administration during CCTs of patients with severe hypoxemic respiratory failure from October 2009 through December 2012 from referring hospitals to three tertiary care hospitals., Results: Two hundred thirty-nine charts were identified for review. Medications were administered by the CCT team to 98.7% of these patients, with only three patients not receiving any medications from the team. Fifty-nine medications were administered in total with 996 instances of administration. Fifteen drugs were each administered to only one patient. The mean number of medications per patient was 4.2 (SD=1.8) with a mean of 1.9 (SD=1.1) drug infusions per patient., Conclusions: These results demonstrate that, even within a relatively homogeneous population of patients transferred with hypoxemic respiratory failure, a wide range of medications were administered. The CCT teams frequently initiated, titrated, and discontinued continuous infusions, in addition to providing numerous doses of bolused medications.

Trauma outcomes are improved by protocols for substantial bleeding, typically activated after physician evaluation at a hospital. Previous analysis suggested that prehospital vital signs contained patterns indicating the presence or absence of substantial bleeding. In an observational study of adults (aged ≥18 years) transported to level I trauma centers by helicopter, we investigated the diagnostic performance of the Automated Processing of the Physiological Registry for Assessment of Injury Severity (APPRAISE) system, a computational platform for real-time analysis of vital signs, for identification of substantial bleeding in trauma patients with explicitly hemorrhagic injuries. We studied 209 subjects prospectively and 646 retrospectively. In our multivariate analysis, prospective performance was not significantly different from retrospective. The APPRAISE system was 76% sensitive for 24-h packed red blood cells of 9 or more units (95% confidence interval, 59% - 89%) and significantly more sensitive (P < 0.05) than any prehospital Shock Index of 1.4 or higher; sensitivity, 59%; initial systolic blood pressure (SBP) less than 110 mmHg, 50%; and any prehospital SBP less than 90 mmHg, 50%. The APPRAISE specificity for 24-h packed red blood cells of 0 units was 87% (88% for any Shock Index ≥1.4, 88% for initial SBP <110 mmHg, and 90% for any prehospital SBP <90 mmHg). Median APPRAISE hemorrhage notification time was 20 min before arrival at the trauma center. In conclusion, APPRAISE identified bleeding before trauma center arrival. En route, this capability could allow medics to focus on direct patient care rather than the monitor and, via advance radio notification, could expedite hospital interventions for patients with substantial blood loss.

Objective: Pain relief is a key out-of-hospital patient care outcome measure, yet many trauma patients do not receive prompt analgesia. Although specialty critical care transport (CCT) teams provide analgesia frequently, successfully, and safely, there is still a population of CCT patients to whom analgesia is not offered. We report the factors associated with non-administration of analgesia and with analgesic effect in trauma patients cared for by CCT teams., Methods: This is a retrospective review of consecutive transport records for nonintubated trauma patients with self-reported pain during specialty CCT care. Patient demographics, CCT interventions, clinical traits, and pain self-reports are measured. Means comparisons are made with a univariate analysis of variance, and odds ratios (ORs) with 95% confidence intervals (CIs) are reported for between-group comparisons., Results: Of the 209 enrolled patients, 169 (80.9%; 95% CI, 75.6%-86.2%) were treated (147 received analgesia and 22 offered analgesia but refused). In patients with pain scale documentation (n=145), self-reported pain on a scale from 0 to 10 decreased from 6.8+/-2.8 to 3.3+/-2.4 (P

Background: Our state has consensus guides for helicopter emergency medical services (HEMS) scene dispatch, based on physiologic, anatomic, and special criteria (e.g., ejection from a vehicle, age < 10 or > 55 years). There has been much attention paid to improving HEMS triage criteria, but less focus on whether current HEMS uses meet existing criteria., Objectives: To assess a HEMS program's compliance with regional air medical dispatch guidelines and to identify factors associated with noncompliant flights., Methods: Using chart review and discussion with referring agencies, we conducted a consecutive case review of a HEMS program's initial 100 flights in one year (2005), collecting data pertinent to triage, prehospital times, and hospital course. Analysis (p = 0.05) of the outcome "met triage criteria" (MTC) used Kruskal-Wallis and Fisher's exact tests. Logistic regression, reporting odds ratios (ORs) with 95% confidence intervals (CIs), was used to adjust for covariates while assessing predictors of the dichotomous outcome MTC. The predictors assessed included demographics, advanced life support (ALS) scene presence, and whether transports occurred during rush hours (0700-1000 and 1600-1900)., Results: The 100 patients (98 blunt trauma; 73% male) from four Massachusetts emergency medical services (EMS) regions (n = 94) and New Hampshire (n = 6) were classified as MTC in 73% of cases. Physiologic criteria were met in 19% of cases (they were the sole criterion met in one case), anatomic criteria in 49% (sole criterion n = 24), and special criteria in 67% (sole criterion n = 15). There was no association between MTC status and age (p = 0.98), gender (p = 0.39), rush-hour transport (p = 0.81), or ALS-trained ground EMS presence on scene (p = 0.98). Analysis adjusting for transport distance and injury mechanism identified an association between EMS region and MTC transport status (p = 0.006); regions' likelihoods of MTC proportions ranged from 50% to 94%., Conclusion: Despite promulgation of consensus guidelines, nearly a fourth of HEMS transports were non-MTC. Wide interregional variation in the likelihood of MTC HEMS use provides a focus for further research/education. Regional systems should strive not only for the refinement of, but also the compliance with, HEMS triage guidelines.

Care provision and benchmarking for patients with ST-elevation myocardial infarction (STEMI) have focused on streamlining time between initial hospital presentation and opening of theinfarct-related artery. In a Boston-area regional system already characterized by expedited advanced life support (ALS) dispatch and paramedic performance of prehospital electrocardiogram (EKG), a critical pathway was designed that allows for helicopter dispatch based on ground ALS providers' STEMI diagnosis. The pathway dictates that as soon as ALS crews make the diagnosis of STEMI from their 12-lead EKG, they will contact Boston MedFlight (BMF) and a helicopter will be immediately dispatched to the participating community hospital (Lawrence General Hospital [LGH]). Based on historical and predicted time patterns, it is expected that BMF will arrive at LGH soon after the ALS ambulance delivers the patient to the LGH emergency department (ED). The patient will then undergo BMF transport from the ED into central Boston with direct transfer into an awaiting cardiac catheterization suite (ie, bypassing the receiving hospital ED). The pathway minimizes the delay between patient arrival at LGH and BMF arrival for transport to the catheterization laboratory. It is hoped that implementation of the critical pathway will allow the region's patients with STEMI to achieve coronary arterial patency within 90 minutes of LGH presentation. If the pathway proves effective, it can serve as a model for other regions and programs with similar clinical and logistic situations and advance the concept of "diagnosis-to-balloon" time.

Introduction: Pain relief is one of the most important interventions for out-of-hospital patient care providers. This paper documents the need for and benefits from the administration of fentanyl to trauma patients during critical care transport., Methods: We underwent a retrospective review of the transport charts of 100 trauma patients who received fentanyl analgesia during transport and who were able to use a numeric response scale to rate their pain from 0 to 10., Results: Mean initial pain report was 7.6 +/- 2.2 units, relieved to 3.7 +/- 2.8 units by a mean total fentanyl dose of 1.6 +/- 0.8 microg/kg (P < .001). Neither initial pain level nor pain relief differed between male and female patients, but did differ between patients originating at the site of injury and those transferred between hospitals. Fentanyl dose correlated poorly with the magnitude of pain relief (r = 0.22), but a dose greater than 2 microg/kg provided more relief than lower doses (5.1 +/- 2.1 vs 3.6 +/- 2.4, P < .02)., Conclusion: Fentanyl analgesia from these critical care transport teams provided significant pain relief to trauma patients. Pain reduction was greater for patients who received more than 2.0 microg/kg of fentanyl.

This study assessed frequency, safety and efficacy of prehospital fentanyl analgesia during 6 months' adult and pediatric helicopter trauma scene transports (213 doses in 177 patients). We reviewed flight records for pain assessment and analgesia provision, effect, and complications. Analgesia was administered to 46/49 (93.9%) intubated patients. In non-intubated patients, pain assessment was documented in 112 of 128 (87.5%), and analgesia was offered, or there was no pain, in 97/128 (75.8%). Of the 67 non-intubated patients to whom analgesia was administered, post-analgesia pain assessment was documented in 62 (92.5%) and pain improved in 53 (79.1% of 67). Post-analgesia blood pressure dropped below 90 torr in 2/177 cases (1.1%, 95% confidence interval [CI] 0.1-4.0%). Post-analgesia S(p)O(2) did not drop below 90% in any patients (95% CI 0-2.3%). In this study, prehospital providers performed well with respect to pain assessment and treatment. Fentanyl was provided frequently, with good effect and minimal cardiorespiratory consequence.

The study goal was the analysis of effectiveness of hemodynamic management of patients undergoing interfacility transport for suspected acute aortic dissection (SAAD). Our retrospective, consecutive-case review examined 62 nonhypotensive patients transported by an air emergency medical services (EMS) service during 1998 to 2002, with referral hospital diagnosis of SAAD. Of patients with systolic blood pressure (SBP) less than 120 upon air EMS arrival, antihypertensives had been given in only 23/42 (54.8%). In 19 cases where pretransport SBP is less than 120, with no referral hospital antihypertensive therapy given, median pretransport SBP was 158 (range, 122-212). In 20/62 cases (32.3%), the air EMS agency instituted antihypertensive therapy, which was successful; of 42 cases with pretransport SBP less than 120, mean intratransport SBP decrement was 24 (95% confidence interval, 16-32). In patients undergoing transport for SAAD, pretransport hemodynamic therapy was frequently omitted and often inadequate, generating an opportunity for air EMS intervention. Education to improve SAAD care should focus upon both referral hospitals and transport services.

In patients with traumatic injuries, prehospital hypotension that resolves by Emergency Department (ED) arrival is of uncertain significance. We examined the impact of prehospital hypotension (PH) in normotensive ED patients with traumatic injuries on predicting mortality and chest/abdominal operative intervention. A retrospective cohort study was conducted of consecutive patients undergoing helicopter transport to two trauma centers between 1993 and 1997. Outcomes were mortality and chest or abdominal operative intervention. Of 545 scene transports, 55 (10.1%) patients were hypotensive on ED arrival, leaving 490 normotensive ED patients. Of 490 patients, 35 (7%) had PH and 455 (93%) had no PH. Multiple logistic regression showed the PH group to have a relative risk for death of 4.4 (95% CI: 1.2-16.6, p < 0.03) and for chest or abdominal operative intervention of 2.9 (1.1-7.6, p < 0.03). In this study of normotensive trauma center patients, prehospital hypotension was associated with increased risk of mortality and significant chest or abdominal injury.

Objective: To evaluate the frequency of concomitant injuries that can complicate and/or contraindicate the use of traction splints (TSs) for femur fracture immobilization (FFI) in a population of multisystem trauma patients., Methods: This was a descriptive, prospective study utilizing a data collection tool to identify patients with multisystem trauma for which a TS was in place for FFI. Patient care records and follow-up diagnoses were reviewed to identify patients with positive femur fracture(s) who concurrently had injuries that can complicate and/or contraindicate TS use. Injuries considered to complicate or contraindicate traction splint use include 1) pelvic injury, 2) patellar fracture or ligamentous knee injury, and 3) tibia/fibula fracture., Results: Forty patients were identified as having a TS in place with an underlying diagnosis of multisystem trauma. All 40 had follow-up diagnosis information available, 39 of which were positive for femur fracture on the side of the extremity on which the splint was placed, or bilaterally. The incidence of complicating and/or contraindicating injuries was 38%., Conclusion: Traction splints are commonly used in the prehospital and transport setting for immobilization of femur fractures. There are limited data available on the benefit of traction splint use for femur fracture in the prehospital or transport environment. This study identified that concomitant injuries that complicate and/or contraindicate traction splint use are common.

Based on its roots in military air evacuation, helicopter emergency medical services (HEMS) has always been emphasized as a tool for trauma transportation. Despite much discussion regarding resource allocation for HEMS, a literature search found little recent systematic review of pertinent studies. As HEMS utilization is subject to increased scrutiny in a health care dollar-conscious environment, it was felt that a compendium of available outcomes-related literature could assist those assessing utility of HEMS trauma transport. The current study utilized a Medline search to identify outcomes studies relative to HEMS trauma transport. The goal of this review is to provide a useful resource for those interested in pursuing systematic review of the HEMS trauma outcomes literature. The primary purpose of the review is bibliographic, but there is editorial comment after each paper's summary. The initial article in this two-part series focused on HEMS outcomes literature covering noninjured patients as well as papers assessing outcome in mixed trauma-nontrauma HEMS study groups.

While helicopter emergency medical services (HEMS) has its roots in military transport of wounded soldiers, rotor-wing transport is also used for a wide variety of nontrauma indications. Despite this common use of HEMS for noninjured patients, a Medline search found little systematic review of the literature pertinent to HEMS use for nontrauma. With HEMS utilization subject to appropriately increased scrutiny, those seeking to research HEMS utility in noninjured patients could benefit from existence of a collection of the topical literature. This paper aims to provide such a review, in the form of an annotated bibliography of Index Medicus journal studies assessing potential medical risks and benefits of HEMS transport for noninjured patients. The paper's goal is to provide a useful resource for those interested in pursuing more focused review of various sectors of the nontrauma HEMS literature. As such, the main objective of the article summaries is to provide a brief outline of study design and results; there is also limited editorial comment included after each summary.

Background: In 1996, when the Food and Drug Administration (FDA) approved use of thrombolytic therapy for ischemic stroke, interfacility transport of stroke patients assumed increasing urgency., Objective: To describe one helicopter emergency medical services (HEMS) program's 15-year experience with interfacility transport of patients with suspected stroke, with emphasis on reporting changing patterns seen after the advent of thrombolytic therapy for stroke., Methods: This was a retrospective study of patients undergoing HEMS transport, during 1985-1999, with a pre-transport diagnosis of suspected ischemic stroke. Data collected included patient demographics and times of symptom onset, community hospital arrival, community hospital request for HEMS, and receiving hospital arrival. Patients were divided into pre-thrombolysis era (1985-1995) and thrombolysis era (1996-1999). Group characteristics were compared using Pearson chi-square, Fisher's exact, rank-sum, and logistic regression analysis., Results: There were 192 total transports, 76 (40%) pre-thrombolysis era and 116 (60%) thrombolysis era. Thrombolysis era patients were more likely (p < 0.0001) to have time of symptom onset documented, and also had significantly (p = 0.0003) shorter time intervals between referring and receiving hospital arrival. The shorter time intervals were due in part to decreased time lapse between referring hospital arrival and that hospital's request for helicopter transport; thrombolysis era patients were 2.5 times more likely than pre-thrombolysis era patients to have HEMS activation within three hours of community hospital arrival., Conclusions: Helicopter EMS transport is playing an increasing role in interfacility transfer of patients with ischemic stroke. Earlier HEMS activation is associated with decreased time lapse between referral and receiving hospital arrival.

The objective was to compare rates of successful endotracheal intubation (ETI) and requirement for multiple ETI attempts in patients receiving etomidate (ETOM) versus succinylcholine (SUX). This retrospective study analyzed adults in whom oral ETI was attempted by a helicopter EMS (HEMS) service between July 1997 to July 1999. Data were from records of the HEMS service, which uses a RN/EMTP crew; analysis was with chi-square and logistic regression (P = .05). ETI was successful in 269 (97.8%) of 275 patients, with multiple attempts occurring in 54 (20.1%) of 269. Success rates for SUX (209 of 213, 98.1%) and ETOM (60 of 62, 96.8%) were similar (P = .62). However, of 60 ETOM patients successfully intubated, 7 (11.7%) required rescue succinylcholine. When these patients are tallied as ETOM failures and SUX successes, resultant success rates for ETOM (86.9%) and SUX (98.2%) are different (P = .001). ETOM patients were more likely (P = .004) than SUX patients to require multiple attempts (33.3% versus 16.3%). ETI success rates were high in patients receiving SUX or ETOM as primary adjuncts for airway control, but initial success was more likely with SUX, and ETOM patients were more likely to require multiple attempts.

Rotor-wing aircraft have previously proven utility in disaster operations, but recent expert reviewers have identified areas of potential improvement in integration of helicopter emergency medical services (HEMS) resources into disaster planning and management. This paper discusses salient points regarding helicopter operations in disaster management, using prior reports regarding rotor-wing aircraft utilization as a basis upon which to provide a concise review of HEMS operations in disasters.

Objectives: Guidelines for pediatric endotracheal tube (ETT) size and insertion depth are important in the helicopter EMS (HEMS) setting, where intubated patients are frequently transported by a non-physician flight crew providing protocol-based care in an environment noted for limitations in clinical airway assessment. The objectives of this study were to characterize, in a HEMS pediatric population, the frequency of compliance with guideline-recommended ETT size and insertion depth, and to test for association between guideline noncompliance and subsequent receiving hospital adjustment of ETT size or insertion depth., Design: This retrospective review analyzed 216 consecutive pediatric (age <14) scene and interfacility HEMS transports, of patients intubated before or during HEMS transport, by an urban two-helicopter HEMS service providing protocol-based care with a nurse/paramedic crew configuration. Patients were transported to one of three receiving academic pediatric referral centers. Pediatric Advanced Life Support (PALS) criteria for ETT size and insertion depth were used to assess guideline-appropriateness of pediatric ETTs. Receiving hospital records were reviewed to determine if post-transport ETT size or lipline adjustment were associated with guideline-appropriateness of size and lipline during HEMS transport. Univariate (chi-square and Fisher's exact) and multivariate (logistic regression) statistics were used to assess and control for the following covariates: intubator group (physician, flight crew, ground EMS), transport year, sex, age, transport type (scene versus interfacility), and receiving hospital. For all analyses, statistical significance was set at the 0.05 level., Results: The initial ETT size was within 0.5 mm of guideline-recommended sizes in 178 (83.6%) of the 213 patients for whom this data were available. Inappropriate sized ETTs were nearly always (32 of 35, 91.4%) too small. Compared to initial ETTs placed by ground EMS personnel, initial ETTs placed by flight crew or physicians were more likely to be appropriate as defined by guidelines (P = .008 and .032, respectively). Receiving hospitals changed the ETT size in 18 (8.3% of 216) cases. Receiving hospital ETT size change was more likely with later transport year (P = .018) and less likely in patients over 2 years of age (P = .03); there was no significant association between receiving hospital ETT size change and intubator group (P > .22) or guideline-appropriateness of ETT size (P = 0.94). The initial ETT insertion depth was within 1 cm of the guideline-recommended lipline in 86 (43.2%) of the 199 patients for whom this data were available. Inappropriate liplines were almost always (109 of 113, 96.5%) too deep. Compared to initial ETT liplines determined by ground EMS personnel, initial liplines determined by flight crew (P = .007), but not physician (P = .47) were more likely to be appropriate as defined by guidelines. Receiving hospitals changed the ETT insertion depth in 72 (33.3% of 216) cases. Receiving hospital lipline change was more likely (P = .03) in patients older than 2 years of age, but was not associated with intubator group (P = .75) or lipline guideline-appropriateness (P = .35)., Conclusions: As judged by frequently used guidelines, pediatric ETTs are often too small and commonly inserted too deep. However, this retrospective study, limited by lack of clinical correlation for ETT size and insertion depth, failed to find an association between lack of ETT size or lipline guideline compliance and subsequent ETT adjustment at receiving pediatric centers. This study's findings, which should be confirmed with prospective investigation, cast doubt upon the utility of pediatric ETT size/lipline guidelines as strict clinical or quality assurance tools for use in pediatric airway management.

Receiving trauma centers often duplicate laboratory and radiograph testing performed by referring institutions. Our objective was to quantify frequency and costs of this practice. In this prospective study of 104 consecutive interfacility-transported adult trauma patients flown by an emergency medical service to an urban level I center, flight crew noted which labs and radiographs were done at referring hospitals, which tests were sent with patients, and which were repeated on trauma center arrival. Overall, results from 246 of 283 (86.9%) laboratory tests and 241 of 249 (96.8%) radiographs done at referring hospitals were sent with patients. Repetition of laboratory tests at the receiving hospital was frequent regardless of whether initial results were sent (P = .6 by chi2), and radiograph repetition was unrelated to whether sent films were originals or copies (P = .2 by chi2). For these 104 patients, the receiving hospital charged $66,463 for repetition of work-up done at referring facilities.

Objective: To review the 5.5-year safety record of a protocol guiding fentanyl administration to pediatric trauma patients undergoing aeromedical transport., Methods: Retrospective review of an urban aeromedical program's trauma scene responses from October 1991 to March 1997 identified the study population as all pediatric patients (age <15 years) receiving fentanyl for analgesia during air transport. Patients receiving fentanyl concurrently with other agents, eg, paralytics, were not studied. The air transport team consisted of a flight nurse and flight paramedic who provided protocol-driven patient care with off-line medical control. Study patients' flight records were reviewed to determine vital signs (systolic blood pressure [SBP], heart rate [HR], and oxygen saturation [SAT]) before and after fentanyl administration. Postfentanyl vital signs were reviewed for evidence of hemodynamic or ventilatory compromise. Pre- and postfentanyl vital signs were compared with the paired t test (P < 0.05). Flight records were also analyzed for narrative information, eg, naloxone administration and assisted ventilation, indicative of fentanyl side effects., Results: Fentanyl (0.33-5.0 microg/kg) was administered 211 times to 131 patients who had a median age of 6.2 years (0.1-14 years), median Glasgow coma score (GCS) of 9 (3-15), and a mean pediatric trauma score of 8.3+/-2.4. Seventy-nine (60.3%) patients were intubated; these patients received 139 (65.9 %) of the 211 total fentanyl doses. No adverse effects from fentanyl were noted in flight record narratives. The median interval between fentanyl administration and postfentanyl vital sign assessment was 9.5 minutes (1-35 minutes). Median postfentanyl changes in SBP and HR were -4.7 and -2.9%, respectively. No patient became hypotensive after fentanyl administration. In nonintubated patients, mean postfentanyl SAT (99.2+/-1.3%) was not significantly different (P = 0.70) from prefentanyl SAT (99.1+/-1.3%), and no patient was noted to have clinically significant SAT decrement after fentanyl., Conclusion: Retrospective review of more than five years of prehospital fentanyl administration revealed no untoward events. Although prospective definitive demonstration of fentanyl's field use is pending, it is reasonable to continue discretionary fentanyl administration to injured pediatric children in pain.

Objective: To present guidelines for writing admission and discharge policies for adult intermediate care units., Data Sources: Opinion of practitioners with experience and expertise in managing critical and intermediate care units., Data Synthesis: Consensus was reached regarding the characteristics of patients best suited for management in an intermediate care unit, as supported by a literature review., Conclusion: Criteria were developed that define patients who are optimal candidates for management in an intermediate care unit.

This study's goal was to analyze aeromedical emergency medical services (EMS) endotracheal intubation (ETI) success rates for in-flight intubations, and to retrospectively compare in-flight ETI success rates with those achieved in hospital and trauma scene settings. Patients undergoing flight crew ETI during a 3-year study period were reviewed, and flight team-performed intubations were classified as in-flight, hospital (at referring hospital), or ground (at trauma scene). Flight crews attempted ETI in 302 patients, with success in 291 patients (96.4%). ETI success rates for in-flight, hospital, and ground groups were 94.2%, 96.8%, and 98.3%, respectively (P = .22). There were no differences among the groups in proportions of pediatric patients (P = .55) or multiple intubation attempts (P = .83). Use of paralytic agents was more frequent in ground and in-flight groups as compared with hospital group patients (P = .03). We conclude that with the aircraft and aeromedical crew studied, ETI was as likely to be successful in-flight as in other settings.

Introduction: Advanced patient stabilization skills provided by air medical providers were hypothesized to result in streamlined emergency department (ED) stabilization of patients with head injuries requiring urgent cranial computed tomography (CCT). The goal of this study was to compare initial ED stabilization times between air- and ground-transported patients requiring urgent CCT and emergency neurosurgical hematoma evacuation., Setting: Academic Level trauma center (annual ED census 60,000) receiving patients from ground EMS and a nurse/paramedic air medical transport team., Methods: This retrospective study identified, from a database of 15 months of ED visits, consecutive group of adults who had CCT performed within 60 minutes of ED arrival and underwent emergent craniotomy for intracranial hematoma. Demographics, hemodynamic status, patient acuity, and time intervals between ED and CCT suite arrivals were compared between air and ground patients using chi-square, Fisher's exact, and t-tests (p = 0.05)., Results: Eleven air- and 39 ground-transported patients were eligible. All patient acuity data were similar between groups. Air patients were more likely to be intubated (100% versus 71.8%, p = .04) and had shorter mean ED stabilization times (29 versus 40 minutes, p = .02) than the ground., Conclusion: This study suggests that advanced patient stabilization offered by air medical transport may result in reduced ED stabilization time for patients requiring urgent craniotomy.

Introduction: Use review has become increasingly important in the current atmosphere of cost justification for air medical transport. One criterion for use review is patient discharge from receiving hospitals within 24 hours of transport. The objective of this study was to determine the frequency and characteristics of patients discharged within 24 hours of air transport; the goal was to identify particular patient types likely to be discharged soon after air transport., Methods: Flight records from November 1994 to September 1995 were reviewed. Follow-up identified patients who were discharged within 24 hours of air medical transport; these were designated the "24-hour group." Other patients were designated the "overall group." Comparisons between groups were made using the t test, Wilcoxon rank sum, and chi-square analysis (alpha = 0.05) for the following factors: age, vital signs, Glasgow coma score, percentage of intubated patients, and percentage of trauma and scene transports., Results: Of the 945 flights analyzed, 42 (4.4%) transported patients who were discharged within 24 hours of air transport. Patients in the 24-hour group were younger, less likely to be intubated, and more likely to be scene-trauma transports compared with the overall group., Conclusion: This study demonstrates that air medical transports meet currently accepted criteria for helicopter transport. This study suggests that inappropriate air medical transport is rare, even in patients discharged from receiving hospitals within 24 hours of air transport.

The purpose of this study was to determine whether pediatric trauma patients were transferred from community hospitals to trauma centers more expeditiously than adults of similar injury acuity. The study analyzed the air medical activation time, defined as the time delay between patient arrival at community hospitals and subsequent request for air medical transport to a Level I trauma center. Retrospective analysis of all interfacility air medical trauma transports by one service from October 1994 to June 1995 identified 40 pediatric and 156 adult patients. The mean air medical activation times for pediatric and adult trauma Interfacility transports were 36.5 and 70.1 minutes, respectively (P = .016). The study shows that community hospitals are able to expedite transfer of pediatric trauma patients and suggests that transfer delays for adult trauma patients may be reducible.

Introduction: Most patients transported by air who require endotracheal intubation undergo endotracheal intubation before transport. However, in-flight endotracheal intubation may be indicated in the setting of certain scene conditions, in-flight patient deterioration, or endotracheal tube dislodgement. A previous report of high endotracheal intubation efficacy in the BK-117 in-flight recommended that flight programs review endotracheal intubation capabilities in their own aircraft. This study was conducted to determine whether in-aircraft endotracheal intubation times in the AS365N2 Dauphin were comparable to those previously reported for the BK-117., Setting: AS365N2 and BK-117 helicopters stationary on a helipad., Methods: Eight flight team members per formed three mannequin endotracheal intubations in each aircraft. Three time intervals were assessed: Setup, time required for equipping and positioning for endotracheal intubation; placement, time from laryngoscopy to endotracheal intubation; and total (Setup + Placement). Mean times for the BK-117 and AS365N2 were compared using the t test (a=0.05)., Results: All endotracheal intubation attempts were successful, but setup (p=0.0001), placement (p=0.0271), and total (p=0.0011) times were longer in the Dauphin. Crew members unanimously expressed endotracheal intubation difficulty caused by positioning problems in the Dauphin., Conclusion: In-aircraft intubation is significantly more time-consuming in the Dauphin than in the BK-117. This prolongation of intubation appears to be due to problems with positioning of the air medical crew and patient.

Objectives: To review the existing literature and task force opinions on regionalization of critical care services, and to synthesize a judgement on possible costs, benefits, disadvantages, and strategies., Data Sources: Pertinent literature in the English language., Study Selection: One hundred forty-six English language papers were studied to determine possible ramifications of regionalization of critical care or other similar services., Data Extraction: Information on possible influence on the care of the critically ill was sought and integrated with the opinions of task force members. Possible costs, benefits, as well as disadvantages to the patient, transferring and receiving institutions, and region as a whole were sought., Data Synthesis: Regionalization of critical care services was thought to be advantageous to the patient. The larger academic institutions tend to have more resources, better subspecialty availability, and expertise in the care of the critically ill. Efficiency and safety during transport need to be in place. Disadvantages of overutilization, possible costliness to both the referring institution as well as to the receiving institution were outlined. It was agreed that pediatric critical care medicine was a separate issue., Conclusions: Regionalization of critical care medicine probably is beneficial and the concept should be explored.

Thirty-two multiple trauma patients with severe head injury and a Glasgow Coma Scale (GCS) score of 8 or less were prospectively studied to assess the occurrence of deep venous thrombosis (DVT) and pulmonary embolism (PE). All patients required mechanical ventilation. A sequential compression device (SCD) was used in 14 patients and 18 patients received no prophylaxis for thromboembolism. Bilateral lower extremity technetium venoscans and ventilation/perfusion (V/Q) lung scans were performed within 6 days of admission and every week for 1 month or until the patient developed DVT or PE or was discharged from the SICU. Deep venous thrombosis occurred in two patients (6%) at 16 and 28 days following trauma. Twenty-five patients had normal or low probability V/Q scans. Six had high probability V/Q scans confirmed by pulmonary arteriograms (PAGs) at 12.5 +/- 4 days. Clinical signs of PE were absent in all patients with a positive PAG. There were no differences in age, Injury Severity Score (ISS), GCS Score, APACHE II Score, or Trauma Score between the patients who developed DVT or PE and those who did not. A SCD was used in four of the eight patients with DVT or PE. All but one patient with DVT or PE underwent placement of a vena caval filter. Multiple trauma patients with severe head injury (GCS score < or = 8) are at high risk for thromboembolism. The available means of prevention and diagnosis of DVT or PE in multiple trauma patients with severe head injury are not entirely effective.

Chronic renal disease is associated with fluid retention, electrolyte disturbances, anemia, platelet dysfunction, malnutrition, and, often, underlying disease such as diabetes, hypertension, and coronary artery disease. The mortality and morbidity of trauma increases when the victim has pre-existing renal disease. Special attention must be given to fluid resuscitation in these patients because of their limited or absent ability to excrete solutes and fluids. Invasive hemodynamic monitoring is helpful in guiding the resuscitation efforts because urine output and acid-base balance are unreliable markers. Knowledge of pharmacokinetics and pharmacodynamics is necessary in patients with renal disease. Choice of therapy for solute and fluid removal depends on the patient's hemodynamic status, the presence or absence of coagulopathy, and the type of traumatic injury. Renal replacement therapies are recommended for hemodynamically compromised patients.

We have discussed the basic principles of pharmacokinetics and convective solute removal in the context of each other. Clinical observations appear to follow the theoretical expectations. For practical purposes plasma and plasma water are not different. In the calculation of drug sieving, venous samples do not contribute enough to warrant their extra costs. We recommend that drug removal in hemofiltration be expressed by the sieving coefficient, UF/A. Drug sieving data in humans undergoing CAVH are tabulated. Recommendations for supplemental dosing are discussed which are applicable to any clinical setting.