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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.

Hemorrhage, and particularly noncompressible torso hemorrhage (NCTH) remains a leading cause of potentially preventable prehospital death from trauma in the United States and globally. A subset of severely-injured patients either die in the field or develop irreversible hemorrhagic shock before they can receive hospital definitive care, resulting in poor outcomes. The focus of this opinion paper is to delineate (a) the need for existing trauma systems to adapt so that potentially life-saving advanced resuscitation and truncal hemorrhage control interventions can be delivered closer to the point-of-injury in select patients, and (b) a possible mechanism through which some trauma systems can train and incorporate select prehospital advanced resuscitative care teams to deliver those interventions.

Introduction Placement of percutaneous ventricular support devices such as an intraaortic balloon pump (IABP) or Abiomed Impella device can treat severe cardiogenic shock. Critical care transport medicine (CCTM) providers frequently manage patients supported by these devices during interfacility transfers, often using a helicopter air ambulance (HAA). An understanding of patient needs and management during transport is essential to informing crew configuration and training, and this study adds to the limited existing data on the HAA transport of this complex patient population. Methods We performed a retrospective chart review of all HAA transports of patients with an IABP ( n = 38) or Impella ( n = 11) device at a single CCTM program from 2016 to 2020. We evaluated transport times and composite variables for the frequency of adverse events, condition changes requiring critical care evaluation, and critical care interventions. Results In this observational cohort, patients with an Impella device more frequently had an advanced airway and at least 1 vasopressor or inotrope active prior to transport. While flight times were similar, CCTM teams remained at referring facilities longer for patients with an Impella device (99 vs 68 minutes; p = 0.0097). Compared to patients with an IABP, patients with an Impella device more frequently had a condition change requiring critical care evaluation (100% vs 42%; p = 0.0005) and more frequently received critical care interventions (100% vs 53%; p = 0.0037). Adverse events were uncommon and did not differ for patients with an Impella device compared to an IABP (27% vs 11%; p = 0.178). Conclusion Patients requiring mechanical circulatory support with IABP and Impella devices frequently require critical care management during transport. Clinicians should ensure the CCTM team has appropriate staffing, training, and resources to meet the critical care needs of these high acuity patients.

The aim of this study was to evaluate the feasibility of statin administration by a critical care transport medicine (CCTM) team during rotor wing transport for ST-elevation myocardial infarction patients to a percutaneous intervention-capable center.We conducted a retrospective study at a single CCTM program after an intervention focused on statin administration for ST-elevation myocardial infarction that included a formulary change and a single brief educational presentation to flight physicians. A comparison group of flight nurse practitioners underwent training after the study period and were used as a control. Two authors completed an independent chart review to collect data. Descriptive statistics and chi-square or Mann-Whitney U testing were used to compare groups.Statin administration (or documentation of statin administration before CCTM crew arrival or contraindication to statin administration) occurred during 15 of 19 (79%) transports staffed by trained providers and 3 of 18 (17%) transports staffed by untrained providers (P.001 by chi-square test). Scene times were not significantly different between transports by trained and untrained providers.In summary, we demonstrate the feasibility and safety of a protocol for statin administration in the CCTM setting.

Background: Prehospital intubation success is routinely treated as a dichotomous outcome based on an endotracheal tube passing through vocal cords regardless of number of attempts or occurrence of ...

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.

Objective Prehospital intubation success is routinely treated as a dichotomous outcome based on an endotracheal tube passing through vocal cords regardless of number of attempts or occurrence of hypoxia, or hypotension, which are associated with worse outcomes. We explore patient, provider, and procedure-related variables associated with successful definitive airway sans hypoxia/hypotension on first attempt (DASH-1A) in traumatically injured subjects undergoing endotracheal intubation at the scene of injury by a helicopter EMS system. Methods This single-center retrospective chart review included patients with traumatic injuries and at least one attempted intubation by helicopter EMS at the scene of injury. Demographic and clinical variables were tested for association with DASH-1A and overall first-attempt success using univariate comparisons and multivariable logistic regression to produce adjusted odds ratios (aORs) and 95% confidence intervals (CIs). Purposeful backwards stepwise elimination was used to develop logistic regression models for outcomes. Initial inclusion of covariates in multivariable models was based on clinical judgement, known or suspected risk factors and confounders for intubation success, and univariate associations. Results Of 419 subjects screened, 263 met inclusion criteria. Median age was 34 years and the majority of subjects were Caucasian (95%), male (76%), and suffered blunt trauma (90%). A total of 142 (55.3%) subjects had a successful DASH-1A airway, 198 (75%) had a successful first attempt non-DASH-1A airway, and overall, 246 (94%) had an endotracheal tube passed successfully before hospital arrival. Factors significantly associated with successful DASH-1A were no ground EMS intubation attempt prior to arrival (aOR 2.2), lack of airway secretions (1.9), Cormack-Lehane Score of I and II (12.3 & 3.2, respectively), and bougie use (5.4). For endotracheal tube passing only, the following were significantly associated with first pass success: grade of view I and II (87.3 & 6.8, respectively), lack of secretions (4.9), bougie use (7.8), direct laryngoscopy (5.1) and not using apneic oxygenation through a nasal cannula (2.5). Conclusions In our helicopter EMS system, successful endotracheal intubation on the first attempt and without an episode of hypoxia was associated with no ground EMS intubation attempt prior to flight crew arrival, lack of airway secretions, Cormack-Lehane Score, and bougie use.

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.

Background Hemorrhage is a leading cause of death in traumatically injured patients. Currently, the importance of earlier administration of packed red blood cells (pRBC) to improve outcomes is limited. We evaluated the association of earlier pRBC administration and mortality when compared with later transfusion initiation. Methods This single-center retrospective cohort study of trauma patients transported by a single helicopter service from the scene of injury to an urban academic trauma center included patients receiving at least one unit of pRBC within 24 hours of hospital arrival. The final cohort included patients transported to the trauma center between March 11, 2010, and October 30, 2013. The helicopter service carries two units of pRBC for protocol-driven prehospital transfusion. Logistic regression was used to model odds of death, and 95% confidence intervals were calculated. Results The 94 patients meeting inclusion criteria had a mean (SD) age of 43 (19) years; 87 (93%) of 94 were white, 66 (70%) of 94 were male, and 88(94%) of 94 sustained blunt force injuries. Median Injury Severity Score was 29 (range, 2-75), and 31 (33%) of 94 died within 30 days. Most patients [82/94 (87%)] received their first pRBC transfusion during transport or within one hour of arrival at the emergency department (ED). For the 82 patients receiving a first pRBC transfusion within one hour of ED arrival, each 10-minute increase in time to transfusion increased the odds of death [OR, 1.27 (95% CI, 1.01-1.62; p = 0.044)], controlling for TRISS. At 30 days, 29/82 (35%) patients who received a pRBC transfusion within one hour of ED arrival, and 2 (16%) of 12 patients who received delayed transfusion were deceased (difference, 19%; 95% CI, -5% to 42%). Conclusion In this study, delays in time to pRBC administration of as short as 10 minutes were associated with increased odds of death for patients receiving ultra-early pRBC transfusion. Expedient prehospital and ED transfusion capabilities may improve outcomes after trauma. Level of evidence Therapeutic/care management study, level III.

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.

Background This study assessed the feasibility, self-efficacy and cost of providing a high fidelity medical simulation experience in the difficult environment of an air ambulance helicopter. Methods Seven of 12 EM residents in their first postgraduate year participated in an EMS flight simulation as the flight physician. The simulation used the Laerdal SimMan™ to present a cardiac and a trauma case in an EMS helicopter while running at flight idle. Before and after the simulation, subjects completed visual analog scales and a semi-structured interview to measure their self-efficacy, i.e. comfort with their ability to treat patients in the helicopter, and recognition of obstacles to care in the helicopter environment. After all 12 residents had completed their first non-simulated flight as the flight physician; they were surveyed about self-assessed comfort and perceived value of the simulation. Continuous data were compared between pre- and post-simulation using a paired samples t-test, and between residents participating in the simulation and those who did not using an independent samples t-test. Categorical data were compared using Fisher's exact test. Cost data for the simulation experience were estimated by the investigators. Results The simulations functioned correctly 5 out of 7 times; suggesting some refinement is necessary. Cost data indicated a monetary cost of $440 and a time cost of 22 hours of skilled instructor time. The simulation and non-simulation groups were similar in their demographics and pre-hospital experiences. The simulation did not improve residents' self-assessed comfort prior to their first flight (p > 0.234), but did improve understanding of the obstacles to patient care in the helicopter (p = 0.029). Every resident undertaking the simulation agreed it was educational and it should be included in their training. Qualitative data suggested residents would benefit from high fidelity simulation in other environments, including ground transport and for running codes in hospital. Conclusion It is feasible to provide a high fidelity medical simulation experience in the difficult environment of the air ambulance helicopter, although further experience is necessary to eliminate practical problems. Simulation improves recognition of the challenges present and provides an important opportunity for training in challenging environments. However, use of simulation technology is expensive both in terms of monetary outlay and of personnel involvement. The benefits of this technology must be weighed against the cost for each institution.