REPORT. EUPHOREA 7 th Meeting, Zürich, April 27 28, 2015

Transcription

1 EUPHOREA 7 th Meeting, Zürich, April 27 28, 2015 Present: 32 participants; please see attached list Agenda: Please see attached agenda Minute taker: Kirsti S. Holm/the speakers themselves Monday April 27 Welcoming words; Ivo Breitenmoser Rega Ivo wishes everyone welcome to the 7 th EUPHOREA Meeting in Zürich. Marius Rehn (N/UK) Research and Development in London s Air Ambulance: The London s Air Ambulance (LAA) and the Norwegian Air Ambulance Foundation have formalised their cooperation on research, education, clinical procedures and charity work. Marius Rehn currently works as a HEMS Registrar in London and described the operational framework related to publications as well as the main injury mechanisms seen by the LAA. Further, he described the research structure in place as well as current and future research projects. Per Bredmose (N) The effect of medical simulation training in HEMS a Ph.D. project: Weekly simulation for an on call helicopter emergency medical crew: feasible or impossible? In-situ training can be a time-effective way to give pre-hospital personnel an opportunity to train procedures and interventions as a team. We describe the feasibility of weekly simulation training for on-duty crews at Oslo, Norway, helicopter emergency medical service (HEMS). Methods: HEMS crews (doctor, HEMS crew member and pilot) were given the opportunity to do insitu simulation during on call hours once a week. A simple mannequin and training equipment similar to equipment used in daily practice in the service were used. All training took place locally, either indoors or outdoors near the base. A single facilitator conducted all training during daytime. Scenarios were changed to allow all doctors to go through a set of themes during one year, and to give variability for the rest of the crew. We recorded data on the number of simulations that were carried out and time consumption, and collected data from the participating crews on a feedback form. Results: During one year 52 % of the planned simulations were completed. The major reasons for not performing training were missions. The median total time (and interquartile range (IQR)) for a complete simulation training epiosode was 65 min (58,74). The median score from the participants regarding attitude to this kind of training was 1 on a 7 pt. Likert scale (1= most positive score possible). Discussion: Weekly simulation provided a unique opportunity to train the whole crew in medical matters, team matters and decision-making. This form of training is cost effective because it takes place during working hours for the on-call crew. By training on-site with familiar operational equipment the HEMS rescue man and the pilot also get hands-on training and familiarisation with procedures and equipment. Conclusion: In situ simulation training during on-call hours is feasible in a busy HEMS service with no additional costs than for a facilitator. 1

2 Lars Jacobsen (N) Prehospital Ultrasound Point of Care Diagnostics in HEMS - a Ph.D. project: In order to evaluate prehospital point of care ultrasound implementation in HEMS, we try to build our knowledge on the Utstein formula of survival. Medical science + local implementation + educational efficiency together add up to improved patient survival. The SNLA prehospital ultrasound study will look into the following aspects: Educational efficiency; is remote, low dose, high frequency training any good in improving examiner s skills? A randomized controlled study is planned in the autumn. The second study is PUS(H) EMS a descriptive study looking into quality and diagnostic reproducibility. The study awaits electro-medical equipment acceptance, but is otherwise ready for startup. A sub-study, randomized ultrasound vs. blind arterial line placement will evaluate time usage and success rates. The last study, Air Echo, will look into more advanced cardiac echo examinations done prehospitally are our findings comparable to inhospital results? Andreas Krüger (N) Today, no system for quality estimation of HEMS activity is in use in Norway. We will invite representative authorities on P-EMS, as well as directors, politicians and representatives for patient-organisations. By using a nominal group technique (expert panel method), the panel will propose quality dimensions for quality estimation of P-EMS. These quality dimensions can be used in quality estimation of P-EMS. The panel will not be bound to a certain set of existing data when developing the quality dimensions. The panel should also reach a consensus regarding the impact of each factor, and the balance between the factors. Ultimately, these quality dimensions can be put into a model for quality estimation of P-EMS. Roland Albrecht (CH) Ebola the closed isolation transport concept of Rega: The recent outbreak of Ebola in Western Africa has fueled a rising demand for air transport of infected or possibly highly infectious patients. Therefore Rega together with a private company has developed a patient isolation unit (PIU) which allows a safe transport in our long-range repatriation jets as well as on any ambulance vehicle. Many even rare situations had to be taken into consideration and solutions to be found; e.g. leakage of the PIU after rapid cabin decompression can be prevented by a compensation airbag; a patient with threatened airway can be ventilated/intubated thanks to reach-in glove sleeves and ready-touse airway tools including a one-way fiberoptic a.s.o. For the correct handling of the PIU, checklists need to be thoroughly followed under the watchful eyes of a supervisor. Extensive training for every member of the crew involved in this sort of mission has made it possible to bring the response time down to 3 hours. Visit at Rega hangar and helicopter flight simulator incl. demonstration of the simulator Tuesday April 28 Patrick Schoettker (CH) A mirror periscope transformed into a high-tech indirect laryngoscope: Airway management has changed greatly since the introduction of video-laryngoscopy into clinical practice. Numerous devices exist and each must still undergo rigorous evaluation. We performed numerous clinical in-hospital studies, simulating difficult airway management with the help of a cervical collar, therefore immobilizing the neck and limiting the mouth opening to 2 cm. 2

3 In one of our studies, we developed an iphone app (AirView for iphone, freely available on the app store), allowing the iphone to be put on a Airtraq with a dedicated adaptor ( By using the high quality camera, lightning and recording capabilities of the iphone, we managed to transform the Airtraq into a powerful intubating tool. A comparison of the AirView Airtraq with the King Vision in a simulated manikin study demonstrated that the Airtraq-Airview performed better and quicker to visualize and intubate the trachea (see attached). A clinical study is currently underway. Tracheal intubation in patients with an unstable cervical spine injury is a complex and challenging task. The airway must be secured while the cervical spine is immobilized by a cervical collar or manual inline axial stabilization. Numerous airway devices and techniques exist and have been shown to generate specific cervical spine movements, with a potential for secondary injury. Intubation with a fiberoptic bronchoscope is still described as the preferred technique in an elective setting by experienced anesthesiologists, causing minimal cervical spine movement. We compared the neurophysiologic modifications associated with tracheal intubation performed randomly by an Airtraq or a fibrescope in patients with an unstable cervical spine fracture immobilized by a cervical collar and demonstrated that tracheal intubation with an Airtraq appears to be safe and is a viable option to intubation with a fiberoptic bronchoscope, without any detectable neurophysiological modifications. Time necessary to secure an airway in these patients is significantly shorter with the Airtraq. Airway management is changing. In experienced hands, the place these devices can take in the prehospital airway management must be properly addressed. Lorenz Theiler (CH) Intubation success rate of different intubation aids under extreme daylight conditions in high altitude: Videolaryngoscopes may improve intubation conditions in skilled hand, but the evidence is far from satisfactory. If VLS are being used, it is most likely of benefit to use blades that allow the provider to switch to direct laryngoscopy in case of failure to identify laryngeal structures due to blood. Experience remains the single most important factor for success. In a study on 1200 patients with a created difficult airway (extrication collar), overall success rate was mostly >90%. A tracheal tube guiding channel did not improve intubation success rate in experienced hands. In a manikin study on the Aletsch glacier 3450m above sea level, we found no influence of performance of physicians because of altitude. All VLS showed impaired vision in direct sunlight (dark screen), there was no improvement by wearing sunglasses and polarization may completely obliterate screen visibility. Covering the patient and the provider with a dark blanket reversed all detrimental sun effects. The standard Macintosh direct laryngoscopy remained a fast and reliable option in extreme daylight conditions. The most favoured devices were Macintosh, C-MAC and McGrath Philipp Stein (CH) Prehospital airway management in Switzerland in children up to 16 years of age: A poster will be presented at the ESA Congress in Berlin on May Thereafter the manuscript will be submitted (in order to be published) to a peer reviewed journal: Retrospective analysis of pediatric patients (<17 years of age) with any kind of airway management during 5 years transported by the HEMS Rega. 425 children in primary and secondary missions were included. Descriptive statistics concerning the incidence of difficult airway situations are performed. All intubations are evaluated concerning correct tube size and intubation depth. 3

4 Mikael Gellerfors (S) Prehospital advanced airway management in Nordic countries a prospective multicenter observational study: Prehospital Advanced Airway Management (PHAAM) is a potentially lifesaving intervention. A recent Danish multicentre single country study demonstrated a 99,7% incidence of successful anaesthesiologist prehospital endotracheal intubation, with a PHAAM-related complication rate of 7.9%. A London study revealed a significantly higher intubation failure rate among nonanaesthesiologist physicians. In Scandinavia different types of emergency medical services (EMS) and professions provide PHAAM. The success rate of prehospital endotracheal intubation (PHETI), incidence of difficult intubation and complications in the Nordic countries are not known. The aim of this study is to define PHAAM success rate and complications in different types of Nordic EMS organisations and physician critical care teams. The study is a prospective observational study with collection of PHAAM data according to the Utstein template by Sollid et al. in the 12 participating Nordic Countries EMS/ HEMS centres and physician critical care teams. The primary endpoint is PHETI success on 2 attempts and no complications. Mikael Gellerfors (S) Endotracheal intubation with and without night vision goggles in a helicopter and emergency room setting a manikin study: Securing the airway by endotracheal intubation (ETI) is a key issue in civilian and military prehospital critical care. Night vision goggles (NVG) are used by personnel operating in low-light tactical environments. We examined the feasibility of an anaesthesiologist performed ETI using binocular NVG in a helicopter setting. Twelve anaesthesiologists performed ETI on a manikin in an emergency room (ER) setting and two helicopter-settings, with randomization to either rotary wing daylight (RW-D) or rotary wing in total darkness using binocular NVG (RW-NVG). Primary endpoint was intubation time. The median intubation time was shorter for the RW-D compared to the RW-NVG setting (16,5 s vs 30,0 s; p=0,03). We found no difference in median intubation time for the ER and RW-D settings (16,8 s vs 16,5 s; p=0,91). For all scenarios success rate was 100%. This study suggests that anaesthesiologists successfully and quickly can perform ETI in a helicopter setting both in daylight and in darkness using binocular NVG, but with shorter intubation times in daylight. Stephen Sollid (N) Update on the AIRPORT study: The AIRPORT study has completed data collection and has recruited 2335 patients from 21 bases in 6 countries. We are now analysing the data and the first manuscript has been submitted to SJTREM for review. A second manuscript is «in the making». The final part of the PhD project of Geir Arne will be the revision of the Airway Template in a Utstein meeting. We hope to facilitate the consensus meeting sometime in Philipp Stein (CH) Tranexamic acid effects on coagulation parameters and outcome in polytraumatized and isolated brain-injured patients: Administration of Tranexamic Acid in the Preclinical Setting and Its Effect on Coagulation Parameters and Outcome in Multiple Trauma Patients and Isolated TBI in EMS (Schutz Und Rettung Zürich) and Helicopter Rescue(REGA). (NCT ) Primary Outcome Measures: Tranexamic Acid administered in the preclinical setting and its influence on coagulation parameters laboratory and thromboelastometry) [ Time Frame: 12 Months ] [ Designated as safety issue: No ] TXA will be given to multiple trauma patients or patients with isolated TBI in the preclinical setting (n=50). Before tranexamic acid is given, one tube of citrated blood is drawn. Once patients arrive in 4

5 the emergency room as second tube of citrated blood is drawn. The two tubes will be used to perform rotational thromboelastometry (ROTEM) measurements and standard coagulation measurements (aptt, PT, INR, Ouick's value, fibrinogen). The coagulation parameters on scene will be compared to those in the emergency department to find out if coagulation is improved by this. In a previously performed study, 50 patients got blood taken on scene and in the emergency room without receiving TXA. In this study by Theusinger et al. it was shown that coagulation is impaired during this time period. (Theusinger OM et al. Anesth Analg Dec 24.PMID: ). The population of this study will serve as control group for the actually performed study. Closing remarks by Stephen Sollid Thanking each and every one specifically for his or her contribution and wishing everyone back for the next meeting. Short discussion and agreement upon new dates for the next meeting. *~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~ Next EUPHOREA Meeting: Please make a note of the next EUPHOREA Meeting that will take place on Saturday October 31 st and Sunday November 1 st in Prague, Czech Republic, immediately following the ERC Congress October in Prague, this time hosted by the EMS Of The Hradec Králové Region, with Anatolij Truhlář in the lead. The choice of days (on a weekend) is not reflecting a new tendency of the EUPHOREA Meetings, but was voted for rather of practical reasons, as many of the participants will already be present at the ERC Conference. More information to come! Best regards, Kirsti S. Holm EUPHOREA Coordinator 5