HEMS in an urbansetting. Anne Weaver RESUS 2013, Limerick 27 th April 2013

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Dinah Jennings
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1 HEMS in an urbansetting Anne Weaver RESUS 2013, Limerick 27 th April 2013

3 Car at night

6 12 minutes by air 40 minutes by road 10 million people 25 mile radius

7 London HEMS Pan London service Operates as a charity Now known as London s Air Ambulance Mixed funding part state / part charity Charity funding - corporate / individuals

8 Why use a helicopter in an urban environment?

9 Average traffic speed: Normal traffic Emergency vehicles 9 mph 20 mph

10 Crew configuration 1 doctor 1 paramedic 1 training position Doctor Paramedic 2 pilots

11 Role of London s Air Ambulance Dedicated tomajor trauma patients Primary phase of incident 7 missions per day 4 day 3 night 365 days per year Physician Response Unit medical case mix Quality CPR, Autopulse, PCI protocol

per day 4 day 3 night 365 days per year Physician

12 Current workload 24/7 service 2000 trauma missions per year RTC 50% 50% pedestrian Falls 20% Penetrating Injury 25% Misc 5% Due to reach missions by Nov 2013

13 Photo of thoractomy survivor and paper of accountant that was knifed Stabbed after midnight died in the street

14 Dec-07 Nov-07 Oct-07 Sep-07 Aug-07 Jul-07 Jun-07 May-07 Apr-07 Mar-07 Feb-07 Jan-07 Dec-06 Nov-06 Oct-06 Sep-06 Aug-06 Jul-06 Jun-06 May-06 Apr-06 Mar-06 Feb-06 Jan-06 Dec-05 Nov-05 Oct-05 Sep-05 Aug-05 Jul-05 Jun-05 May-05 Apr-05 Mar-05 Feb-05 Jan-05 Adult Trauma Calls Major Incident Day [08:00-17:00] Evening [17:00-24:00] Night [24:00-08:00] 1/3 rd were injured when service was not available Liz Foster 15/01/08; Data Source Anita West, Trauma Service Database

21 19 18 65 13 31 28 8 35 18 11 40 39 13 24 25 29 24 23 19 21 32 13 29 26 11 30 33 20 24 33 19 37 41 20 29 41 18 32 25 24 34 23 27 37 38 26 43 35 29 32 36 26 49 29 46 17 38 29 9 46 31 23 44 33 25 37

15 London HEMS milestones 1988 Commenced operations as Paramedic only Ad hoc requests eg organ pick up / transfers 1989 Medical team operations - physician & paramedic 1990 Commenced helipad operations at the Royal London First Rapid sequence induction 1991 First thoracotomy 2000 Evening car service 3 nights / week (midnight finish) Physician Response Unit 2010 London Trauma Network established, HEMS 24/ Blood on board

Royal London First Rapid sequence induction 1991 First thoracotomy 2000 Evening car service 3 nights /

24 CODE RED Pre-alert from HEMS team Average age 34 yrs Mortality 49%

26 Major Incident response

29 Time to Definitive Care

30 Dispatch 4000 calls / day

31 Standard Operating Procedures Clinical & non-clinical Based on experience of service Encourages consistent practice Understanding tested in detail Aids decision making

32 Emergency Anaesthesia Kit Dump

33 Checklists Aircraft Rapid Response cars Medical packs Start & end of day routines Pre anaesthesia Challenge & response Reduce human factors effect

34 Catastrophic haemorrhage in PHC C ABC Tourniquets Novel haemostatic agents Handling and packaging Splintage Permissive hypotension Damage control resuscitation

35 Catastrophic London HEMS Utility of pre-alert protocols Massive haemorrhage protocols Pre-hospital transfusion Emergency reversal of warfarin Novel anticoagulants Aggressive vascular control in the field

39 CODE RED Developed and established at Royal London Now used by all SE England Air Ambulancesand the TaysideTrauma Team in Scotland

41 Pelvic injury

44 Early plasma

45 DECLARE CODE RED if: Systolic BP < 90 Poor response to initial fluid resuscitation Suspected active haemorrhage Non-evidence based criteria Activation based on PHYSIOLOGY NOT LABORATORY

46 CODE RED Massive Haemorrhage protocol Average age 34 yrs Mortality 49% Not good enough?

47 Blood on board March 2012

48 Golden Hour box 4 units O negative PRBC Data logger Paperwork

49 Belmont buddy lite Light weight Battery powered Temp sensor Extracts air from circuit Warms blood or saline Pressure limited 300mmHg

50 >1000 missions 50 prehospital transfusions 28 Code Red in extremis 22 traumatic cardiac arrests 11 PLE on scene 10 ROSC 1 infant in arrest to ED March September 2012 data

51 39 PH Txn to ED 24 survived 8 died in ED 3 died in OR 4 died on ICU March September 2012 data

52 Mean age 35yrs 80% male 45% ROSC from TCA March September 2012 data

53 2.8 units PRBC transfused On-scene time 37 mins Hb 14.0 ph 7.07 BE 12.8 March September 2012 data

54 Blood on board progress Over 100 pre-hospital transfusions Data collection for 50 transfusions Traumatic arrest improved ROSC (45%) Survivors have received blood and vascular control at scene iethoracotomy

55 What else can we do? Tranexamic acid Prothrombin Complex Concentrates

57 WARFARIN

60 Can pre-hospital teams make a difference? LAS activation On scene Hospital RSI CT INR result Reversal mins HEMS activation HEMS on scene HEMS RSI HEMS INR Reversal HEMS at RLH CT mins

62 Prothrombin Complex Concentrates (Octaplex / Beriplex)

64 The future for bleeding patients? Freeze dried FFP / thawed FFP Fibrinogen concentrate Hand held ROTEM sophisticated pre-alert

65 Innovation for pre-hospital vascular control Thoracotomy for sub-diaphragmatic catastrophic bleeding (blunt and penetrating). To provide manual aortic occlusion and volume resuscitation with blood. REBOA resuscitative endovascular balloon occlusion of the aorta. Alternative way to occlude the aorta.

67 Urban pre-hospital care Aircraft essential for traversing congested areas rather than travelling long distances. Rapid response vehicles used for physician response unit, HEMS resilience and major incident response. Physicians offer the opportunity to deliver life-saving intervention close to time of injury. LAA have introduced interventions to reduce disability and death eg blood transfusion, PCC use. Developed expertise in penetrating trauma and major incident management.

Dr Anne Weaver London s Air Ambulance CODE RED THE BLEEDING PATIENT

Dr Anne Weaver London s Air Ambulance CODE RED THE BLEEDING PATIENT Objectives Describe the background to Code Red Describe our Standard Operating Procedure Share our data The bleeding problem Major haemorrhage