Network Five: Retrieval Medicine

Network Five: Episode 6 – Retrieval medicine

Participants: Dr Ruby Hsu, Dr Ruth Parsell, Dr Pramod Chandru, Shannon Townsend, Yelise Foon, Shreyas Iyer and Samoda Wilegoda Mudalige.

Part 1

In this episode, we will first discuss the impact of pre-hospital advanced airway management on the neurological outcomes in patients with out-of-hospital cardiac arrest (OOHCA). Presenter – Yelise Foon – ED senior resident medical officer

• Benoit JL, Stolz U, McMullan JT, Wang HE. Duration of exposure to a prehospital advanced airway and neurological outcome for out-of-hospital cardiac arrest: A retrospective cohort study. Resuscitation. 2021 Mar;160:59-65

Take-Home Points:

• This study was a retrospective cohort study that looked at adult, non-traumatic OOHCA patients with an advanced airway (supraglottic or endotracheal).
• The timing of airway placement (intra-arrest versus post-ROSC) and patient outcomes (with respect to the cerebral performance category, or CPC) were analyzed. 
• They observed a higher CPC in the group that had the advanced airway placed post-ROSC (i.e. 21.7% in post-arrest group versus 7.5% in intra-arrest group).
• They concluded that the timing of the airway placement was not associated with poor neurological outcomes. 

Part 2

In this second part of the series, we dissect down the much dreaded (but potentially lifesaving!) scalpel cricothyroidotomy. Presenter – Shannon Townsend, ED advanced trainee at Orange Health Service.

• Aziz S, Foster E, Lockey DJ, Christian MD. Emergency scalpel cricothyroidotomy use in a prehospital trauma service: a 20-year review. Emerg Med J. 2021 May;38(5):349-354

Take-Home Points:

• This was a retrospective observational study conducted from 2000 to 2019 using clinical records and aimed to (1) ascertain the rate of scalpel cricothyroidotomy and (2) understand indications for and factors associated with this procedure.
• They observed that the main indication for scalpel cricothyroidotomy was as a rescue airway (for failed laryngoscopy due to a large volume of blood in the airway).
• They noted high levels of procedural success, but the overall mortality in patients receiving this procedure was high (due to a number of factors). 
• The rate of scalpel cricothyroidotomy has decreased over the years due to factors such as the introduction of supraglottic airways and longer-acting muscle relaxants (rocuronium versus suxamethonium). 
• It is important to remember that, if we optimize our intubation conditions (e.g. improving patient position, carefully choosing drugs and equipment according to patient’s clinical situation), we are likely to increase our first pass success with laryngoscopy. 
• It is important to (1) recognize the indications for scalpel cricothyroidotomy, (2) be familiar with the procedure itself, (3) overcome the mental barriers against performing it, and (4) perform it confidently and competently.

Part 3

In this final part of the series, we infuse ourselves into a discussion about pre-hospital administration of thawed plasma in patients at risk of haemorrhagic shock. Presenter – Dr Ruth Parsell

• Sperry JL et al. Prehospital Plasma during Air Medical Transport in Trauma Patients at Risk for Hemorrhagic Shock. N Engl J Med. 2018 Jul 26;379(4):315-326

Take-Home Points:

• In this pragmatic, multi-center, cluster-randomized, phase 3 superiority trial, the efficacy of administering thawed plasma to patients at risk of haemorrhagic shock was studied. 
• The comparative arm was standard-care resuscitation (with crystalloid fluids).
• The primary outcome was mortality at the 30-day mark. 
• They concluded that administration of thawed plasma to patients at risk of haemorrhagic shock resulted in (1) lower 30-day mortality and (2) lower median prothrombin-time ratio

These episodes were produced with help of HETI’s Emergency Medicine Training Network 5. Please send us an email to let us know what you thought. You can contact us at [email protected]