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Objectives: Emergency intubation in children is an infrequent procedure both in the pre-hospital and hospital setting. The anatomical, physiological and situational challenges together with limited clinician exposure can make this a difficult procedure with high risk of adverse events. The aim of this collaborative study between a state-wide ambulance service and a tertiary children's hospital was to describe the characteristics of pre-hospital paediatric intubations by Intensive Care Paramedics., Methods: We conducted a retrospective review of state-wide ambulance service electronic patient care records (ePCRs) in Victoria, Australia, population: 6.5 million. Children aged 0-18 years who were attended by paramedics over a 12-month period that required advanced airway management were analysed for demographics and first-pass success rate., Results: Paramedics attended 2674 cases aged 0-18 years over the 12-month study period who received basic or advanced airway management. A total of 78 cases required advanced airway management. The median age of patients was 12 years (interquartile range 3-16) and most were male (60.2%). Sixty-eight patients (87.5%) were intubated successfully on the first attempt, first-pass success was lowest in children <1 year of age. The most common indications for pre-hospital intubation were closed head injury and cardiac arrest. It was not possible to report complication rates because of incomplete documentation., Conclusion: Pre-hospital intubation in children is performed infrequently in an extremely unwell patient group. Continued high-level paramedic training is required to prevent adverse events and ensure patient safety., (© 2023 Australasian College for Emergency Medicine.)

Objectives: Transfusion of a high ratio of plasma to packed red blood cells (PRBCs), to treat or prevent acute traumatic coagulopathy, has been associated with survival after major trauma. However, the effect of prehospital plasma on patient outcomes has been inconsistent. The aim of this pilot trial was to assess the feasibility of transfusing freeze-dried plasma with red blood cells (RBCs) using a randomized controlled design in an Australian aeromedical prehospital setting., Methods: Patients attended by helicopter emergency medical service (HEMS) paramedics with suspected critical bleeding after trauma managed with prehospital RBCs were randomized to receive 2 units of freeze-dried plasma (Lyoplas N-w) or standard care (no plasma). The primary outcome was the proportion of eligible patients enrolled and provided the intervention. Secondary outcomes included preliminary data on effectiveness, including mortality censored at 24 h and at hospital discharge, and adverse events., Results: During the study period of June 1 to October 31, 2022, there were 25 eligible patients, of whom 20 (80%) were enrolled in the trial and 19 (76%) received the allocated intervention. Median time from randomization to hospital arrival was 92.5 min (IQR 68-101.5 min). Mortality may have been lower in the freeze-dried plasma group at 24 h (RR 0.24, 95% CI 0.03-1.73) and at hospital discharge (RR 0.73, 95% CI 0.24-2.27). No serious adverse events related to the trial interventions were reported., Conclusions: This first reported experience of freeze-dried plasma use in Australia suggests prehospital administration is feasible. Given longer prehospital times typically associated with HEMS attendance, there is potential clinical benefit from this intervention and rationale for a definitive trial., (© 2023 The Authors. Academic Emergency Medicine published by Wiley Periodicals LLC on behalf of Society for Academic Emergency Medicine.)

Objective: Cricothyroidotomy is an advanced airway procedure for critically ill or injured patients. In Victoria, Australia, intensive care paramedics (ICPs) perform needle cricothyroidotomy utilizing the proprietary QuickTrach II (QTII) device. Recently, an Ambulance Victoria (AV) institutional change in workflow included pre-puncture surgical incision to assist in successful placement. This review aims to explore whether a surgical pre-incision prior to the insertion of the device improved overall procedural success rates of needle cricothyroidotomy using the QTII., Methods: This was a retrospective review of all patients who received a needle cricothyroidotomy by ICPs from May 1, 2015 through September 15, 2020. Data and patient care records were sourced from the AV data warehouse., Results: A total of 27 patients underwent a needle cricothyroidotomy with the mean age of patients being 50.2 years. Most cricothyroidotomies were performed using the QuickTrach II kit (92.6%). Prior to modification of the QTII procedure, front-of-neck access (FONA) success was 50.0%; however, this improved to 82.4% after the procedures recent update. The overall success rate of all paramedic-performed needle cricothyroidotomy during the study period was 74.1% (n = 20)., Conclusions: This review demonstrates that propriety devices such as the QTII device achieve a low success rate for a FONA intervention. Despite the low frequency of this procedure, ICPs with extensive training and regular maintenance can perform needle cricothyroidotomy using scalpel assistance with a reasonable success rate. But when compared to the broader literature, success rate using a more straightforward technique such as a surgical cricothyroidotomy technique is likely going to be higher.

Introduction: Rapid sequence intubation (RSI) is used to secure the airway of traumatic brain injury (TBI) patients, with ketamine frequently used for induction. Studies show that ketamine-induction RSI might cause lower blood pressures when compared to etomidate. It is not clear if the results from that research can be extrapolated to systems that use different dosing regimens for ketamine RSI. Ambulance Victoria authorized the use of 1.5 mg/kg ketamine in January 2015 for head injury RSI induction by road-based paramedics. This study aims to examine whether systolic blood pressure changed when ketamine was introduced for prehospital head injury RSI., Methods: This study was a retrospective analysis of out-of-hospital suspected TBI that received RSI by paramedics. Our analysis employs an interrupted time-series analysis (ITSA), which is a quasi-experimental method that tested whether hypotension and systolic blood pressures changed after the switch to ketamine induction in 2015. This ITSA utilized an ordinary least squares regression on complete observations using Newey-West standard errors., Results: During the study period, paramedics performed RSI in 8,613 patients, and 1,759 (20.4%) had a TBI. Ketamine usage increased by 52.7% in January 2015 (p < 0.001) after road-based paramedics were authorized to use ketamine induction. This analysis found significant 5% increase in post-RSI hypotension (p = 0.046) after the introduction of ketamine, and thereafter the incidence of post-RSI hypotension increased steadily by 0.5% every 3 months (p = 0.004). Concurrently, changes in systolic blood pressure, as measured by the interval just before induction to the last measured on scene, show an average decrease of 7.8 mm Hg (p = 0.04) at the start of 2015 with the ketamine rollout., Conclusions: This ITSA shows that postinduction hypotension and also decreases in systolic blood pressures became evident after the introduction of ketamine. Further research to investigate the association between ketamine induction and survival is needed., (© 2021 by the Society for Academic Emergency Medicine.)

Objective: To determine the frequency of finger thoracostomy performed by intensive care flight paramedics after the introduction of a training programme in this procedure and complications of the procedure that were diagnosed after hospital arrival., Methods: This was a retrospective cohort study of adult and paediatric trauma patients undergoing finger thoracostomy performed by paramedics on a helicopter emergency medical service between June 2015 and May 2018. Hospital data were obtained through a manual search of the medical records at each of the three receiving major trauma services. Additional data were sourced from the Victorian State Trauma Registry., Results: The final analysis included 103 cases, of which 73.8% underwent bilateral procedures with a total of 179 finger thoracostomies performed. The mean age of patients was 42.8 (standard deviation 21.4) years and 73.8% were male. Motor vehicle collision was the most common mechanism of injury accounting for 54.4% of cases. The median Injury Severity Score was 41 (interquartile range 29-54). There were 30 patients who died pre-hospital, with most (n = 25) having finger thoracostomy performed in the setting of a traumatic cardiac arrest. A supine chest X-ray was performed prior to intercostal catheter insertion in 38 of 73 patients arriving at hospital; of these, none demonstrated a tension pneumothorax. There were three cases of potential complications related to the finger thoracostomy., Conclusion: Finger thoracostomy was frequently performed by intensive care flight paramedics. It was associated with a low rate of major complications and given the deficiencies of needle thoracostomy, should be the preferred approach for chest decompression., (© 2020 Australasian College for Emergency Medicine.)

Objective: Rapid sequence intubation (RSI) is an advanced airway procedure for critically ill or injured patients. Paramedic-performed RSI in the prehospital setting remains controversial, as unsuccessful or poorly conducted RSI is known to result in significant complications. In Victoria, intensive care flight paramedics (ICFPs) have a broad scope of practice including RSI in both the adult and pediatric population. We sought to describe the success rates and characteristics of patients undergoing RSI by ICFPs in Victoria, Australia., Methods: A retrospective data review was conducted of adult (≥ 16 years) patients who underwent RSI by an ICFP between January 1, 2011, and December 31, 2016. Data were sourced from the Ambulance Victoria data warehouse., Results: A total of 795 cases were included in analyses, with a mean age of 45 (standard deviation = 19.6) years. The majority of cases involved trauma (71.7%), and most patients were male (70.1%). Neurological pathologies were the most common clinical indication for RSI (68.3%). The first pass success rate of intubation was 89.4%, and the overall success rate was 99.4%. Of the 5 failed intubations (0.6%), all patients were safely returned to spontaneous respiration. Two patients were returned via bag/valve/mask (BVM) support alone, two with BVM and oropharyngeal airway, and one via supraglottic airway. No surgical airways were required. Overall, we observed transient cases of hypotension (5.2%), hypoxemia (1.3%), or both (0.1%) in 6.6% of cases during the RSI procedure., Conclusion: A very high RSI procedural success rate was observed across the study period. This supports the growing recognition that appropriately trained paramedics can perform RSI safely in the prehospital environment.

Background: Paramedic-performed out-of-hospital ultrasound is a novel skill that has gained popularity in some services in recent years. In this setting point-of care ultrasound (POCUS) can provide additional information that can assist with management and guide transport to the most appropriate facility. We sought to explore the different educational approaches used for training paramedics in ultrasound in the out-of-hospital setting., Methods: Ovid MEDLINE, EMBASE, EBM Reviews, The Cochrane Library, CINAHL plus, The Monash University Research Repository and the British Thesis Library were searched from the 1 st of January 1990 to the 6 th of April 2016. Google Scholar was searched and reference lists of relevant papers were examined to identify additional studies. Articles were included if they reported on out-of-hospital and POCUS educational approaches for paramedics., Results: A total of 2002 unique articles were identified of which 18 articles met the inclusion criteria. Most articles reported combined cohorts of emergency providers with varying years of experience though most operators were POCUS naïve. The most common clinical assessment for which paramedic POCUS curricula was described was the focused assessment sonography for trauma (FAST) examination. Education programs varied from two-minutes to two-days with all studies including both didactic and practical training., Conclusion: Education programs for POCUS for paramedics vary considerably, and do not appear to align with qualification level or clinical experience. Further research investigating education and subsequent clinical application of POCUS by paramedics is required, as well as prospective, outcome based studies in order to measure the clinical utility of out-of-hospital POCUS.