Outcome after severe head injury treated by an integrated trauma system.
OBJECTIVES: To describe outcome after treatment of severe head injury within an integrated trauma system. METHODS: A retrospective analysis of all patients with severe head injury admitted to the Royal London Hospital by the Helicopter Emergency Medical Service (HEMS) between 1991 and 1994. Type of injury was defined on initial computed tomography of the head and outcomes assessed 12 months after injury using the Glasgow outcome score. RESULTS: 6.5% of HEMS patients had long term severe disability (severe disability or persistent vegetative state on the outcome score); 34.5% made a good recovery. CONCLUSIONS: The concern that a large number of severely disabled long term survivors might result as a consequence of this system of trauma management is not confirmed. The case mix of severity of extracranial injuries in these patients makes comparison with other published series difficult, but these data fit the hypothesis that pre-hospital correction of hypoxia and hypotension after head injury improves outcome. (+info)
Safety of air medical transportation after tissue plasminogen activator administration in acute ischemic stroke.
BACKGROUND AND PURPOSE: We sought to determine the safety of air medical transport (AMT) of patients with acute ischemic stroke (AIS) immediately after or during administration of tissue plasminogen activator (tPA). Patients with AIS treated with tPA in nonuniversity hospitals frequently need transfer to tertiary care centers that can provide specialized care. AMT is a widely available mode of transport that is crucial in providing expedient and quality health care to critically ill patients while assuring high level of care during transportation. The safety of AMT of patients with AIS after or during administration of tPA has not been examined. METHODS: We performed retrospective chart review of 24 patients with AIS who were treated with intravenous tPA and transferred by helicopter to the Hospital of the University of Pennsylvania or the University of Cincinnati Hospital. The charts were reviewed for neurological complications, systemic complications, and adherence to the National Institutes of Neurological Disorders and Stroke (NINDS) protocol for AIS management. RESULTS: No major neurological or systemic complications occurred. Four patients had hypertension warranting treatment, 3 patients experienced motion sickness, 1 patient developed a transient confusional state, and 1 patient experienced minor systemic bleeding. Four NINDS protocol violations occurred, all related to blood pressure management. CONCLUSIONS: In this small series, AMT of AIS patients after thrombolysis was not associated with any major neurological or systemic complications. Flight crew education on the NINDS AIS protocol is essential in limiting the number of protocol violations. AMT of patients with AIS provides fast and safe access to tertiary centers that can provide state of the art stroke therapy. (+info)
Helicopter transfer offers a potential benefit to patients with acute stroke.
BACKGROUND AND PURPOSE: Rapid transport of patients to specialized centers is widely used in the management of myocardial infarction, trauma, and more recently, acute stroke. We evaluated the role of helicopter transportation as it relates to the availability of acute stroke therapies and patients' perceptions of care. METHODS: We reviewed records of all patients transferred to a university hospital within 24 hours of stroke onset from January 1996 to December 1997. Data were collected on demographics, neurological deficit, treatment, and outcome. In addition, a questionnaire was sent to all patients with items about perceived reasons for helicopter transfer, expected and actual treatment, outcome, and overall impression. RESULTS: Helicopter transfer was used for 73 stroke patients. Before transfer, 8 patients (11%) received tissue plasminogen activator (tPA). On arrival, no patient received tPA, 38 patients (52%) were enrolled in acute stroke studies, and 35 patients (48%) received no specific medication. All but 2 patients were managed in a specialized stroke unit. Of the 35 patients who received no specific therapy, 24 (69%) were ineligible for treatment or study enrollment owing to 1 or more exclusion criteria, but rarely (3%) because of time. Of the 45 respondents to the survey, most (84%) were transferred at the suggestion of the physician at the originating hospital because of a possible treatment that was unavailable there. Most patients (93%) believed that there was a benefit from emergent helicopter transfer to a stroke center, although 40% of respondents received no specific therapy. CONCLUSION: Interhospital transfer by air may benefit a substantial number of acute stroke patients by offering potential therapies and intensive management not available elsewhere. (+info)
Doctor-staffed ambulance helicopters: to what extent can the general practitioner replace the anaesthesiologist?
During two years, a rural ambulance helicopter programme saved 41 patients' lives. In 29 of these patients, the decisive medical interventions were carried out by the flight anaesthesiologist before reaching the hospital. We asked an expert panel to assess whether these interventions could have been carried out by a general practitioner (GP). This was the case for 17 (59%) of the 29 patients, while more advances skills, equipment or drugs were needed for 11 (38%). Among these 11, three patients would probably have died without the interventions. We conclude that GPs can manage a majority of life saving missions for a rural ambulance helicopter programme, but the lack of a flight anaesthesiologist may imply substantial health losses for a few patients. (+info)
A trauma resource allocation model for ambulances and hospitals.
OBJECTIVE: To develop a mathematical model for the location of trauma care resources. DATA SOURCES/STUDY SETTING: Severely injured patients queried from Maryland hospital discharge and vital statistics data. A spatial injury profile was created by parsing these patients into ZIP codes. STUDY DESIGN: The Trauma Resource Allocation Model for Ambulances and Hospitals (TRAMAH) was formulated using integer and heuristic programming. To maximize coverage of severely injured patients, trauma centers and aeromedical depots were simultaneously sited using TRAMAH. A severe injury was considered covered if at least one trauma center was sited within a time standard by ground, or if an aeromedical depot-trauma center pair was sited in such a way that the sum of the flying time from the aeromedical depot to the scene of injury plus the flying time from the scene of injury to the trauma center was within the same time standard. PRINCIPAL FINDINGS: From 1992 to 1994, 26,774 severe injuries were considered for coverage. Across Maryland, 94.8 percent of severely injured residents had access to trauma system resources within 30 minutes and 70.3 percent had access within 15 minutes. For the same number of resources as the existing Maryland Trauma System, TRAMAH achieved a coverage objective of 99.97 percent within 30 minutes. This translated into an additional 461 severely injured people covered each year. Holding in place the trauma centers of the existing system, approximately the same percentage of coverage as that of the existing system was achieved within 15 minutes by optimally locating six fewer aeromedical depots. CONCLUSIONS: TRAMAH will allow trauma systems planners to better locate their resources with respect to spatial needs and response times. (+info)
Thrombolysis in the air. Air-ambulance paramedics flying to remote communities treat patients before hospitalization.
PROBLEM ADDRESSED: First Nations* communities in the North have a high prevalence of coronary artery disease and type 2 diabetes and face an increasing incidence of myocardial infarction (MI). Many conditions delay timely administration of thrombolysis, including long times between when patients first experience symptoms and when they present to community nursing stations, delays in air transfers to treating hospitals, uncertainty about when planes are available, and poor flying conditions. OBJECTIVE OF PROGRAM: To develop a program for administration of thrombolysis on the way to hospital by air ambulance paramedics flying to remote communities to provide more rapid thrombolytic therapy to northern patients experiencing acute MIs. COMPONENTS OF PROGRAM: Critical care flight paramedics fly to northern communities from Sioux Lookout, Ont; assess patients; communicate with base hospital physicians; review an exclusion criteria checklist; and administer thrombolytics according to the Sioux Lookout District Health Centre/Base Hospital Policy and Procedure Manual. Patients are then flown to hospitals in Sioux Lookout; Winnipeg, Man; or Thunder Bay, Ont. CONCLUSION: This thrombolysis program is being pilot tested, and further evaluation and development is anticipated. (+info)
Profile and outcomes of patients transported to an accident and emergency department by helicopter: prospective case series.
OBJECTIVES: To study the profile of airlifted patients and their outcomes after arrival at the hospital, and to evaluate the appropriateness of their prehospital care and the decision to use aeromedical evacuation. DESIGN: Prospective case series. SETTING: Accident and emergency department of a public hospital, Hong Kong. PATIENTS: All patients transported to the department by a helicopter of the Government Flying Service from June 1998 through November 1998. MAIN OUTCOME MEASURES: Demographic data, sources and locations of referral, clinical features, triage category, interventions used, and outcome. RESULTS: A total of 186 patients were transferred by helicopter during the 6-month study period. The 101 patients who had been transferred from a rural hospital or clinic were older (mean age, 50 years versus 35 years), comprised more females (55% versus 26%), had a higher overall mortality rate (19.8% versus 3.6%), and had a higher hospital admission rate (91.1% versus 37.6%) than the 85 patients who had been airlifted from the scene of an emergency. Neurological disorders were the most common presentation among interfacility transfers (21.8%). Among the 85 scene transfers, limb injuries (32.1%) and heat illnesses (24.4%) were the most common reasons for helicopter transport. Most interfacility transfers were appropriate, but 34.1% of patients who had been transferred from the scene of the emergency were later discharged and 21.1% refused consultation. CONCLUSIONS: Scene and interfacility transfers by helicopter have different patient profiles, and a substantial proportion of scene transfers may be inappropriate. Guidelines such as field triage and helicopter dispatch criteria need to be established. (+info)
Treatment of refractory unstable angina in geographically isolated areas without cardiac surgery. Invasive versus conservative strategy (TRUCS study).
AIMS: We compared invasive (on-site coronary angioplasty or emergency air-ambulance transfer for bypass grafting surgery) vs conservative (persistent medical treatment) strategies in the management of refractory unstable angina in geographically isolated hospitals without cardiac surgical facilities. METHODS AND RESULTS: One hundred and forty eight randomized patients with refractory unstable angina were compared on an intention-to-treat basis. Outcomes (invasive vs conservative): (a) in hospital: stabilization (96% vs 43%, P=0.0001), non-fatal myocardial infarction (2.6% vs 4.2%, P=ns), death (1.3% vs 8.3%, P=0.046), combined outcome (3.9% vs 12.5%, P=0.053) and hospitalization (11.4+/-6.3 vs 12.4+/-8.0 days, P=ns). (b) 30-days follow-up: non-fatal myocardial infarction (2.6% vs 4.2%, P=ns), death (2.6% vs 11.1%, P=0.030) and combined outcome (5.3% vs 15.3%, P=0.031). (c) 12 month follow-up: non-fatal myocardial infarction (3. 9% vs 4.2%, P=ns), death (3.9% vs 12.5%, P=0.053), combined outcome (7.9% vs 16.7%, P=ns), re-admissions for unstable angina: (17.1% vs 23.6%, P=ns), late coronary angioplasty: (15.8% vs 11.1%, P=ns) and (d) late coronary bypass grafting: (7.9% vs 12.5%, P=ns). CONCLUSION: Invasive treatment of patients with refractory angina in remote areas without surgical back-up results in significant in-hospital stabilization and a reduction in major events in-hospital and at 30 days. Coronary angioplasty in stand-alone units and air-transfer of these patients seems safe. (+info)