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BUILDING THE EVIDENCE BASE FOR PRACTICE



Broselow Tape

Potential Underdosing

ACNP/Flight Nurse, Carolyn Nieman recently discovered that sometimes motherhood is the mother of invention. Ms. Nieman, who works as a flight nurse specialist for Metro Life Flight and is a member of the CASE faculty. Three years ago, while watching her thirteen-year-old daughter and ten-year-old son perform at a school concert, she first thought of the idea that the Broselow Tape may underestimate children's size. Soon afterward, she began devising a way to improve on the “Broselow Tape” method traditionally used in emergency medical situations involving children requiring resuscitation. The method is used to estimate medication dosing and equipment sizing based on a child’s age and body size. “I always thought my kids were normal size, but that night they seemed so much smaller than everyone else on stage,” she says. “So when I came to work, I started thinking there’s no way that the Broselow Tape can be accurate anymore, and it became more clear to me everywhere I went that kids seemed bigger and bigger.”

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Environmental Cues

Situational Awareness

Situational awareness is a key factor in preparedness for emergencies. The range of sensory cues identified in this observational and interview study include six categories of cues. They are visual, acoustic, vibration, air current, thermal, and smell. Examples of sensory cues identified include VISUAL: observation of treatment provided by first responders, wind direction, fireworks being launched into the air, shadows of poles and trees that were not themselves visible, blinking lights that might indicate the presence of obstruction of "steady" light sources, damage to vehicles and buildings, the inability to visualize, monitor power failure, estimating the size of confined spaces; ACOUTSIC: inability to hear change in breath sounds (thus choosing to electively place chest tube for 50 mL hemothorax), noise produced by generators, fire trucks and extrication tools, rotor sound; THERMAL: air temperature and temperature of fluids during fluid resuscitation; SMELL: smell of jet fuel (potential emergency condition) versus jet exhaust (time signal on close approach). The sensory cues identified will be used to develop a "synthetic natural environment" to conduct training of advanced practice nurses and to conduct clinical research using simulated patients under a wide range of environmental conditions.

Kangaroo Transport Instead of Incubator Transport

Potential to Decrease Risks Associated with Incubator Transport

A nurse-physician research team (based in Boston and Germany) reported the findings of a descriptive study of the use of "Kangaroo" care during transport of infants with an implied comparison to the traditional use of incubators during transport. Thirty one infants were studied in Germany. They ranged in gestational age from 26 to 41 weeks with birth weights ranging from 870 g to 3,470 g. Transport time ranged from 10 minutes to 5 hours and covered from 2 to 400 km. Two of the transports were by helicopter and the remaining by ground ambulance.

Heart rate, ventilatory rate, oxygen saturation and rectal temperature remained stable during all kangaroo transports.

Kangaroo transport can promote mother-infant closeness and might ameliorate some of the risks associated with incubator transport. For more information, see:

Sontheimer D, Fishcer CB & Buch KE. (2004). Kangaroo transport instead of incubator transport. Pediatrics, 113, 920-923.

Air Medical Transport of Cardiac Patients

Transport without major complications

This literature review conducted in 2003 looked at the efficacy of air medical transfer of cardiac patients. Several potential risks of flight were identified including hypoxia at altitude, patient anxiety related to the flight, and complications related to patient movement.

Short distance emergency helicopter transport of patients with acute myocardial infarction was found to be safe. Long distance elective commercial transport is safe within 2 to 3 weeks following acute coronary syndrome in patients without high risk. Long distance elective air transport, limited to one study, was found to be safe 3 to 7 days after admission or 48 to 72 hours after resolution of chest pain. Long distance emergency air ambulance transport was reported without major complications.

Further research is needed using large prospective studies to better define criteria for safe long distance air medical transport and revision of current guidelines may be needed to include the use of medical escorts and intensive level equipped air ambulances. For more information, see:

Essebag V, Halabi AB, Churchill-Smith M & Lutchmedial S. (2003) Air medical transport of cardiac patients. Chest, 124, 1937-1945. [review prepared by Andrew Reimer BSN RN]

Neuromuscular Blockade Improves Intubation Success

Eight Hour Training Course

This study conducted in San Diego County, trained approximately ¾ of practicing paramedics in rapid sequence intubation (RIS) using neuromuscular blocking agents with an 8 hour course and certification.

The target population was adult trauma victims with severe traumatic head injury (TBI), a GCS of 8 or less and transportation time of greater than 10 minutes. The medication regime consisted of midazolam for sedation, succinycholine for paralysis, rocuronium for paralysis maintenance and morphine for hypertensive stress response. A total of 249 patients meet inclusion criteria and 123 patients were entered into the trial. The indications for RSI included clenched jaw, presence of gag reflex and a combative patient. The total procedure was performed on 114 patients with success in 113 (99%) with ET intubation in 96 patients and Combitube placement in 17 patients.

Performing the procedure added 14 minutes to on-scene time and reduced the number of RSI performed by airmedical crews. The 99% success rate shows improvement over the general 84% success rate of ET intubations alone. The findings may not be generalizable to other districts due to the experience and already aggressive airway management protocols in place before the trial. For more information, see:

Davis DP, Ochs M, Hoyt DB, et al. (2003). Paramedic-administerred neuromuscular blockade improves prehospital intubation success in severely head-injured patients. The Journal of Trauma, Injury, Infection and Crticial Care, 55, 713-719. [review prepared by Andrew Reimer BSN RN]

Potential Limitation of FAST

Reported Case

A 64 year old male pedestrian was struck by a truck, sustaining blunt trauma to the right chest, abdomen and pelvis. In the emergency department, he was conscious complaining of chest and back pain. The patient had right flail chest and hemopneumothorax with abdominal distention.

Chest thoracostomy was performed draining 400 mL blood in the first 60 minutes and another 500mL of blood over the next 30 minutes. Tachycardia and hypotension proved refractory to aggressive fluid resuscitation. Serial focused assessment with sonography for trauma (FAST) exams were performed on three occasions, proving negative. Chest thoracotomy was performed revealing a large amount of blood draining from the abdomen into the chest through a diaphragmatic laceration. Laparotomy was performed showing a liver laceration with partial avulsion of the right lobe, the primary site of hemorrhage. Repeat laparotomy was performed 3 days later due to ongoing hemodynamic instability and worsening acidosis, revealing significant hemoperitoneum related to the liver laceration - the patient developed bradycardia during the procedure that progressed to asystole, no resuscitation was attempted.

This case demonstrates a potential pitfall in relying on the FAST exam for evaluation of unstable blunt abdominal trauma. The potential hemoperitoneum was dissipated through the diaphragmatic laceration and manifested as a hemothorax. Indications include the realization that initial FAST examination on the arrival of a trauma patient may not allow sufficient time for development of significant hemoperitoneum. It is suggested that serial FAST examinations reduce the incidence of missed injuries with ongoing hemorrhage. For more information, see:

Ryan, M., & Stella, J. (2004). Massive hemorrhage from hepatic laceration with diaphragmatic laceration: A potential limitation of the FAST examination: Case report. Journal of TRAUMA Injury, Infection, and Critical Care, 57(3), 633-634. [review prepared by Andrew Reimer BSN RN]

Lower Extremity Fracture in Motor Vehicle Crashes

The Role of Restraint Use

This retrospective analysis was conducted to measure the association between seatbelt use and airbag deployment and the risk of lower extremity fractures following frontal motor vehicle crashes (MVCs). Data was obtained from the National Automotive Sampling System (NASS) that reports light passenger vehicle MVCs which include crashes that are police reported, involved a harmful event and at least one vehicle was towed away.

The sample included 15,188,292 front seat occupants (1995-2000), being in either the driver or passenger seats. Frontal collisions were defined as primary direction of force between 11 and 1 o'clock to the frontal aspect of the vehicle, and crashes were equal to or greater than 15 kilometers per hour.

The study found that occupants restrained with a seatbelt had only a significantly lower risk of pelvis, femur and tibia/fibula fractures whereas occupants restrained with only an airbag had significantly higher risks of these fractures. The combination of seatbelt use and airbag deployment was similarly associated with a reduced risk of pelvis, femur and tibia/fibula fractures. This provides data useful in processing scene assessment and expected injuries when responding to motor vehicle crashes. For more information, see:

Estrada, L.S., Alonso, J.E., McGwin, G., et al. (2004). Restraint use and lower extremity fractures in frontal motor vehicle collisions. Journal of Trauma, Injury, Infection, and Critical Care, 57(2), 323-328. [review prepared by Andrew Reimer BSN RN]

Auto Launch/Early Activation of Air Medical Services

The purpose of this survey was to determine the incidence of the use of auto launch/early activation by AAMS members. The author defined "Auto launch" as "the simultaneous dispatch of air and ground resources to a 9-1-1 request for EMS based upon predesignated trauma and/or medical criteria set up by local or regional EMS systems. The auto launch requests need come through 9-1-1 operations so dispatchers are aware of the resources being sent…". Of 240 AAMS members surveyed, 93 flight programs responded to the survey and 86 were determined to be usable responses. Of the 86 usable responses, 83 (96.5%) agreed with the auto launch definition.

Approximately half of the 86 usable respondents use some sort of auto launch/early activation. However, it is noted that criteria, protocol, and implementation differ widely among these programs. Criteria for auto launch commonly consisted of patient condition, event related, and geographical factors. The authors suggest that auto launch/early activation may potentially reduce scene response times, emphasizing the use in rural areas.

It is not clear if the benefit of auto launch/early activation is related to decreased time from injury to arrival at a trauma center or due to early intervention by clinicians who bring definitive treatment to the patient regardless of their location or condition. The authors acknowledge the potential of bias by the respondents as programs who do not favor auto launch/early activation were less likely to respond. For more information, see:

Wish, J., Davis, D. (2005). Auto launch/early activation: A survey of AAMS members and literature review. Air Medical Journal, 24(2), 83-88. [review prepared by Jonathan C. Sague, BSN, RN, EMT-P]

Excessive Exposure of Sick Neonates to Sound During Transport

Excessive Sound during Air Transport

Thirty-eight neonatal transports were selected for study between March 2000 and January 2001 in Christchurch, New Zealand. Noise on ambulance, fixed wing aircraft, and rotorcraft were measured using a calibrated sound meter placed within the incubator. A standard transportation documentation sheet was also used to correlate flight events with time logged on the sound meter.

Maximum sound levels audible to the human ear (Lmax) were recorded in decibels (dB) as well as peak levels reached outside frequencies heard by the human ear (Peak "C"). Lmax levels for fixed wing and helicopter were 83.3 dB (2.3) and 84.1 dB (2.10) respectively. Peak "C" levels reached 107.9 dB (6.9) and 121 dB (0.4). Brief, extremely high noise levels occurred during take off and when the internal air compressor for the transport ventilator was started.

Sound and vibration are known causes of increased oxygen consumption, fatigue and stress in adults. International guidelines recommend that sound levels during transport do not exceed 60 dB. Commercially available ear protection in neonatal units eases sound by only 7dB. Exposure of infants to sound during medical transport must be modified for better immediate and long-term outcomes. For more information, see:

Buckland L, Austin N, Jackson A & Inder T. (2003). Excessive exposure of sick neonates to sound during transport. Arch Dis Child Fetal Neonatal Ed, 88, F513-F516. [review prepared by Laura Rosenthal BSN RN CCRN]

Comparison of Helicopter & Ground Ambulance Transport Times

When is the helicopter faster?

A retrospective study completed in Fresno and Kings County used records from an EMS database to demonstrate overall helicopter versus ground ambulance transport times. Data collected between June 1996 and June 2000 included 8,929 transported patients, 30% were of trauma patients with 47% transported to the regional Level I trauma center. Records included 1,075 helicopter transports, 715 Simultaneous Dispatch (SD) and 360 Non Simultaneous Dispatch (NSD), and 7,854 ground ambulance runs. SD referred to helicopter dispatched simultaneously with ground unit within 5 minutes of the initial 911 call, while NSD referred to helicopter dispatch after ground unit response. All inter-facility transfers were excluded. The transport time was defined as the time in minutes from the receipt of the initial 911 call to arrival at the receiving hospital. Transport distance was defined as the straight-line distance between the scene location and the receiving hospital.

Overall, ground transport yielded the shortest transport time when scenes were within 10 miles of the hospital. When greater than 10 miles away from the hospital, quickest transport resulted from SD helicopter immediately after the 911 call. Finally, when helicopter dispatch was delayed until after ground personnel assessed the patient (NSD), helicopter transport time did not become shorter until the distance from the hospital was greater than 45 miles.

Despite these findings, many variables factors such as cost, severity of illness, and condition of patient. The decision should not be made on the basis of cost alone, because there may be some benefit in delivering a higher level of care to a scene even if transport is not faster. For more information, see:

Diaz, M.A., Hendey, G.W., Bivins, H.G. (2005). When is the helicopter faster? A comparison of helicopter and ground ambulance transport times. The Journal of Trauma Injury, Infection, and Critical Care, 58, 148-153. [review prepared by Laura Rosenthal BSN RN CCRN]

Thoracic Ultrasound for Detecting Pneumothraces

Pneumothoraces (PTX) are found in 1/5 major blunt trauma victims who are found alive. PTX are dynamic and become life-threatening, especially when positive pressure ventilation is use and during air medical transport at altitude. The purpose of this study was the prospective evaluation of the usefulness of hand-held sonography in addition to physical exam to detect PTXs during initial resuscitation of trauma victims.

225 patients were examined after traumatic injuries. The median Injury Severity Score (ISS) was 14, 74% were men, the median age was 37 years. Of the 225 patients examined, 207 were victims of blunt trauma. Normal determinations could be made in under a minute, and 65 PTX were identified in 52 patients. Occult PTXs were present in 14.6% of all patients and 24.6% using chest CT scan as the "gold" standard.

Compared with CT scan, EFAST performed with greater accuracy than chest xray. Two false-positives involving suspected left-sided PTXs were the result of right mainstem intubation. With repositioning of the ETT above the carina, the sonogram returned to normal. This finding demonstrates a potential further use of EFAST in operational environments where auscultation is difficult or impossible.

For more information, see:

Kirkpatrick AW, Sirois M, Laupland KB, Liu D, et al.(2004). Hand-held thoracic sonography for dectecting post-traumatic pneumothoraces:  The extended focused assessment sonography for trauma (EFAST). Journal of Trauma, 57, 288-295. [review prepared by Andrew Reimer BSN RN]

Children in Side-Impact Motor Vehicle Crashes

Seating Position and Injury Mechanisms

Side-impact crashes result in higher rates of injury than frontal crashes. A prospective study conducted in Canada describes the injuries sustained by children based upon their seat position within the motor vehicle.

Near-side occupants (n=13) were most severely injured with a predominance of head, neck, and brain injuries related to direct intrusion into the occupant compartment. Thoracic, abdominal, pelvic girdle, and limb injuries commonly accompanied the head injuries. The median Injury Severity Score (ISS) was 21, with an average vehicular crush depth of 63 cm. The only fatalies in this study were among near-side occupants.

Center-seat occupants (n=9) experienced mostly low-severity injuries (concussions, lacerations, and low-energy fractures) from contact with other occupants. Median ISS was 6. Far-side occupants (n=9) demonstrated mild to moderate injuries from contact with the vehicle, belt-restraints or other occupants. Median ISS was 3.5.

Seating position strongly influences expected injuries, which may be helpful in the triage and treament of multiple restrained children from the same motor vehicle crash. Children, where possible, should be kept away from potential zones of intrusion. For more information, see:

Rothman HA, McKeag A, Pazmino-Canizares J, Monk B, Comeau JL, Mills D, Blazeski S, Hale I & German A. (2004). Children in side-impact motor vehicle crashes: Seating positions and injury mechanisms. Journal of Trauma, 56, 1276-1285. [review prepared by Laura Rosenthal BSN RN]