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Chapter 28: Prehospital and Austere Environments

Mark Robidoux; Jimmy Bliss; Christopher Partyka; Kjell Lindgren; John L. Hick

INTRODUCTION

Prehospital ultrasound allows caregivers to dramatically increase the amount of diagnostic information gathered as well as reduce the time to diagnosis. Information obtained can be used to mobilize appropriate definitive care resources as well as accelerate and improve accuracy of interventions. Ambient noise, vibration, and other factors not encountered in the hospital can impede usual patient assessment techniques in the prehospital environment. Many of these limitations can be addressed by the use of ultrasound.

CURRENT STATE OF PREHOSPITAL ULTRASOUND

Since the early 2000s, prehospital ultrasound has rapidly progressed from initial case reports1,2 to feasibility studies, and more recently to describing effect on outcomes in trauma and medical patients in meta-analysis, confirming the rapid maturation of its application.3,4 Several recent studies have concluded that use of prehospital ultrasound results in significant changes in patient management (Table 28-1).

TABLE 28-1.STUDIES EXAMINING THE IMPACT OF PREHOSPITAL ULTRASOUND ON PATIENT CARE5–7
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TABLE 28-1. STUDIES EXAMINING THE IMPACT OF PREHOSPITAL ULTRASOUND ON PATIENT CARE5–7
Study Examination Operator n Impact

O’Dochartaigh (2017)

Lung, cardiac, abdominal

HEMS nurses and paramedics

455 (318 nonphysician, 137 physician)

Scans performed by physicians were associated with more interventions than by nonphysicians. Most common interventions were to guide or cease resuscitation efforts, alter IV fluid administration, supplementing report at destination, triaging multiple patients on scene, and early activation of trauma team

Ketelaars (2018)

Abdominal

HEMS Physicians

1495

Ultrasound affected care of 12.6% patients. Decisions impacted were information provided to the destination hospital, mode of transportation, choice of destination hospital and fluid management.

Ketelaars (2018)

Cardiac

HEMS Physicians

56 patients, 102 total scans

61% of the ultrasound examinations impacted treatment decisions in 88% of the patients. The impacted treatment was related to termination of CPR (57%), fluid management (14%), drugs selection and doses (14%), choice of destination hospital (5%).

Ketelaars (2013)

Chest

HEMS Physicians

281

In 4% of patients the plan to place chest tube was abandoned. In 4% the destination hospital was changed.

Walcher (2006)

Abdominal

HEMS flight nurses and paramedics

202

Care was influenced in 21% by managing fluids differently (permissive hypotension for suspected hemorrhage) in 22% choice of receiving hospital was changed.

The United States

Initial description of ultrasound use on aeromedical units in the early 2000s was followed in 2010 by ground-based advanced life support ambulance demonstration projects.1,2 In the subsequent decade there has been rapid adoption of ultrasound in the prehospital environment, particularly by rotor-wing critical care units. Though the indications for use vary, most published applications address the use of the focused assessment with sonography for trauma (FAST) examination. These ultrasound examinations are goal-directed (limited windows, binary interpretation of results) to accommodate the training level of the providers and simplify interpretation as real-time interpretation and oversight ...

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