Charles Bethea MD Raj Chandwaney MD Neurology David L. Gordon MD Anna Wanahita MD Obstetrics Michael Gardner MD Pediatrics Amanda L. Bogie MD Michael Gomez MD

Cecilia C. Guthrie MD Surgery & Trauma John Blebea MD Jason Lees MD Michael Charles MD Referring Facility Stabilizing Patients Rapidly for

INTerfacility transport Course overview & 5 Ws General principles/steps for all patients Principles related to specific diagnoses Recommendations summary Post-course follow-up & plans Discussion outline Receiving

Hospital SPRINT overview: 5 Ws What is SPRINT? Why a new program? Who are audience targets? Where and when are courses?

SPRINT general principles Core message: Fast, Safe, and Sound Strive for quickness (while avoiding haste) Keep patient safety as top priority Practice sound, evidence-based medicine Goal: Minimize HEMS time at referring hospital Time HEMS crew spends at patients bedside SPRINTs focus: Patient stabilization time (PST)

SPRINT goal: Streamline PST Efficiency is desirable in any acute patient Incremental benefit with time savings Trauma Vascular emergencies Categorical endpoint: meeting time window Percutaneous coronary intervention for STEMI Lysis therapy for ischemic stroke (iCVA)

SPRINT and patient care timeline SPRINT time frame after transport decision SPRINT is not intended to address: Making decision to transport Determining transport mode/service Designating receiving facility SPRINT is not meant to dictate transport decisions, modalities, or receiving centers SPRINT steps: Initial information

Referring & receiving hospital data Unit, physician, contact info Bed status: Ready, not ready, etc. Patient parameters Name and birthdate Complaint/transport reason Height, weight & widest girth SPRINT steps: Initial info

Additional clinical parameters Medications Equipment (eg. pumps, vent) Safety (eg. patient agitation) Other issues Will family be at referring hospital with patient? Weather questions on referring hospital end SPRINT steps: Logistics & paperwork Prepare the LZ and personnel

Refer to LZ training courses Prepare to assist crew as needed SPRINT steps: Airway #1 issue (for flight crews & receiving doctors) Endotracheal intubation (ETI) problems: HEMS ETI is widely perceived as too frequent Flight crew ETI is associated with prolonged PST Flight crew can offer significant ETI expertise Decision on ETI pre-transport vs. in-flight:

Estimation of ETI difficulty isnt always precise Patient and logistics factors contribute to decision Bottom line: Situational judgment is best Guides to assist referring providers: If airway needs management, manage it When in doubt, secure airway Discuss prn with en route crews When airway is managed Describe difficulties to crew Note airway, size, and depth

SPRINT steps: Airway SPRINT steps: Breathing Breathing problem: manage airway Mechanical ventilation preferred Optimize/report vent settings Vascular access

2 functioning and secured lines usually required If IV access is problematic, alert en route HEMS crew Fluids: Discuss with receiving; prepare infusates SPRINT steps: Circulation SPRINT steps: Medications Drug Rx often causes preventable delays Execute/consider following time savers:

Administer all ordered medications Clarify allergies Anticipate medications that may be needed Alert transport crews to drugs/times given: Antibiotics Analgesics Sedatives Paralytics

Cardiovascular support (cardio-/vaso-active agents) Disease-specific therapy SPRINT steps: Other procedures Gastric tube Foley catheter Pneumothorax tx SPRINT steps: Flight crew arrival

Crew to pt for pass-off Assure 2 IVs Transfer infusions to HEMS pumps Assure ordered meds given Discuss situation with family Situationally consider:

ABCs management Spinal immobilization Analgesia, sedation, antiemetics, other prn meds Foley, gastric tube, Dx-specific therapy SPRINT steps: Patient hand-off 1) Patient demographics 2) Chief complaint & HPI 3) Dx and basic therapies Labs, radiography, meds Identify treatment as:

Fully completed Partly complete Planned/ordered Admin times for key meds Analgesia Antiepileptics

Sedation Paralytics 4) Ventilator patients Airway/lung assessment ETI medications/problems

ETT size, depth ETT confirmation method Vent changes/responses 5) Summarize working dx 6) Ask if report complete 7) Receiving crew review Presentation key points Interventions/meds Points to consider Diagnosis-specific principles

Burns Cardiac Neurology Obstetrics Pediatrics Trauma Vascular Streamlining PST: Burns 1) Airway: Aggressive can be conservative

Inhalational/airway, facial burns: ETI likely Save PST on by managing airway early 2) Fluids (warm if possible) Use formula (BRI, Parkland) to calculate fluids Monitor and report urine output 3) Dressings: Use minimalist approach 4) Thermoregulation: Keep patients warm Streamlining PST: STEMI for PCI

1) Administer meds ASA almost always No clopidogrel Heparin bolus 50-70 u/kg 2) No IV infusions No heparin drip No nitroglycerin drip 3) Consider R-sided EKG 4) Gown patient

Streamlining PST: Seizures 1) Stop seizures 2) Report what worked (and when) 3) Avoid paralytics Streamlining PST: Stroke 1) Avoid paralytics 2) Generate BP plan Hemorrhage mgmt?

Lysis-eligible: 185/110 Post-lysis: 180/105 Streamlining PST: Obstetrics 1) 2) 3) 4) Transport by air?: Contractions and cervix Perfusion: left lateral decubitus position Analgesics and antiemetics (both are fine)

BP control: Formulate plan and start treating Streamlining PST: Pediatrics Airway: Intubate if needed Watch tube size/depth Streamlining PST: Pediatrics VS: Pay attention to BP cuff, SpO2 site, temp Fluids: Make plan for fluids and have them ready

Streamlining PST: Trauma Airway, breathing, and circulation Consider managing airway Assure IV access in place Foley catheters Assure infusates (e.g. blood) are ready

Spinal immobilization In unclear cases: fully immobilize Discuss with receiving surgeon Clarify why spine (or parts) cleared Streamlining PST: Trauma 1) Fractures: Splint, treat pain 2) Guard against hypothermia 3) Pneumothorax/chest tubes Thoracostomy: Heimlich valve

Pneumothorax: Decompress? Streamlining PST: Vascular 1) Cold extremities: Time is key Clarify time of sx onset Heparin bolus/infusion: almost always 2) Aortic disease (non-trauma) Large-bore access; judicious analgesia Permissive hypotension (AAA) Anti-impulse Rx (dissection)

Decision to transfer T0 Execute logistics/admin jobs Develop a concrete clinical plan Provide ordered and/or needed Tx Expedite the report to transport crew Facilitate movement to transport vehicle

Summary SPRINT: Post-course [email protected] Thanks for your time and for your time savings

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