The Intra-aortic Balloon Pump: A Focused Review of Physiology, Transport Logistics, Mechanics, and Complications.

Critical care transport medicine (CCTM) teams are playing an increasing role in the care of patients in cardiogenic shock requiring mechanical circulatory support devices. Hence, it is important that CCTM providers are familiar with the pathophysiology of cardiogenic shock, the role of mechanical circulatory support, and the management of these devices in the transport environment. The intra-aortic balloon pump is a widely used and accessible cardiac support device capable of increasing cardiac output and reducing work on the left ventricle through diastolic augmentation and counterpulsation.

Prehospital Ground and Helicopter-Based Extracorporeal Cardiopulmonary Resuscitation (ECPR) Reduce Barriers to ECPR: A GIS Model.

Introduction: Evidence suggests that Extracorporeal Cardiopulmonary Resuscitation (ECPR) can improve survival rates for nontraumatic out-of-hospital cardiac arrest (OHCA). However, when ECPR is indicated over 50% of potential candidates are unable to qualify in the current hospital-based system due to geographic limitations. This study employs a Geographic Information System (GIS) model to estimate the number of ECPR eligible patients within the United States in the current hospital-based system, a prehospital ECPR ground-based system, and a prehospital ECPR Helicopter Emergency Medical Services (HEMS)-based system.

Association of Geographic Distance and Hospital Characteristics With Use of Interhospital Transfer by Air: A Multicenter Retrospective Study.

Objective: Interhospital transfer by air (IHTA) represents the majority of helicopter air ambulance transports in the United States, but the evaluation of what factors are associated with utilization has been limited. We aimed to assess the association of geographic distance and hospital characteristics (including patient volume) with the use of IHTA.

Methods: This was a multicenter, retrospective study of helicopter flight request data from 2018 provided by a convenience sample of 4 critical care transport medicine programs in 3 US census regions.

Percutaneous left ventricular assist devices in refractory cardiac arrest: The role of chest compressions.

Background: Recent studies describe an emerging role for percutaneous left ventricular assist devices such as Impella CP® as rescue therapy for refractory cardiac arrest. We hypothesized that the addition of mechanical chest compressions to percutaneous left ventricular assist device assisted CPR would improve hemodynamics by compressing the right ventricle and augmenting pulmonary blood flow and left ventricular filling. We performed a pilot study to test this hypothesis using a swine model of prolonged cardiac arrest.

Wolf Creek XVII part 9: Wolf Creek Innovator in Cardiac Arrest and Resuscitation Science Award.

The Wolf Creek Conferences on Cardiac Arrest Resuscitation began in 1975, and have served as an important forum for thought leaders and scientists from industry and academia to come together with the common goal of advancing the field of cardiac arrest resuscitation. The Wolf Creek XVII Conference was hosted by the Max Harry Weil Institute of Critical Care Research and Innovation in Ann Arbor, Michigan on June 14-17, 2023. A new component of the conference was the Wolf Creek Innovator in Cardiac Arrest and Resuscitation Science Award competition.

The Successful Rotor Wing Transport of 2 Patients Requiring Biventricular Impella Support: A Case Series and Review.

Despite many advances in care, the mortality rate for cardiogenic shock remains high. Because the medical management of patients with cardiogenic shock is limited, many patients often require mechanical circulatory support. As such, cardiogenic shock patients requiring percutaneous ventricular support devices such as the Impella (Abiomed, Danvers, MA) may be encountered by critical care transport crews with increasing frequency.

Effect of percutaneous ventricular assisted device on post-cardiac arrest myocardial dysfunction in swine model with prolonged cardiac arrest.

Background: It remains unclear if percutaneous left ventricular assist device (pLVAD) reduces post-cardiac arrest myocardial dysfunction.

Methods: This is a prespecified analysis of a subset of swine that achieved return of spontaneous circulation (ROSC) in a study comparing pLVAD, transient aortic occlusion (AO), or both during cardiopulmonary resuscitation (CPR). Devices were initiated after 24 minutes of ventricular fibrillation cardiac arrest (8 min no-flow and 16 min mechanical CPR).

Takotsubo Cardiomyopathy Syndrome in Critical Care Transport: A Case and Critical Review.

Takotsubo cardiomyopathy syndrome, or simply takotsubo syndrome (TTS), is a form of stress cardiomyopathy thought to be caused by excess catecholamines in association with physical or emotional stress. Providers should maintain a high index of suspicion for TTS in patients with symptoms of acute coronary syndrome, acute decompensated heart failure, substernal chest pain, or dyspnea. However, TTS is a diagnosis of exclusion, and patients should initially be evaluated and treated for other causes, such as acute myocardial infarction.

Impact of emergency department-based intensive care unit on outcomes of decompensating boarding emergency department patients.

Objectives: Emergency department (ED) boarding, or remaining in the ED after admission before transfer to an inpatient bed, is prevalent. Boarding patients may decompensate before inpatient transfer, necessitating escalation to the intensive care unit (ICU). We evaluated the impact of an ED-ICU on decompensating boarding ED patients.

Haemodynamic impact of aortic balloon occlusion combined with percutaneous left ventricular assist device during cardiopulmonary resuscitation in a swine model of cardiac arrest.

Aim: To investigate the effect of tandem use of transient balloon occlusion of the descending aorta (AO) and percutaneous left ventricular assist device (pl-VAD) during cardiopulmonary resuscitation in a large animal model of prolonged cardiac arrest.

Methods: Ventricular fibrillation was induced and left untreated for 8 minutes followed by 16 minutes of mechanical CPR (mCPR) in 24 swine, under general anesthesia. Animals were randomized to 3 treatment groups (n = 8 per group): A) pL-VAD (Impella CP®) B) pL-VAD+AO, and C) AO.

Lateral Canthotomy Task Trainer in an Educational Small Group for Flight Providers.

Objective: Lateral canthotomy is a rare, emergent, vision-preserving procedure to treat orbital compartment syndrome. Using Ericsson's deliberate practice model, we aimed to develop a multimodal small group intervention including a modified low-fidelity task trainer to improve flight physician knowledge and technical competency for lateral canthotomy in the prehospital context.

Methods: Two cohorts of resident (postgraduate year 1) flight physicians received small group training during an all-day competency-based flight physician orientation.

Remnant Blood Quantification: Informing the Definition of Minimal Risk in Clinical Research.

Guidelines from the Office for Human Research Protections regarding categories of research that institutional review boards (IRBs) may review through expedited procedures limit the volume of blood that can be obtained from research participants for minimal risk research purposes. As defined by the Common Rule, minimal risk research is research in which the probability and magnitude of harm or discomfort anticipated are not greater than the probability and magnitude of harm or discomfort encountered from routine clinical tests. For this study, we considered the volume of remnant blood following routine clinical tests in light of the current definition of minimal risk in research.

Management of Acute Upper Gastrointestinal Bleeding in Critical Care Transport.

Upper gastrointestinal bleeding is a relatively common and life-threatening condition encountered by critical care transport crews. It is of paramount importance that transport crews understand the underlying pathophysiology of variceal and nonvariceal gastrointestinal bleeding as well as the nuanced management of this patient population. This article reviews the current clinical evidence on initial resuscitation, medical management, and advanced invasive therapies (such as balloon tamponade devices) that transport crews should be familiar with to manage these patients.

Troubleshooting FoCUS Image Acquisition: Patient Positioning, Transducer Manipulation, and Image Optimization.

Focused cardiac ultrasound (FoCUS) is a limited, clinician-performed application of echocardiography to add real-time information to patient care. These bedside exams are problem oriented, rapidly and repeatedly performed, and largely qualitative in nature. Competency in FoCUS includes mastery of the stereotactic and psychomotor skills required for transducer manipulation and image acquisition.

Management of patients with impella devices or intra-aortic balloon pumps during helicopter air ambulance transport in observational data.

Introduction: Placement of percutaneous ventricular support devices such as an intraaortic balloon pump (IABP) or Abiomed Impella device can treat severe cardiogenic shock. Critical care transport medicine (CCTM) providers frequently manage patients supported by these devices during interfacility transfers, often using a helicopter air ambulance (HAA). An understanding of patient needs and management during transport is essential to informing crew configuration and training, and this study adds to the limited existing data on the HAA transport of this complex patient population.

Current summary of the evidence in drone-based emergency medical services care.

Interventions for many medical emergencies including cardiac arrests, strokes, drug overdoses, seizures, and trauma, are critically time-dependent, with faster intervention leading to improved patient outcomes. Consequently, a major focus of emergency medical services (EMS) systems and prehospital medicine has been improving the time until medical intervention in these time-sensitive emergencies, often by reducing the time required to deliver critical medical supplies to the scene of the emergency. Medical indications for using unmanned aerial vehicles, or drones, are rapidly expanding, including the delivery of time-sensitive medical supplies.

Eligibility of out-of-hospital cardiac arrest patients for extracorporeal cardiopulmonary resuscitation in the United States: A geographic information system model.

Background: Recent evidence suggest that extracorporeal cardiopulmonary resuscitation (ECPR) may improve survival rates for nontraumatic out-of-hospital cardiac arrest (OHCA). Eligibility criteria for ECPR are often based on patient age, clinical variables, and facility capabilities. Expanding access to ECPR across the U.

Extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest - who, when, and where?

Purpose Of Review: Extracorporeal cardiopulmonary resuscitation (ECPR) is an invasive and resource-intensive therapy used to care for patients with refractory cardiac arrest. In this review, we highlight considerations for the establishment of an ECPR system of care for patients suffering refractory out-of-hospital cardiac arrest (OHCA).

Recent Findings: ECPR has been shown to improve neurologically favorable outcomes in patients with refractory cardiac arrest in numerous studies, including a single randomized control trial.

Statin Administration for ST-Elevation Myocardial Infarction During Rotor Wing Transport.

Objective: The aim of this study was to evaluate the feasibility of statin administration by a critical care transport medicine (CCTM) team during rotor wing transport for ST-elevation myocardial infarction patients to a percutaneous intervention-capable center.

Methods: We conducted a retrospective study at a single CCTM program after an intervention focused on statin administration for ST-elevation myocardial infarction that included a formulary change and a single brief educational presentation to flight physicians. A comparison group of flight nurse practitioners underwent training after the study period and were used as a control.

Management of Respiratory Distress and Failure in Morbidly and Super Obese Patients During Critical Care Transport.

Morbidly and super obese patients are a unique patient population that presents critical care transport providers with unique clinical and logistical challenges in the setting of respiratory distress and failure. These patients are more likely to have chronic respiratory issues at baseline, unique anatomic and physiologic abnormalities, and other comorbidities that leave them poorly able to tolerate respiratory illness or injury. This requires specialized understanding of their respiratory mechanics as well as how to tailor standard treatment modalities, such as noninvasive ventilation, to meet their needs.

Impella in Transport: Physiology, Mechanics, Complications, and Transport Considerations.

Cardiogenic shock (CS) represents a spectrum of hemodynamic deficits in which the cardiac output is insufficient to provide adequate tissue perfusion. The Impella (Abiomed Inc, Danvers, MA) device, a contemporary percutaneous ventricular support, is most often indicated for classic, deteriorating, and extremis Society for Coronary Angiography and Intervention stages of CS, which describe CS that is not responsive to optimal medical management and conventional treatment measures. Impella devices are an evolving field of mechanical support that is used with increasing frequency.

Alteplase and Adjuvant Therapies for Acute Ischemic Stroke.

Acute ischemic stroke (AIS) is a time sensitive medical emergency and a leading cause of morbidity and mortality worldwide. Intravenous (IV) recombinant tissue plasminogen activator (IV alteplase) is currently the only proven effective medication for the treatment of AIS with promising adjuvant medications currently under investigation. Recent advances in endovascular thrombectomy have broadened therapeutic options in specific patient populations, with modern treatment strategies utilizing advanced imaging modalities to extend the window for treatment.