Resuscitative endovascular balloon occlusion of the aorta (REBOA) has recently gained popularity as a minimally invasive alternative to open aortic cross-clamping in the management of patients with non-compressible hemorrhage arising below the diaphragm. The purpose of this review is to provide a description of the technical aspects of REBOA use along with an overview of the current animal and clinical data regarding its use.

There is limited guidance on the use of helicopter medical personnel to facilitate care of critically ill COVID‐19 patients. This manuscript describes the emergence of this novel virus, its mode of transmission, and the potential impacts on patient care in the unique environment of rotor wing aircraft. It details the development of clinical and operational guidelines for flight crew members. This allows other out‐of‐hospital clinicians to utilize our framework to augment or supplement their own for the current response effort to COVID‐19. It further serves as a road map for future response to the care of high consequence infectious disease patients.

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Introduction:In October 2017, the American Association of Blood Bankers (AABB; Bethesda, Maryland USA) approved a petition to allow low-titer group O whole blood as a standard product without the need for a waiver. Around that time, a few Texas, USA-based Emergency Medical Services (EMS) systems incorporated whole blood into their ground ambulances. The purpose of this project was to describe the epidemiology of ground ambulance patients that received a prehospital whole blood transfusion. The secondary aim of this project was to report an accounting analysis of these ground ambulance prehospital whole blood programs.Methods:The dataset came from the Harris County Emergency Service District 48 Fire Department (HCESD 48; Harris County, Texas USA) and San Antonio Fire Department (SAFD; San Antonio, Texas USA) whole blood Quality Assurance/Quality Improvement (QA/QI) databases from September 2017 through December 2018. The primary outcome of this study was the prehospital transfusion indication. The secondary outcome was the projected cost per life saved during the first 10 years of the prehospital whole blood initiative.Results:Of 58 consecutive prehospital whole blood administrations, the team included all 58 cases. Hemorrhagic shock from a non-traumatic etiology accounted for 46.5% (95% CI, 34.3%-59.2%) of prehospital whole blood recipients. In the non-traumatic hemorrhagic shock cohort, gastrointestinal hemorrhage was the underlying etiology of hemorrhagic shock in 66.7% (95% CI, 47.8%-81.4%) of prehospital whole blood transfusion recipients. The projected average cost to save a life in Year 10 was US$5,136.51 for the combined cohort, US$4,512.69 for HCESD 48, and US$5,243.72 for SAFD EMS.Conclusion:This retrospective analysis of ground ambulance patients that receive prehospital whole blood transfusion found that non-traumatic etiology accounted for 46.5% (95% CI, 34.3%-59.2%) of prehospital whole blood recipients. Additionally, the accounting analysis suggests that by Year 10 of a ground ambulance whole blood transfusion program, the average cost to save a life will be approximately US$5,136.51.

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Background Emergency medical services (EMS) patients with acute dyspnea require prompt treatment. Limited data describe out‐of‐hospital dyspnea treatment with non‐invasive, positive‐pressure ventilation (NIPPV), including continuous positive airway pressure (CPAP) or bi‐level positive air pressure (BPAP). We sought to determine the course and outcomes of out‐of‐hospital acute dyspnea patients treated with NIPPV. Methods We analyzed retrospective data on 1289 EMS agencies from the ESO Data Collaborative (ESO, Inc., Austin, TX) between January and December 2018. We defined acute dyspnea as adults with an initial respiratory rate ≥ 30 breaths/min (bpm), with a primary or secondary EMS subjective impression of a respiratory condition, who received oxygen and/or a respiratory medication and had 2 or more recordings of respiratory rate (RR). We excluded patients with trauma and those with altered mental status. We identified cases receiving care with and without NIPPV. The primary outcome was change in respiratory rate (RR), censored at 90 minutes of treatment. We compared baseline characteristics between NIPPV and non‐NIPPV patients. We compared RR changes between NIPPV and non‐NIPPV patients at 20 and 40 minutes of treatment. Using mixed linear, fractional polynomial, and multiple spline models, we examined the association of out‐of‐hospital NIPPV with overall change in RR. Secondary outcomes included whether the patient received advanced airway treatment (intubation, supraglottic airway device, and/or cricothyroidotomy). Results We analyzed 33,585 EMS encounters for patients with acute dyspnea, including 8,750 (26.1%) NIPPV and 24,835 (73.9%) non‐NIPPV encounters. Median treatment duration was similar between NIPPV and non‐NIPPV (23.3 minutes vs 23.6 minutes, rank‐sum P = 0.266). Common concurrent treatments included albuterol (NIPPV, 48.8%; non‐NIPPV, 46.2%), ipratropium bromide (27.9%, 24.8%), and methylprednisolone (24.9%, 18.5%). At 20 minutes, mean RR change was slightly lower for the NIPPV group than non‐NIPPV; −6.0 versus −6.8 breaths/min. At 40 minutes, mean RR change was similar between NIPPV and non‐NIPPV groups; −7.7 versus −7.9 breaths/min. On linear mixed modeling adjusted for age, sex, incident location, race, ethnicity, agency type, initial RR, and medication use, NIPPV was associated with a smaller RR decrease across time than NIPPV; [NIPPV × time] interaction P < 0.001. Out‐of‐hospital advanced airway placement (endotracheal intubation or supraglottic airway insertion) was higher for NIPPV than non‐NIPPV group (2.3% vs 1.3%, odds ratio = 2.23, 95% confidence interval = 2.01–2.47). Conclusions NIPPV has been proven to be an effective treatment for out‐of‐hospital patients experiencing acute dyspnea through prior studies. Our findings provide detailed insight into characteristics and use of NIPPV and highlight the commonality of this treatment modality with use in over 1 in 4 patients in respiratory distress.

Background: Minorities and impoverished persons experience disparities in access to healthcare. Large inequalities in out-of-hospital cardiac arrest (OHCA) care have been described. We sought to characterize racial and socioeconomic disparities in OHCA care and outcomes in Texas. Hypothesis: There are census tract level disparities in OHCA care and outcomes in Texas. Methods: We analyzed Texas-Cardiac Arrest Registry to Enhance Survival (CARES) data from 13 EMS agencies providing care in 15 counties to roughly 30% of the state population. We included all adult (>=18 year) OHCA from 1/1/14 through 12/31/18 with complete data. Using census tract data, we stratified census tracts into racial/ethnic categories: >50% non-Hispanic/Latino white, >50% black, and >50% Hispanic/Latino. We also stratified census tracts into neighborhoods above and below the median for socioeconomic characteristics: household income, employment rate, and high school graduation. We defined outcomes as bystander CPR rates, public bystander AED use, and survival to hospital discharge. Using mixed models, we analyzed the associations between outcomes and neighborhood (1) racial/ethnic categories and (2) socioeconomic categories. Results: We included data on 18,487 OHCAs from 1,727 census tracts. Relative to white neighborhoods, black neighborhoods had a significantly lower rate of bystander AED use (OR 0.3, CI 0.1-0.9), and Latino neighborhoods had a lower rate of bystander CPR (OR 0.7, CI 0.6-0.8), bystander AED use (OR 0.4, CI 0.3-0.6) and survival to hospital discharge (OR 0.9, CI 0.8-0.98). Lower income was associated with a lower rate of bystander CPR (OR 0.8, CI 0.7-0.8), bystander AED use (OR 0.5, 0.4-0.8), and survival to hospital discharge (OR 0.6, CI 0.5-0.9). Lower high school graduation was associated with a lower rate of bystander CPR (OR 0.8, CI 0.7-0.9) and bystander AED use (OR 0.6, CI 0.4-0.9). High unemployment was associated with lower rates of bystander CPR (OR 0.9, CI 0.8-0.94) and bystander AED use (OR 0.7, CI 0.5-0.99). Conclusion: Minority and poor neighborhoods in Texas experience large and unacceptable disparities in OHCA bystander response and outcomes. These data present an important opportunity for targeted resuscitation training and quality improvement.

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