Pre-hospital ultrasound: a review of its applications and effectiveness
Article information
Abstract
Although ultrasound technology has long been used in the hospital setting, portable ultrasound devices have recently started to be utilized by pre-hospital providers. This technology is still in its preliminary stages of documented use in the pre-hospital setting, but pre-hospital providers have shown improvements in patient outcomes with its utilization. This study is a literature review of the pre-hospital use of ultrasound technology and its effectiveness. Pre-hospital providers have effectively utilized ultrasound on multi-system trauma patients, and it has been demonstrated that an initial one-day training enables pre-hospital providers to be proficient in utilizing ultrasound examinations for trauma patients. Multiple studies have shown that 95% of paramedics can proficiently conduct a FAST examination within 5 minutes. Furthermore, 100% of students participating in the initial training passed the examination and were able to proficiently utilize ultrasound technology and properly interrogate the ultrasound images. More research needs to be performed with pre-hospital providers from multiple agencies to yield more precise results. Further study is also needed to provide more information on the exact amount of time saved in the trauma bay by examination results provided by pre-hospital providers prior to the patient’s arrival to the trauma bay.
INTRODUCTION
Ultrasound technology has been more prominent with the newer generation of hospital providers. Ultrasound sonography has been accepted by trauma physician’s being as beneficial first-line imaging tool used for all multi-system trauma patients. In recent years portable ultrasound has been able to be placed on medical aero transport and ground transport units. With increased technological advancements of this imaging, the availability increased for multiple pre-hospital agencies.
Abdominal trauma has been the leading cause of mortality in multi-system trauma patients in all age groups. Pre-hospital providers will be the patients first contact in trauma situations such as motor vehicle accidents which multi-system trauma occurs. Emergency medical services (EMS) is the youngest in the healthcare profession. Pre-hospital providers have increasingly gained more responsibility and standards in the last decade. Ultrasound technology is the next crucial step improving these providers clinically. Pre-hospital providers will be more informed of a patient acuity and transport needs due to the role they provide in patient care.
Nature of problem
In the pre-hospital setting involving trauma, providers are constantly reminded of the term golden hour. The golden hour relates to the time pre-hospital providers have to get a critically injured trauma patient to the operating room. Each state or agency has a term called a trauma alert. When a patient is declared a trauma alert this places a patient as a high priority requiring multiple resources to be on alert at the receiving hospital. With early activation, the receiving hospital multiple resources are activated such as neurologists, trauma surgeons, emergency medicine doctors, and nurses. Pre-hospital providers attempt to obtain all information needed to provide shorter times in a trauma bay giving an in-depth report. Pre-hospital providers perform an in-depth trauma assessment to obtain what organ systems could be involved. Pre-hospital providers have limited resources to best obtain this information, mainly relying on their physical assessment. EMS agencies practice a 10-minute scene time but, there can be complications on why this goal is complicated to achieve. For patients who are entrapped extrication can prolong this on scene time tremendously limiting the patient meeting the golden hour standard. With this delay, excellent reporting from pre-hospital providers may decrease time needed in the emergency room.
With limited accuracy of a physical hands-on assessment, ultrasound greatly improves a provider trauma assessment. The Journal of Emergencies, Trauma, and Shock completed a study demonstrating pre-hospital providers completing a focused assessment with sonography for trauma (FAST) ultrasound achievable. From the conclusion, it was stated “36 patients completed a full FAST exam in little as 2 to 3 minutes during short transports of 8 minutes. 95.3% of images deemed adequate” [1]. There are common traumatic injuries that can hide from an initial physical exam such as intra-abdominal hemorrhage, pericardial tamponade, and pneumothorax. Common findings of a textbook presentation of intra-abdominal hemorrhage are “abdominal tenderness, abdominal discomfort, signs of bruising, tachycardia, and hypotension” [2]. With pericardial tamponade and pneumothorax pre-hospital providers must auscultate heart tones and lung sounds. A stethoscope is the pre-hospital best diagnostic tool. Pre-hospital providers have limited accuracy recognizing these conditions due to conditions they are faced to work in. Loud sirens during transport and hectic scenes limit a provider’s accuracy. With pre-hospital providers initiating more advanced assessment with ultrasound technology the receiving hospital is adequately informed. This will help hospital providers to further isolate and treat life threatening injuries. The more pre-hospital providers assist during transport increases a patient’s survivability by having first line imaging performed. Every minute can change a patient’s overall outcome.
Purpose of the research
As practicing medicine has taught providers over the years, patient presentations can deceive a life-threating condition. Pre-hospital providers are extremely limited on resources available on-scene. The purpose of this research study is to improve the capabilities of pre-hospital providers and improve patient outcomes.
Significance to pre-hospital providers
With the limited resources currently available to pre-hospital providers, improving the tools available will enhance the ability of these providers. With the ability to improve reporting, transmit imaging, and limit under triaging patients, receiving facilities as well as the patients greatly benefit with one extra tool. With this improvement pre-hospital providers would have a more active role in modern day medicine.
Research question
What impact does a positive fast exam related from pre-hospital providers have in relation to trauma bay time to surgery.
REVIEW OF LITERATURE
EMS providers have been an essential part of patient survivability since the birth of this concept in 1973. As stated from Dharap et al. in 2017 [3], with this creation EMS professionals have provided emergency medical technicians (EMTs) as well as the introduction as paramedics (EMT-P), providing higher levels of care. Some regions without access to an EMS system showed increased mortality with patients. A region without an adequate EMS system, the mortality was 24% greater than with an adequate EMS system. A study in India by Dharap et al. [3] found that 35% of these patients needed advanced airway management and 13% of patients needing needle decompression or chest tube placement. EMS will always be an essential part of the health care system. Pre-hospital providers have been given more responsibilities, training, and protocols compared to the initial introduction of pre-hospital providers. The tools available to pre-hospital providers have improved at a slower rate than information and responsibilities [4].
Patients’ textbook trauma presentations were dependent on co-morbidities, age, and medications taken by the patient. Pre-hospital providers rely on a physical assessment and vital signs on a trauma call [2]. This primary tool is overall extremely limited which leads to delays at the receiving hospital. Delays are caused by limited resources available for pre-hospital providers finding these life-threating conditions for the not so textbook patient. Hospital providers spend more time in the emergency room performing ultrasound imaging, chest thoracotomy, pericardiocentesis, and getting blood. These delays are mitigated by pre-hospital providers provided with ultrasound technology in the field. A pre-hospital provider will take an average of 3 minutes or less to complete this exam. Transports to the hospital depend on region but, ambulances in an urban setting have transport time averaging 10 minutes. Pre-hospital providers have shown that they can complete this in little time in high stress situations. Pre-hospital providers that used ultrasound technology in the field were reviewed on image quality from physicians [5]. During this review, the exam was completed during transport to the receiving hospital. Ambulances have not been known to be the most stable environment to work in based off road conditions and even the person operating the ambulance. With this the images that were studied showed a 95% quality and 99% accurate diagnosis from the pre-hospital provider. With this exam being completed on scene or during transport, providers will communicate their findings and transmit the imaging to the facility ensuring the receiving facility is adequately prepared. This will decrease delays spent in the emergency room with hospital providers having mass transfusion protocol already set up and complex procedures that a patient required is ready for the patient. With abdominal trauma being the lead cause of death in trauma considerable time lost ruling this out with imaging. With this being provided from pre-hospital providers less time can be spent looking for the hidden bleed [5].
Pre-hospital providers have shown how this tool makes a positive change for patients. This positive change has been shown on multiple levels. Pre-hospital providers will be able to ensure a patient is going to the appropriate facility. Not all hospitals specialize in management of trauma patients. Over the last few years, there has been an influx of stand-alone hospitals which are limited in the ability to manage trauma patients. Even larger hospitals are limited in their ability to manage this patient group. Hospitals must acquire a certificate of need which means not every hospital can be a trauma receiving facility. This being the case getting the patient to the right hospital decreases time to adequate care. Hospitals transfer these patients to the correct facility and this patient starts in the trauma bay. With ultrasound exams done pre-hospital this decreases that occurrence. A positive change with the use of pre-hospital ultrasound occurred in 22% of patients involved in blunt abdominal trauma ensuring proper transport to a trauma receiving hospital [1].
Pre-hospital present applications
Currently only a small portion of agencies have access to this technology with protocol utilizing the FAST exam as a standard in trauma patients. Military medicine research initially fore fronted research with this being newer technology for civilian EMS, military medicine has been leading using ultrasound during combat operations. This shows how this can be used in the pre-hospital environment based off the conditions the military faces which is considerably harsher than civilian EMS faces [5]. Pre-hospital providers are provided with information military medicine has encountered resulting in how EMTs and paramedics provide care on the civilian side regarding trauma. Military medics started to use ultrasound technology in forward treatments facilities and even during combat operations. Reported from a study that ultrasound technology was successfully used providing increase survivability. “Our findings suggest that training in both the FAST exam and E-FAST exam has the potential to improve patient care for military trauma patients” [5].
Initial training success has been studied on the military and civilian pre-hospital providers. One thing that was found in common with the civilian side and military medics is that initial training can be done in a one-day class. participants in these classes were paramedics and combat medics ranging from all levels of experience. Participants were given a 4-hour expert led ultrasound training. In this 4-hour training, hands-on teaching and PowerPoint presentations were used. Participants learned about the FAST exam and extended FAST (E-FAST) exam during this class [6]. The FAST exam evaluates the right upper quadrant, pericardium, left upper quadrant, suprapubic, and anterior thorax. Using this exam, participants would be able to locate bleeding in and around the heart, liver, spleen, bladder, and lungs. Participants would also be able to spot pneumothoraxes as well. Participants completed hands-on skills test out as well as a written exam. Military student’s pre-test scores had a mean of 27%. Posttest students improved the score significantly with a mean score of 83%. On the hands-on assessment students had a mean score of 20.8 out of 22 possible points [7]. The civilian students, no pre-test was given to compare a change in knowledge. The post test showed a similar mean score to the military of 80%. During the hands-on portion, each student with 100% accuracy was able to complete the exam in 2 minutes [8]. Results show that a 4-hour class can be taught resulting in an adequate knowledge base to perform this exam.
With paramedics showing adequate performance with limited training, shows how this is a feasible solution for the limited assessment accuracy of a hands-on assessment. Studies relate on how this has been an effective tool with current EMS agencies utilizing ultrasound after initial training has shown their providers match the diagnosis accuracy of physicians. Agencies performing at this elevated level ensure providers are given the initial training and ensure continued education is performed. One agency had a 99% of providers integrate the images correctly with ultrasound. Another agency reviewed 45 cases and noted only six cases showed the need for further review with the provider performing the exam. A rotor-wing (helicopter) transport agency provider had 100% diagnostic accuracy using ultrasound technology [9]. With paramedics receiving an initial training of 1 year and an initial 4-hour expert lead class proves advanced education is not necessary. Physicians will spend 4 years in medical school with additional residency training and pre-hospital providers establish similar standards.
Pre-hospital future applications
With the advances of tele-health medicine, having a physician able to be at the side of a pre-hospital provider is an achievable concept. Studies are being conducted investigating the possibilities regarding providers with questions in the field they can send in imaging to a physician for further review. Also, all imaging can be sent in to help the receiving facility have this completed exam prior to the patient’s arrival. This will decrease the time spent in the trauma bay, therefore getting the patient to surgery quicker. Images that were transmitted were noted to be adequate for physicians to integrate successfully even in the challenging condition pre-hospital providers face. With pre-hospital providers performing a FAST exam providing results in field prior to hospital arrival were compared to a physician E-FAST exam in hospital. Pre-hospital providers were noted to be slightly inferior compared to the physician review but deemed negligible [10].
Additionally, El Zahran and El Sayed [1] report other locations are being researched with ultrasound that could also be used by pre-hospital providers to improve patient care reports and improve time in the trauma bay for the patient. Currently research includes gastric tubes placed with intubated patients in the pre-hospital setting. Again, a stethoscope is the paramedics tool to ensure proper placement. With ultrasound they will be able to confirm placement of a gastric tube, ensuring hospital staff do not have to second guess placement. Thus, the hospital does not have to remove the pre-hospital equipment, placing a new gastric tube decreasing needed time in the trauma bay. Use of ultrasound has been noted to be used to diagnosed intracanal hemorrhage in trauma patients. Also, ultrasound technology has been used to accurately diagnose fractures that might not be obvious from a pre-hospital’s providers hands-on assessment El Zahran and El Sayed [1]. With these additional uses and advances of this technology pre-hospital providers will transmit an enormous amount of information to the hospital. With this information given prior to arrival the patient will spend less time in the trauma bay getting this patient to surgery thus, increasing patient survivability. Seconds count in trauma and ultrasound technology has been shown to shave these seconds in the trauma bay when imaging is done pre-hospital.
METHODOLOGY AND PROCEDURES
The methodology for this study was a literature review. The study began with the question: What impact does a positive fast exam related from prehospital providers have in relation to trauma bay time to surgery? With the data collected from the stated sources, this is an achievable goal.
Methodology
The methodology for this study was a literature review. The literature review is on what impact does a positive fast exam related from prehospital providers have in relation to trauma bay time to surgery. A literature review is a document demonstrating knowledge and understanding of the academic literature on a specific topic.
Procedures
Multiple research articles were reviewed for this literature review. The Seminole State College ESBCO database was used. These articles were reviewed that provide information on effectiveness, training requirements, and pitfalls of pre-hospital ultrasound use.
Search procedures
A careful review of the significant literature related to pre-hospital use of ultrasound will be conducted. The review will highlight the following topics: reducing a patient’s time in the trauma bay with pre-hospital ultrasound use, education needed to provide positive results, future applications for pre-hospital ultrasound use.
·Libraries used: there was only one library used to search for sources for this project. The Seminole State College of Florida Library was used for this project.
·Search engines and databases used: the following databases were used to search for the sources for this project: EBSCO data base.
·Search terms: several search terms were used to identify sources for this project. The search terms included: “Pre-Hospital, Ultrasound, EMS, Paramedic, and Pre-hospital Trauma.”
·Boolean strings: Boolean strings were considered for this literature search. No Boolean strings were used.
·Age of the sources: the significant literature will be reviewed. Sources from the last 5 years will be considered for inclusion in the review of literature. Pertinent historical or seminal articles will also be considered.
·Research modalities: the available literature reveals multiple research modalities, including observation, descriptive, and survey design.
·Study subjects: in this research study multi-system trauma patients were the primary study group. Also included were participants in the initial education studies.
Assumptions
It was noted that ultrasound technology was a new tool available to pre-hospital providers. It was noted that this technology was currently used in some EMS agencies with positive results.
Limitations
Limitations noted with this review was length of time studying the use of ultrasound in the pre-hospital setting. Limited data due to this technology being available for pre-hospital providers are relatively new.
EXPECTATIONS
The expectations of this research were to demonstrate the use of pre-hospital ultrasound to decrease the time a patient is spent in the trauma bay. Expected the study to show a decrease mortality rate with data provided by pre-hospital providers. In addition, the expectation was to show a decrease in time needed to get a patient to surgery based off a pre-hospital’s provider exam performed prior to arriving at the hospital. Show effectiveness of pre-hospital providers using this technology and limited initial education needed.
Anticipated benefits
The most important benefit is decreasing mortality for your patients. Befits include, better educated, and equipped pre-hospital providers increasing a patients’ survival rate. Ability to have imaging sent to the receiving hospital. Having a better prepared receiving hospital trauma team due to importance of received information prior to patient arrival.
Importance to pre-hospital providers
Trauma has been the leading cause of mortality with limited tools being available to pre-hospital providers. Pre-hospital ultrasound has shown to be a tool that significantly decreases patient mortality. Training can be completed in one day and any level of provider shows proficiency using this technology. With that being available, better patient care is provided, better information is relayed, and the oath to do no harm is maintained.
Improvement of health care delivery systems
The results of this study will improve the health care system on multiple aspects. This research improves patient care in the pre-hospital setting and hospital setting. Better information can be obtained prior to the patient arriving at the hospital, giving the trauma team a better idea how to adequately prepare for the patient. Abdominal trauma is the deadliest and hardest diagnosis to obtain without ultrasound technology. Pre-hospital providers are extremely limited on tools and had not seen improvement to these tools, regarding trauma assessment until portable ultrasounds were established. Less patients would be transported to a non-trauma receiving facility decreasing time to proper care.
DISCUSSION, CONCLUSIONS, AND RECOMMENDATIONS
Pre-hospital providers have been relaying on basic tools when hospital providers have progressively increased the available technology. Pre-hospital providers need to increase the available technology to provide better and up to date care. Hospital providers relay on an ultrasound FAST exam to initially rule out internal trauma prior to computed tomography. This exam is noted to take between 3 to 5 minutes to complete. Pre-hospital providers can perform this exam on-scene or during transport. Pre-hospital providers were able to interrogate these images with a specificity of 95% which is a close comparison with this exam being done by physicians.
Discussion
Was also noted that a one-day course can be given for an initial onboarding of the use of ultrasound technology. There was a 100% pass rate for a practical and written exam with all students. Students had a wide range of experience levels which shows that this could be incorporated in the initial schooling for pre-hospital providers. Technology has improved to the point where imaging can be sent to the receiving facility where the trauma team can interrogate imaging. This better prepares the receiving hospital thus decreasing the delays getting the patient to the operating room.
Conclusion
Ultrasound should be a standard of care for pre-hospital providers. With the information provided should be a catalyst to provide this technology as a standard of care. Pre-hospital providers need to increase the tools available to keep up with technology available to the pre-hospital provider. With trauma being one of the leading causes of death EMS agencies have not seen improvements in technology to combat this cause of mortality. This will improve patient outcomes and assist the hospital getting the patient to the operating room faster. This decrease of time spent can provide a positive outcome for a patient.
Recommendation
Recommend further studies showing exact time decreased in the trauma bay due to pre-hospital providers utilizing ultrasound technology in multi-system trauma patients. This technology is still relatively new therefore studies have been limited. Further studies should document the cost associated with providing this technology and if this cannot be done due to lack of finical support to the agency. Recommend a study on how to reduce costs of devices and make this readily available to make this a standard of care in the pre-hospital setting.
Notes
FUNDING
None.
CONFLICT OF INTEREST
No potential conflict of interest relevant to this article was reported.