The Field's mass shooting: emergency medical services response.

BACKGROUND: Major incidents (MI) happen infrequently in Scandinavia and mass shootings are even less frequently occurring. Case reports and research are called for, as literature is scarce. On 3rd July 2022, a mass shooting took place at the shopping mall Field's in Copenhagen, Denmark. Three people were killed and seven injured by a gunman, firing a rifle inside the mall. A further 21 people suffered minor injuries during the evacuation of the mall. In this case report, we describe the emergency medical services (EMS) incident response and evaluate the EMS´ adherence to the MI management guidelines to identify possible areas of improvement. CASE PRESENTATION: Forty-eight EMS units including five Tactical Emergency Medical Service teams were dispatched to the incident. Four critically injured patients were taken to two trauma hospitals. The deceased patients were declared dead at the scene and remained there for the sake of the investigation. A total of 24 patients with less severe and minor injuries were treated at four different hospitals in connection with the attack. The ambulance resources were inherently limited in the initial phase of the MI, mandating improvisation in medical incident command. Though challenged, Command and Control, Safety, Communication, Assessment, Triage, Treatment, Transport (CSCATTT) principles were followed. CONCLUSIONS: The EMS response generally adhered to national guidelines for MI. The activation of EMS and the hospital preparedness program was relevant. Important findings were communication shortcomings; inherent lack of readily available ambulance resources in the initial critical phase; uncertainty regarding the number of perpetrators; uncertainty regarding number of casualties and social media rumors that unnecessarily hampered and prolonged the response. The incident command had to use non-standard measures to mitigate potential challenges.

Accuracy of triage systems for mass casualty incidents in live simulations - a systematic review.

INTRODUCTION: In mass casualty incidents, insufficient triage may lead to increased morbidity and mortality due to delayed evacuation and treatment of the most critically injured patients. We report current litterature findings on accuracy of primary prehospital triage systems for mass casualty incidents in full-scale live simulations and map the challenges that lie ahead for finding the most accurate triage system. METHODS: This study was registered with PROSPERO ID: CRD42018091889. We searched the databases EMBASE, MEDLINE, Central, Web of Science, Reference lists, Scopus, ClinicalTrials.gov and Google Scholar. We included primary triage systems, studies reporting accuracy or outcomes convertible to accuracy and studies performed in full-scale live simulations. We excluded studies using paediatric, chemical, biological, radiological or nuclear populations or triage systems. Bias rating was based on a modified version of the QUADAS-2. RESULTS: A total of 15 studies were included. Six of 41 existing triage methods were tested. The studies showed substantial heterogeneity in both study characteristics and findings. Different reference standards were applied and most were based on author-defined triage categories. All studies carried an unclear-to-high risk of bias. Therefore, no quantitative comparisons were made. CONCLUSION: In general, the studies suffered from substantial heterogeneity and risk of bias. A standardised protocol for future live simulations is needed to encourage consistent and comparable data collection. We identified some of the most important topics to address in such a protocol.

Accuracy of prehospital triage systems for mass casualty incidents in trauma register studies - A systematic review and meta-analysis of diagnostic test accuracy studies.

BACKGROUND: Prioritising patients in mass casualty incidents (MCI) can be extremely difficult. Therefore, triage systems are important in every emergency medical service. This study reviews the accuracy of primary triage systems for MCI in trauma register studies. METHODS: We registered a protocol at PROSPERO ID: CRD42018115438. We searched MEDLINE, EMBASE, Central, Web of Science, Scopus, Clinical Trials, Google Scholar, and reference lists for eligible studies. We included studies that both examined a primary triage system for MCI in trauma registers and provided sensitivity and specificity for critically injured vs non-critically injured as results. We excluded studies that used paediatric, chemical, biological, radiological or nuclear MCIs populations or triage systems. Finally, we calculated intra-study relative sensitivity, specificity and diagnostic odds ratio for each triage system. RESULTS: Triage Sieve (TS) significantly underperformed in relative diagnostic odds ratio (DOR) when compared to START and CareFlight (CF) (START vs TS: 19.85 vs 13.23 (p<0.0001)│CF vs TS: 23.72 vs 12.83 (p<0.0001)). There was no significant difference in DOR between TS and Military Sieve (MS) (p<0.710). Compared to START, MS and CF TS had significantly higher relative specificity (START vs TS: 93.6% vs 96.1% (p=0.047)│CF vs TS: 96% vs 95.3% (p=0.0006)│MS vs TS: 94% vs 88.3% (p=0.0002)) and lower relative sensitivity (START vs TS: 57.8% vs 34.8% (p<0.0001)│CF vs TS: 53.9% vs 34.7% (p<0.0001)│MS vs TS: 51.9% vs 35.2% p<0.0001)). CF had significantly better relative DOR than START (CF vs START: 23.56 vs 27.79 (p=0.043)). MS had significantly better relative sensitivity than CF and START (MS vs CF: 49.5% vs 38.7% (p<0.0001)│MS vs START: 49.4% vs 43.9% (p=0.01)). In contrast, CF had significantly better relative specificity than MS (MS vs CF: 91.3% vs 93.3% (p<0.0001)). The remaining comparisons did not yield any significant differences. CONCLUSION: As the included studies were at risk of bias and had heterogenic characteristics, our results should be interpreted with caution. Nonetheless, our results point towards inferior accuracy of Triage Sieve compared to START and CareFlight, and less firmly point towards superior accuracy of Military Sieve compared to START, CareFlight and Triage Sieve.

[Perimortem caesarean section and timely decision making]. / Perimortem sectio og rettidig kritisk beslutningstagning.

Perimortem caesarean section can be decisive for the outcome of a cardiac arrest in pregnancy for both mother and fetus. We describe a case story of the management of cardiac arrest in early labour where perimortem caesarean section proved to be life-saving for both mother and child. The child was delivered alive seven minutes after recorded cardiac arrest, and the mother had return of spontaneous circulation one minute after delivery. The mother recovered well with no serious sequelae to the resuscitation. We discuss the importance of timely decision and execution of perimortem caesarean.

[Cricoid pressure a.m. Sellick in rapid sequence intubation?]. / Cricoideatryk a.m. Sellick ved akut anaestesiindledning?

Since Brian Sellick introduced the cricoid pressure in 1961, it has become standard practice for the rapid sequence intubation. The manoeuvre has a high priority and is recommended maintained even during difficult intubation. In this review the lack of evidence for the aspiration-reducing effect of cricoid pressure is discussed. The findings suggest that it may have harmful effects in connection with intubation, laryngeal mask placement and ventilation. In conclusion, it is suggested that cricoid pressure is released in the case of intubation difficulties.