Inter hospital transfers in rotor wing aircraft. Patterns and challenges. Protocol for a scoping review.

BACKGROUND: Inter-hospital transfer is necessary for the transport of patients to specialized treatment. Rotor-wing aircraft may be used in lieu of ambulances in time-critical conditions over long distances and when specialist team skills are called for. The purpose of the review is to assess the current scientific literature that describes the scenario to develop a national guideline for inter-hospital transfers using rotor-wing aircraft. The aim is to describe the patterns and challenges. METHODS AND ANALYSIS: The authors will conduct a scoping review as per Joanna Briggs Institute guideline. The protocol for the scoping review will adhere to the Open Science Framework guideline for scoping reviews and we will report the findings of the scoping review as per PRISMA-ScR guideline. We have developed the search strategy with the help of a research librarian and will conduct search in relevant electronic databases and include gray literature as well, using the PRESS and PRISMA-S guidelines. Two authors will independently screen titles and abstracts for inclusion as per eligibility criteria and conflicts will be resolved by a third reviewer. Full text retrieval will be conducted accordingly. We will analyze the extracted data using validated statistical methods. ETHICS AND DISSEMINATION: According to Danish law, scoping reviews are exempt from ethics committee approval. The findings of this scoping review will provide the scientific foundation for a national guideline on rotor-wing aircraft conveyed inter-hospital transfers in Denmark. Furthermore, we will publish the results of the scoping review in a relevant scientific journal.

Anesthesiologists' skills in emergency cricothyroidotomy mandate a brush-up training after 3 months-A randomized controlled trial.

BACKGROUND: In the Difficult Airway Society's 2015 "cannot intubate, cannot oxygenate" guideline, the emergency cricothyroidotomy is the final option when managing an unanticipated difficult airway. How often training for maintenance of this skill is required for anesthesiologists remains unknown. We aimed to assess if specialist-trained anesthesiologists' skills improved from a brush-up intervention and if skills were retained after 3 months. METHODS: In this multicenter, randomized, controlled trial, participants were randomized to either a simulation-based brush-up or no brush-up. Both groups performed a mannequin-based technical skills emergency cricothyroidotomy test twice and were assessed by a blinded rater using a structured assessment tool that included time, positioning, palpation, appropriate employment of instruments, and stepwise progression. After 3 months of non-training, participants completed identical tests of retention. RESULTS: A total of 54 anesthesiologists were included from three hospitals in the Region of Southern Denmark. Thirty-seven percent of the participants had received skills training in emergency cricothyroidotomy in the prior 12 months. The intervention group (N = 27) performed better in the initial tests, with a mean time of 51.5 s (SD = 10.82), a total score per minute of 15.9 points (SD = 4.91), and 93% passing both initial tests compared to the control group (N = 27) with a mean time of 76.8 s (SD = 35.82), a total score per minute of 6.6 (SD = 4.68) and only 15% passing both initial tests. The intervention group managed to retain overall performance in retention tests in terms of performance time (48.9 s, p = .26), total score per minute (13.6 points, p = .094), and passing the tests (75%, p = .059). CONCLUSION: Exposure to simulation-based brush-up training in emergency cricothyroidotomy improved anesthesiologists' technical performance and was overall retained after 3 months. Some loss of skill concerning specific items was observed, highlighting the need for regular training in emergency cricothyroidotomy. Simulation-based training should be prioritized to improve and maintain technical skills in infrequent high-stakes procedures.

Ambulance and helicopter response time. Association with patient outcome and illness severity: Protocol of a systematic literature review and meta-analysis.

BACKGROUND: Response time for emergency medical service units is a key performance indicator. Studies have shown reduced response time association with improved outcome for specific critical conditions. To achieve short response time, emergency vehicles utilize lights and sirens, and crews are allowed to be non-compliant with traffic rules, posing a risk for accident. The purpose of the systematic review and meta-analysis is to provide an overview of the current body of evidence regarding the association, if any, between ambulance and helicopter response time and major complications and mortality in patients conveyed by ambulance and/or helicopter. Our secondary aim will be to enhance knowledge in the field of criteria-based dispatch to provide decision makers with evidence to optimize dispatch of limited resources. RESEARCH QUESTIONS: What is the association between overall emergency medical services unit response time and patient outcomes, major complications, and time-critical conditions? What is the internal and external validity of the included literature? METHODS: We plan the systematic review and meta-analysis to be in accordance with the Cochrane Handbook and Joanna Briggs Institute Manual for Systematic Reviews. The methodology will include formulating the review questions using a Population, Exposure, and Outcome framework. Every study design is eligible, including qualitative, quantitative, and mixed-methods designs. We will include all articles in English, Scandinavian, German, French and Portuguese in this systematic review. RESULTS: We will publish results from the systematic review and meta-analysis in a peer-reviewed journal and we will present the results at scientific conferences and meetings. Results will also be available at www.ahrtemis.dk. CONCLUSION: We will base our conclusions on the findings of the review and meta-analysis.

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.

Association of intraosseous and intravenous access with patient outcome in out-of-hospital cardiac arrest.

Here we report the results of a study on the association between drug delivery via intravenous route or intraosseous route in out-of-hospital cardiac arrest. Intraosseous drug delivery is considered an alternative option in resuscitation if intravenous access is difficult or impossible. Intraosseous uptake of drugs may, however, be compromised. We have performed a retrospective cohort study of all Danish patients with out-of-hospital cardiac arrest in the years 2016-2020 to investigate whether mortality is associated with the route of drug delivery. Outcome was 30-day mortality, death at the scene, no prehospital return of spontaneous circulation, and 7- and 90-days mortality. 17,250 patients had out-of-hospital cardiac arrest. 6243 patients received no treatment and were excluded. 1908 patients had sustained return of spontaneous circulation before access to the vascular bed was obtained. 2061 patients were unidentified, and 286 cases were erroneously registered. Thus, this report consist of results from 6752 patients. Drug delivery by intraosseous route is associated with increased OR of: No spontaneous circulation at any time (OR 1.51), Death at 7 days (OR 1.94), 30 days (2.02), and 90 days (OR 2.29). Intraosseous drug delivery in out-of-hospital cardiac arrest is associated with overall poorer outcomes than intravenous drug delivery.

Communication in Sudden-Onset Major Incidents: Patterns and Challenges-Scoping Review.

OBJECTIVE: To identify and describe patterns and challenges in communication in sudden-onset major incidents. METHODS: Systematic scoping review according to Joanna Briggs Institute and PRISMA-ScR guidelines. Data sources included Cochrane Library, EMBASE, PubMed/MEDLINE, Scopus, SweMed+, Web of Science, and Google Scholar. Non-indexed literature was searched as well. The included literature went through data extraction and quality appraisal as per pre-registered protocol. RESULTS: The scoping review comprised 32 papers from different sources. Communication breakdown was reported in 25 (78.1%) of the included papers. Inter-authority communication challenges were reported in 18 (56.3%) of the papers. System overload and incompatibility was described in 9 papers (28.1%). Study design was clearly described in 30 papers (93.8%). CONCLUSIONS: The pattern in major incident communication is reflected by frequent breakdowns with potential and actual consequences for patient survival and outcome. The challenges in communication are predominantly inter-authority communication, system overload and incompatibility, and insufficient pre-incident planning and guidelines.

The Great Belt train accident: the emergency medical services response.

BACKGROUND: Major incidents (MI) are rare occurrences in Scandinavia. Literature depicting Scandinavian MI management is scarce and case reports and research is called for. In 2019, a trailer falling off a freight train struck a passing high-speed train on the Great Belt Bridge in Denmark, killing eight people instantly and injuring fifteen people. We aim to describe the emergency medical services (EMS) response to this MI and evaluate adherence to guidelines to identify areas of improvement for future MI management. CASE PRESENTATION: Nineteen EMS units were dispatched to the incident site. Ambulances transported fifteen patients to a trauma centre after evacuation. Deceased patients were pronounced life-extinct on-scene. Radio communication was partly compromised, since 38.9% of the radio shifts were not according to the planned radio grid and presented a potential threat to patient outcome and personnel safety. Access to the incident site was challenging and delayed due to traffic congestion and safety issues. CONCLUSION: Despite harsh weather conditions and complex logistics, the availability of EMS units was sufficient and patient treatment and evacuation was uncomplicated. Triage was relevant, but at the physicians' discretion. Important findings were communication challenges and the consequences of difficult access to the incident site. There is a need for an expansion of capacity in formal education in MI management in Denmark.

Risk of delirium and impaired neurological outcome associated with delay in neurorehabilitation after acquired brain injury.

INTRODUCTION Brain injury from haemorrhage, trauma, aneurysm and stroke is characterised by high mortality and impaired neurological outcome. In the OUTREACH study, the authors wanted to assess patient care from admission to intensive neuro rehabilitation to discharge. We hypothesised that early rehabilitation was beneficial to neurological outcome. METHODS 180-day mortality and modified Rankin Scale (mRS) were primary end points. Secondary end points included length of stay, Glasgow Coma Scale (GCS) on admission, ventilator days, Simplified Acute Physiology Score (SAPS II/III) and serious adverse events. RESULTS Sixty-seven patients were included. Mortality at 180 days was 17.91% and the median mRS score was four. Length of stay was 20.89 ± 12.33 days. GCS at admittance was 13 (3-15). The average SAPS II/III score was 55.72 ± 20.03. Twenty-eight patients suffered from serious adverse events. In all, 47 patients waited for transfer to another facility for an average of 7.77 ± 6.08 days. For mRS, the linear model indicated a negative effect of waiting time (effect = -0.056 (95% confidence interval (CI): -0.117-0.004); p = 0.07). Risk of delirium was significantly affected by waiting time; an additional day of waiting increased the risk of delirium by 13.4% (odds ratio = 1.134 (95% CI: 1.028-1.252); p = 0.01). CONCLUSIONS In this study, mortality and neurological outcome were comparable with those reported in similar studies. Waiting for transfer to another facility due to capacity significantly impairs neurological outcome and increases delirium. FUNDING none. TRIAL REGISTRATION not relevant.

[Intentional suicide with cyclizine].

Cyclizine is an antihistamine with a sedative effect. In Denmark it is an over-the-counter drug, whereas it is a prescription drug in many other countries. It possesses anticholinergic and antiemetic properties, although the exact mechanism of action is unknown. At doses greater than 5 mg/kg potent side effects of anticholinergic character can be expected. This case report is a description of an intentional suicide with a dose greater than 70 mg/kg.