Prehospital Care of Severely Intoxicated Patients by a Dutch Physician-Staffed Helicopter Emergency Medical Services: A Retrospective Study.

OBJECTIVE: Intoxicated patients are often encountered by emergency medical services (eg, in cases of recreational drug use, accidental ingestion, or inhalation of toxic substances or [attempted] suicide). Earlier research showed that a physician-staffed helicopter emergency medical service (P-HEMS) is regularly dispatched for intoxicated patients. However, it is still unclear if there is added value of P-HEMS compared with standard care provided by an ambulance crew. The aim of this study was to analyze the contribution of additional expertise and equipment that P-HEMS brings to the prehospital scene. METHODS: In this retrospective study, we searched the database of the helicopter emergency medical service Lifeliner 1 serving the northwestern quadrant of the Netherlands for cases that involved intoxications from January 2013 to July 2020. Patients were included in this study if the primary reason for P-HEMS dispatch was intoxication. The types of intoxication were categorized as (illicit/recreational) drug related, suicide attempt, or accidental. The agents were categorized as stimulants, depressants, hallucinogenic, cannabinoids, and other substances such as bleach or insulin. Patient characteristics, vital signs, and the therapeutic interventions performed were recorded for analysis. RESULTS: In our study period, P-HEMS was dispatched 23,878 times. Of these dispatches, a total of 259 cases were included for further analysis. The majority of patients were male (64.5%). Sixty-six patients (25.5%) had an intoxication of depressant agents alone, whereas 60 patients (23.2%) had an intoxication with a combination of agents. With 159 (61.4%) patients, the majority of cases involved recreational drug intoxications. Unintentional intoxications were treated in 27 (10.4%) patients, whereas 73 (28.2%) cases involved suicide attempts. In 159 patients (61.4%), prehospital endotracheal intubation was required; the vast majority was performed by the helicopter emergency medical service physician. Specific antidotes were administered in 56 (21.6%) of the cases. CONCLUSION: In this study, we found that P-HEMS crews might complement usual prehospital care by ambulance crews for patients with severe intoxications by bringing advanced skills (eg, airway management and specific antidotes) to the scene.

Prehospital Intubation of Patients with Severe Traumatic Brain Injury: A Dutch Nationwide Trauma Registry Analysis.

OBJECTIVE: Patients with severe traumatic brain injury (TBI) are commonly intubated during prehospital treatment despite a lack of evidence that this is beneficial. Accumulating evidence even suggests that prehospital intubation may be hazardous, in particular when performed by inexperienced EMS clinicians. To expand the limited knowledge base, we studied the relationship between prehospital intubation and hospital mortality in patients with severe TBI in a large Dutch trauma database. We specifically hypothesized that the relationship differs depending on whether a physician-based emergency medical service (EMS) was involved in the treatment, as opposed to intubation by paramedics. METHODS: A retrospective analysis was performed using the Dutch Nationwide Trauma Registry that includes all trauma patients in the Netherlands who are admitted to any hospital with an emergency department. All patients treated for severe TBI (Head Abbreviated Injury Scale score ≥4) between January 2015 and December 2019 were selected. Multivariable logistic regression was used to assess the relationship between prehospital intubation and mortality while adjusting for potential confounders. An interaction term between prehospital intubation and the involvement of physician-based EMS was added to the model. Complete case analysis as well as multiple imputation were performed. RESULTS: 8946 patients (62% male, median age 63 years) were analyzed. The hospital mortality was 26.4%. Overall, a relationship between prehospital intubation and higher mortality was observed (complete case: OR 1.86, 95% CI 1.35-2.57, p < 0.001; multiple imputation: OR 1.92, 95% CI 1.56-2.36, p < 0.001). Adding the interaction revealed that the relationship of prehospital intubation may depend on whether physician-based EMS is involved in the treatment (complete case: p = 0.044; multiple imputation: p = 0.062). Physician-based EMS involvement attenuated but did not completely remove the detrimental association between prehospital intubation and mortality. CONCLUSION: The data do not support the common practice of prehospital intubation. The effect of prehospital intubation on mortality might depend on EMS clinician experience, and it seems prudent to involve prehospital personnel well proficient in prehospital intubation whenever intubation is potentially required. The decision to perform prehospital intubation should not merely be based on the largely unsupported dogma that it is generally needed in severe TBI, but should rather individually weigh potential benefits and harms.

Face-to-Face Versus Telephonic Extended Glasgow Outcome Score Testing After Traumatic Brain Injury.

OBJECTIVE: The Extended Glasgow Outcome Scale (GOS-E) is used for objective assessment of functional outcome in traumatic brain injury (TBI). In situations where face-to-face contact is not feasible, telephonic assessment of the GOS-E might be desirable. The aim of this study is to assess the level of agreement between face-to-face and telephonic assessment of the GOS-E. SETTING: Multicenter study in 2 Dutch University Medical Centers. Inclusion was performed in the outpatient clinic (face-to-face assessment, by experienced neurologist), followed by assessment via telephone of the GOS-E after ±2 weeks (by trained researcher). PARTICIPANTS: Patients ±6 months after TBI. DESIGN: Prospective validation study. MAIN MEASURES: Interrater agreement of the GOS-E was assessed with Cohen's weighted κ. RESULTS: From May 2014 until March 2018, 50 patients were enrolled; 54% were male (mean age 49.1 years). Median time between trauma and in-person GOS-E examination was 158 days and median time between face-to-face and telephonic GOS-E was 15 days. The quadratic weighted κ was 0.79. Sensitivity analysis revealed a quadratic weighted κ of 0.77, 0.78, and 0.70 for moderate-severe, complicated mild, and uncomplicated mild TBI, respectively. CONCLUSION: No disagreements of more than 1 point on the GOS-E were observed, with the κ value representing good or substantial agreement. Assessment of the GOS-E via telephone is a valid alternative to the face-to-face interview when in-person contact is not feasible.