Pre-hospital emergency anaesthesia in trauma patients treated by anaesthesiologist and nurse anaesthetist staffed critical care teams.

BACKGROUND: Pre-hospital tracheal intubation in trauma patients has recently been questioned. However, not only the trauma and patient characteristics but also airway provider competence differ between systems making simplified statements difficult. METHOD: The study is a subgroup analysis of trauma patients included in the PHAST study. PHAST was a prospective, observational, multicentre study on pre-hospital advanced airway management by anaesthesiologist and nurse anaesthetist manned pre-hospital critical care teams in the Nordic countries May 2015-November 2016. Endpoints include intubation success rate, complication rate (airway-related complication according to Utstein Airway Template by Sollid et al), scene time (time from arrival of the critical care team to departure of the patient) and pre-hospital mortality. RESULT: The critical care teams intubated 385 trauma patients, of which 65 were in shock (SBP <90 mm Hg), during the study. Of the trauma patients, 93% suffered from blunt trauma, the mean GCS was 6 and 75% were intubated by an experienced provider who had performed >2500 tracheal intubations. The pre-hospital tracheal intubation overall success rate was 98.6% and the complication rate was 13.6%, with no difference between patients with or without shock. The mean scene time was significantly shorter in trauma patients with shock (21.4 min) compared to without shock (21.4 vs 25.1 min). Following pre-hospital tracheal intubation, 97% of trauma patients without shock and 91% of the patients in shock with measurable blood pressure were alive upon arrival to the ED. CONCLUSION: Pre-hospital tracheal intubation success and complication rates in trauma patients were comparable with in-hospital rates in a system with very experienced airway providers. Whether the short scene times contributed to a low pre-hospital mortality needs further investigation in future studies.

[Successful resuscitation of a pulseless young woman with pulmonary embolus in rural Iceland]. / Mannbjorg a Modrudal a Fjollum.

A 27 year old woman suffered a witnessed cardiac arrest in rural Iceland and regained pulse after one hour's resuscitation. She was transported by an air ambulance to a tertiary medical center in Reykjavik where she was diagnosed with a large pulmonary embolus. After 24 hours therapeutic hypothermia she was rewarmed and extubated two days later. She was discharged from the hospital after two weeks neurologically intact. This case illustrates that even in rural circumstances the chain of survival works if all the links are strong, with early access, early resuscitation and early advanced care.

[Can acute renal insufficiency increase the effect of warfarin?]. / Kan akut nyreinsufficiens øge effekten af warfarin?

The use of warfarin is complicated by its narrow therapeutic index. The risk of severe complications in the form of haemorrhage is significantly increased by an elevated degree of anticoagulation. We present a case in which a patient in stable warfarin treatment was admitted with acute renal failure and extremely high international normalized ratio (INR). No single mechanism can fully explain this. We find that it was probably caused by accumulation of active metabolites, an inhibitory factor in uraemic blood, which reduces hepatic metabolism and a genotype with an unstable metabolism of warfarin.