Inhaled nitric oxide as temporary respiratory stabilization in patients with COVID-19 related respiratory failure (INOCOV): Study protocol for a randomized controlled trial.

BACKGROUND: In March 2020, WHO announced the COVID-19 a pandemic and a major global public health emergency. Mortality from COVID-19 is rapidly increasing globally, with acute respiratory failure as the predominant cause of death. Many patients experience severe hypoxia and life-threatening respiratory failure often requiring mechanical ventilation. To increase safety margins during emergency anaesthesia and rapid sequence intubation (RSI), patients are preoxygenated with a closed facemask with high-flow oxygen and positive end-expiratory pressure (PEEP). Due to the high shunt fraction of deoxygenated blood through the lungs frequently described in COVID-19 however, these measures may be insufficient to avoid harmful hypoxemia. Preoxygenation with inhaled nitric oxide (iNO) potentially reduces the shunt fraction and may thus allow for the necessary margins of safety during RSI. METHODS AND DESIGN: The INOCOV protocol describes a phase II pharmacological trial of inhaled nitric oxide (iNO) as an adjunct to standard of care with medical oxygen in initial airway and ventilation management of patients with known or suspected COVID-19 in acute respiratory failure. The trial is parallel two-arm, randomized, controlled, blinded trial. The primary outcome measure is the change in oxygen saturation (SpO2), and the null hypothesis is that there is no difference in the change in SpO2 following initiation of iNO. TRIAL REGISTRATION: EudraCT number 2020-001656-18; WHO UTN: U1111-1250-1698. Protocol version: 2.0 (June 25th, 2021).

Pre-hospital critical care management of severe hypoxemia in victims of Covid-19: a case series.

OBJECTIVE: Despite critical hypoxemia, Covid-19 patients may present without proportional signs of respiratory distress. We report three patients with critical respiratory failure due to Covid-19, in which all presented with severe hypoxemia refractory to supplemental oxygen therapy. We discuss possible strategies for ventilatory support in the emergency pre-hospital setting, and point out some pitfalls regarding the management of these patients. Guidelines for pre-hospital care of critically ill Covid-19 patients cannot be established based on the current evidence base, and we have to apply our understanding of respiratory physiology and mechanics in order to optimize respiratory support. METHODS: Three cases with similar clinical presentation were identified within the Norwegian national helicopter emergency medical service (HEMS) system. The HEMS units are manned by a consultant anaesthesiologist. Patient's next of kin and the Regional committee for medical and health research ethics approved the publication of this report. CONCLUSION: Patients with Covid-19 and severe hypoxemia may pose a considerable challenge for the pre-hospital emergency medical services. Intubation may be associated with a high risk of complications in these patients and should be carried out with diligence when considered necessary. The following interventions are worth considering in Covid-19 patients with refractory hypoxemia before proceeding to intubation. First, administering oxygen via a tight fitting BVM with an oxygen flow rate that exceeds the patient's ventilatory minute volume. Second, applying continuous positive airway pressure, while simultaneously maintaining a high FiO2. Finally, assuming the patient is cooperative, repositioning to prone position.

Out-of-Hospital Perimortem Cesarean Delivery Performed in a Woman at 32 Weeks of Gestation: A Case Report.

A 34-year-old pregnant woman experienced cardiac arrest at home. Out-of-hospital perimortem cesarean delivery was performed 27 minutes after the collapse. Both mother and child were resuscitated and had return of spontaneous circulation before they were transported to a university hospital. The mother underwent hysterectomy and developed disseminated intravascular coagulation. Despite intensive treatment, she died 8.5 hours after arrival. The infant was extubated the next day, and her subsequent hospital course was uneventful. She was later diagnosed with cerebral palsy and severe gastroesophageal reflux. At 2 years of age, she communicated by sounds, eye contact, and smiling.

Oslo government district bombing and Utøya island shooting July 22, 2011: the immediate prehospital emergency medical service response.

BACKGROUND: On July 22, 2011, a single perpetrator killed 77 people in a car bomb attack and a shooting spree incident in Norway. This article describes the emergency medical service (EMS) response elicited by the two incidents. METHODS: A retrospective and observational study was conducted based on data from the EMS systems involved and the public domain. The study was approved by the Data Protection Official and was defined as a quality improvement project. RESULTS: We describe the timeline and logistics of the EMS response, focusing on alarm, dispatch, initial response, triage and evacuation. The scenes in the Oslo government district and at Utøya island are described separately. CONCLUSIONS: Many EMS units were activated and effectively used despite the occurrence of two geographically separate incidents within a short time frame. Important lessons were learned regarding triage and evacuation, patient flow and communication, the use of and need for emergency equipment and the coordination of helicopter EMS.

Incidence of desaturation during prehospital rapid sequence intubation in a physician-based helicopter emergency service.

BACKGROUND: Hypoxemia may occur during rapid sequence intubation (RSI). This study establishes the incidence of this adverse event in patients intubated by physicians in a helicopter emergency service in Norway. METHODS: This was a prospective, observational study of all RSIs performed by helicopter emergency service physicians during a 12-month period. Hypoxemia was defined as a decrease in Spo(2) values to below 90% or a decrease of more than 10% if the initial Spo(2) was less than 90%. RESULTS: A total of 122 prehospital intubations were performed during the study period. Spo(2) data were available for 101 (82.8%) patients. Hypoxemia was present in 11 (10.9%) patients. CONCLUSIONS: Prehospital, RSI-related hypoxemia rates in this study are lower than reported rates in similar studies and are comparable with in-hospital rates. Prehospital RSI may accordingly be considered a safe procedure when performed by experienced physicians with appropriate field training.