Mortality after paediatric emergency calls for patients with or without pre-existing comorbidity: a nationwide population based cohort study.

BACKGROUND: Life-threatening conditions are infrequent in children. Current literature in paediatric prehospital research is centred around trauma and paediatric out-of-hospital cardiac arrests (POHCA). The aims of this study were to (1) outline the distribution of trauma, POHCA or other medical symptoms among survivors and non-survivors after paediatric emergency calls, and (2) to investigate these clinical presentations' association with mortality in children with and without pre-existing comorbidity, respectively. METHODS: Nationwide population-based cohort study including ground and helicopter emergency medical services in Denmark for six consecutive years (2016-2021). The study included all calls to the emergency number 1-1-2 regarding children ≤ 15 years (N = 121,230). Interhospital transfers were excluded, and 1,143 patients were lost to follow-up. Cox regressions were performed with trauma or medical symptoms as exposure and 7-day mortality as the outcome, stratified by 'Comorbidity', 'Severe chronic comorbidity' and 'None' based on previous healthcare visits. RESULTS: Mortality analysis included 76,956 unique patients (median age 5 (1-12) years). Annual all-cause mortality rate was 7 per 100,000 children ≤ 15 years. For non-survivors without any pre-existing comorbidity (n = 121), reasons for emergency calls were trauma 18.2%, POHCA 46.3% or other medical symptoms 28.9%, whereas the distribution among the 134 non-survivors with any comorbidity was 7.5%, 27.6% and 55.2%, respectively. Compared to trauma patients, age- and sex-adjusted hazard ratio for patients with calls regarding medical symptoms besides POHCA was 0.8 [0.4;1.3] for patients without comorbidity, 1.1 [0.5;2.2] for patients with comorbidity and 6.1 [0.8;44.7] for patients with severe chronic comorbidity. CONCLUSION: In both non-survivors with and without comorbidity, a considerable proportion of emergency calls had been made because of various medical symptoms, not because of trauma or POHCA. This outline of diagnoses and mortality following paediatric emergency calls can be used for directing paediatric in-service training in emergency medical services.

Prehospital tracheal intubations by anaesthetist-staffed critical care teams: a prospective observational multicentre study.

BACKGROUND: Prehospital tracheal intubation is a potentially lifesaving intervention, but is associated with prolonged time on-scene. Some services strongly advocate performing the procedure outside of the ambulance or aircraft, while others also perform the procedure inside the vehicle. This study was designed as a non-inferiority trial registering the rate of successful tracheal intubation and incidence of complications performed by a critical care team either inside or outside an ambulance or helicopter. METHODS: This observational multicentre study was performed between March 2020 and September 2021 and involved 12 anaesthetist-staffed critical care teams providing emergency medical services by helicopter in Denmark, Norway, and Sweden. The primary outcome was first-pass successful tracheal intubations. RESULTS: Of the 422 drug-assisted tracheal intubations examined, 240 (57%) took place in the cabin of the ambulance or helicopter. The rate of first-pass success was 89.2% for intubations in-cabin vs 86.3% outside. This difference of 2.9% (confidence interval -2.4% to 8.2%) (two sided 10%, including 0, but not the non-inferiority limit Δ=-4.5) fulfils our criteria for non-inferiority, but not significant superiority. These results withstand after performing a propensity score analysis. The mean on-scene time associated with the helicopter in-cabin procedures (27 min) was significantly shorter than for outside the cabin (32 min, P=0.004). CONCLUSIONS: Both in-cabin and outside the cabin, prehospital tracheal intubation by anaesthetists was performed with a high success rate. The mean on-scene time was shorter in the in-cabin helicopter cohort. CLINICAL TRIAL REGISTRATION: NCT04206566.

Prehospital vital sign monitoring in paediatric patients: an interregional study of educational interventions.

BACKGROUND: Prehospital vital sign documentation in paediatric patients is incomplete, especially in patients ≤ 2 years. The aim of the study was to increase vital sign registration in paediatric patients through specific educational initiatives. METHODS: Prospective quasi-experimental study with interrupted time-series design in the North Denmark and South Denmark regions. The study consecutively included all children aged < 18 years attended by the emergency medical service (EMS) from 1 July 2019 to 31 December 2021. Specific educational initiatives were conducted only in the North Denmark EMS and included video learning and classroom training based on the European Paediatric Advanced Life Support principles. The primary outcome was the proportion of patients who had their respiratory rate, peripheral capillary oxygen saturation, heart rate and level of consciousness recorded at least twice. We used a binomial regression model stratified by age groups to compare proportions of the primary outcome in the pre- and post-intervention periods in each region. RESULTS: In North Denmark, 7551 patients were included, while 15,585 patients from South Denmark were used as a reference. Virtually all of the North Denmark EMS providers completed the video learning (98.7%). The total study population involved patients aged ≤ 2 months (5.5%), 3-11 months (7.4%), 1-2 years (18.8%), 3-7 years (16.2%) and ≥ 8 years (52.1%). In the intervention region, the primary outcome increased from the pre- to the post-intervention period from 35.3% to 40.5% [95% CI for difference 3.0;7.4]. There were large variations in between age groups with increases from 18.8% to 27.4% [95% CI for difference 5.3;12.0] among patients aged ≤ 2 years, from 33.5% to 43.7% [95% CI for difference 4.9;15.5] among patients aged 3-7 years and an insignificant increase among patients aged ≥ 8 years (from 46.4% to 47.9% [95% CI for difference - 1.7;4.7]). In the region without the specific educational interventions, proportions were steady for all age groups throughout the entire study period. CONCLUSIONS: Mandatory educational initiatives for EMS providers were associated with an increase in the extent of vital sign registration in paediatric patients ≤ 7 years. Incomplete vital registration was associated with, but not limited to non-urgent cases.

Rapid sequence induction: where did the consensus go?

BACKGROUND: Rapid Sequence Induction (RSI) was introduced to minimise the risk of aspiration of gastric contents during emergency tracheal intubation. It consisted of induction with the use of thiopentone and suxamethonium with the application of cricoid pressure. This narrative review describes how traditional RSI has been modified in the UK and elsewhere, aiming to deliver safe and effective emergency anaesthesia outside the operating room environment. Most of the key aspects of traditional RSI - training, technique, drugs and equipment have been challenged and often significantly changed since the procedure was first described. Alterations have been made to improve the safety and quality of the intervention while retaining the principles of rapidly securing a definitive airway and avoiding gastric aspiration. RSI is no longer achieved by an anaesthetist alone and can be delivered safely in a variety of settings, including in the pre-hospital environment. CONCLUSION: The conduct of RSI in current emergency practice is far removed from the original descriptions of the procedure. Despite this, the principles - rapid delivery of a definitive airway and avoiding aspiration, are still highly relevant and the indications for RSI remain relatively unchanged.

Checklists in pre-hospital advanced airway management.

BACKGROUND: In pre-hospital care, pre-intubation checklists (PICL) are widely implemented as a safety measure and guidelines support their use. However, the true value of PICL among experienced airway providers is unknown. This study aims to explore possible benefits and disadvantages of PICL in the pre-hospital setting. METHODS: We performed a subgroup analysis of a prospective, observational, multicentre study on pre-hospital advanced airway management in the Nordic countries between May 2015 and November 2016. The original trial was designed to investigate the success rates of pre-hospital tracheal intubations and the incidence of complications. Our study limited inclusion to drug assisted intubations performed by anaesthesiologists. Intubation success rates and complication rates were plotted against checklist use. RESULTS: We analyzed 588 pre-hospital intubations for medical and traumatic emergencies. Overall, checklists were used in 60.5% of instances. Applying checklists was associated with increased success at first and second intubation attempts. There was no significant difference in the overall success rates (99.4% and 99.1%). Oesophageal misplacement was more common in the No-PICL group (2.2% vs 0.3%) but otherwise the incidence of airway related complications did not differ between the groups. Scene time was significantly shorter in the No-PICL group (23.6 vs 27.5 minutes). CONCLUSION: In this retrospective study, checklist use correlated with fewer attempts at intubation when securing the airway. Despite this, we found no association between checklist use and the overall TI success rate or the incidence of serious adverse events. Scene times were shorter without PICL.

Saving lives together. / Sammen redder vi liv.

Training in first aid has a long tradition in Norway. We believe that survival after time-critical events outside hospital can be further improved through systematic training.

Collecting core data in physician-staffed pre-hospital helicopter emergency medical services using a consensus-based template: international multicentre feasibility study in Finland and Norway.

BACKGROUND: Comparison of services and identification of factors important for favourable patient outcomes in emergency medical services (EMS) is challenging due to different organization and quality of data. The purpose of the present study was to evaluate the feasibility of physician-staffed EMS (p-EMS) to collect patient and system level data by using a consensus-based template. METHODS: The study was an international multicentre observational study. Data were collected according to a template for uniform reporting of data from p-EMS using two different data collection methods; a standard and a focused data collection method. For the standard data collection, data were extracted retrospectively for one year from all FinnHEMS bases and for the focused data collection, data were collected prospectively for six weeks from four selected Norwegian p-EMS bases. Completeness rates for the two data collection methods were then compared and factors affecting completeness rates and template feasibility were evaluated. Standard Chi-Square, Fisher's Exact Test and Mann-Whitney U Test were used for group comparison of categorical and continuous data, respectively, and Kolomogorov-Smirnov test for comparison of distributional properties. RESULTS: All missions with patient encounters were included, leaving 4437 Finnish and 128 Norwegian missions eligible for analysis. Variable completeness rates indicated that physiological variables were least documented. Information on pain and respiratory rate were the most frequently missing variables with a standard data collection method and systolic blood pressure was the most missing variable with a focused data collection method. Completeness rates were similar or higher when patients were considered severely ill or injured but were lower for missions with short patient encounter. When a focused data collection method was used, completeness rates were higher compared to a standard data collection method. CONCLUSIONS: We found that a focused data collection method increased data capture compared to a standard data collection method. The concept of using a template for documentation of p-EMS data is feasible in physician-staffed services in Finland and Norway. The greatest deficiencies in completeness rates were evident for physiological parameters. Short missions were associated with lower completeness rates whereas severe illness or injury did not result in reduced data capture.

Best practice advice on pre-hospital emergency anaesthesia & advanced airway management.

BACKGROUND: Effective and timely airway management is a priority for sick and injured patients. The benefit and conduct of pre-hospital emergency anaesthesia (PHEA) and advanced airway management remains controversial but there are a proportion of critically ill and injured patients who require urgent advanced airway management prior to hospital arrival. This document provides current best practice advice for the provision of PHEA and advanced airway management. METHOD: This best practice advice was developed from EHAC Medical Working Group enforced by pre-hospital critical care experts. The group used a nominal group technique to establish the current best practice for the provision of PHEA and advanced airway management. The group met on three separate occasions to discuss and develop the guideline. All members of the working party were able to access and edit the guideline online. RESULTS: This EHAC best practice advice covers all areas of PHEA and advanced airway management and provides up to date evidence of current best practice. CONCLUSION: PHEA and advanced airway management are complex interventions that should be delivered by appropriately trained personnel using a well-rehearsed approach and standardised equipment. Where advanced airway interventions cannot be delivered, careful attention should be given to applying basic airway interventions and ensuring their effectiveness at all times.

A systematic review and meta-analysis comparing mortality in pre-hospital tracheal intubation to emergency department intubation in trauma patients.

BACKGROUND: Pre-hospital endotracheal intubation is frequently used for trauma patients in many emergency medical systems. Despite a wide range of publications in the field, it is debated whether the intervention is associated with a favourable outcome, when compared to more conservative airway measures. METHODS: A systematic literature search was conducted to identify interventional and observational studies where the mortality rates of adult trauma patients undergoing pre-hospital endotracheal intubation were compared to those undergoing emergency department intubation. RESULTS: Twenty-one studies examining 35,838 patients were included. The median mortality rate in patients undergoing pre-hospital intubation was 48% (range 8-94%), compared to 29% (range 6-67%) in patients undergoing intubation in the emergency department. Odds ratios were in favour of emergency department intubation both in crude and adjusted mortality, with 2.56 (95% CI: 2.06, 3.18) and 2.59 (95% CI: 1.97, 3.39), respectively. The overall quality of evidence is very low. Twelve of the twenty-one studies found a significantly higher mortality rate after pre-hospital intubation, seven found no significant differences, one found a positive effect, and for one study an analysis of the mortality rate was beyond the scope of the article. CONCLUSIONS: The rationale for wide and unspecific indications for pre-hospital intubation seems to lack support in the literature, despite several publications involving a relatively large number of patients. Pre-hospital intubation is a complex intervention where guidelines and research findings should be approached cautiously. The association between pre-hospital intubation and a higher mortality rate does not necessarily contradict the importance of the intervention, but it does call for a thorough investigation by clinicians and researchers into possible causes for this finding.

Termination of prehospital resuscitative efforts: a study of documentation on ethical considerations at the scene.

BACKGROUND: Discussions on ethical aspects of life-and-death decisions within the hospital are often made in plenary. The prehospital physician, however, may be faced with ethical dilemmas in life-and-death decisions when time-critical decisions to initiate or refrain from resuscitative efforts need to be taken without the possibility to discuss matters with colleagues. Little is known whether these considerations regarding ethical issues in crucial life-and-death decisions are documented prehospitally. This is a review of the ethical considerations documented in the prehospital medical records of patients in a Danish prehospital setting for whom the decision to resuscitate or not was made at the scene. METHODS: The study is based on discharge summaries of all patients subjected to crucial life-and-death decisions by the Mobile Emergency Care Unit in Odense in the years 2010 to 2014. The medical records with possible documentation of ethical issues were independently reviewed by two philosophers in order to identify explicit ethical or philosophical considerations pertaining to the decision to resuscitate or not. RESULTS: In total, 1275 patients were either declared dead at the scene without exhibiting layman's reliable signs of death or admitted to hospital following resuscitation. In a total of 62 patients, 85 specific ethical issues related to resuscitation were documented. The expressions of the ethical considerations were generally vague or unclear and almost exclusively concerned the interests of the patient and not the relatives. In the vast majority of cases where an ethical content was identified, the ethical considerations led to a decision to terminate treatment. CONCLUSIONS: A strengthened practice of documenting ethical considerations in prehospital life-and-death decision-making in the patient's medical records is required. We suggest that a template be implemented in the prehospital medical records describing the basis for any ethical decisions. This template should contain information regarding the persons involved in the deliberations and notes on ethical considerations. The documentation should include considerations concerning the patient's end-of-life wishes, the estimations of the quality of life before and after the incident, and a summary of other ethical concerns taken into account, such as the integrity of the patient and frame of mind of relatives.

Characteristics and prognoses of patients treated by an anaesthesiologist-manned prehospital emergency care unit. A retrospective cohort study.

OBJECTIVE: When planning and dimensioning an emergency medical system, knowledge of the population serviced is vital. The amount of literature concerning the prehospital population is sparse. In order to add to the current body of literature regarding prehospital treatment, thus aiding future public health planning, we describe the workload of a prehospital anaesthesiologist-manned mobile emergency care unit (MECU) and the total population it services in terms of factors associated with mortality. PARTICIPANTS: The study is a register-based study investigating all missions carried out by a MECU operating in a mixed urban/rural area in Denmark from 1 May 2006 to 31 December 2014. Information on missions was extracted from the local MECU registry and linked at the individual level to the Danish population-based databases, the National Patient Registry and the Civil Registration System. PRIMARY AND SECONDARY OUTCOME MEASURES: Primary outcome measures were number of missions and number of patient contacts. Secondary patient variables were mortality and association between mortality and age, sex, comorbidity, prior admission to hospital and response time. RESULTS: The MECU completed 41 513 missions (mean 13.1 missions/day) having 32 873 patient contacts, corresponding to 19.2 missions and 15.2 patient encounters per 1000 patient years. Patient variables: the median age was 57 years (range 0-108 years), 42.8% (42.3% to 43.4%) were women. For patients admitted to hospital alive, 30-day mortality was 5.7% (5.4% to 6.0%); 90-day mortality was 8.1% (7.8% to 8.5%) while 2-year mortality was 16.4% (16.0% to 16.8%). Increasing age, male sex, comorbidity and prior admission to hospital but not response time were associated with mortality. CONCLUSIONS: Mortality following an incident requiring the assistance of a MECU was high in the first 2 years following the incident. MECU response time assessed as a continuous parameter was not associated with patient outcome.

[Rapid development in prehospital physician staffed intensive care]. / Snabb utveckling inom prehospital läkarbemannad intensivvård.

For the most severely injured and unstable patients physician staffed second tier emergency medical service (EMS) units are used in many European areas. Physician staffed prehospital care is associated with a high rate of survival, advanced trauma care and beneficial cost-effectiveness. In the Nordic countries anaesthesiologists staff the rapid response cars and ambulance helicopters. This article reviews the current status of physician EMS in Sweden and the rapid development of new prehospital intensive care methods.

Effect of an organizational change in a prehospital trauma care protocol and trauma transport directive in a large urban city: a before and after study.

BACKGROUND: Trauma systems and regionalized trauma care have been shown to improve outcome in severely injured trauma patients. The aim of this study was to evaluate the implementation of a prehospital trauma care protocol and transport directive, and to determine its effects on the number of primary admissions and secondary trauma transfers in a large Scandinavian city. METHODS: We performed a retrospective observational study based on local trauma registries and hospital and ambulance records in Stockholm County; patients > 15 years of age with an Injury Severity Score (ISS) > 15 transported to any emergency care hospitals in the Stockholm area were included for the years 2006 and 2008. We also included secondary transferred patients to the regional trauma center during 2006, 2008, and 2013. RESULTS: A total of 693 primarily admitted trauma patients were included for the years 2006 and 2008. For the years 2006, 2008 and 2013, we included 114 secondarily transported trauma patients. The number of primary patient transports to the trauma center increased during the years by 20.2%, (p < 0.001); patients primarily transported to the trauma center had a significantly higher Injury Severity Score in 2008 than in 2006, and the number of patients transported secondarily to the trauma center in 2006 was higher compared to 2008 and to 2013 (p < 0.001, all 3 years). DISCUSSION: Our data indicate that implementation of a prehospital trauma care protocol may have an effect on transportation of severely injured trauma patients. A decrease in secondarily transported trauma patients to the regional trauma center was noted after 1 year and persisted at 7 years after the organizational change. Patients primarily admitted to the trauma center after the change had more severe injuries than patients transported to other emergency hospitals in the area even if 20 % of patients were not admitted primarily to a trauma center. This does not imply that the transport directives or the criteria were not followed but rather reveals the difficulties and uncertainties of field triage. CONCLUSIONS: With the introduction of a prehospital trauma transport directive in a large urban city, an increase in patients transported to the regional trauma center and a decrease in secondary transfers were detected, but a considerable number of severely injured patients were still transported to local hospitals.

Do male and female trauma patients receive the same prehospital care?: an observational follow-up study.

BACKGROUND: Trauma-related mortality can be lowered by efficient prehospital care. Less is known about whether gender influences the prehospital trauma care provided. The aim of this study was to explore gender-related differences in prehospital trauma care of severely injured trauma patients, with a special focus on triage, transportation, and interventions. METHODS: We performed a retrospective observational study based on local trauma registries and hospital and ambulance records in Stockholm County, Sweden. A total of 383 trauma patients (279 males and 104 females) > 15 years of age with an Injury Severity Score (ISS) of > 15 transported to emergency care hospitals in the Stockholm area were included. RESULTS: Male patients had a 2.75 higher odds ratio (95 % CI, 1.2-6.2) for receiving the highest prehospital priority compared to females on controlling for injury mechanism and vital signs on scene. No significant difference between genders was detected regarding other aspects of the prehospital care provided. CONCLUSIONS: This study indicated that prehospital prioritization among severely injured late adolescent and adult trauma patients differs between genders. Knowledge of a more diffuse presentation of symptoms in female trauma patients despite severe injury may help to adapt and improve prehospital trauma care for this group.

Endotracheal Intubation With and Without Night Vision Goggles in a Helicopter and Emergency Room Setting: A Manikin Study.

BACKGROUND: Securing the airway by endotracheal intubation (ETI) is a key issue in prehospital critical care. Night vision goggles (NVG) are used by personnel operating in low-light environments. We examined the feasibility of an anesthesiologist performed ETI using NVG in a helicopter setting. METHODS: Twelve anesthesiologists performed ETI on a manikin in an emergency room (ER) setting and two helicopter settings, with randomization to either rotary wing daylight (RW-D) or rotary wing in total darkness using binocular NVG (RW-NVG). Primary endpoint was intubation time. Secondary endpoints included success rate, Cormack-Lehane (CL) score, and subjective difficulty according to the Visual Analoge Scale (VAS). RESULTS: The median intubation time was shorter for the RW-D compared to the RW-NVG setting (16.5 seconds vs. 30.0 seconds; p = 0,03). We found no difference in median intubation time for the ER and RW-D settings (16.8 seconds vs. 16.5 seconds; p = 0.91). For all scenarios, success rate was 100%. CL and VAS varied between the ER setting (CL 1.8, VAS 2.8), RW-D setting (CL 2.0, VAS 3.0), and RW-NVG setting (CL 3.0, VAS 6.5). CONCLUSION: This study suggests that anesthesiologists successfully and quickly can perform ETI in a helicopter setting both in daylight and in darkness using binocular NVG, but with shorter intubation times in daylight.

Does transport time help explain the high trauma mortality rates in rural areas? New and traditional predictors assessed by new and traditional statistical methods.

BACKGROUND: Trauma is a leading global cause of death. Trauma mortality rates are higher in rural areas, constituting a challenge for quality and equality in trauma care. The aim of the study was to explore population density and transport time to hospital care as possible predictors of geographical differences in mortality rates, and to what extent choice of statistical method might affect the analytical results and accompanying clinical conclusions. METHODS: Using data from the Norwegian Cause of Death registry, deaths from external causes 1998-2007 were analysed. Norway consists of 434 municipalities, and municipality population density and travel time to hospital care were entered as predictors of municipality mortality rates in univariate and multiple regression models of increasing model complexity. We fitted linear regression models with continuous and categorised predictors, as well as piecewise linear and generalised additive models (GAMs). Models were compared using Akaike's information criterion (AIC). RESULTS: Population density was an independent predictor of trauma mortality rates, while the contribution of transport time to hospital care was highly dependent on choice of statistical model. A multiple GAM or piecewise linear model was superior, and similar, in terms of AIC. However, while transport time was statistically significant in multiple models with piecewise linear or categorised predictors, it was not in GAM or standard linear regression. CONCLUSIONS: Population density is an independent predictor of trauma mortality rates. The added explanatory value of transport time to hospital care is marginal and model-dependent, highlighting the importance of exploring several statistical models when studying complex associations in observational data.

Is prehospital treatment of acute stroke too expensive? An economic evaluation based on the first trial.

BACKGROUND: Recently, a strategy for treating stroke directly at the emergency site was developed. It was based on the use of an ambulance equipped with a scanner, a point-of-care laboratory, and telemedicine capabilities (Mobile Stroke Unit). Despite demonstrating a marked reduction in the delay to thrombolysis, this strategy is criticized because of potentially unacceptable costs. METHODS: We related the incremental direct costs of prehospital stroke treatment based on data of the first trial on this concept to one year direct cost savings taken from published research results. Key parameters were configuration of emergency medical service personnel, operating distance, and population density. Model parameters were varied to cover 5 different relevant emergency medical service scenarios. Additionally, the effects of operating distance and population density on benefit-cost ratios were analyzed. RESULTS: Benefits of the concept of prehospital stroke treatment outweighed its costs with a benefit-cost ratio of 1.96 in the baseline experimental setting. The benefit-cost ratio markedly increased with the reduction of the staff and with higher population density. Maximum benefit-cost ratios between 2.16 and 6.85 were identified at optimum operating distances in a range between 43.01 and 64.88 km (26.88 and 40.55 miles). Our model implies that in different scenarios the Mobile Stroke Unit strategy is cost-efficient starting from an operating distance of 15.98 km (9.99 miles) or from a population density of 79 inhabitants per km2 (202 inhabitants per square mile). CONCLUSION: This study indicates that based on a one-year benefit-cost analysis that prehospital treatment of acute stroke is highly cost-effective across a wide range of possible scenarios. It is the highest when the staff size of the Mobile Stroke Unit can be reduced, for example, by the use of telemedical support from hospital experts. Although efficiency is positively related to population density, benefit-cost ratios can be greater than 1 even in rural settings.