The design of the PRINCESS 2 trial: A randomized trial to study the impact of ultrafast hypothermia on complete neurologic recovery after out-of-hospital cardiac arrest with initial shockable rhythm.

BACKGROUND: Delayed hypothermia, initiated after hospital arrival, several hours after cardiac arrest with 8-10 hours to reach the target temperature, is likely to have limited impact on overall survival. However, the effect of ultrafast hypothermia, i.e., delivered intra-arrest or immediately after return of spontaneous circulation (ROSC), on functional neurologic outcome after out-of-hospital cardiac arrest (OHCA) is unclear. In two prior trials, prehospital trans-nasal evaporative intra-arrest cooling was safe, feasible and reduced time to target temperature compared to delayed cooling. Both studies showed trends towards improved neurologic recovery in patients with shockable rhythms. The aim of the PRINCESS2-study is to assess whether cooling, initiated either intra-arrest or immediately after ROSC, followed by in-hospital hypothermia, significantly increases survival with complete neurologic recovery as compared to standard normothermia care, in OHCA patients with shockable rhythms. METHODS/DESIGN: In this investigator-initiated, randomized, controlled trial, the emergency medical services (EMS) will randomize patients at the scene of cardiac arrest to either trans-nasal cooling within 20 minutes from EMS arrival with subsequent hypothermia at 33°C for 24 hours after hospital admission (intervention), or to standard of care with no prehospital or in-hospital cooling (control). Fever (>37,7°C) will be avoided for the first 72 hours in both groups. All patients will receive post resuscitation care and withdrawal of life support procedures according to current guidelines. Primary outcome is survival with complete neurologic recovery at 90 days, defined as modified Rankin scale (mRS) 0-1. Key secondary outcomes include survival to hospital discharge, survival at 90 days and mRS 0-3 at 90 days. In total, 1022 patients are required to detect an absolute difference of 9% (from 45 to 54%) in survival with neurologic recovery (80% power and one-sided α=0,025, ß=0,2) and assuming 2,5% lost to follow-up. Recruitment starts in Q1 2024 and we expect maximum enrolment to be achieved during Q4 2024 at 20-25 European and US sites. DISCUSSION: This trial will assess the impact of ultrafast hypothermia applied on the scene of cardiac arrest, as compared to normothermia, on 90-day survival with complete neurologic recovery in OHCA patients with initial shockable rhythm. TRIAL REGISTRATION: NCT06025123.

Prehospital and emergency department airway management of severe penetrating trauma in Sweden during the past decade.

BACKGROUND: Prehospital tracheal intubation (TI) is associated with increased mortality in patients with penetrating trauma, and the utility of prehospital advanced airway management is debated. The increased incidence of deadly violence in Sweden warrants a comprehensive evaluation of current airway management for patients with penetrating trauma in the Swedish prehospital environment and on arrival in the emergency department (ED). METHODS: This was an observational, multicenter study of all patients with penetrating trauma and injury severity scores (ISSs) ≥ 15 included in the Swedish national trauma register (SweTrau) between 2011 and 2019. We investigated the frequency and characteristics of prehospital and ED TI, including 30-day mortality and patient characteristics associated with TI. RESULT: Of 816 included patients, 118 (14.5%) were intubated prehospitally, and 248 (30.4%) were intubated in the ED. Patients who were intubated prehospitally had a higher ISS, 33 (interquartile range [IQR] 25, 75), than those intubated in the ED, 25 (IQR 18, 34). Prehospital TI was associated with a higher associated mortality, OR 4.26 (CI 2.57, 7.27, p < 0.001) than TI in the ED, even when adjusted for ISS (OR 2.88 [CI 1.64, 5.14, p < 0.001]). Hemodynamic collapse (≤ 40 mmHg) and low GCS score (≤ 8) were the characteristics most associated with prehospital TI. Traumatic cardiac arrests (TCAs) occurred in 154 (18.9%) patients, of whom 77 (50%) were intubated prehospitally and 56 (36.4%) were intubated in the ED. A subgroup analysis excluding TCA showed that patients with prehospital TI did not have a higher mortality rate than those with ED TI, OR 2.07 (CI 0.93, 4.51, p = 0.068), with OR 1.39 (0.56, 3.26, p = 0.5) when adjusted for ISS. CONCLUSION: Prehospital TI was associated with a higher mortality rate than those with ED TI, which was specifically related to TCA; intubation did not affect mortality in patients without cardiac arrest. Mortality was high when airway management was needed, regardless of cardiac arrest, thereby emphasizing the challenges posed when anesthesia is needed. Several interventions, including whole blood transfusions, the implementation of second-tier EMS units and measures to shorten scene times, have been initiated in Sweden to counteract these challenges.

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 transportation of severe penetrating trauma victims in Sweden during the past decade: a police business?

INTRODUCTION: Sweden is facing a surge of gun violence that mandates optimized prehospital transport approaches, and a survey of current practice is fundamental for such optimization. Management of severe, penetrating trauma is time sensitive, and there may be a survival benefit in limiting prehospital interventions. An important aspect is unregulated transportation by police or private vehicles to the hospital, which may decrease time but may also be associated with adverse outcomes. It is not known whether transport of patients with penetrating trauma occurs outside the emergency medical services (EMS) in Sweden and whether it affects outcome. METHOD: This was a retrospective, descriptive nationwide study of all patients with penetrating trauma and injury severity scores (ISSs) ≥ 15 registered in the Swedish national trauma registry (SweTrau) between June 13, 2011, and December 31, 2019. We hypothesized that transport by police and private vehicles occurred and that it affected mortality. RESULT: A total of 657 patients were included. EMS transported 612 patients (93.2%), police 10 patients (1.5%), and private vehicles 27 patients (4.1%). Gunshot wounds (GSWs) were more common in police transport, 80% (n = 8), compared with private vehicles, 59% (n = 16), and EMS, 32% (n = 198). The Glasgow coma scale score (GCS) in the emergency department (ED) was lower for patients transported by police, 11.5 (interquartile range [IQR] 3, 15), in relation to EMS, 15 (IQR 14, 15) and private vehicles 15 (IQR 12.5, 15). The 30-day mortality for EMS was 30% (n = 184), 50% (n = 5) for police transport, and 22% (n = 6) for private vehicles. Transport by private vehicle, odds ratio (OR) 0.65, (confidence interval [CI] 0.24, 1.55, p = 0.4) and police OR 2.28 (CI 0.63, 8.3, p = 0.2) were not associated with increased mortality in relation to EMS. CONCLUSION: Non-EMS transports did occur, however with a low incidence and did not affect mortality. GSWs were more common in police transport, and victims had lower GCS scorescores when arriving at the ED, which warrants further investigations of the operational management of shooting victims in Sweden.

Permissive hypoventilation equally effective to maintain oxygenation as positive pressure ventilation after porcine class III hemorrhage and whole blood resuscitation.

BACKGROUND: Prehospital anesthesia may lead to circulatory collapse after severe hemorrhage. It is possible that permissive hypoventilation, refraining from tracheal intubation and accepting spontaneous ventilation, decreases this risk, but it is not known if oxygen delivery can be maintained. We investigated the feasibility of permissive hypoventilation after class III hemorrhage and whole blood resuscitation in three prehospital phases: 15 min on-scene, 30 min whole blood resuscitation, and 45 min after. STUDY DESIGN AND METHODS: 19 crossbred swine, mean weight 58.5 kg, were anesthetized with ketamine/midazolam and hemorrhaged to a mean (SD) 1298 (220) mL (33%) and randomized to permissive hypoventilation (n = 9) or positive pressure ventilation with FiO2 21% (n = 10). RESULTS: In permissive hypoventilation versus positive pressure ventilation, indexed oxygen delivery (DO2 I) decreased to mean (SD) 4.73 (1.06) versus 3.70 (1.13) mL min-1 kg-1 after hemorrhage and increased to 8.62 (2.09) versus 6.70 (1.56) mL min-1 kg-1 at completion of resuscitation. DO2 I, indexed oxygen consumption (VO2 I), and arterial saturation (SaO2 ) did not differ. Permissive hypoventilation increased the respiratory rate and increased pCO2 . Positive pressure ventilation did not deteriorate circulation. Cardiac index (CI), systolic arterial pressure (SAP), hemoglobin (Hb), and heart rate did not differ. DISCUSSION: Permissive hypoventilation and positive pressure ventilation were equally effective to maintain oxygen delivery in all phases. A respiratory rate of 40 was feasible, showing no signs of respiratory fatigue for 90 min, indicating that whole blood resuscitation may be prioritized in select patients with severe hemorrhage and spontaneous breathing.

Comparison of emergency surgical cricothyroidotomy and percutaneous cricothyroidotomy by experienced airway providers in an obese, in vivo porcine hemorrhage airway model.

BACKGROUND: Emergency front-of-neck airway (eFONA) is a life-saving procedure in "cannot intubate, cannot oxygenate" (CICO). The fastest and most reliable method of eFONA has not been determined. We compared two of the most advocated approaches: surgical cricothyroidotomy and percutaneous cricothyroidotomy, in an obese, in vivo porcine hemorrhage model, designed to introduce real-time physiological feedback, relevant and high provider stress. The primary aim was to determine the fastest method to secure airway. Secondary aims were arterial saturation and partial pressure of oxygen, proxy survival and influence of experience. METHODS: Twelve pigs, mean weight (standard deviation, SD) (60.3 ± 4.1) kg, were anesthetized and exposed to 25-35% total blood volume hemorrhage before extubation and randomization to Seldinger technique "percutaneous cricothyroidotomy" (n = 6) or scalpel-bougie-tube technique "surgical cricothyroidotomy" (n = 6). Specialists in anesthesia and intensive care in a tertiary referral hospital performed the eFONA, simulating an actual CICO-situation. RESULTS: In surgical cricothyroidotomy vs. percutaneous cricothyroidotomy, the median (interquartile range, IQR) times to secure airway were 109 (IQR 71-130) s and 298 (IQR 128-360) s (P = 0.0152), arterial blood saturation (SaO2) were 74.7 (IQR 46.6-84.2) % and 7.9 (IQR 4.1-15.6) % (P = 0.0167), pO2 were 7.0 (IQR 4.7-7.7) kPa and 2.0 (IQR 1.1-2.9) kPa (P = 0.0667), and times of cardiac arrest (proxy survival) were 137-233 s, 190 (IQR 143-229), from CICO. All six animals survived surgical cricothyroidotomy, and two of six (33%) animals survived percutaneous cricothyroidotomy. Years in anesthesia, 13.5 (IQR 7.5-21.3), did not influence time to secure airway. CONCLUSION: eFONA by surgical cricothyroidotomy was faster and had increased oxygenation and survival, when performed under stress by board certified anesthesiologists, and may be an indication of preferred method in situations with hemorrhage and CICO, in obese patients.

Pediatric Prehospital Advanced Airway Management by Anesthesiologist and Nurse Anesthetist Staffed Critical Care Teams.

INTRODUCTION: Prehospital pediatric tracheal intubation (TI) is a possible life-saving intervention that requires adequate experience to mitigate associated complications. The pediatric airway and respiratory physiology present challenges in addition to a relatively rare incidence of prehospital pediatric TI. STUDY OBJECTIVE: The aim of this study was to describe characteristics and outcomes of prehospital TI in pediatric patients treated by critical care teams. METHODS: This is a sub-group analysis of all pediatric (<16 years old) patients from a prospective, observational, multi-center study on prehospital advanced airway management in the Nordic countries from May 2015 through November 2016. The TIs were performed by anesthesiologists and nurse anesthetists staffing six helicopter and six Rapid Response Car (RRC) prehospital critical care teams. RESULTS: In the study, 74 children were tracheal intubated, which corresponds to 3.7% (74/2,027) of the total number of patients. The pediatric patients were intubated by very experienced providers, of which 80% had performed ≥2,500 TIs. The overall TI success rate, first pass success rate, and airway complication rate were in all children (<16 years) 98%, 82%, and 12%. The corresponding rates among infants (<2 years) were 94%, 67%, and 11%. The median time on scene was 30 minutes. CONCLUSION: This study observed a high overall prehospital TI success rate in children with relatively few associated complications and short time on scene, despite the challenges presented by the pediatric prehospital TI.

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.

The advanced machine learner XGBoost did not reduce prehospital trauma mistriage compared with logistic regression: a simulation study.

BACKGROUND: Accurate prehospital trauma triage is crucial for identifying critically injured patients and determining the level of care. In the prehospital setting, time and data are often scarce, limiting the complexity of triage models. The aim of this study was to assess whether, compared with logistic regression, the advanced machine learner XGBoost (eXtreme Gradient Boosting) is associated with reduced prehospital trauma mistriage. METHODS: We conducted a simulation study based on data from the US National Trauma Data Bank (NTDB) and the Swedish Trauma Registry (SweTrau). We used categorized systolic blood pressure, respiratory rate, Glasgow Coma Scale and age as our predictors. The outcome was the difference in under- and overtriage rates between the models for different training dataset sizes. RESULTS: We used data from 813,567 patients in the NTDB and 30,577 patients in SweTrau. In SweTrau, the smallest training set of 10 events per free parameter was sufficient for model development. XGBoost achieved undertriage rates in the range of 0.314-0.324 with corresponding overtriage rates of 0.319-0.322. Logistic regression achieved undertriage rates ranging from 0.312 to 0.321 with associated overtriage rates ranging from 0.321 to 0.323. In NTDB, XGBoost required the largest training set size of 1000 events per free parameter to achieve robust results, whereas logistic regression achieved stable performance from a training set size of 25 events per free parameter. For the training set size of 1000 events per free parameter, XGBoost obtained an undertriage rate of 0.406 with an overtriage of 0.463. For logistic regression, the corresponding undertriage was 0.395 with an overtriage of 0.468. CONCLUSION: The under- and overtriage rates associated with the advanced machine learner XGBoost were similar to the rates associated with logistic regression regardless of sample size, but XGBoost required larger training sets to obtain robust results. We do not recommend using XGBoost over logistic regression in this context when predictors are few and categorical.

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.

A Protocol for Helicopter In-Cabin Intubation.

OBJECTIVE: The gold standard for prehospital intubation is to avoid intubating in confined spaces. For our helicopter service, this is not always realistic. Operating in a rural region with a subarctic, cold climate, our crews are frequently forced to intubate inside ambulances or in our helicopter. This article describes a protocol for in-cabin intubation and compares it with standard open space conditions. METHODS: Fourteen prehospital physicians were randomized to solve a simplified clinical scenario during which they were to intubate a mannequin either inside the helicopter, in accordance with our in-cabin protocol, or outside on an ambulance stretcher. Participants scored intubating conditions using a visual analog scale (VAS) and the Cormack-Lehane classification. The number of intubation attempts was recorded. Three timing end points were also measured. RESULTS: All intubations were successful on the first attempt. All participants reported an optimal glottic view of Cormack-Lehane 1 in both scenario conditions. Participants perceived in-cabin intubation to be less difficult than intubating outdoors. (VAS 1 vs. VAS 2, P = .02). We found no difference in the duration of intubation. Scene time was 53.5 seconds (P = .04) shorter in the in-cabin group. In-cabin intubation delayed the establishment of a secure airway by 63 seconds (P = .01). CONCLUSION: Our study suggests that protocolized in-cabin intubation can be performed in a timely manner under conditions that are equal to or better than when intubating outside on a stretcher with 360-degree patient access. Although delaying the establishment of a secure airway, in-cabin intubation may reduce scene times.

Prehospital Invasive Arterial Pressure: Use of a Minimized Flush System.

IntroductionInvasive blood pressure (IBP) monitoring could be of benefit for certain prehospital patient groups such as trauma and cardiac arrest patients. However, there are disadvantages with using conventional IBP devices. These include time to prepare the transducer kit and flush system as well as the addition of long tubing connected to the patient. It has been suggested to simplify the IBP equipment by replacing the continuous flush system with a syringe and a short stopcock.HypothesisIn this study, blood pressures measured by a standard IBP (sIBP) transducer kit with continuous flush was compared to a transducer kit connected to a simplified and minimized flush system IBP (mIBP) using only a syringe. METHODS: A mechanical, experimental model was used to create arterial pressure pulsations. Measurements were made simultaneously using a sIBP and mIBP device, respectively. This was repeated four times using different mean arterial pressure (MAP): 40, 70, 110, and 140mm Hg. For each series, 16 measurements were taken during 20 minutes. Data were analyzed using Bland-Altman plots. Measurement error greater than five percent was regarded as clinically significant. RESULTS: Mean bias and standard deviation (SD) for systolic blood pressure (SBP), diastolic blood pressure (DBP), and MAP was -3.05 (SD = 2.07), 0.2 (SD = 0.48), and -0.3 (SD = 0.55) mmHg, respectively. Bland-Altman plots revealed that the bias and SD for systolic pressures was mainly due to an increased under-estimation of pressures in lower ranges. All MAP and 98.4% of diastolic pressure measurements had an error of less than five percent. Systolic pressures in the MAP 40 series all had an error of greater than five percent. All other systolic pressures had an error of less than five percent. CONCLUSION: Thus, IBP with the mIBP flush system provides accurate measurement of MAP and DBP in a wide range of physiological pressures. For SBP, there was a tendency to under-estimate pressures, with larger error in lower pressures. Implementation of a simplified flush system could allow further development and potentially simplify the use of IBP for prehospital critical care teams. KarlssonJ, LindeJ, SvensenC, GellerforsM. Prehospital invasive arterial pressure: use of a minimized flush system. Prehosp Disaster Med. 2018;33(5):490-494.

The mission characteristics of a newly implemented rural helicopter emergency medical service.

BACKGROUND: Physician-staffed helicopter emergency services (HEMS) can provide benefit through the delivery of specialist competence and equipment to the prehospital scene and through expedient transport of critically ill patients to specialist care. This paper describes the integration of such a system in a rural Swedish county. METHODS: This is a retrospective database study recording the outcomes of every emergency call centre dispatch request as well as the clinical and operational data from all completed missions during this service's first year in operation. RESULTS: During the study period, HEMS completed 478 missions out of which 405 (84,7%) were primary missions to prehospital settings and 73 (15,3%) were inter-hospital critical care transfers. A majority (55,3%) of primary missions occurred in the regions furthest from our hospitals, in municipalities housing only 15,6% of the county's population. The NACA (IQR) score on primary and secondary missions was 4 (2) and 5 (1), respectively. CONCLUSIONS: This study describes the successful integration of a physician-based air ambulance service in a Scandinavian rural region. Municipalities distant from our hospitals benefitted as they now have access to early specialist intervention and expedient transport to critical hospital care. Our hospitals and most populated areas benefitted from HEMS secondary mission capability as they gained a dedicated ICU transport service that could provide specialist intensive care during rapid inter-hospital transfer.

[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.

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.

Helicopter In-flight Resuscitation with Freeze-dried Plasma of a Patient with a High-velocity Gunshot Wound to the Neck in Afghanistan - A Case Report.

Massive hemorrhage with coagulopathy is one of the leading causes of preventable death in the battlefield. The development of freeze-dried plasma (FDP) allows for early treatment with coagulation-optimizing resuscitation fluid in the prehospital setting. This report describes the first prehospital use of FDP in a patient with carotid artery injury due to a high-velocity gunshot wound (HVGSW) to the neck. It also describes in-flight constitution and administration of FDP in a Medevac Helicopter. Early administration of FDP may contribute to hemodynamic stabilization and reduction in trauma-induced coagulopathy and acidosis. However, large-scale studies are needed to define the prehospital use of FDP and other blood products.

Use of the Airtraq® device for airway management in the prehospital setting--a retrospective study.

BACKGROUND: Difficulties with prehospital intubations have encouraged the development of indirect laryngoscopy techniques, facilitating laryngeal visualization. Airtraq® is a relatively new single-use indirect laryngoscope. The Airtraq® has been evaluated in several prehospital mannequin intubation trials. However, prehospital clinical experience with the device is limited. METHODS: A retrospective medical chart review was performed for patients who underwent prehospital endotracheal intubation in the Stockholm County between January 2008 and December 2012. Both anaesthesiologists and nurse anaesthetists performed prehospital intubations during the study period. All Airtraq® intubations during this period were included in the analysis. The objective was to estimate the success rate of Airtraq® used in a prehospital setting. RESULTS: During the 5-year period (January 2008- December 2012), 2453 tracheal intubations were performed. Airtraq® was used in 28 cases (1%). The overall Airtraq® intubation success rate was 68%. Among patients with anticipated or unexpected difficult airway (23/28) the Airtraq® success rate was 61% (14/23). Among patients who underwent drug facilitated or rapid-sequence intubation protocols 4/5 (80%) were successfully intubated with Airtraq®. CONCLUSION: In conclusion, this retrospective study showed a higher Airtraq® success rate than previous prospective prehospital trials. However, compared to other prehospital direct and indirect intubation methods the Airtraq success rate is low. Further clinical trials are necessary to evaluate the role of Airtraq® in the prehospital airway management.