Role of emergency teleradiology in a mass motorcycle event: the experience of the 2021 International Six Days of Enduro (ISDE).

PURPOSE: Provision of healthcare support at mass gathering sporting events is of paramount importance for the success of the event. Many of such events, like motorsports, have been increasingly taking place in remote and austere environments. In these settings, the use of first-line diagnostic tools, such as point of care ultrasound and portable X-ray, could aid in definitive care on the field for patients with minor trauma while also ensuring fast access to the appropriate level of care for patients requiring hospitalization. METHODS: As part of the ISDE 2021 medical response plan, a field hospital equipped with portable digital X-ray and telemedicine was established. Data on patient admission, triage, treatments, diagnostics, and outcomes were collected for analysis. RESULTS: During the 6-day competition, 79 patients sought medical care at the field hospital, with traumatic injuries accounting for 77% of cases. Of these, 47 were athletes and 32 were non-athletes. The majority (91%) arrived spontaneously, while 9% were transported directly. Upon admission, 68 patients were triaged as non-urgent (code 3) and 11 as urgent (code 2). Of those admitted, 69 received treatment and were discharged at the field hospital, while 10 were transferred elsewhere. Notably, four patients had major trauma, two had isolated fractures, and one needed a CT scan after losing consciousness. Overall, 29 missions were conducted on the race field, including 13 primary transports to local hospitals and 6 to the field hospital. Primary transport was primarily due to major trauma. Among 31 patients who had radiological exams, 11 (35.5%) had traumatic injuries. Of these, 5 were treated with braces and casts and discharged without hospitalization, 3 were advised for post-event care, and 3 were hospitalized. In contrast, patients with negative X-rays received on-site treatment, with 7 able to continue competing. CONCLUSIONS: In summary, the successful implementation of portable X-ray machines and teleradiology at remote and austere high-risk sporting events holds great promise for enhancing on-site medical capabilities, allowing clinicians informed decisions, avoiding unnecessary hospitalization, and allowing athletes to continue with their competition. Provided that challenges related to cost, safety, connectivity, and power supply are effectively addressed.

Lung response to prone positioning in mechanically-ventilated patients with COVID-19.

BACKGROUND: Prone positioning improves survival in moderate-to-severe acute respiratory distress syndrome (ARDS) unrelated to the novel coronavirus disease (COVID-19). This benefit is probably mediated by a decrease in alveolar collapse and hyperinflation and a more homogeneous distribution of lung aeration, with fewer harms from mechanical ventilation. In this preliminary physiological study we aimed to verify whether prone positioning causes analogue changes in lung aeration in COVID-19. A positive result would support prone positioning even in this other population. METHODS: Fifteen mechanically-ventilated patients with COVID-19 underwent a lung computed tomography in the supine and prone position with a constant positive end-expiratory pressure (PEEP) within three days of endotracheal intubation. Using quantitative analysis, we measured the volume of the non-aerated, poorly-aerated, well-aerated, and over-aerated compartments and the gas-to-tissue ratio of the ten vertical levels of the lung. In addition, we expressed the heterogeneity of lung aeration with the standardized median absolute deviation of the ten vertical gas-to-tissue ratios, with lower values indicating less heterogeneity. RESULTS: By the time of the study, PEEP was 12 (10-14) cmH2O and the PaO2:FiO2 107 (84-173) mmHg in the supine position. With prone positioning, the volume of the non-aerated compartment decreased by 82 (26-147) ml, of the poorly-aerated compartment increased by 82 (53-174) ml, of the normally-aerated compartment did not significantly change, and of the over-aerated compartment decreased by 28 (11-186) ml. In eight (53%) patients, the volume of the over-aerated compartment decreased more than the volume of the non-aerated compartment. The gas-to-tissue ratio of the ten vertical levels of the lung decreased by 0.34 (0.25-0.49) ml/g per level in the supine position and by 0.03 (- 0.11 to 0.14) ml/g in the prone position (p < 0.001). The standardized median absolute deviation of the gas-to-tissue ratios of those ten levels decreased in all patients, from 0.55 (0.50-0.71) to 0.20 (0.14-0.27) (p < 0.001). CONCLUSIONS: In fifteen patients with COVID-19, prone positioning decreased alveolar collapse, hyperinflation, and homogenized lung aeration. A similar response has been observed in other ARDS, where prone positioning improves outcome. Therefore, our data provide a pathophysiological rationale to support prone positioning even in COVID-19.

Physical and psychological impairment in survivors of acute respiratory distress syndrome: a systematic review and meta-analysis.

BACKGROUND: Survivors of acute respiratory distress syndrome (ARDS) are at risk of long-term comorbidities. This systematic review and meta-analysis evaluated health-related quality of life (HRQoL), and physical and psychological impairments in ARDS survivors from 3 months to 5 yr follow-up after ICU discharge. METHODS: Systematic search of PubMed, AMED, BNI, and CINAHL databases from January 2000 to date. The primary outcome was HRQoL. Secondary outcomes included physical, pulmonary, and cognitive function, mental health, and return to work. A secondary analysis compared classical ARDS with severe acute respiratory syndrome coronavirus disease-2 (SARS-CoV-2) ARDS. RESULTS: Forty-eight papers met inclusion criteria including 11 693 patients; of those 85% (n=9992) had classical ARDS and 14% (n=1632) had SARS-CoV-2 ARDS. The 36-Item Short Form Health Survey (SF-36) physical component summary score mean (95% confidence interval [CI]) was 46 (41-50) at 3 months, 39 (36-41) at 6 months, and 40 (38-43) at 12 months. The SF-36 mental component summary mean score was 53 (48-57) at 3 months, 45 (40-50) at 6 months, and 44 (42-47) at 12 months. SF-36 values were lower than those found in the normal population up to 5 yr. The predictive distance walked in 6 min was 57% (45-69), 63% (56-69), and 66% (62-70) at 3, 6, and 12 months, respectively. Classical ARDS and SARS-CoV-2 ARDS showed no difference in HRQoL and physical function; however, patients with classical ARDS had higher incidence of anxiety and depression (P<0.001). CONCLUSION: ARDS survivors can experience reduced HRQoL and physical and mental health impairment. These symptoms might not recover completely up to 5 yr after ICU discharge. SYSTEMATIC REVIEW REGISTRATION: PROSPERO: CRD42021296506.

A Framework for Case-Based Learning in Prehospital Medicine: The London's Air Ambulance Experience.

Clinical governance is the framework around which health care organizations can maintain a higher standard of safety and care. One of the central aspects of clinical governance is continuous professional education, including case-based review and case-based learning. In this article, we present the case-based education process in use at London's Air Ambulance, a mature advanced prehospital system in London, UK. The case review process begins with an on-scene hot debrief, an informal process often involving other emergency services. This is usually followed by internal team feedback and debrief and patient follow-up. All cases are then reviewed over the next 24 to 48 hours by the duty prehospital consultant (attending) in the rapid review process. After this, certain cases are volunteered or selected for discussion in the twice weekly death and disability (D&D) meeting or the monthly dispatch meeting. A small subset of cases is highlighted through this process for full formal audit and presentation at the monthly clinical governance meetings based on their educational value. Another subset of cases involving a fatality is also discussed at the monthly clinical pathology correlation meeting with the input of local forensic pathologists. Organization of the process, structure of the meetings, and educational value are described in detail.

Return to Work After Coronavirus Disease 2019 Acute Respiratory Distress Syndrome and Intensive Care Admission: Prospective, Case Series at 6 Months From Hospital Discharge.

OBJECTIVES: Joblessness is common in survivors from critical care. Our aim was to describe rates of return to work versus unemployment following coronavirus disease 2019 acute respiratory distress syndrome requiring intensive care admission. DESIGN: Single-center, prospective case series. SETTING: Critical Care Follow-Up Clinic, Humanitas Clinical and Research Center-IRCCS, Rozzano, Italy. PATIENTS: One hundred and one consecutive laboratory-confirmed coronavirus disease 2019 patients were discharged from our hospital following an ICU stay between March 1, 2020, and June 30, 2020. Twenty-five died in the ICU. Seventy-six were discharged alive from hospital. Two patients refused participation, while three were unreachable. The remaining 71 were alive at 6 months and interviewed. INTERVENTIONS: Baseline and outcome healthcare data were extracted from the electronic patient records. Employment data were collected using a previously published structured interview instrument that included current and previous employment status, hours worked per week, and timing of return to work. Health-related quality of life status was assessed using the Italian EQ-5D-5L questionnaire. MEASUREMENTS AND MAIN RESULTS: Of the 71 interviewed patients, 45 (63%) were employed prior to coronavirus disease 2019, of which 40 (89%) of them worked full-time. Thirty-three (73%) of the previously employed survivors had returned to work by 6 months, 10 (22%) were unemployed, and 2 (5%) were newly retired. Among those who returned to work, 20 (85%) of them reported reduced effectiveness at work. Those who did not return to work were either still on sick leave or lost their job as a consequence of coronavirus disease 2019. Reported quality of life of survivors not returning to work was worse than of those returning to work. CONCLUSIONS: The majority of coronavirus disease 2019 survivors following ICU in our cohort had returned to work by 6 months of follow-up. However, most of them reported reduced work effectiveness. Prolonged sick leave and unemployment were common findings in those not returning.

Cognitive appraisals and team performance under stress: A simulation study.

OBJECTIVES: The present study explored how challenge and threat responses to stress relate to performance, anxiety, confidence, team identity and team characteristics (time spent in training and postgraduate experience) in a medical simulation-based team competition. METHODS: The study was conducted during a national simulation-based training event for residents, the SIMCUP Italia 2018. The SIMCUP is a simulation competition in which teams of four compete in simulated medical emergency scenarios. Cross-sectional data were collected prior to the 3 days of the competition. Subjects included 95 participants on 24 teams. Before the competition on each day, participants completed brief self-report measures that assessed demands and resources (which underpin challenge and threat responses to stress), cognitive and somatic anxiety, self-confidence and team identification. Participants also reported time (hours) spent practising as a team and years of postgraduate experience. A team of referees judged each scenario for performance and assigned a score. A linear mixed model using demands and resources was built to model performance. RESULTS: The data showed that both demands and resources have positive effects on performance (31 [11-50.3] [P < .01] and 54 [25-83.3] [P < .01] percentage points increase for unitary increases in demands and resources, respectively); however, this is balanced by a negative interaction between the two (demands * resources interaction coefficient = -10 [-16 to -4.2]). A high level of resources is associated with better performance until demands become very high. Cognitive and somatic anxieties were found to be correlated with demands (Pearson's r = .51 [P < .01] and Pearson's r = .48 [P < .01], respectively). Time spent training was associated with greater perceptions of resources (Pearson's r = .36 [P < .01]). CONCLUSIONS: We describe a model of challenge and threat that allows for the estimation of performance according to perceived demands and resources, and the interaction between the two. Higher levels of resources and lower demands were associated with better performance.

Wearable Proximity Sensors for Monitoring a Mass Casualty Incident Exercise: Feasibility Study.

BACKGROUND: Over the past several decades, naturally occurring and man-made mass casualty incidents (MCIs) have increased in frequency and number worldwide. To test the impact of such events on medical resources, simulations can provide a safe, controlled setting while replicating the chaotic environment typical of an actual disaster. A standardized method to collect and analyze data from mass casualty exercises is needed to assess preparedness and performance of the health care staff involved. OBJECTIVE: In this study, we aimed to assess the feasibility of using wearable proximity sensors to measure proximity events during an MCI simulation. In the first instance, our objective was to demonstrate how proximity sensors can collect spatial and temporal information about the interactions between medical staff and patients during an MCI exercise in a quasi-autonomous way. In addition, we assessed how the deployment of this technology could help improve future simulations by analyzing the flow of patients in the hospital. METHODS: Data were obtained and collected through the deployment of wearable proximity sensors during an MCI functional exercise. The scenario included 2 areas: the accident site and the Advanced Medical Post, and the exercise lasted 3 hours. A total of 238 participants were involved in the exercise and classified in categories according to their role: 14 medical doctors, 16 nurses, 134 victims, 47 Emergency Medical Services staff members, and 27 health care assistants and other hospital support staff. Each victim was assigned a score related to the severity of his/her injury. Each participant wore a proximity sensor, and in addition, 30 fixed devices were placed in the field hospital. RESULTS: The contact networks show a heterogeneous distribution of the cumulative time spent in proximity by the participants. We obtained contact matrices based on the cumulative time spent in proximity between the victims and rescuers. Our results showed that the time spent in proximity by the health care teams with the victims is related to the severity of the patient's injury. The analysis of patients' flow showed that the presence of patients in the rooms of the hospital is consistent with the triage code and diagnosis, and no obvious bottlenecks were found. CONCLUSIONS: Our study shows the feasibility of the use of wearable sensors for tracking close contacts among individuals during an MCI simulation. It represents, to our knowledge, the first example of unsupervised data collection-ie, without the need for the involvement of observers, which could compromise the realism of the exercise-of face-to-face contacts during an MCI exercise. Moreover, by permitting detailed data collection about the simulation, such as data related to the flow of patients in the hospital, such deployment provides highly relevant input for the improvement of MCI resource allocation and management.

Simulation-based medical training for paediatric residents in Italy: a nationwide survey.

BACKGROUND: A prompt start to an appropriate neonatal and paediatric resuscitation is critical to reduce mortality and morbidity. However, residents are rarely exposed to real emergency situations. Simulation-based medical training (SBMT) offers the opportunity to improve medical and non-technical skills in a controlled setting. This survey describes the availability and current use of SBMT by paediatric residents in Italy with the purpose of understanding residents' expectations regarding neonatal and paediatric emergency training, and identifying gaps and potential areas for future implementation. METHODS: A survey was developed and distributed to Italian residents. SBMT was defined as any kind of training with a mannequin in a contextualised clinically realistic scenario. RESULTS: The response rate was 14.4%, covering the 71% of Italian paediatric residency programmes. Among them, 88% stated that Out of the 274 residents, 88% stated that they received less than 5 h of SBMT during the past training year, with 66% not participating in any kind of simulation activity. In 62% of the programmes no simulation training facility was available to residents. Among those who received SBMT, 46% used it for procedures and skills, 30% for clinical scenarios, but only 24% of them reported a regular use for debriefing. Of the overall respondents, 93% were interested in receiving SBMT to improve decision-making abilities in complex medical situations, to improve technical/procedural skills, and to improve overall competency in neonatal and paediatric emergencies, including non-technical skills. The main barriers to the implementation of SBMT programmes in Italian paediatric residencies were: the lack of experts (57%), the lack of support from the school director (56%), the lack of organisation in planning simulation centre courses (42%) and the lack of teaching materials (42%). CONCLUSIONS: This survey shows the scarce use of SBMT during paediatric training programmes in Italy and points out the main limitations to its diffusion. This is a call to action to develop organised SBMT during paediatric residency programs, to train qualified personnel, and to improve the quality of education and care in this field.

Professionalization of anesthesiologists and critical care specialists in humanitarian action: a nationwide poll among italian residents.

BACKGROUND: Over the last decades, humanitarian crises have seen a sharp upward trend. Regrettably, physicians involved in humanitarian action have often demonstrated incomplete preparation for these compelling events which have proved to be quite different from their daily work. Responders to these crises have included an unpredictable mix of beginner-level, mid-level, and expert-level providers. The quality of care has varied considerably. The international humanitarian community, in responding to international calls for improved accountability, transparency, coordination, and a registry of professionalized international responders, has recently launched a call for further professionalization within the humanitarian assistance sector, especially among academic-affiliated education and training programs. As anesthetists have been involved traditionally in medical relief operations, and recent disasters have seen a massive engagement of young physicians, the authors conducted, as a first step, a poll among residents in Anesthesia and Critical Care Medicine in Italy to evaluate their interest in participating in competency-based humanitarian assistance education and in training incorporated early in residencies. METHODS: The Directors of all the 39 accredited anesthesia/critical care training programs in Italy were contacted and asked to submit a questionnaire to their residents regarding the objectives of the poll study. After acceptance to participate, residents were enrolled and asked to complete a web-based poll. RESULTS: A total of 29 (74%) of the initial training programs participated in the poll. Out of the 1,362 questionnaires mailed to residents, 924 (68%) were fully completed and returned. Only 63(6.8%) of the respondents voiced prior participation in humanitarian missions, but up to 690 (74.7%) stated they were interested in participating in future humanitarian deployments during their residency that carried over into their professional careers. Countrywide, 896 (97%) favored prior preparation for residents before participating in humanitarian missions, while the need for a specific, formal, professionalization process of the entire humanitarian aid sector was supported by 889 (96.2%). CONCLUSIONS: In Italy, the majority of anesthesia/critical care residents, through a formal poll study, affirmed interest in participating in humanitarian assistance missions and believe that further professionalization within the humanitarian aid sector is required. These results have implications for residency training programs worldwide.

An unusual case of marathon-related exercise associated collapse: Case report and some considerations for medical care at endurance mass participation events.

This article presents a unique exercise-associated collapse case during a marathon, highlighting the significance of evidence-based management for athletes on field. The patient, a 61-year-old experienced runner, collapsed near the finish line of the Milano City Marathon. He was aided immediately with CPR and AED. After excluding, through validated algorithms, common and life-threatening causes of collapse, the patient was transferred to hospital. The patient underwent diagnostic procedures, including CT and MRI scans, and hormonal tests that revealed pituitary hemorrhage and underlying coronary artery disease. Follow-up assessments and personalized care were instrumental in the patient's successful recovery and safe return to exercise.

State of the art of trauma teams in Italy: A nationwide study.

Trauma teams play a vital role in providing prompt and specialized care to trauma patients. This study aims to provide a comprehensive description of the presence and organization of trauma teams in Italy. A nationwide cross-sectional epidemiological study was conducted between July and October 2022, involving interviews with 137 designated trauma centers. Centers were stratified based on level: higher specialized trauma centers (CTS), intermediate level trauma centers (CTZ + N) and district general hospital with trauma capacity (CTZ). A standardized structured interview questionnaire was used to gather information on hospital characteristics, trauma team prevalence, activation pathways, structure, components, leadership, education, and governance. Descriptive statistics were used for analysis. Results showed that 53 % of the centers had a formally defined trauma team, with higher percentages in CTS (73 %) compared to CTZ + N (49 %) and CTZ (39 %). The trauma team activation pathway varied among centers, with pre-alerts predominantly received from emergency medical services. The study also highlighted the lack of formally defined massive transfusion protocols in many centers. The composition of trauma teams typically included airway and procedure doctors, nurses, and healthcare assistants. Trauma team leadership was predetermined in 59 % of the centers, with anesthesiologists/intensive care physicians often assuming this role. The study revealed gaps in trauma team education and governance, with a lack of specific training for trauma team leaders and low utilization of simulation-based training. These findings emphasize the need for improvements in trauma management education, governance, and the formalization of trauma teams. This study provides valuable insights that can guide discussions and interventions aimed at enhancing trauma care at both local and national levels in Italy.

Health related quality of life, physical function, and cognitive performance in mechanically ventilated COVID-19 patients: A long term follow-up study.

BACKGROUND: Survivors of severe COVID-19 related respiratory failure may experience durable functional impairments. We aimed at investigating health-related quality of life (HR-QoL), physical functioning, fatigue, and cognitive outcomes in COVID-19 patients who received invasive mechanical ventilation (IMV). METHODS: Case-series, prospective, observational cohort study at 18 months from hospital discharge. Patients referring to the Intensive Care Unit (ICU) of Humanitas Research Hospital (Milan, Italy) were recruited if they needed IMV due to COVID-19 related respiratory failure. After 18 months, these patients underwent the 6-min walking test (6MWT), the Italian version of the 5-level EQ-5D questionnaire (EQ-5D-5L), the Functional Assessment of Chronic Illness Therapy - Fatigue questionnaire (FACIT-F), the Trail Making Test-B (TMT-B) and the Montreal Cognitive Assessment-BLIND test (MoCA-BLIND). RESULTS: 105 patients were studied. The population's age was 60 ± 10 years on average, with a median Frailty Scale of 2 (Hodgson et al., 2017; Carenzo et al., 2021a [2,3]). EQ-VAS was 80 [70-90] out of 100, walked distance was 406 [331-465] meters, corresponding to about 74 ± 19,1% of the predicted value. FACIT-F score was 43 [36-49] out of 52, and MoCa-BLIND score was 19 (DeSalvo et al., 2006; von Elm et al., 2008; Herdman et al., 2011; Scalone et al., 2015 [16-20]) out of 22. The median TMT-B time was 90 [62-120] seconds. We found a possible age and gender specific effect on HR-QoL and fatigue. CONCLUSIONS: After 18 months from ICU discharge, survivors of severe COVID-19 respiratory failure experience a moderate reduction in HR-QoL, and a severe reduction in physical functioning. Fatigue prevalence is higher in younger patients and in females. Finally, cognitive impairment was present at a low frequency.

Humanitarian Aeromedical Retrieval using a Long-Range Commercial Aircraft: A Field Report.

This field report presents the planning and execution of a large-scale aeromedical refugee retrieval operation amid the on-going Russia-Ukraine crisis. The retrieval was coordinated by the Italian Department of Civil Protection and led by the Centrale Remota Operazioni Soccorso Sanitario (CROSS), a governmental facility overseeing medical assistance. An Airbus A320 was chosen for its capacity of 165 passengers, with one emergency stretcher maintaining maximum seating. The aircraft was equipped with an Advanced Life Support kit, and specific considerations for medical equipment compliance were made. Special cases, including patients with on-going chemotherapy and end-stage kidney disease, underwent fit-to-fly screening. The boarding process in Lublin, Poland involved triage and arrangements for passengers with gastroenteric symptoms. Notably, 22 passengers with recent episodes of illness were isolated. The successful operation, demonstrating the viability of evacuating vulnerable individuals via commercial airlines, underscores the importance of precise planning and coordination in crisis situations.

The anesthesiologist's perspective on emergency aortic surgery: Preoperative optimization, intraoperative management, and postoperative surveillance.

The management of emergencies related to the aorta requires a multidisciplinary approach involving various health care professionals. Despite technological advancements in treatment methods, the risks and mortality rates associated with surgery remain high. In the emergency department, definitive diagnosis is usually obtained through computed tomography angiography, and management focuses on controlling blood pressure and treating symptoms to prevent further deterioration. Preoperative resuscitation is the main focus, followed by intraoperative management aimed at stabilizing the patient's hemodynamics, controlling bleeding, and protecting vital organs. After the operation, factors such as organ protection, transfusion management, pain control, and overall patient care must be taken into account. Endovascular techniques are becoming more common in surgical treatment, but they also present new challenges in terms of complications and outcomes. It is recommended that patients with suspected ruptured abdominal aortic aneurysms be transferred to facilities with both open and endovascular treatment options and a track record of successful outcomes to ensure the best patient care and long-term results. To achieve optimal patient outcomes, close collaboration and regular case discussions between health care professionals are necessary, as well as participation in educational programs to promote a culture of teamwork and continuous improvement.

A Region-Wide All-Hazard Training Program for Prehospital Mass Casualty Incident Management: A Real-World Case Study.

OBJECTIVE: We report the development, implementation, and results of a sustainable region-wide mass-casualty management prehospital training program implemented by the Regione Lombardia emergency medical services (EMS) agency AREU in Italy. METHODS: The educational program learning objectives are: (1) command and control, communications, and resource management; (2) mass casualty triage and the START triage protocol; (3) on-scene management; (4) Regione Lombardia and AREU Mass Casualty standard operating procedures; and (5) inter-agency communications and relations. For each course edition data on participants' summative assessment, participants' feedback and costs were collected. RESULTS: Between June 26, 2013, and December 31, 2020, a total of 84 editions of the provider training event were delivered, training an overall 1329 prehospital providers; 1239 (93%) passed the summative assessment and were qualified as being operationally "ready." Regarding participant feedback, the overall program was rated 4.4 ± 0.7 out of 5. The overall cost of running the provider program during the study period was €321 510 (circa US $382 000). The average cost per edition was €3828 and €242 per participant. CONCLUSIONS: We have described a simple yet interactive simulation and blended-learning approach, which has yielded good pass rates, good participant satisfaction, and contained costs to systematically train emergency medical service personnel.

Multicentre observational study on practice of prehospital management of hypotensive trauma patients: the SPITFIRE study protocol.

INTRODUCTION: Major haemorrhage after injury is the leading cause of preventable death for trauma patients. Recent advancements in trauma care suggest damage control resuscitation (DCR) should start in the prehospital phase following major trauma. In Italy, Helicopter Emergency Medical Services (HEMS) assist the most complex injuries and deliver the most advanced interventions including DCR. The effect size of DCR delivered prehospitally on survival remains however unclear. METHODS AND ANALYSIS: This is an investigator-initiated, large, national, prospective, observational cohort study aiming to recruit >500 patients in haemorrhagic shock after major trauma. We aim at describing the current practice of hypotensive trauma management as well as propose the creation of a national registry of patients with haemorrhagic shock. PRIMARY OBJECTIVE: the exploration of the effect size of the variation in clinical practice on the mortality of hypotensive trauma patients. The primary outcome measure will be 24 hours, 7-day and 30-day mortality. Secondary outcomes include: association of prehospital factors and survival from injury to hospital admission, hospital length of stay, prehospital and in-hospital complications, hospital outcomes; use of prehospital ultrasound; association of prehospital factors and volume of first 24-hours blood product administration and evaluation of the prevalence of use, appropriateness, haemodynamic, metabolic and effects on mortality of prehospital blood transfusions. INCLUSION CRITERIA: age >18 years, traumatic injury attended by a HEMS team including a physician, a systolic blood pressure <90 mm Hg or weak/absent radial pulse and a confirmed or clinically likely diagnosis of major haemorrhage. Prehospital and in-hospital variables will be collected to include key times, clinical findings, examinations and interventions. Patients will be followed-up until day 30 from admission. The Glasgow Outcome Scale Extended will be collected at 30 days from admission. ETHICS AND DISSEMINATION: The study has been approved by the Ethics committee 'Comitato Etico di Area Vasta Emilia Centro'. Data will be disseminated to the scientific community by abstracts submitted to international conferences and by original articles submitted to peer-reviewed journals. TRIAL REGISTRATION NUMBER: NCT04760977.