Outcomes of patients suffering unwitnessed hypothermic cardiac arrest rewarmed with extracorporeal life support: A systematic review.

Prolonged cardiac arrest (CA) may lead to neurologic deficit in survivors. Good outcome is especially rare when CA was unwitnessed. However, accidental hypothermia is a very specific cause of CA. Our goal was to describe the outcomes of patients who suffered from unwitnessed hypothermic cardiac arrest (UHCA) supported with Extracorporeal Life Support (ECLS). We included consecutive patients' cohorts identified by systematic literature review concerning patients suffering from UHCA and rewarmed with ECLS. Patients were divided into four subgroups regarding the mechanism of cooling, namely: air exposure; immersion; submersion; and avalanche. A statistical analysis was performed in order to identify the clinical parameters associated with good outcome (survival and absence of neurologic impairment). A total of 221 patients were included into the study. The overall survival rate was 27%. Most of the survivors (83%), had no neurologic deficit. Asystole was the presenting CA rhythm in 48% survivors, of which 79% survived with good neurologic outcome. Variables associated with survival included the following: female gender (P < .001); low core temperature (P = .005); non-asphyxia-related mechanism of cooling (P < .001); pulseless electrical activity as an initial rhythm (P < .001); high blood pH (P < .001); low lactate levels (P = .003); low serum potassium concentration (P < .001); and short resuscitation duration (P = .004). Severely hypothermic patients with unwitnessed CA may survive with good neurologic outcome, including those presenting as asystole. The initial blood pH, potassium, and lactate concentration may help predict outcome in hypothermic CA.

Telephone triage performed by nurses reduces non-urgent ambulance missions: A prospective observational pilot study in Finland.

BACKGROUND: The increased workload in emergency medical services (EMS) is a global phenomenon in welfare states. It has been suggested that telephone triage by nurses may reduce the increasing use of EMS services, by directing patient flow to appropriate care. This study aimed to investigate whether, after an emergency medical communication centre (EMCC) provider assessed risk, a telephone nurse could assess the patient's needs and guide patients to social and health care services in non-urgent cases. METHODS: This prospective observational study was performed in the Kainuu Hospital District in northern Finland from March to April 2018. All EMS requests classified as non-urgent by the EMCC were transferred to a telephone triage nurse. Subsequent patient guidance was recorded. The International Classifications of Primary Care categories were recorded. RESULTS: We studied phone calls of 700 patients with non-urgent needs. Of these, the nurse transferred 63.7% to EMS and 17.3% were guided to other social and health care services. Nineteen per cent of the calls were handled over the phone by the nurse, who provided health advice and instructions. The most common needs for care were general and unspecified symptoms, musculoskeletal symptoms, mental health problems and substance abuse. CONCLUSION: By providing telephone counseling, care instructions and patient guidance to other social and health services than EMS, the telephone triage reduced non-urgent EMS missions by one third. The results imply that telephone triage could be a viable model for managing non-urgent missions. Patient safety issues should be monitored when developing new service concepts.

Development and internal validation of an algorithm for estimating mortality in patients encountered by physician-staffed helicopter emergency medical services.

BACKGROUND: Severity of illness scoring systems are used in intensive care units to enable the calculation of adjusted outcomes for audit and benchmarking purposes. Similar tools are lacking for pre-hospital emergency medicine. Therefore, using a national helicopter emergency medical services database, we developed and internally validated a mortality prediction algorithm. METHODS: We conducted a multicentre retrospective observational register-based cohort study based on the patients treated by five physician-staffed Finnish helicopter emergency medical service units between 2012 and 2019. Only patients aged 16 and over treated by physician-staffed units were included. We analysed the relationship between 30-day mortality and physiological, patient-related and circumstantial variables. The data were imputed using multiple imputations employing chained equations. We used multivariate logistic regression to estimate the variable effects and performed derivation of multiple multivariable models with different combinations of variables. The models were combined into an algorithm to allow a risk estimation tool that accounts for missing variables. Internal validation was assessed by calculating the optimism of each performance estimate using the von Hippel method with four imputed sets. RESULTS: After exclusions, 30 186 patients were included in the analysis. 8611 (29%) patients died within the first 30 days after the incident. Eleven predictor variables (systolic blood pressure, heart rate, oxygen saturation, Glasgow Coma Scale, sex, age, emergency medical services vehicle type [helicopter vs ground unit], whether the mission was located in a medical facility or nursing home, cardiac rhythm [asystole, pulseless electrical activity, ventricular fibrillation, ventricular tachycardia vs others], time from emergency call to physician arrival and patient category) were included. Adjusted for optimism after internal validation, the algorithm had an area under the receiver operating characteristic curve of 0.921 (95% CI 0.918 to 0.924), Brier score of 0.097, calibration intercept of 0.000 (95% CI -0.040 to 0.040) and slope of 1.000 (95% CI 0.977 to 1.023). CONCLUSIONS: Based on 11 demographic, mission-specific, and physiologic variables, we developed and internally validated a novel severity of illness algorithm for use with patients encountered by physician-staffed helicopter emergency medical services, which may help in future quality improvement.

Defibrillation and the quality of layperson cardiopulmonary resuscitation-dispatcher assistance or training?

AIMS OF THE STUDY: To examine whether basic life support-defibrillation (BLS-D) training of laypersons enhances the speed of defibrillation and the quality of cardiopulmonary resuscitation (CPR) during a simulated ventricular fibrillation scenario compared with a situation where the care provider has no previous BLS-D training but receives dispatcher assistance with the use of an automated external defibrillator (AED) and the performance of CPR. METHODS: Fifty-two military conscripts of the Finnish Defence Forces who without previous medical education had been tested in a simulated cardiac arrest scenario with dispatcher assistance and thereafter received a 4-h BLS-D training. Six months later they were randomly divided to form teams of two and again tested in a similar scenario but without dispatcher assistance. The time interval from collapse to first shock, hands-off time and the quality of CPR were compared between the two tests. RESULTS: The quality of mouth-to-mouth ventilation was better after training, but there was only a minor improvement in the quality of compressions and the speed of defibrillation. CONCLUSIONS: Training improved the quality of mouth-to-mouth ventilation performed by laypersons but had only a minor effect on defibrillation and the quality of compressions.

AED use in a passenger during a long-haul flight: repeated defibrillation with a successful outcome.

INTRODUCTION: Sudden cardiac arrest is one of the leading causes of death, and early defibrillation of ventricular fibrillation (VF) is the single most important intervention for improving survival. The automated external defibrillator (AED) and the concept of public access defibrillation provide a solution to shorten defibrillation delays. Commercial aircraft create a unique environment for the use of the AED since an emergency medical service system (EMS) response is not available. We review published studies on this subject and describe the case of a passenger who developed VF during an intercontinental flight and was successfully resuscitated despite recurrent episodes of VF. CASE REPORT: A 60-yr-old man developed VF during a flight from Tokyo to Helsinki. VF frequently recurred and shocks were delivered 21 times altogether. The aircraft was diverted to the city of Kuopio. When the local EMS crew encountered the patient 3 h after the onset of the cardiac arrest, the rhythm again converted to VF and three further shocks were delivered. The patient recovered, and 3 wk later he was transported to his home country, fully alert. DISCUSSION: There are three large studies reporting placing AEDs on commercial aircraft. No harm for co-passengers or malfunctions were reported. Survival rates have been higher than those obtained by well-performing EMS. According to previous studies, placing AEDs on commercial aircraft is also cost effective. The absence of a suitable diversion destination should not influence the rescuers' decision to attempt CPR on board.

Prehospital on-scene anaesthetist treating severe traumatic brain injury patients is associated with lower mortality and better neurological outcome.

BACKGROUND: Patients with isolated traumatic brain injury (TBI) are likely to benefit from effective prehospital care to prevent secondary brain injury. Only a few studies have focused on the impact of advanced interventions in TBI patients by prehospital physicians. The primary end-point of this study was to assess the possible effect of an on-scene anaesthetist on mortality of TBI patients. A secondary end-point was the neurological outcome of these patients. METHODS: Patients with severe TBI (defined as a head injury resulting in a Glasgow Coma Score of ≤8) from 2005 to 2010 and 2012-2015 in two study locations were determined. Isolated TBI patients transported directly from the accident scene to the university hospital were included. A modified six-month Glasgow Outcome Score (GOS) was defined as death, unfavourable outcome (GOS 2-3) and favourable outcome (GOS 4-5) and used to assess the neurological outcomes. Binary logistic regression analysis was used to predict mortality and good neurological outcome. The following prognostic variables for TBI were available in the prehospital setting: age, on-scene GCS, hypoxia and hypotension. As per the hypothesis that treatment provided by an on-scene anaesthetist would be beneficial to TBI outcomes, physician was added as a potential predictive factor with regard to the prognosis. RESULTS: The mortality data for 651 patients and neurological outcome data for 634 patients were available for primary and secondary analysis. In the primary analysis higher age (OR 1.06 CI 1.05-1.07), lower on-scene GCS (OR 0.85 CI 0.79-0.92) and the unavailability of an on-scene anaesthetist (OR 1.89 CI 1.20-2.94) were associated with higher mortality together with hypotension (OR 3.92 CI 1.08-14.23). In the secondary analysis lower age (OR 0.95 CI 0.94-0.96), a higher on-scene GCS (OR 1.21 CI 1.20-1.30) and the presence of an on-scene anaesthetist (OR 1.75 CI 1.09-2.80) were demonstrated to be associated with good patient outcomes while hypotension (OR 0.19 CI 0.04-0.82) was associated with poor outcome. CONCLUSION: Prehospital on-scene anaesthetist treating severe TBI patients is associated with lower mortality and better neurological outcome.

Prehospital induction of therapeutic hypothermia during CPR: a pilot study.

AIM OF THE STUDY: We studied induction of therapeutic hypothermia during prehospital resuscitation from cardiac arrest using an infusion of ice-cold Ringer's solution in five adult patients. MATERIAL AND METHODS: Paramedics infused +4 degrees C Ringer's solution into the antecubital vein of the patients with a maximum rate of 33 ml/min to a target temperature of 33.0 degrees C. RESULTS: The mean infused volume of cold fluid was 14.0 ml/kg, which resulted in a mean decrease of 2.5 degrees C in nasopharyngeal temperature. The decrease in temperature continued after the cessation of infusion in two patients, causing suboptimal temperatures below 32 degrees C. CONCLUSION: We conclude that the infusion of small volumes of ice-cold Ringer's solution during resuscitation results in an effective decrease in nasopharyngeal temperature. Caution should be taken to avoid temperatures below the range of mild therapeutic hypothermia.

Induction of therapeutic hypothermia during prehospital CPR using ice-cold intravenous fluid.

AIM OF THE STUDY: Primarily, to investigate induction of therapeutic hypothermia during prehospital cardiopulmonary resuscitation (CPR) using ice-cold intravenous fluids. Effects on return of spontaneous circulation (ROSC), rate of rearrest, temperature and haemodynamics were assessed. Additionally, the outcome was followed until discharge from hospital. MATERIALS AND METHODS: Seventeen adult prehospital patients without obvious external causes for cardiac arrest were included. During CPR and after ROSC, paramedics infused +4 degrees C Ringer's acetate aiming at a target temperature of 33 degrees C. RESULTS: ROSC was achieved in 13 patients, 11 of whom were admitted to hospital. Their mean initial nasopharyngeal temperature was 35.17+/-0.57 degrees C (95% CI), and their temperature on hospital admission was 33.83+/-0.77 degrees C (-1.34 degrees C, p<0.001). The mean infused volume of cold fluid was 1571+/-517 ml. The rate of rearrest after ROSC was not increased compared to previous reports. Hypotension was observed in five patients. Of the 17 patients, 1 survived to hospital discharge. CONCLUSION: Induction of therapeutic hypothermia during prehospital CPR and after ROSC using ice-cold Ringer's solution effectively decreased nasopharyngeal temperature. The treatment was easily carried out and well tolerated.

Pulseless electrical activity and unsuccessful out-of-hospital resuscitation: what is the cause of death?

AIMS: To study the cause of deaths after witnessed cardiac arrest followed by pulseless electrical activity and unsuccessful of out-of-hospital resuscitation; and to detect any differences between causes of death determined at autopsy and those inferred from clinical history. METHODS: In this prospective observational study, data were collected from 91 individuals treated by the emergency medical services in three urban communities in southern Finland. RESULTS: Cause of death was determined at autopsy in 59 cases and without autopsy in 32 cases. There were significantly more diagnoses of acute myocardial infarction and fewer of pulmonary embolism and aortic dissection and rupture among cases without autopsy compared with those followed by autopsy. CONCLUSION: In unsuccessful resuscitation from out-of-hospital cardiac arrest with pulseless electrical activity as initial rhythm, an autopsy should be performed to determine the correct cause of death.

Does the prehospital National Early Warning Score predict the short-term mortality of unselected emergency patients?

OBJECTIVES: The prehospital research field has focused on studying patient survival in cardiac arrest, as well as acute coronary syndrome, stroke, and trauma. There is little known about the overall short-term mortality and its predictability in unselected prehospital patients. This study examines whether a prehospital National Early Warning Score (NEWS) predicts 1-day and 30-day mortalities. METHODS: Data from all emergency medical service (EMS) situations were coupled to the mortality data obtained from the Causes of Death Registry during a six-month period in Northern Finland. NEWS values were calculated from first clinical parameters obtained on the scene and patients were categorized to the low, medium and high-risk groups accordingly. Sensitivities, specificities, positive predictive values (PPVs), negative predictive values (NPVs), and likelihood ratios (PLRs and NLRs) were calculated for 1-day and 30-day mortalities at the cut-off risks. RESULTS: A total of 12,426 EMS calls were included in the study. The overall 1-day and 30-day mortalities were 1.5 and 4.3%, respectively. The 1-day mortality rate for NEWS values ≤12 was lower than 7% and for values ≥13 higher than 20%. The high-risk NEWS group had sensitivities for 1-day and 30-day mortalities 0.801 (CI 0.74-0.86) and 0.42 (CI 0.38-0.47), respectively. CONCLUSION: In prehospital environment, the high risk NEWS category was associated with 1-day mortality well above that of the medium and low risk NEWS categories. This effect was not as noticeable for 30-day mortality. The prehospital NEWS may be useful tool for recognising patients at early risk of death, allowing earlier interventions and responds to these patients.

Factors determining level of hospital care and its association with outcome after resuscitation from pre-hospital pulseless electrical activity.

BACKGROUND: Patients resuscitated from out-of-hospital cardiac arrest (OHCA) with pulseless electrical activity (PEA) as initial cardiac rhythm are not always treated in intensive care units (ICUs): some are admitted to high dependency units with various level of care, others to ordinary wards. Aim of this study was to describe the factors determining level of hospital care after OHCA with PEA, post-resuscitation care and survival. METHODS: Adult OHCA patients with PEA (n = 221), who were resuscitated in southern Finland between 2010 and 2013 were included, provided patient survived to hospital admission. The patients were divided into four groups according to the level of hospital care provided: ordinary ward and Level 1-3 ICUs. Differences in patient characteristics, post-resuscitation care and survival were compared between the groups. RESULTS: Most patients (62.4%) were treated at Level 2 ICUs. Longer time to ROSC and advanced age decreased admission rate to Level 2 or 3 post-resuscitation care, whereas good pre-arrest CPC (1-2) increased the admission rate to Level 2/3 ICUs independently. Treatment with targeted temperature management (TTM) (4.1%) or early coronary angiography (3.2%) were very rare. Prognostic decisions were made earlier in the lower treatment intensity groups (p < 0.01). One-year survival rate was 24.0, 17.1% survived with good neurological outcome. Neurological outcome was better with more intensive care. After adjustment, level of care was not independent predictor for outcome: only return of spontaneous circulation (ROSC) time, cardiac arrest cause and pre-arrest performance affected independently to 1-year survival, age and ROSC for neurologic outcome. CONCLUSIONS: PEA are usually admitted to Level 2 ICUs for post-resuscitation care in the capital area of Finland. Age, ROSC and pre-arrest CPC were independent predictors for level of post-resuscitation care. TTM and early CAG were rare and provided only for Level 3 ICU patients. Prognostication was earlier in lower level of care units. Good neurologic survival was more common with more intensive level of post-resuscitation care. After adjustment, level of care was not independent predictor for survival or neurologic outcome: only ROSC, cardiac arrest cause and pre-arrest performance predicted 1-year survival; age and ROSC neurologic outcome.

Hypothermia outcome prediction after extracorporeal life support for hypothermic cardiac arrest patients: The HOPE score.

AIMS: Currently, the decision to initiate extracorporeal life support for patients who suffer cardiac arrest due to accidental hypothermia is essentially based on serum potassium level. Our goal was to build a prediction score in order to determine the probability of survival following rewarming of hypothermic arrested patients based on several covariates available at admission. METHODS: We included consecutive hypothermic arrested patients who underwent rewarming with extracorporeal life support. The sample comprised 237 patients identified through the literature from 18 studies, and 49 additional patients obtained from hospital data collection. We considered nine potential predictors of survival: age; sex; core temperature; serum potassium level; mechanism of hypothermia; cardiac rhythm at admission; witnessed cardiac arrest, rewarming method and cardiopulmonary resuscitation duration prior to the initiation of extracorporeal life support. The primary outcome parameter was survival to hospital discharge. RESULTS: Overall, 106 of the 286 included patients survived (37%; 95% CI: 32-43%), most (84%) with a good neurological outcome. The final score included the following variables: age, sex, core temperature at admission, serum potassium level, mechanism of cooling, and cardiopulmonary resuscitation duration. The corresponding area under the receiver operating characteristic curve was 0.895 (95% CI: 0.859-0.931) compared to 0.774 (95% CI: 0.720-0.828) when based on serum potassium level alone. CONCLUSIONS: In this large retrospective study we found that our score was superior to dichotomous triage based on serum potassium level in assessing which hypothermic patients in cardiac arrest would benefit from extracorporeal life support. External validation of our findings is required.

Presumed futility in paramedic-treated out-of-hospital cardiac arrest: an Utstein style analysis in Tampere, Finland.

AIM: To report prospectively the outcome from prehospital cardiac arrest according to the Utstein template in the city of Tampere, Finland, with special reference to those patients in whom resuscitation was not attempted. MATERIALS AND METHODS: In Tampere (population 203,000), a two-tiered emergency medical service (EMS) system provides first response and basic life support (BLS), supported by advanced life support (ALS) units staffed with nurse-paramedics. We analysed all out-of-hospital cardiac arrests considered for resuscitation during a 12-month period. RESULTS: Of 191 patients with prehospital cardiac arrest, resuscitation was not attempted in 98 patients (51%). Reasons to withhold from resuscitation were estimated futility (97 cases) and a do-not-attempt-resuscitation order (1). Sixty percent of the patients with no resuscitation had secondary signs of death, 97% had asystole as the initial cardiac rhythm and 98% had suffered an unwitnessed cardiac arrest. Resuscitation was successful in 45 of the remaining 93 patients with attempted resuscitation. Twelve patients were discharged (overall survival rate 13%), nine of them with a CPC score of 1 or 2. Fifteen patients were treated with therapeutic hypothermia. Of the bystander-witnessed cardiac arrests with VF as initial rhythm, 29% survived. CONCLUSIONS: The Tampere EMS system initiated resuscitation less frequently than reported from other EMS systems, but the reasons to withhold resuscitation seemed justified. The overall and Utstein's 'golden standard' survival rates were comparable with previous reports.

Physician-staffed helicopter emergency medical service has a beneficial impact on the incidence of prehospital hypoxia and secured airways on patients with severe traumatic brain injury.

BACKGROUND: After traumatic brain injury (TBI), hypotension, hypoxia and hypercapnia have been shown to result in secondary brain injury that can lead to increased mortality and disability. Effective prehospital assessment and treatment by emergency medical service (EMS) is considered essential for favourable outcome. The aim of this study was to evaluate the effect of a physician-staffed helicopter emergency medical service (HEMS) in the treatment of TBI patients. METHODS: This was a retrospective cohort study. Prehospital data from two periods were collected: before (EMS group) and after (HEMS group) the implementation of a physician-staffed HEMS. Unconscious prehospital patients due to severe TBI were included in the study. Unconsciousness was defined as a Glasgow coma scale (GCS) score ≤ 8 and was documented either on-scene, during transportation or by an on-call neurosurgeon on hospital admission. Modified Glasgow Outcome Score (GOS) was used for assessment of six-month neurological outcome and good neurological outcome was defined as GOS 4-5. RESULTS: Data from 181 patients in the EMS group and 85 patients in the HEMS group were available for neurological outcome analyses. The baseline characteristics and the first recorded vital signs of the two cohorts were similar. Good neurological outcome was more frequent in the HEMS group; 42% of the HEMS managed patients and 28% (p = 0.022) of the EMS managed patients had a good neurological recovery. The airway was more frequently secured in the HEMS group (p < 0.001). On arrival at the emergency department, the patients in the HEMS group were less often hypoxic (p = 0.024). In univariate analysis HEMS period, lower age and secured airway were associated with good neurological outcome. CONCLUSION: The introduction of a physician-staffed HEMS unit resulted in decreased incidence of prehospital hypoxia and increased the number of secured airways. This may have contributed to the observed improved neurological outcome during the HEMS period. TRIAL REGISTRATION: ClinicalTrials.gov IDNCT02659046. Registered January 15th, 2016.

Influence of medical direction on the management of prehospital myocardial infarction.

Prehospital management of myocardial infarction was evaluated in two differently structured Emergency Medical Service (EMS) systems in Southern Finland: a physician directed EMS with on-site physician involvement (physician EMS) and an EMS without operational physician involvement with paramedics only (non-physician EMS). The management of 641 consecutive acute ST-elevation myocardial infarction (STEMI) patients between 1997 and 1999 (263 patients in the physician EMS group and 378 patients in non-physician EMS group) were studied. Patients treated in the physician EMS received all necessary medical care including thrombolytic therapy at the scene whereas patients in the non-physician EMS were transported to hospital for definitive treatment after initial care. There were no differences in the demographics of the patients. The delays from onset of pain to initiation of thrombolysis were shorter in the physician EMS-group (124+/-101 min (25-723) versus 196+/-150 min (12-835), p<0.001). In 2% of the patients in the physician EMS group the pain to therapy-time was unknown compared to 27% in the non-physician EMS group (p<0.001). Fifty-two patients (20%) in the physician EMS received thrombolytic therapy after cardiopulmonary resuscitation compared to two patients in the non-physician EMS (p<0.001). Of the resuscitated patients in the physician directed EMS group 60% were discharged from the hospital, and 44% of these had a good neurological recovery. We conclude that a physician directed EMS is able to reduce the pain to therapy delays significantly in STEMI patients and may offer thrombolytic therapy to a wider patient group compared to an EMS without operational medical involvement.

Epidemiology and aetiology of impaired level of consciousness in prehospital nontrauma patients in an urban setting.

BACKGROUND: There is little information on the epidemiology and aetiology of nontraumatic loss of consciousness in patients in the Emergency Department, and this high-risk patient group has been poorly characterized in the prehospital setting as well. The aim of this study was to study the epidemiology and aetiology of nontraumatic impaired level of consciousness among the patients treated by an urban Emergency Medical Service (EMS) system in Finland. METHODS: Data of all emergency calls not related to trauma in an urban EMS system in southern Finland during 2012 were analysed. The inclusion criterion in this study was impaired level of consciousness as identified from the EMS run sheets. Diagnoses made in the receiving facility were cross-checked with the data. RESULTS: During the study period, the EMS was alerted to 22 184 emergency calls. Of these, 306 calls met the inclusion criterion. The included patients could be categorized into four groups: seizures (32%), diabetes (24%), intoxication (17%) and impaired level of consciousness with no other obvious or specific cause (27%). The overall case fatality rate was 8%. CONCLUSION: Of all EMS calls, patients who presented with an impaired level of consciousness represented 1.4% of all patients, but the fatality rate in those who remained with an impaired level of consciousness during the prehospital phase was considerable. Impaired level of consciousness was associated with a multitude of aetiologies, of which seizures were the most common.

Medical priority dispatch codes-comparison with National Early Warning Score.

BACKGROUND: In Finland, calls for emergency medical services are prioritized by educated non-medical personnel into four categories-from A (highest risk) to D (lowest risk)-following a criteria-based national dispatch protocol. Discrepancies in triage may result in risk overestimation, leading to inappropriate use of emergency medical services units and to risk underestimation that can negatively impact patient outcome. To evaluate dispatch protocol accuracy, we assessed association between priority assigned at dispatch and the patient's condition assessed by emergency medical services on the scene using an early warning risk assessment tool. METHODS: Using medical charts, clinical variables were prospectively recorded and evaluated for all emergency medical services missions in two hospital districts in Northern Finland during 1.1.2014-30.6.2014. Risk assessment was then re-categorized as low, medium, or high by calculating the National Early Warning Score (NEWS) based on the patients' clinical variables measured at the scene. RESULTS: A total of 12,729 emergency medical services missions were evaluated, of which 616 (4.8%) were prioritized as A, 3193 (25.1%) as B, 5637 (44.3%) as C, and 3283 (25.8%) as D. Overall, 67.5% of the dispatch missions were correctly estimated according to NEWS. Of the highest dispatch priority missions A and B, 76.9 and 78.3%, respectively, were overestimated. Of the low urgency missions (C and D), 10.7% were underestimated; 32.0% of the patients who were assigned NEWS indicating high risk had initially been classified as low urgency C or D priorities at the dispatch. DISCUSSION AND CONCLUSION: The present results show that the current Finnish medical dispatch protocol is suboptimal and needs to be further developed. A substantial proportion of EMS missions assessed as highest priority were categorized as lower risk according to the NEWS determined at the scene, indicating over-triage with the protocol. On the other hand, only a quarter of the high risk NEWS patients were classified as the highest priority at dispatch, indicating considerable under-triage with the protocol.

Airway management in out-of-hospital cardiac arrest in Finland: current practices and outcomes.

BACKGROUND: Though airway management methods during out-of-hospital cardiac arrest (OHCA) remain controversial, no studies on the topic from Finland have examined adherence to OHCA recommendations in real life. In response, the aim of this study was to document the interventions, success rates, and adverse events in airway management processes in OHCA, as well as to analyse survival at hospital discharge and at follow-up a year later. METHODS: During a 6-month study period in 2010, data regarding all patients with OHCA and attempted resuscitation in southern and eastern Finland were prospectively collected. Emergency medical services (EMS) documented the airway techniques used and all adverse events related to the process. Study endpoints included the frequency of different techniques used, their success rates, methods used to verify the correct placement of the endotracheal tube, overall adverse events, and survival at hospital discharge and at follow-up a year later. RESULTS: A total of 614 patients were included in the study. The incidence of EMS-attempted resuscitation was determined to be 51/100,000 inhabitants per year. The final airway technique was endotracheal intubation (ETI) in 413 patients (67.3%) and supraglottic airway device (SAD) in 188 patients (30.2%). The overall success rate of ETI was 92.5%, whereas that of SAD was 85.0%. Adverse events were reported in 167 of the patients (27.2%). Having a prehospital EMS physician on the scene (p < .001, OR 5.05, 95% CI 2.94-8.68), having a primary shockable rhythm (p < .001, OR 5.23, 95% CI 3.05-8.98), and being male (p = .049, OR 1.80, 95% CI 1.00-3.22) were predictors for survival at hospital discharge. CONCLUSIONS: This study showed acceptable ETI and SAD success rates among Finnish patients with OHCA. Adverse events related to airway management were observed in more than 25% of patients, and overall survival was 17.8% at hospital discharge and 14.0% after 1 year.

Pre-hospital severe traumatic brain injury - comparison of outcome in paramedic versus physician staffed emergency medical services.

BACKGROUND: Traumatic brain injury (TBI) is one of the leading causes of death and permanent disability. Emergency Medical Services (EMS) personnel are often the first healthcare providers attending patients with TBI. The level of available care varies, which may have an impact on the patient's outcome. The aim of this study was to evaluate mortality and neurological outcome of TBI patients in two regions with differently structured EMS systems. METHODS: A 6-year period (2005 - 2010) observational data on pre-hospital TBI management in paramedic-staffed EMS and physician-staffed EMS systems were retrospectively analysed. Inclusion criteria for the study were severe isolated TBI presenting with unconsciousness defined as Glasgow coma scale (GCS) score ≤ 8 occurring either on-scene, during transportation or verified by an on-call neurosurgeon at admission to the hospital. For assessment of one-year neurological outcome, a modified Glasgow Outcome Score (GOS) was used. RESULTS: During the 6-year study period a total of 458 patients met the inclusion criteria. One-year mortality was higher in the paramedic-staffed EMS group: 57 % vs. 42 %. Also good neurological outcome was less common in patients treated in the paramedic-staffed EMS group. DISCUSSION: We found no significant difference between the study groups when considering the secondary brain injury associated vital signs on-scene. Also on arrival to ED, the proportion of hypotensive patients was similar in both groups. However, hypoxia was common in the patients treated by the paramedic-staffed EMS on arrival to the ED, while in the physician-staffed EMS almost none of the patients were hypoxic. Pre-hospital intubation by EMS physicians probably explains this finding. CONCLUSION: The results suggest to an outcome benefit from physician-staffed EMS treating TBI patients. TRIAL REGISTRATION: ClinicalTrials.gov ID NCT01454648.

Quality of life of elderly patients after prehospital thrombolytic therapy.

We studied the long-term outcome and quality of life of elderly patients after prehospital thrombolysis to treat acute ST-elevation myocardial infarction. Data of 218 patients after prehospital thrombolytic therapy given by two physician staffed Helicopter Emergency Medical Service (HEMS) units were collected prospectively. Physical and mental status was evaluated at 4--6 months after discharge, and 1-year mortality was determined. Patients older than 65 years were compared with those younger than 65 years. There were 112 elderly and 106 younger patients. The elderly patients had more previous coronary events and more medications. Pain to therapy times between the two groups were equal (<65 years: 108+/-93 min (range 27--500 min) versus >65 years: 108+/-70 min (20-357 min)). After 4--6 months, the Barthel Daily Living Index or the Beck Depression Inventory (BDI) (depression, if BDI >/=10) showed no differences between the two groups (<65 years: 99+/-5 (range 65--100) versus >65 years: 98+/-12 (10--100); BDI>/=10, 18% versus 9%). One-year survival was lower among the elderly (79% versus 93%; p=0.001). No differences in the frequency of arrhythmias, haemodynamic problems during thrombolysis or complications such as intracranial haemorrhage after thrombolysis were detected. We concluded that elderly patients treated with prehospital thrombolysis for acute ST-elevation myocardial infarction recover mentally and physically as well as younger patients.