Use of Helicopters to Reduce Health Care System Delay in Patients With ST-Elevation Myocardial Infarction Admitted to an Invasive Center.

Timely reperfusion in ST-elevation myocardial infarction (STEMI) is essential. This study aimed to evaluate the reduction in system delay (time from emergency medical service [EMS] call to primary percutaneous coronary intervention [PPCI]) in patients with STEMI when using helicopter EMS (HEMS) rather than ground-based EMS (GEMS). This was a retrospective, nationwide cohort study of consecutive patients with STEMI treated with PPCI at 5 PPCI centers in Denmark. Polynomial spline curves were constructed to describe the association between system delay and distance to the PPCI center stratified by transportation mode. A total of 26,433 patients with STEMI were treated with PPCI between January 1, 1999, and December 31, 2016. In 16,436 patients field triaged directly to the PPCI center, the proportion treated within 120 minutes of the EMS call was 75% for those living 0 to 25 km from the PPCI center compared with 65% for all patients transported by GEMS (median transport distance 50 km [interquartile range 23 to 90]) and 64% for all patients transported by HEMS (median transport distance 119 km [interquartile range 99 to 142]). The estimated reduction in system delay owed to using HEMS rather than GEMS was 14, 16, 20, and 29 minutes for patients living 75, 100, 125, and 170 km from a PPCI center. In conclusion, this study confirmed that using HEMS ensures that most patients with STEMI, living up to 170 km from a PPCI center, can be treated within 120 minutes of their EMS call provided they are field triaged directly to the PPCI center.

Helicopter emergency medical services missions to islands and the mainland during a 3-year period in Denmark: a population-based study on patient and sociodemographic characteristics, comorbidity, and use of healthcare services.

BACKGROUND: The Danish Helicopter Emergency Medical Services (HEMS) is part of the Danish Emergency Medical Services System serving 5.7 million citizens with 1% living on islands not connected to the mainland by road. HEMS is dispatched based on pre-defined criteria including severity and urgency, and moreover to islands for less urgent cases, when rapid transport to further care is needed. The study aim was to characterize patient and sociodemographic factors, comorbidity and use of healthcare services for patients with HEMS missions to islands versus mainland. METHODS: Descriptive study of data from the HEMS database in a three-year period from 1 October 2014 to 30 September 2017. All missions in which a patient was either treated on scene or transported by HEMS were included. RESULTS: Of 5776 included HEMS missions, 1023 (17.7%) were island missions. In total, 90.2% of island missions resulted in patient transport by HEMS compared with 62.1% of missions to the mainland. Disease severity was serious or life-threatening in 34.7% of missions to islands compared with 65.1% of missions to mainland and less interventions were performed by HEMS on island missions. The disease pattern differed with more "Other diseases" registered on islands compared with the mainland where cardiovascular diseases and trauma were the leading causes of contact. Patients from islands were older than patients from the mainland. Sociodemographic characteristics varied between inhabiting island patients and mainland patients: more island patients lived alone, less were employed, more were retired, and more had low income. In addition, residing island patients had to a higher extend severe comorbidity and more contacts to general practitioners and hospitals compared with the mainland patients. CONCLUSIONS: HEMS missions to islands count for 17.7% of HEMS missions and 90.2% of island missions result in patient transport. The island patients encountered by HEMS are less severely diseased or injured and interventions are less frequently performed. Residing island patients are older than mainland patients and have lower socioeconomic position, more comorbidities and a higher use of health care services. Whether these socio-economic differences result in longer hospital stay or higher mortality is still to be investigated.

Characteristics of patients treated by the Danish Helicopter Emergency Medical Service from 2014-2018: a nationwide population-based study.

BACKGROUND: A national Helicopter Emergency Medical Service (HEMS) was introduced in Denmark in 2014 to ensure the availability of physician-led critical care for all patients regardless of location. Appropriate dispatch of HEMS is known to be complex, and resource utilisation is a highly relevant topic. Population-based studies on patient characteristics are fundamental when evaluating and optimising a system. The aim of this study was to describe the patient population treated by the Danish HEMS in terms of demographics, pre-hospital diagnostics, severity of illness or injury, and the critical care interventions performed. METHOD: The study is a retrospective nationwide population-based study based on data gathered from the Danish HEMS database. We included primary missions resulting in a patient encounter registered between October 1st 2014 and April 30th 2018. RESULTS: Of 13.391 dispatches registered in the study period we included 7133 (53%) primary missions with patient encounter: 4639 patients were air lifted to hospital, 174 patients were escorted to hospital by the HEMS physician in an ambulance, and in 2320 cases HEMS assisted the ground crew on scene but did not escort the patient to hospital. Patient age ranged from 0-99 years and 64% of the population were men. The median age was 60 years. The main diagnostic groups were cardio-vascular emergencies (41%), trauma (23%) and neurological emergencies (16%). In 61% of the cases, the patient was critically ill/injured corresponding to a NACA (National Advisory Committee for Aeronautics) score between 4 and 7 (both included). In more than one third of the missions a critical care intervention was performed. Ultrasound examination and endo-tracheal intubation were the critical care interventions most frequently performed (21% and 20%, respectively). CONCLUSION: The national Danish HEMS primarily attends severely ill or injured patients and often perform critical care interventions. In addition, the Danish HEMS provides rapid transport to highly specialised treatment for patients in the more rural parts of the country. Patients with cardio-vascular emergencies, trauma and neurological emergencies are among those patient groups most commonly seen. We conclude that the overall dispatch profile appears appropriate but emphasise that continuous development and refinement is essential.

Prehospital treatment of patients with acute intracranial pathology: adherence to guidelines and blood pressure recommendations by the Danish Air Ambulance.

BACKGROUND: Hypoxia and hypotension may be associated with secondary brain injury and negative outcomes in patients with traumatic and non-traumatic intracranial pathology. Guidelines exist only for the prehospital management of patients with severe traumatic brain injury (TBI). In patients with non-traumatic intracranial pathology, TBI guideline recommendations may be applied to assess whether hypoxia and hypotension should be avoided during prehospital treatment. The main study objective was to assess the extent to which Danish Helicopter Emergency Medical Service (HEMS) critical care teams adhere to the prehospital TBI guideline recommendations for the management of patients with a clinical diagnosis of non-traumatic intracranial pathology or isolated TBI. Furthermore, in the same two groups of patients, we evaluated the adherence of the Danish HEMS critical care teams to recommendations aiming to maintain systolic blood pressure (SBP) > 110 mmHg and > 120 mmHg. METHODS: In total, 211 prehospital patient records were studied. All patients were treated for non-traumatic intracranial pathology or isolated TBI by the Danish HEMS critical care teams from October 1, 2014, to January 1, 2017. Adherence to the prehospital TBI guideline recommendations and the SBP recommendations above was assessed in non-TBI and TBI populations. RESULTS: The adherence rates to TBI guideline recommendations among Danish HEMS critical care teams were 69% (n = 106 [95% CI: 61-77%]) in the non-TBI population and 74% (n = 43 [95% CI: 61-85%]) in the TBI population. SBP > 110 mmHg was observed in 74% (n = 113 [95% CI: 66-81%]) and 69% (n = 40 [95% CI: 56-81%]) of cases in the non-TBI and TBI population, respectively. SBP > 120 mmHg was observed in 55% (n = 84, [95% CI: 47-63%]) of patients in the non-TBI population and 55% (n = 32 [95% CI: 42-68%]) of the patients in the TBI population. CONCLUSIONS: Due to a lack of comparative data, it is difficult to determine the performance quality of the Danish HEMS critical care teams. Our findings may suggest that adherence to TBI guidelines and SBP recommendations needs to be a continuous focal point for the Danish HEMS to avoid secondary brain damage.

Prehospital triage of patients suffering severe dyspnoea using N-terminal pro-brain natriuretic peptide, the PreBNP trial: a randomised controlled clinical trial.

PURPOSE: The purpose of this study was to examine whether the addition of brain natriuretic peptide measurement to the routine diagnostic work-up by prehospital critical care team physicians improves triage in patients with severe dyspnoea. METHODS: Prehospital critical care team physicians randomly assigned patients older than 18 years with severe dyspnoea to routine diagnostic work-up or diagnostic work-up with incorporated point-of-care N-terminal pro-brain natriuretic peptide (NT-proBNP) measurement. The primary endpoint was the proportion of patients with dyspnoea of primary cardiac origin triaged directly to a department of cardiology. RESULTS: A total of 747 patients were randomly assigned and 711 patients consented to participate, 350 were randomly assigned to the NT-proBNP group and 361 to the routine work-up group. NT-proBNP was measured in 90% (315/350) of patients in the NT-proBNP group and in 19% (70/361) of patients in the routine work-up group. There was no difference in the proportion of patients with dyspnoea of primary cardiac origin triaged directly to a department of cardiology between the NT-proBNP group and the routine work-up group (75% vs. 69%, P=0.22) in the intention-to-treat analysis. Sensitivity analysis according to the de facto diagnostics performed showed results consistent with this. No differences in hospital length of stay, intensive care unit admission rates or mortality between the NT-proBNP group and the routine work-up group were observed. CONCLUSION: Routine supplementary point-of-care measurement of NT-proBNP in patients with severe dyspnoea did not improve triage of patients with dyspnoea primarily caused by heart disease. ClinicalTrials.gov identifier NCT02050282.

Anaesthetist-provided pre-hospital advanced airway management in children: a descriptive study.

BACKGROUND: Pre-hospital advanced airway management has been named one of the top-five research priorities in physician-provided pre-hospital critical care. Few studies have been made on paediatric pre-hospital advanced airway management. The aim of this study was to investigate pre-hospital endotracheal intubation success rate in children, first-pass success rates and complications related to pre-hospital advanced airway management in patients younger than 16 years of age treated by pre-hospital critical care teams in the Central Denmark Region (1.3 million inhabitants). METHODS: A prospective descriptive study based on data collected from eight anaesthetist-staffed pre-hospital critical care teams between February 1st 2011 and November 1st 2012. Primary endpoints were 1) pre-hospital endotracheal intubation success rate in children 2) pre-hospital endotracheal intubation first-pass success rate in children and 3) complications related to prehospital advanced airway management in children. RESULTS: The pre-hospital critical care anaesthetists attempted endotracheal intubation in 25 children, 13 of which were less than 2 years old. In one patient, a neonate (600 g birth weight), endotracheal intubation failed. The patient was managed by uneventful bag-mask ventilation. All other 24 children had their tracheas successfully intubated by the pre-hospital critical care anaesthetists resulting in a pre-hospital endotracheal intubation success rate of 96 %. Overall first pass success-rate was 75 %. In the group of patients younger than 2 years old, first pass success-rate was 54 %. The total rate of airway management related complications such as vomiting, aspiration, accidental intubation of the oesophagus or right main stem bronchus, hypoxia (oxygen saturation < 90 %) or bradycardia (according to age) was 20 % in children younger than 16 years of age and 38 % in children younger than 2 years of age. No deaths, cardiac arrests or severe bradycardia (heart rate <60) occurred in relation to pre-hospital advanced airway management. CONCLUSION: Compared with the total population of patients receiving pre-hospital advanced airway management in our system, the overall success rate following pre-hospital endotracheal intubations in children is acceptable but the first-pass success rate is low. The complication rates in the paediatric population are higher than in our pre-hospital advanced airway management patient population as a whole. This illustrates that young children may represent a substantial pre-hospital airway management challenge even for experienced pre-hospital critical care anaesthetists. This may influence future training and quality insurance initiatives in paediatric pre-hospital advanced airway management.

Predicting the lack of ROSC during pre-hospital CPR: should an end-tidal CO2 of 1.3 kPa be used as a cut-off value?

AIM: The aim of this study was to investigate if an initial ETCO2 value at or below 1.3 kPa can be used as a cut-off value for whether return of spontaneous circulation during pre-hospital cardio-pulmonary resuscitation is achievable or not. MATERIALS AND METHODS: We prospectively registered data according to the Utstein-style template for reporting data from pre-hospital advanced airway management from February 1st 2011 to October 31st 2012. Included were consecutive patients at all ages with pre-hospital cardiac arrest treated by eight anaesthesiologist-staffed pre-hospital critical care teams in the Central Denmark Region. RESULTS: We registered data from 595 cardiac arrest patients; in 60.2% (n=358) of these cases the pre-hospital critical care teams performed pre-hospital advanced airway management beyond bag-mask ventilation. An initial end-tidal CO2 measurement following pre-hospital advanced airway management were available in 75.7% (n=271) of these 358 cases. We identified 22 patients, who had an initial end-tidal CO2 at or below 1.3 kPa. Four of these patients achieved return of spontaneous circulation. CONCLUSION: Our results indicates that an initial end-tidal CO2 at or below 1.3 kPa during pre-hospital CPR should not be used as a cut-off value for the achievability of return of spontaneous circulation.

Remote ischemic perconditioning as an adjunct therapy to thrombolysis in patients with acute ischemic stroke: a randomized trial.

BACKGROUND AND PURPOSE: Remote ischemic preconditioning is neuroprotective in models of acute cerebral ischemia. We tested the effect of prehospital rPerC as an adjunct to treatment with intravenous alteplase in patients with acute ischemic stroke. METHODS: Open-label blinded outcome proof-of-concept study of prehospital, paramedic-administered rPerC at a 1:1 ratio in consecutive patients with suspected acute stroke. After neurological examination and MRI, patients with verified stroke receiving alteplase treatment were included and received MRI at 24 hours and 1 month and clinical re-examination after 3 months. The primary end point was penumbral salvage, defined as the volume of the perfusion-diffusion mismatch not progressing to infarction after 1 month. RESULTS: Four hundred forty-three patients were randomized after provisional consent, 247 received rPerC and 196 received standard treatment. Patients with a nonstroke diagnosis (n=105) were excluded from further examinations. The remaining patients had transient ischemic attack (n=58), acute ischemic stroke (n=240), or hemorrhagic stroke (n=37). Transient ischemic attack was more frequent (P=0.006), and National Institutes of Health Stroke Scale score on admission was lower (P=0.016) in the intervention group compared with controls. Penumbral salvage, final infarct size at 1 month, infarct growth between baseline and 1 month, and clinical outcome after 3 months did not differ among groups. After adjustment for baseline perfusion and diffusion lesion severity, voxelwise analysis showed that rPerC reduced tissue risk of infarction (P=0.0003). CONCLUSIONS: Although the overall results were neutral, a tissue survival analysis suggests that prehospital rPerC may have immediate neuroprotective effects. Future clinical trials should take such immediate effects, and their duration, into account. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00975962.

Standard operating procedure changed pre-hospital critical care anaesthesiologists' behaviour: a quality control study.

INTRODUCTION: The ability of standard operating procedures to improve pre-hospital critical care by changing pre-hospital physician behaviour is uncertain. We report data from a prospective quality control study of the effect on pre-hospital critical care anaesthesiologists' behaviour of implementing a standard operating procedure for pre-hospital controlled ventilation. MATERIALS AND METHODS: Anaesthesiologists from eight pre-hospital critical care teams in the Central Denmark Region prospectively registered pre-hospital advanced airway-management data according to the Utstein-style template. We collected pre-intervention data from February 1st 2011 to January 31st 2012, implemented the standard operating procedure on February 1st 2012 and collected post intervention data from February 1st 2012 until October 31st 2012. We included transported patients of all ages in need of controlled ventilation treated with pre-hospital endotracheal intubation or the insertion of a supraglottic airways device. The objective was to evaluate whether the development and implementation of a standard operating procedure for controlled ventilation during transport could change pre-hospital critical care anaesthesiologists' behaviour and thereby increase the use of automated ventilators in these patients. RESULTS: The implementation of a standard operating procedure increased the overall prevalence of automated ventilator use in transported patients in need of controlled ventilation from 0.40 (0.34-0.47) to 0.74 (0.69-0.80) with a prevalence ratio of 1.85 (1.57-2.19) (p = 0.00). The prevalence of automated ventilator use in transported traumatic brain injury patients in need of controlled ventilation increased from 0.44 (0.26-0.62) to 0.85 (0.62-0.97) with a prevalence ratio of 1.94 (1.26-3.0) (p = 0.0039). The prevalence of automated ventilator use in patients transported after return of spontaneous circulation following pre-hospital cardiac arrest increased from 0.39 (0.26-0.48) to 0.69 (0.58-0.78) with a prevalence ratio of 1.79 (1.36-2.35) (p = 0.00). CONCLUSION: We have shown that the implementation of a standard operating procedure for pre-hospital controlled ventilation can significantly change pre-hospital critical care anaesthesiologists' behaviour.

Refraining from pre-hospital advanced airway management: a prospective observational study of critical decision making in an anaesthesiologist-staffed pre-hospital critical care service.

INTRODUCTION: We report prospectively recorded observational data from consecutive cases in which the attending pre-hospital critical care anaesthesiologist considered performing pre-hospital advanced airway management but decided to withhold such interventions. MATERIALS AND METHODS: Anaesthesiologists from eight pre-hospital critical care teams in the Central Denmark Region (a mixed rural and urban region with 1.27 million inhabitants) registered data from February 1st 2011 to October 31st 2012. Included were patients of all ages for whom pre-hospital advanced airway management were considered but not performed. The main objectives were to investigate (1) the pre-hospital critical care anaesthesiologists' reasons for considering performing pre-hospital advanced airway management in this group of patients (2) the pre-hospital critical care anaesthesiologists' reasons for not performing pre-hospital advanced airway management (3) the methods used to treat these patients (4) the incidence of complications related to pre-hospital advanced airway management not being performed. RESULTS: We registered data from 1081 cases in which the pre-hospital critical care anaesthesiologists' considered performing pre-hospital advanced airway management. The anaesthesiologists decided to withhold pre-hospital advanced airway management in 32.1% of these cases (n = 347). In 75.1% of these cases (n = 257) pre-hospital advanced airway management were withheld because of the patient's condition and in 30.8% (n = 107) because of patient co-morbidity. The most frequently used alternative treatment was bag-mask ventilation, used in 82.7% of the cases (n = 287). Immediate complications related to the decision of not performing pre-hospital advanced airway management occurred in 0.6% of the cases (n = 2). CONCLUSION: We have illustrated the complexity of the critical decision-making associated with pre-hospital advanced airway management. This study is the first to identify the most common reasons why pre-hospital critical care anaesthesiologists sometimes choose to abstain from pre-hospital advanced airway management as well as the alternative treatment methods used.

Pre-hospital advanced airway management by experienced anaesthesiologists: a prospective descriptive study.

INTRODUCTION: We report data from the first Utstein-style study of physician-provided pre-hospital advanced airway management. MATERIALS AND METHODS: Anaesthesiologists from eight pre-hospital critical care teams in the Central Denmark Region (a mixed rural and urban region with 1.27 million inhabitants) prospectively registered data according to the template for reporting data from pre-hospital advanced airway management. Data collection took place from February 1st 2011 to October 31st 2012. Included were patients of all ages on whom pre-hospital advanced airway management was performed. The objective was to estimate the incidences of failed and difficult pre-hospital endotracheal intubation, and complications related to pre-hospital advanced airway management. RESULTS: The overall incidence of successful pre-hospital endotracheal intubation among 636 intubation attempts was 99.7%, even though 22.4% of pre-hospital endotracheal intubations required more than one intubation attempt. The overall incidence of complications related to pre-hospital advanced airway management was 7.9%. Following rapid sequence intubation, the incidence of first pass success was 85.8%, the overall incidence of complications was 22.0%, the incidence of hypotension 7.3% and that of hypoxia 5.3%. Multiple endotracheal intubation attempts were associated with an increased overall incidence of complications. No airway management related deaths occurred. DISCUSSION: The overall incidence of successful pre-hospital endotracheal intubations compares to those found in other physician-staffed pre-hospital systems. The incidence of pre-hospital endotracheal intubations requiring more than one attempt is higher than suspected. The incidence of hypotension or hypoxia after pre-hospital rapid sequence intubation compares to those found in UK emergency departments. CONCLUSION: Pre-hospital advanced airway management including pre-hospital endotracheal intubation performed by experienced anaesthesiologists is associated with high success rates and relatively low incidences of complications. An increased first pass success rate following pre-hospital endotracheal intubation may further reduce the incidence of complications and enhance patient safety in our system.

[Time gain by helicopter transportation of ST-elevation myocardial infarction patients]. / Tidsgevinst ved brug af lægehelikopter til transport af patienter med ST-elevationsmyokardieinfarkt.

Helicopter transportation of ST-elevation myocardial infarction patients have verified a reduction in the overall system delay, and should be considered in case of long transportation. The most suitable location of the helicopter base is in remote areas, close to the patients to be transferred. Helipads should be adjoining the percutaneous coronary intervention centre in order to allow direct transfer without the ambulance transfer. Helicopters that can operate both day and night and in poor visibility are recommended. Specially trained physicians, able to provide the required, advanced, in-flight treatment, should staff the helicopters.

Earlier reperfusion in patients with ST-elevation myocardial infarction by use of helicopter.

BACKGROUND: In patients with ST-elevation myocardial infarction (STEMI) reperfusion therapy should be initiated as soon as possible. This study evaluated whether use of a helicopter for transportation of patients is associated with earlier initiation of reperfusion therapy. MATERIAL AND METHODS: A prospective study was conducted, including patients with STEMI and symptom duration less than 12 hours, who had primary percutaneous coronary intervention (PPCI) performed at Aarhus University Hospital in Skejby. Patients with a health care system delay (time from emergency call to first coronary intervention) of more than 360 minutes were excluded. The study period ran from 1.1.2011 until 31.12.2011. A Western Denmark Helicopter Emergency Medical Service (HEMS) project was initiated 1.6.2011 for transportation of patients with time-critical illnesses, including STEMI. RESULTS: The study population comprised 398 patients, of whom 376 were transported by ambulance Emergency Medical Service (EMS) and 22 by HEMS. Field-triage directly to the PCI-center was used in 338 of patients. The median system delay was 94 minutes among those field-triaged, and 168 minutes among those initially admitted to a local hospital. Patients transported by EMS and field-triaged were stratified into four groups according to transport distance from the scene of event to the PCI-center: ≤25 km., 26-50 km., 51-75 km. and > 75 km. For these groups, the median system delay was 78, 89, 99, and 141 minutes. Among patients transported by HEMS and field-triaged the estimated median transport distance by ground transportation was 115 km, and the observed system delay was 107 minutes. Based on second order polynomial regression, it was estimated that patients with a transport distance of >60 km to the PCI-center may benefit from helicopter transportation, and that transportation by helicopter is associated with a system delay of less than 120 minutes even at a transport distance up to 150 km. CONCLUSION: The present study indicates that use of a helicopter should be considered for field-triage of patients with STEMI to the PCI-center in case of long transportation. Such a strategy may ensure that patients living up to 150 km. from the PCI-center can be treated within 120 minutes of emergency call.

EMS-physicians' self reported airway management training and expertise; a descriptive study from the Central Region of Denmark.

BACKGROUND: Prehospital advanced airway management, including prehospital endotracheal intubation is challenging and recent papers have addressed the need for proper training, skill maintenance and quality control for emergency medical service personnel. The aim of this study was to provide data regarding airway management-training and expertise from the regional physician-staffed emergency medical service (EMS). METHODS: The EMS in this part of The Central Region of Denmark is a two tiered system. The second tier comprises physician staffed Mobile Emergency Care Units. The medical directors of the programs supplied system data. A questionnaire addressing airway management experience, training and knowledge was sent to the EMS-physicians. RESULTS: There are no specific guidelines, standard operating procedures or standardised program for obtaining and maintaining skills regarding prehospital advanced airway management in the schemes covered by this study. 53/67 physicians responded; 98,1% were specialists in anesthesiology, with an average of 17,6 years of experience in anesthesiology, and 7,2 years experience as EMS-physicians. 84,9% reported having attended life support course(s), 64,2% an advanced airway management course. 24,5% fulfilled the curriculum suggested for Danish EMS physicians. 47,2% had encountered a difficult or impossible PHETI, most commonly in a patient in cardiac arrest or a trauma patient. Only 20,8% of the physicians were completely familiar with what back-up devices were available for airway management. CONCLUSIONS: In this, the first Danish study of prehospital advanced airway management, we found a high degree of experience, education and training among the EMS-physicians, but their equipment awareness was limited. Check-outs, guidelines, standard operating procedures and other quality control measures may be needed.

Urban and rural implementation of pre-hospital diagnosis and direct referral for primary percutaneous coronary intervention in patients with acute ST-elevation myocardial infarction.

AIMS: Primary percutaneous coronary intervention (PCI) is the preferred treatment for ST-elevation myocardial infarction (STEMI). The distance to primary PCI centres and the inherent time delay in delivering primary PCI, however, limit widespread use of this treatment. This study aimed to evaluate the impact of pre-hospital diagnosis on time from emergency medical services contact to balloon inflation (system delay) in an unselected cohort of patients with STEMI recruited from a large geographical area comprising both urban and rural districts. METHODS AND RESULTS: From February 2004 until January 2007, data on pre-hospital timing and transport distance were prospectively recorded. Patients were divided into groups depending on achievement of pre-hospital diagnosis and/or direct referral to a primary PCI centre. Seven hundred and fifty-nine consecutive STEMI patients were included. In patients with a pre-hospital diagnosis and direct referral, the system delay was 92 vs. 153 min in patients without pre-hospital diagnosis (P < 0.001). Patients from rural areas were transported a median of 30 km longer than patients from urban areas; however, this prolonged the system delay by only 9 min. CONCLUSION: Pre-hospital electrocardiographic (ECG) diagnosis and direct referral for primary PCI enables STEMI patients living far from a PCI centre to achieve a system delay comparable with patients living in close vicinity of a PCI centre.

Quality of cardiopulmonary resuscitation in out-of-hospital cardiac arrest is hampered by interruptions in chest compressions--a nationwide prospective feasibility study.

AIM OF THE STUDY: Quality of cardiopulmonary resuscitation (CPR) is a critical determinant of outcome following out-of-hospital cardiac arrest. The aim of our study was to evaluate the quality of CPR provided by emergency medical service providers (Basic Life Support (BLS) capability) and emergency medical service providers assisted by paramedics, nurse anesthetists or physician-manned ambulances (Advanced Life Support (ALS) capability) in a nationwide, unselected cohort of out-of-hospital cardiac arrest cases. METHODS: We conducted a prospective, observational study of out-of-hospital cardiac arrest with non-traumatic etiology (>18 years of age) occurring from the 1st to the 31st of January 2009 and treated by the primary Danish emergency medical service operator, covering approximately 85% of the population. One hundred and ninety-one cases were eligible for analysis. Follow-up was up to one year or death. Quality of CPR was evaluated using measurements of transthoracic impedance. RESULTS: The majority of patients were treated by ambulances with ALS capability (54%). Interruptions in CPR related to loading of the patient into the emergency medical service vehicle were substantial, but independent of whether patients were managed by ALS or BLS capable units (222s versus 224s, P = 0.76) as were duration of interruptions during rhythm analysis alone (20s versus 22s, P = 0.33) and defibrillation (24s versus 26s, P = 0.07). CONCLUSIONS: Nationwide, routine monitoring of transthoracic impedance is feasible. CPR is hampered by extended interruptions, particularly during loading of the patient into the emergency medical service vehicle, rhythm analysis and defibrillation.

The ICP-lowering effect of 10 degrees reverse Trendelenburg position during craniotomy is stable during a 10-minute period.

Recently we studied the effect of 10 degrees reverse Trendelenburg position on subdural pressure and cerebral perfusion pressure (CPP) during craniotomy. Within 1 minute we found a significant decrease in subdural pressure while CPP was unchanged. A longer time span, however, is necessary to exclude a temporary effect. In the present investigation we studied subdural pressure, CPP, and jugular bulb pressure (JBP) before and during a 10-minute period after change in position. Fifteen patients with supratentorial cerebral tumors were anesthetized with propofol/fentanyl in the supine position. Mean arterial blood pressure and JBP were measured invasively, and subdural pressure was measured after removal of the bone flap. End-tidal CO2, PaCO2, PaO2, heart rate, jugular venous oxygen saturation (SjO2), and arteriovenous oxygen difference (AVDO2) were also measured. Dural tension was estimated by the surgeon. The measurements were performed with the patients in a neutral position and during a 10-minute period after positioning the patient in a 10 degrees reverse Trendelenburg position. After 1 minute in the reverse Trendelenburg position, the mean value of subdural pressure decreased from 10.9 +/- 5.7 to 7.3 +/- 5.2 mm Hg (P<0.05) and remained unchanged for the following 9 minutes. Correspondingly, dural tension was lessened significantly. Jugular pressure and mean arterial blood pressure decreased significantly as well (P<0.05), but the CPP was unaffected. No significant changes in PaCO2, PaO2, end-tidal CO2, heart rate, SjO2, or AVDO2 were disclosed. During craniotomy 10 degrees reverse Trendelenburg position reduces subdural pressure and dural tension within 1 minute without reducing CPP. During the following 9 minutes the levels of subdural pressure and CPP are unchanged.

[Seriously injured patients intubated at the accident site. A three-year survey from the mobile emergency care unit in Aarhus]. / Svaert tilskadekomne patienter intuberet på skadestedet. Treårs opgørelse fra laegeambulancen i Aarhus.

BACKGROUND: The success rate of out-of-hospital endotracheal intubations performed by paramedics has been questioned. It seems to be difficult to achieve and keep a routine. The aim was to describe the severity of injuries and the number of such intubations in trauma patients treated by the Mobile Emergency Care Unit (MECU) staffed with an anaesthetist. MATERIALS AND METHODS: The case records of all trauma patients on whom the MECU, Arhus, performed endotracheal intubation at the accident site from 1 May 1997 to 30 April 2000 were studied. Lesions were classified according to the abbreviated injury scale (AIS), and the injury severity scores (ISS) were calculated. Severe injury was defined as an ISS > 15. RESULTS: Over the three-year period the MECU attended 2546 trauma patients, 95 (3.7%) of whom were intubated at the site. In one case, endotracheal intubation was not possible and cricothyrotomy had to be performed. Of the patients intubated at the site 65 had an ISS > 15. This, according to previous studies, corresponded to about 20% of all severely injured patients arriving at our hospital. Sixty patients had severe lesions in the head region. In sixty-eight cases (72%) endotracheal intubation was preceded by anaesthesia. DISCUSSION: Out-of-hospital endotracheal intubation of trauma patients was not a frequent intervention, as compared to all emergency calls, but it was relatively frequent in the severely injured brought to our hospital. If endotracheal intubation is to be one of the available interventions in the prehospital setting, this study confirms that it should preferably be done by physicians experienced in intubation and anaesthesia.

[Prehospital treatment of patients with acute exacerbation of chronic pulmonary disease. Before and after introduction of a mobile emergency unit]. / Praehospital behandling af patienter med akut forvaerring af kronisk lungesygdom. Før og efter indførelse af laegeambulance.

INTRODUCTION: A Mobile Emergency Care Unit (MECU), manned by an anaesthesiologist and a member of the ambulance crew, was introduced in the city of Arhus in 1997. Endotracheal intubation is not performed by ambulance personnel in Denmark. The aim of this study was to describe the influence of prehospital treatment given by the MECU on the rate of endotracheal intubation, hospitalisation, and survival rate in patients suffering from acute exacerbation of chronic pulmonary disease. MATERIAL AND METHODS: We examined the data registered for patients with chronic pulmonary disease, who called for an emergency ambulance. The study covered two periods of three months: before the introduction of the MECU (September to November 1996) and after (September to November 1997). RESULTS: The study comprised 139 patients (72 patients before, 67 patients after). The MECU attended 57% of the patients. Endotracheal intubation was performed in eight patients: two before and six patients after, four of whom were intubated on the spot. Owing to the treatment given by the MECU on the spot, fewer patients were hospitalised, i.e. 50 patients (75%) versus 67 patients (93%) (p < 0.01). The survival rates were 76% before and 85% after. DISCUSSION: The MECU was a useful supplement to the ambulance service. The MECU intubated patients with acute exacerbation of pulmonary disease in the case of life-threatening respiratory failure, and in less severe cases treated the patients at home. Thus, prehospital treatment by a physician meant fewer admissions to hospital.