Efficacy and Safety of Methoxyflurane for Treatment of Acute Traumatic Pain by EMTs during Alpine Rescue Operations: The "PainDrop" Trial.

Background: Treatment of acute traumatic pain is a core task for mountain rescue services. Intravenous access, however, is often difficult, and the vast majority of missions are carried out without a physician at the scene. The spectrum of analgesics available for use by non-physician personnel is limited. Inhaled analgesics, such as methoxyflurane, might prove useful, but currently no data exist on their application by non-physicians in the alpine setting.Methods: This prospective observational alpine field study was conducted over a period of 15 months. Patients suffering traumatic injuries with moderate to severe pain (pain score ≥ 5) after downhill bike accidents in the Tyrol mountains (1,362 m to 2,666 m above sea level) were enrolled. Teams of four mountain rescue service members, one of them a trained EMT, treated the patients with 3 ml of methoxyflurane by inhaler. We measured efficacy as reduction in pain from baseline to 15 minutes after treatment on a numerical rating scale. Safety was assessed by change in vital signs or occurrence of side-effects. Sample-size calculations were based on the efficacy outcome and yielded a need for 20 patients at a power of 0.8.Results: From June 29, 2020 to September 30, 2021, a total of 20 patients (two females; mean age 37 years) were included. The mean initial pain score was 7.2 (SD 1.0) points. After 15 minutes, pain was significantly reduced by a mean of 2.9 (SD 1.4) points. No major adverse events or relevant changes in vital signs were observed.Conclusion: The use of methoxyflurane by EMTs during alpine rescue operations in our study proved to be safe and efficient. We observed no reduction in the efficacy of the inhaler device at moderate altitude.

In Newborn Infants a New Intubation Method May Reduce the Number of Intubation Attempts: A Randomized Pilot Study.

Severe desaturation or bradycardia often occur during neonatal endotracheal intubation. Using continuous gas flow through the endotracheal tube might reduce the incidence of these events. We hypothesized that continuous gas flow through the endotracheal tube during nasotracheal intubation compared to standard nasotracheal intubation will reduce the number of intubation attempts in newborn infants. In a randomized controlled pilot study, neonates were either intubated with continuous gas flow through the endotracheal tube during intubation (intervention group) or no gas flow during intubation (control group). Recruitment was stopped early due to financial and organizational issues. A total of 16 infants and 39 intubation attempts were analyzed. The median (interquartile range) number of intubation attempts and number of abandoned intubations due to desaturation and/or bradycardia were 1 (1-2) and 4 (2-5), (p = 0.056) and n = 3 versus n = 20, (p = 0.060) in the intervention group and control group, respectively. Continuous gas flow through the endotracheal tube during intubation seems to be favorable and there are no major unexpected adverse consequences of attempting this methodology.

Challenges in the PREHOSPITAL emergency management of geriatric trauma patients - a scoping review.

BACKGROUND: Despite a widely acknowledged increase in older people presenting with traumatic injury in western populations there remains a lack of research into the optimal prehospital management of this vulnerable patient group. Research into this cohort faces many uniqu1e challenges, such as inconsistent definitions, variable physiology, non-linear presentation and multi-morbidity. This scoping review sought to summarise the main challenges in providing prehospital care to older trauma patients to improve the care for this vulnerable group. METHODS AND FINDINGS: A scoping review was performed searching Google Scholar, PubMed and Medline from 2000 until 2020 for literature in English addressing the management of older trauma patients in both the prehospital arena and Emergency Department. A thematic analysis and narrative synthesis was conducted on the included 131 studies. Age-threshold was confirmed by a descriptive analysis from all included studies. The majority of the studies assessed triage and found that recognition and undertriage presented a significant challenge, with adverse effects on mortality. We identified six key challenges in the prehospital field that were summarised in this review. CONCLUSIONS: Trauma in older people is common and challenges prehospital care providers in numerous ways that are difficult to address. Undertriage and the potential for age bias remain prevalent. In this Scoping Review, we identified and discussed six major challenges that are unique to the prehospital environment. More high-quality evidence is needed to investigate this issue further.

Factors associated with physician decision making on withholding cardiopulmonary resuscitation in prehospital medicine.

This study seeks to identify factors that are associated with decisions of prehospital physicians to start (continue, if ongoing) or withhold (terminate, if ongoing) CPR in patients with OHCA. We conducted a retrospective study using anonymised data from a prehospital physician response system. Data on patients attended for cardiac arrest between January 1st, 2010 and December 31st, 2018 except babies at birth were included. Logistic regression analysis with start of CPR by physicians as the dependent variable and possible associated factors as independent variables adjusted for anonymised physician identifiers was conducted. 1525 patient data sets were analysed. Obvious signs of death were present in 278 cases; in the remaining 1247, resuscitation was attempted in 920 (74%) and were withheld in 327 (26%). Factors significantly associated with higher likelihood of CPR by physicians (OR 95% CI) were resuscitation efforts by EMS before physician arrival (60.45, 19.89-184.29), first monitored heart rhythm (3.07, 1.21-7.79 for PEA; 29.25, 1.93-442. 51 for VF / pVT compared to asystole); advanced patient age (modelled using cubic splines), physician response time (0.92, 0.87-0.97 per minute) and malignancy (0.22, 0.05-0.92) were significantly associated with lower odds of CPR. We thus conclude that prehospital physicians make decisions to start or withhold resuscitation routinely and base those mostly on situational information and immediately available patient information known to impact outcomes.

Vitamin D assessment in perioperative medicine and critical care : A prospective observational pilot study.

BACKGROUND: There is controversy about the impact of acute illness on vitamin D levels. This study was carried out to assess the influence of perioperative fluid loading on 25-hydroxy-vitamin D [25(OH)D] levels. The study evaluated the clinical utility of a commonly available chemiluminescence assay (ECLIA, IDS-iSYS) and liquid chromatography/mass spectrometry (LC-MS/MS) in the diagnosis of vitamin D deficiency in this setting. METHODS: In this prospective observational pilot study in adult patients undergoing cardiovascular surgery on cardiopulmonary bypass (CPB), blood samples drawn at preoperative baseline (t1), after weaning from CPB (t2), on intensive care unit (ICU) admission (t3) and on the first (t4) and second (t5) postoperative days were analyzed. RESULTS: A total of 26 patients (130 samples) were included in this study. Fluid loading by CPB led to a median reduction of 25(OH)D by -22.6% (range -54.5% to -19.5%) between t1 and t2. Cohen's kappa (κ) for method agreement for vitamin D deficiency (tested cut-off values 20 ng/ml and 12 ng/ml), was κ = 0.291 (p < 0.001) and κ = 0.469 (p < 0.001), respectively. The mean difference between measurements by ECLIA and LC-MS/MS was 4.8 ng/ml (±5.7), Pearson's r for correlation was 0.73 (p < 0.001). The biologically inactive C3-epimer did not contribute to 25(OH)D levels assessed by LC-MS/MS. CONCLUSION: The 25(OH)D measurements by chemiluminescence assays can noticeably deviate from those measured by LC-MS/MS, which can be considered the unequivocal gold standard. These assays may still be acceptably reliable in the screening for vitamin D deficiency, especially in the setting of low vitamin D levels. Stricter definitions, e.g. serum 25(OH)D levels lower than 12 ng/ml, may be used to diagnose deficiency with low false positive rate. TRIAL REGISTRATION: DRKS00009216, German Clinical Trials Registry ( www.drks.de ).

Characteristics of paediatric patients with altered conscious state attended by road ambulances in a metropolitan area - An 8 year observational study.

BACKGROUND: Out-of-hospital paediatric emergencies represent are rare and little is known about characteristics of paediatric patients with severe illness. This study seeks to describe the paediatric population with altered conscious state. METHODS: A retrospective electronic data review was conducted of paediatric patients (≤ 4 years) attended by road ambulances between January 2006 and December 2013. Patients with a Glasgow Coma Scale (GCS) score ≤9 were included. RESULTS: A total of 4533 children were included in the study, 55.9% of which were male. The majority of patients (48.7%) were between one and four years old. Pre-existing neurologic conditions were identified in 26.8% of patients. Seizures were the most common reason for emergency call (68.7%) and were more frequent in children 1-4 years (80.4%) than in <1 year (32.6%), 5-8 years (75.3%) or 9-14 years (53.9%, p < 0.001). Vital signs (heart rate, systolic blood pressure, oxygen saturation, GCS) improved or remained stable from time of first contact with Emergency Medical Service (EMS) to arrival at hospital. CONCLUSIONS: Seizure was the most common reason for ambulance attendances to children with altered conscious state, and most frequently occurred in preschool children. Pre-existing conditions were frequent. Vital signs and level of conscious stateof patients improved during paramedic management.

Single mean arterial blood pressure drops during stroke thrombectomy under general anaesthesia are associated with poor outcome.

BACKGROUND: We examined the influence of periprocedural blood pressure (BP), especially critical BP drops, on 3-month functional outcome in stroke patients undergoing mechanical thrombectomy (MT) under general anaesthesia (GA). METHODS: We screened all patients with anterior circulation large vessel occlusion receiving MT under GA at our centre from January 2011 to June 2016 and selected those who had continuous invasive periinterventional BP monitoring. Clinical and radiological data were prospectively collected as part of an ongoing cohort study, monitoring data were extracted from electronic anaesthesia records. We used uni- and multivariable regression to investigate the association of BP values with unfavourable outcome, defined as modified Rankin Scale scores 3-6 3 months post-stroke. RESULTS: 115 patients were included in this study (mean age 65.3 ± 13.0 years, 55.7% male). Periinterventional systolic, diastolic, and mean arterial BP (MAP) values averaged across MT had no effect on outcome. However, single BP drops were related to unfavourable outcome, with absolute MAP drops showing the highest association compared to both systolic and relative BP drops (with reference to pre-interventional values). The BP value with the strongest association with unfavourable outcome was identified as an MAP ever < 60 mmHg (p = 0.01) with a pronounced effect in patients with poor collaterals. An MAP < 60 mmHg remained independently associated with poor functional outcome in multivariable analysis (p < 0.01). CONCLUSIONS: For patients undergoing MT under GA, single MAP drops < 60 mmHg are independently related to unfavourable 3-month outcome. Therefore, every effort should be made to prevent periinterventional hypotensive episodes, especially below this threshold.

Oxygen Saturation Targeting During Delivery Room Stabilization: What Does This Mean for Regional Cerebral Oxygenation?

Objective: To investigate if preterm neonates with arterial oxygen saturation (SpO2)<80% at 5 min after birth show different regional cerebral tissue oxygen saturation (rcStO2), compared to infants reaching the target. Methods: Retrospective analysis of four prospective observational studies. Preterm neonates needing respiratory support during delivery room stabilization were included. Regional cerebral tissue oxygen saturation was measured with near-infrared spectroscopy (NIRS) during the first 15 min after birth along with SpO2 and heart rate (HR). Neonates were divided into two groups: those with a 5-min SpO2 ≥ 80% ("≥80% group") and those with a 5-min SpO2 < 80% ("<80% group"). Groups were compared regarding rcStO2, SpO2, and HR. Furthermore, we analyzed whether a 5-min SpO2 < 80% was associated with a rcStO2 below the 10th percentile at the same time point. Results: 146 neonates were included, with 68 (47%) in the "≥80% group" and 78 (53%) in the "<80% group." Neonates in the " <80% group" had a significantly lower rcStO2 (p < 0.001). Furthermore, 80.3% of neonates in the " <80% group" and 23.4% in the "≥80% group" had rcStO2 values below the 10th percentile at 5 min (p < 0.001). HR was significantly lower at minute 3 and 4 in the " <80% group" (p < 0.002). Conclusion: Preterm infants needing respiratory support, who do not reach the SpO2 target of 80% at 5 min after birth, show significantly diminished rcStO2 values compared to neonates reaching the target.

Atlanto-occipital dislocation in a patient presenting with out-of-hospital cardiac arrest: a case report and literature review.

BACKGROUND: Atlanto-occipital dislocation is a rare and severe injury of the upper spine associated with a very poor prognosis. CASE PRESENTATION: We report the case of a 59-year-old European man who suffered from out-of-hospital cardiac arrest following a motor vehicle accident. Cardiopulmonary resuscitation was initiated immediately by bystanders and continued by emergency medical services. After 30 minutes of cardiopulmonary resuscitation with a total of five shocks following initial ventricular fibrillation, return of spontaneous circulation was achieved. An electrocardiogram recorded after return of spontaneous circulation at the scene showed signs of myocardial ischemia as a possible cause for the cardiac arrest. No visible signs of injury were found. He was transferred to the regional academic trauma center. Following an extended diagnostic and therapeutic workup in the emergency room, including extended focused assessment with sonography for trauma ultrasound, whole-body computed tomography, and magnetic resonance imaging (of his head and neck), a diagnosis of major trauma (atlanto-occipital dislocation, bilateral serial rip fractures and pneumothoraces, several severe intracranial bleedings, and other injuries) was made. An unfavorable outcome was initially expected due to suspected tetraplegia and his inability to breathe following atlanto-occipital dislocation. Contrary to initial prognostication, after 22 days of intensive care treatment and four surgical interventions (halo fixation, tracheostomy, intracranial pressure probe, chest drains) he was awake and oriented, spontaneously breathing, and moving his arms and legs. Six weeks after the event he was able to walk without aid. After 2 months of clinical treatment he was able to manage all the activities of daily life on his own. It remains unclear, whether cardiac arrest due to a cardiac cause resulted in complete atony of the paravertebral muscles and caused this extremely severe lesion (atlanto-occipital dislocation) or whether cardiac arrest was caused by apnea due the paraplegia following the spinal injury of the trauma. CONCLUSIONS: A plausible cause for the trauma was myocardial infarction which led to the car accident and the major trauma in relation to the obviously minor trauma mechanism. With this case report we aim to familiarize clinicians with the mechanism of injury that will assist in the diagnosis of atlanto-occipital dislocation. Furthermore, we seek to emphasize that patients presenting with electrocardiographic signs of myocardial ischemia after high-energy trauma should primarily be transported to a trauma facility in a percutaneous coronary intervention-capable center rather than the catheterization laboratory directly.

Postoperative pain management in children: Guidance from the pain committee of the European Society for Paediatric Anaesthesiology (ESPA Pain Management Ladder Initiative).

The main remit of the European Society for Paediatric Anaesthesiology (ESPA) Pain Committee is to improve the quality of pain management in children. The ESPA Pain Management Ladder is a clinical practice advisory based upon expert consensus to help to ensure a basic standard of perioperative pain management for all children. Further steps are suggested to improve pain management once a basic standard has been achieved. The guidance is grouped by the type of surgical procedure and layered to suggest basic, intermediate, and advanced pain management methods. The committee members are aware that there are marked differences in financial and personal resources in different institutions and countries and also considerable variations in the availability of analgesic drugs across Europe. We recommend that the guidance should be used as a framework to guide best practice.

Efficacy of pre-hospital rapid sequence intubation in paediatric traumatic brain injury: A 9-year observational study.

INTRODUCTION: Prehospital airway management of the paediatric patient with traumatic brain injury (TBI) is controversial. Endotracheal intubation of children in the field requires specific skills and has potential benefits but also carries potentially serious complications. We aimed to compare mortality and functional outcomes after six months between children with TBI who either underwent prehospital rapid sequence intubation (RSI) by trained Intensive Care paramedics (ICP) or received no intubation. METHODS: We conducted a retrospective study of patients aged ≤14 years with suspected TBI in Victoria, Australia. Patients were either transported via helicopter and received RSI by an ICP (2005-2013) or via road ambulance and received no intubation (2006-2013). Prehospital data was linked to hospital and 6-month follow-up data to assess mortality and functional outcome. RESULTS: A total of 106 patients were included in the study of which 87 received RSI by paramedics and 19 did not receive intubation. Overall, the intubation success rate was 99% (86/87), with a first-pass success rate of 93% (81/87). In total, 67% of patients (n = 41) receiving RSI had a favourable functional outcome, compared with 54% of non-intubated patients (n = 7) (p = 0.36). In the 75 children with major trauma, prehospital RSI was associated with a significant decrease in length of hospital stay (523 h vs. 1939 h, p = 0.03). In the 53 children in this subgroup with available six months data the difference in favourable functional outcome increased to 66% (n = 31)vs. 17% (n = 1) (p = 0.06). DISCUSSION: Prehospital RSI in paediatric patients with TBI can safely be performed by highly trained paramedics. Overall, we observed more favourable long-term outcomes in patients who received prehospital intubation than those who did not, however our study is not powered to detect a significant difference. Intubation prior to transport might be beneficial for major trauma patients.

Prehospital transfusion of red cell concentrates in a paramedic-staffed helicopter emergency medical service.

OBJECTIVE: The optimal volume and type of intravenous fluid for the treatment of blood loss in the prehospital setting is controversial. The use of red cell concentrates (RCCs) may be associated with improved outcomes; however, the administration of blood products is limited to physicians in many jurisdictions. We sought to describe the characteristics of RCC transfusions in a paramedic-staffed helicopter emergency medical system in Victoria, Australia. METHODS: We performed a retrospective analysis of all cases where paramedics consulted the responsible physician for approval of RCC transfusion between July 2011 and December 2015 in Victoria, Australia. Ambulance data was retrieved from electronic patient care records and hospital and outcome data was retrieved from a state-wide trauma registry. RESULTS: A total of 180 primary missions was identified where paramedics requested approval for transfusion of RCCs during the study period. A total of 150 patients received prehospital RCCs, of which 136 had suffered trauma. The majority of these patients were male (66.7%) and were involved in a car accident (62.5%). Most (97.4%) patients had an Injury Severity Score ≥12. There were improvements in median systolic blood pressure (80 mmHg vs 94 mmHg, P < 0.001) and shock index (1.50 vs 1.23, P < 0.001) between time of consultation and arrival at hospital. Overall, mortality for trauma patients was 37.7%. There were no transfusion-related complications identified. CONCLUSION: Prehospital transfusion of RCC by paramedics is feasible. Future studies should compare the outcomes of patients receiving prehospital RCCs with outcomes for patients in which RCCs are administered in hospital.

Hypoxic vascular response and ventilation/perfusion matching in end-stage COPD may depend on p22phox.

Chronic obstructive pulmonary disease (COPD) is a heterogeneous disease in which the amount of emphysema and airway disease may be very different between individuals, even in end-stage disease. Emphysema formation may be linked to the involvement of the small pulmonary vessels. The NAPDH oxidase (Nox) family is emerging as a key disease-related factor in vascular diseases, but currently its role in hypoxia-induced pulmonary remodelling in COPD remains unclear.Here we investigate the role of p22phox, a regulatory subunit of Nox, in COPD lungs, hypoxic pulmonary vasoconstriction (HPV), hypoxia-induced pulmonary vascular remodelling and pulmonary hypertension.In COPD, compared to control lungs, p22phox expression was significantly reduced. The expression was correlated positively with mean pulmonary arterial pressure and oxygenation index and negatively with the diffusing capacity of the lung for carbon monoxide (p<0.02). This suggests a role of p22phox in ventilation/perfusion ratio matching, vascular remodelling and loss of perfused lung area. In p22phox-/- mice, HPV was significantly impaired. In the chronic hypoxic setting, lack of p22phox was associated with improved right ventricular function and decreased pulmonary vascular remodelling.p22phox-dependent Nox plays an important role in the COPD phenotype, by its action on phase II HPV and chronic vascular remodelling.

Amitriptyline and carbamazepine utilize voltage-gated ion channel suppression to impair excitability of sensory dorsal horn neurons in thin tissue slice: An in vitro study.

Amitriptyline, carbamazepine and gabapentin are often used for the treatment of neuropathic pain. However, their analgesic action on central sensory neurons is still not fully understood. Moreover, the expression pattern of their target ion channels is poorly elucidated in the dorsal horn of the spinal cord. Thus, we performed patch-clamp investigations in visualized neurons of lamina I-III of the spinal cord. The expression of the different voltage-gated ion channels, as the targets of these drugs, was detected by RT-PCR and immunohistochemistry. Neurons of the lamina I-III express the TTX-sensitive voltage-gated Na(+) as well as voltage-gated K(+) subunits assembling the fast inactivating (A-type) currents and the delayed rectifier K(+) currents. Our pharmacological studies show that tonically-firing, adapting-firing and single spike neurons responded dose-dependently to amitriptyline and carbamazepine. The ion channel inhibition consecutively reduced the firing rate of tonically-firing and adapting-firing neurons. This study provides evidence for the distribution of voltage-gated Na(+) and K(+) subunits in lamina I-III of the spinal cord and for the action of drugs used for the treatment of neuropathic pain. Our work confirms that modulation of voltage-gated ion channels in the central nervous system contributes to the antinociceptive effects of these drugs.

A Paramedic-staffed Helicopter Emergency Medical Service's Response to Winch Missions in Victoria, Australia.

Winching emergency medical care providers from a helicopter to the scene enables treatment of patients in otherwise inaccessible locations, but is not without risks. The objective of this study was to define characteristics of winch missions undertaken by Intensive Care Flight Paramedics (ICFP) in Victoria, Australia with a focus on extraction methods and clinical care delivered at the scene. A retrospective data analysis was performed to identify all winch missions between November 2010 and March 2014. Demographic data, winch characteristics, physiological parameters, and interventions undertaken on scene by the ICFP were extracted. Out of 5,003 missions in the study period, 125 were identified as winch operations. Winter missions were significantly less frequent than those of any other season. Patients were predominantly male (78.4%) and had a mean age of 38 years (±17.6). A total of 109 (87.2%) patients were identified as experiencing trauma with a mean Revised Trauma Score of 7.5288, and isolated limb fractures were the most frequently encountered injury. Falls and vehicle-related trauma were the most common mechanisms of injury. The total median scene duration was 49 minutes (IQR 23-91). Sixty-three patients (50.4%) were extracted using a stretcher, 45 (36.0%) using a hypothermic strop, and 6 (4.8%) via normal rescue strop. Eleven patients (8.8%) were not winched to the helicopter. Vascular access (38.4%), analgesia (44.0%), and anti-emetic administration (28.8%) were the most frequent clinical interventions. Forty-nine patients (39.2%) did not receive any clinical intervention prior to winch extraction. Winch operations in Victoria, Australia consisted predominantly of patients with minor to moderate traumatic injuries. A significant proportion of patients did not require any clinical treatment prior to winching, and among those who did, analgesia was the most frequent intervention. Advanced medical procedures were rarely required prior to winch extraction.