SummaryUp to 75% of pre-hospital trauma patients experience moderate to severe pain but this is often poorly recognised and treated with insufficient analgesia. Using multi-level logistic regression analysis, we aimed to identify the determinants of pre-hospital analgesia administration and choice of analgesic agent in a single helicopter-based emergency medical service, where available analgesic drugs were fentanyl and ketamine. Of the 1156 patients rescued for isolated limb injury, 657 (57%) received analgesia. Mean (SD) initial pain scores (as measured by a numeric rating scale) were 2.8 (1.8), 3.3 (1.6) and 7.4 (2.0) for patients who did not receive, declined, and received analgesia, respectively (p < 0.001). Fentanyl as a single agent, ketamine in combination with fentanyl and ketamine as a single agent were used in 533 (84%), 94 (14%) and 10 (2%) patients, respectively. A high initial on-scene pain score and a presumptive diagnosis of fracture were the main determinants of analgesia administration. Fentanyl was preferred for paediatric patients and ketamine was preferentially administered for severe pain by physicians who had more medical experience or had trained in anaesthesia.

Background: The survival of completely buried victims in an avalanche mainly depends on burial duration. Knowledge is limited about survival probability after 60 min of complete burial. Aim:We aimed to study the survival probability and prehospital characteristics of avalanche victims with long burial durations. Methods:We retrospectively included all completely buried avalanche victims with a burial duration of !60 min between 1997 and 2018 in Switzerland.Data were extracted from the registry of the Swiss Institute for Snow and Avalanche Research and the prehospital medical records of the physicianstaffed helicopter emergency medical services. Avalanche victims buried for !24 h or with an unknown survival status were excluded. Survival probability was estimated by using the non-parametric AyerÀTurnbull method and logistic regression. The primary outcome was survival probability.Results: We identified 140 avalanche victims with a burial duration of !60 min, of whom 27 (19%) survived. Survival probability shows a slight decrease with increasing burial duration (23% after 60 min, to <6% after 1400 min, p = 0.13). Burial depth was deeper for those who died (100 cm vs 70 cm, p = 0.008). None of the survivors sustained CA during the prehospital phase. Conclusions:The overall survival rate of 19% for completely buried avalanche victims with a long burial duration illustrates the importance of continuing rescue efforts. Avalanche victims in CA after long burial duration without obstructed airway, frozen body or obvious lethal trauma should be considered to be in hypothermic CA, with initiation of cardiopulmonary resuscitation and an evaluation for rewarming with extracorporeal life support.

Objective: The delivery of a safe an effective analgesia is a core principle and a priority of prehospital care. Analgesia in hostile environments (mountain settings, etc.) presents various challenges, and the benefit-risk ratio of the procedure should be evaluated. The objective of this study was to examine pain management strategies and the time spent on scene for analgesia provisions in an alpine environment. Methods:We undertook a retrospective study from a single physician-staffed helicopter emergency medical service in the Swiss Alps. Patients with isolated limb injuries were included. We examined the choice and route of analgesic medication, patient monitoring, medical co-treatments and time delays during the rescue mission.Results: Analgesia was provided to 657 (57%) of the 1156 included patients. Fentanyl was most commonly administered followed by ketamine, with or without fentanyl. Heart rhythm monitoring, oxygen administration, and saline infusion were used infrequently, but were used significantly more often in patients treated with ketamine. The median time on site was 6 minutes longer for patients receiving intravenous analgesia compared with those not receiving it.Conclusion: Analgesia in hostile environments seems to be limited to essential procedures. The safety of this approach must be confirmed.

IntroductiondAlthough ketamine use in emergency medicine is widespread, studies investigating prehospital use are scarce. Our goal was to assess the self-reported modalities of ketamine use, knowledge of contraindications, and occurrence of adverse events associated with its use by physicians through a prospective online survey. MethodsdThe survey was administered to physicians working for Air-Glaciers, a Swiss alpine helicopter-based emergency service, and was available between September 24 and November 23, 2018. We enrolled 39 participants (participation rate of 87%) in our study and collected data regarding their characteristics, methods of ketamine use, knowledge of contraindications, and encountered side effects linked to the administration of ketamine. We also included a clinical scenario to investigate an analgesic strategy. ResultsdKetamine was considered safe and judged irreplaceable by most physicians. The main reason for ketamine use was acute analgesia during painful procedures, such as manipulation of femur fractures. The doses of ketamine administered with or without fentanyl ranged from 0.2 to 0.7 mg$kg-1 intravenously. Most physicians reported using fentanyl and midazolam along with ketamine. The median dose of midazolam was 2 (interquartile range 1e2) mg for a 70-kg adult. Monitoring and oxygen administration were used infrequently. Hallucinations were the most common adverse events. Knowledge of ketamine contraindications was poor. ConclusionsdKetamine use was reported by mountain rescue physicians to be safe and useful for acute analgesia. Most physicians use fentanyl and midazolam along with ketamine. Adverse neuropsychiatric events were rare. Knowledge regarding contraindications to the administration of ketamine should be improved.