Results using videolaryngoscopy in pre-hospital rapid sequence intubation are mixed. A bougie is not commonly used with videolaryngoscopy. We hypothesised that using videolaryngoscopy and a bougie as core elements of a standardised protocol that includes a drugs and a laryngoscopy algorithm would result in a high first-pass tracheal intubation success rate. We employed videolaryngoscopy (C-MAC) combined with a bougie (Frova intubating introducer) in an anaesthetist-staffed helicopter emergency medical service. Data for adult tracheal intubation were collected prospectively as part of the airway registry of our unit for 22 months after implementation of the protocol (n = 543) and compared with controls (n = 238) treated in the previous year before the implementation. The mean first-pass success rate (95%CI) was 98.2% (96.6-99.0%) in the study group and 85.7% (80.7-89.6%) in the control group, p < 0.0001. Combining C-MAC videolaryngoscopy and bougie with a standardised rapid sequence induction protocol leads to a high first attempt intubation success rate when performed by an anaesthetist-led helicopter emergency medical service team.

While prehospital blood transfusion (PHBT) for trauma patients has been established in many services, the literature on PHBT use for nontrauma patients is limited. We aimed to describe and compare nontrauma and trauma patients receiving PHBT who had similar hemodynamic triggers. Methods. We analyzed 3.5 years of registry data from a single prehospital critical care unit. The PHBT protocol included two packed red blood cell units and was later completed with two freeze-dried plasma units. The transfusion triggers were a strong clinical suspicion of massive hemorrhage and systolic blood pressure below 90 mmHg or absent radial pulse. Results. Thirty-six nontrauma patients and 96 trauma patients received PHBT. The nontrauma group had elderly patients (median 65 [interquartile range, IQR, 56-73] vs A c c e p t e d M a n u s c r i p t 2 37 [IQR 25-57] years, p < 0.0001) and included patients with gastrointestinal bleeding (n = 15; 42%), vascular catastrophes (n = 9; 25%), postoperative bleeding (n = 6; 17%), obstetrical bleeding (n = 4; 11%) and other (n = 2; 6%). Cardiac arrest occurred in nine (25%) nontrauma and in 15 (16%) trauma patients. Of these, 5 (56%) and 10 (67%) survived to hospital admission and 3 (33%) and 2 (13%) to hospital discharge. On admission, the nontrauma patients had lower hemoglobin (median 95 [84-119] vs 124 [108-133], p < 0.0001), higher pH (median 7.40 [7.27-7.44] vs 7.30 [7.19-7.36], p = 0.0015) and lower plasma thromboplastin time (median 55 [45-81] vs 72 [58-86], p = 0.0261) than the trauma patients. Conclusions. We identified four nontrauma patient groups in need of PHBT, and the patients appeared to be seriously ill. Efficacy of prehospital transfusion in nontrauma patients should be evaluated futher in becoming studies.

Background: High oxygen levels may worsen cardiac arrest reperfusion injury. We determined the incidence of hyperoxia during and immediately after successful cardiopulmonary resuscitation and identified factors associated with intra-arrest cerebral oxygenation measured with near-infrared spectroscopy (NIRS).Methods: A prospective observational study of out-of-hospital cardiac arrest patients treated by a physician-staed helicopter unit. Collected data included intra-arrest brain regional oxygen saturation (rSO 2 ) with NIRS, invasive blood pressures, end-tidal CO 2 (etCO 2 ) and arterial blood gas samples. Moderate and severe hyperoxia were defined as arterial oxygen partial pressure (paO 2 ) 20.0-39.9 and !40 kPa, respectively. Intra-arrest factors correlated with the NIRS value, rSO 2, were assessed with the Spearman's correlation test.Results: Of 80 recruited patients, 73 (91%) patients had rSO 2 recorded during CPR, and 46 had an intra-arrest paO 2 analysed. ROSC was achieved in 28 patients, of whom 20 had paO 2 analysed. Moderate hyperoxia was seen in one patient during CPR and in four patients (20%, 95% CI 7-42%) after ROSC. None had severe hyperoxia during CPR, and one patient (5%, 95% 0-25%) immediately after ROSC. The rSO 2 during CPR was correlated with intra-arrest systolic (r = 0.28, p < 0.001) and diastolic blood pressure (p = 0.32, p < 0.001) but not with paO 2 (r = 0.13, p = 0.41), paCO 2 (r = 0.18, p = 0.22) or etCO 2 (r = 0.008, p = 0.9). Conclusion:Hyperoxia during or immediately after CPR is rare in patients treated by physician-staed helicopter units. Cerebral oxygenation during CPR appears more dependent, albeit weakly, on hemodynamics than arterial oxygen concentration.

BackgroundHyperglycemia is common and associated with increased mortality after out-of-hospital cardiac arrest (OHCA) and return of spontaneous circulation (ROSC). Mechanisms behind ultra-acute hyperglycemia are not well known. We performed an explorative study to describe the changes in glucose metabolism mediators during the prehospital postresuscitation phase.MethodsWe included patients who were successfully resuscitated from out-of-hospital cardiac arrest in two physician-staffed units. Insulin, glucagon, and glucagon-like peptide 1 (GLP-1) were measured in prehospital and hospital admission samples. Additionally, interleukin-6 (IL-6), cortisol, and HbA1c were measured at hospital admission.ResultsThirty patients participated in the study. Of those, 28 cases (71% without diabetes) had sufficient data for analysis. The median time interval between prehospital samples and hospital admission samples was 96 minutes (IQR 85–119). At the time of ROSC, the patients were hyperglycemic (11.2 mmol/l, IQR 8.8–15.7), with insulin and glucagon concentrations varying considerably, although mostly corresponding to fasting levels (10.1 mU/l, IQR 4.2–25.2 and 141 ng/l, IQR 105–240, respectively). GLP-1 increased 2- to 8-fold with elevation of IL-6. The median glucose change from prehospital to hospital admission was -2.2 mmol/l (IQR -3.6 to -0.2). No significant correlations between the change in plasma glucose levels and the changes in insulin (r = 0.30, p = 0.13), glucagon (r = 0.29, p = 0.17), or GLP-1 levels (r = 0.32, p = 0.15) or with IL-6 (r = (-0.07), p = 0.75), cortisol (r = 0.13, p = 0.52) or HbA1c levels (r = 0.34, p = 0.08) were observed. However, in patients who did not receive exogenous epinephrine during resuscitation, changes in blood glucose correlated with changes in insulin (r = 0.59, p = 0.04) and glucagon (r = 0.65, p = 0.05) levels, demonstrating that lowering glucose values was associated with a simultaneous lowering of insulin and glucagon levels.ConclusionsHyperglycemia is common immediately after OHCA and cardiopulmonary resuscitation. No clear hormonal mechanisms were observed to be linked to changes in glucose levels during the postresuscitation phase in the whole cohort. However, in patients without exogenous epinephrine treatment, the correlations between glycemic and hormonal changes were more obvious. These results call for future studies examining the mechanisms of postresuscitation hyperglycemia and the metabolic effects of the global ischemic insult and medical treatment.

Background Normoventilation is crucial for many critically ill patients. Ventilation is routinely guided by end‐tidal capnography during prehospital anaesthesia, based on the assumption of the gap between arterial partial pressure of carbon dioxide (PaCO2) and end‐tidal carbon dioxide partial pressure (PetCO2) of approximately 0.5 kPa (3.8 mmHg). Methods We retrospectively analysed the airway registry and patient chart data of patients who had been anaesthetised and intubated endotracheally by the prehospital critical care team and had their prehospital arterial blood gases analysed. Bland‐Altman analysis was used to estimate the bias and limits of agreement. Results Altogether 502 patients were included in the study, with a median age of 58 years. The most common patient groups were post‐resuscitation (155, 31%), neurological emergencies (96, 19%), intoxication (75, 15%) and trauma (68, 14%). The median of the gap between PaCO2 and PetCO2 was 1.3 kPa (interquartile range 0.7 to 2.2) (9.8 (5.3‐16.5) mmHg). Mean bias of PetCO2 was −1.6 kPa/12.0 mmHg (standard deviation 1.7 kPa/12.8 mmHg) with 95% confidence limits of agreement −4.9 to 1.9 kPa (−36.8 to 14.3 mmHg). The gap was ≥ 1.0 kPa (>7.5 mmHg) in 297 (66%, 95% confidence interval 55 to 63) patients. Conclusion Our results suggest that end‐tidal capnography alone might not be an adequate method to achieve normoventilation for critically ill patients intubated and mechanically ventilated in prehospital setting. Thus, an arterial blood gas analysis might be useful to recognize patients with an increased gap between PaCO2 and PetCO2.

ABSTRACT.Purpose: To describe a new treatment protocol to deliver panretinal photocoagulation that may avoid further deterioration of vision in patients with type 1 diabetes mellitus with proliferative retinopathy with high risk characteristics for severe visual loss and cystoid macular oedema. Methods: Fundus photography, measurement of foveal thickness with optical coherence tomography and best corrected visual acuity (BCVA) determined by Snellen and ETDRS charts were measured before and after treatment in a 28-year-old man. Results: Over 9 weeks, BCVA improved from 0.05 to 0.25 and the number of letters read at 2 metres from four to 39 after panretinal photocoagulation and adjuvant intravitreal triamcinolone injection under intraconal anaesthesia. Foveal thickness decreased from 691 mm to 239 mm and cysts disappeared by 15 weeks. By 22 weeks, foveal thickness had increased to 282 mm and small cysts had reappeared, but BCVA remained at 0.2 and the number of letters read at 30. Conclusion: Proliferative retinopathy regressed, cystoid macular oedema disappeared and vision improved after panretinal photocoagulation and adjuvant intravitreal triamcinolone acetonide injection under intraconal anaesthesia. This represents a feasible option in cases where pain during laser treatment and impairment of vision afterwards due to cystoid macular oedema result in poor compliance with standard laser treatment under topical anaesthesia.

NIRS is feasible during pre-hospital anaesthesia and substantial changes were observed in some patients. It provides data beyond the standard monitoring used in the pre-hospital setting.

Aim Over the last decades out-of-hour services in Norway have been centralised to cover lager geographical areas, resulting in longer response times for the on-call GP. Reports indicate an unintended increase in requests of helicopter emergency medical services (HEMS) as a result. We aimed to investigate alteration in the requests for HEMS and NACAscore of the patients transported. Method In 2009 nine municipalities in the county of Sogn og Fjordane relocated all local out-of-hour services into one large casualty clinic (SYS-IKL). We included all primary HEMS requests in the county from 2004-2013 and compared missions within the area of SYS-IKL to missions in the rest of the county. Results Preliminary data included 7310 requests. Within SYS-IKL requests were 4.4 per week in the period. Completed and cancelled requests were 3.0 and 1.3 per week before 2009 compared to 2.7 and 1.6 per week after 2009. Outside SYS-IKL requests were 8.9 per week before 2009 and 10.4 per week after 2009. Completed and cancelled requests were 5.1 and 3.4 per week before 2009 compared to 5.5 and 4.6 per week after 2009. Mean NACA-score within SYS-IKL was 3.98 and 3.87 (p=0.115) compared to 3.78 and 3.77 (p=0,786) outside SYS-IKL before and after 2009, respectively. Conclusion Preliminary results did not confirm the hypothesised increase in use of HEMS or reduced NACA-score due to centralization of out-of-hour services. However, further statistical analyses are required. Conflict of interest None Funding Norwegian Air Ambulance Foundation.