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Lockey D.J.,North Bristol NHS Trust | Crewdson K.,Londons Air Ambulance | Lossius H.M.,Norwegian Air Ambulance Foundation | Lossius H.M.,University of Stavanger
British Journal of Anaesthesia | Year: 2014

Advanced airway management is one of the most controversial areas of pre-hospital trauma care and is carried out by different providers using different techniques in different Emergency Medical Services systems. Pre-hospital anaesthesia is the standard of care for trauma patients arriving in the emergency department with airway compromise. A small proportion of severely injured patients who cannot be managed with basic airway management require pre-hospital anaesthesia to avoid death or hypoxic brain injury. The evidence base for advanced airway management is inconsistent, contradictory and rarely reports all key data. There is evidence that poorly performed advanced airway management is harmful and that less-experienced providers have higher intubation failure rates and complication rates. International guidelines carry many common messages about the system requirements for the practice of advanced airway management. Pre-hospital rapid sequence induction (RSI) should be practiced to the same standard as emergency department RSI. Many in-hospital standards such as monitoring, equipment, and provider competence can be achieved. Pre-hospital and emergency in-hospital RSI has been modified from standard RSI techniques to improve patient safety, physiological disturbance, and practicality. Examples include the use of opioids and long-acting neuromuscular blocking agents, ventilation before intubation, and the early release of cricoid pressure to improve laryngoscopic view. Pre-hospital RSI is indicated in a small proportion of trauma patients. Where pre-hospital anaesthesia cannot be carried out to a high standard by competent providers, excellent quality basic airway management should be the mainstay of management. © 2014 The Author 2014. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved.


Hagemo J.S.,Norwegian Air Ambulance Foundation | Hagemo J.S.,University of Oslo
Transfusion | Year: 2013

Increased focus on traumatic coagulopathy over the last decade has led to more aggressive use of hemostatic agents in resuscitation of the massively bleeding patient. Novel formulations of plasma factors and other therapeutics have opened for early intervention to prevent coagulopathy and may even be utilized in the prehospital setting. Careful selection of patients to receive hemostatic agents early during the resuscitation is of great importance due to the potential detrimental effects of this treatment. Several studies have identified coagulation parameters as reliable predictors of massive transfusion, even very early after trauma. Prothrombin time international normalized ratio (PT/INR), activated partial thromboplastin time (aPTT), fibrinogen concentration, and viscoelastic tests such as thrombelastography (TEG) and rotational thrombelastometry (RoTEM) have proved to be of value in predicting massive transfusion when performed in-hospital. PT/INR appears to be slightly more accurate than the other parameters, with a reported sensitivity of 84.8% and an area under the receiver operating curve of 0.87. Comparison studies on PT/INR, aPTT, and viscoelastic assays do suggest that caution should be taken when point-of-care (POC) methods, as opposed to conventional laboratory analyses, are used. Novel techniques for POC measurement of fibrinogen levels are currently being developed, and preclinical data suggest acceptable agreement with conventional methods. A number of factors should be considered regarding the feasibility of POC tests in the prehospital environment. In addition to environmental factors such as temperature, altitude, and humidity, electromagnetic interference issues and operators' skills must be taken into account. Coagulation parameters appear to be a useful tool in identifying patients with increased risk of massive bleeding at an early stage. Further studies are needed to determine if prehospital intervention based on POC analyses improves outcome.


Oveland N.P.,Norwegian Air Ambulance Foundation | Lossius H.M.,Norwegian Air Ambulance Foundation | Lossius H.M.,University of Stavanger | Lossius H.M.,University of Bergen | And 4 more authors.
Chest | Year: 2013

Background: Although thoracic ultrasonography accurately determines the size and extent of occult pneumothoraces (PTXs) in spontaneously breathing patients, there is uncertainty about patients receiving positive pressure ventilation. We compared the lung point (ie, the area where the collapsed lung still adheres to the inside of the chest wall) using the two modalities ultrasonography and CT scanning to determine whether ultrasonography can be used reliably to assess PTX progression in a positive-pressure-ventilated porcine model. Methods: Air was introduced in incremental steps into fi ve hemithoraces in three intubated porcine models. The lung point was identifi ed on ultrasound imaging and referenced against the lateral limit of the intrapleural air space identifi ed on the CT scans. The distance from the sternum to the lung point (S-LP) was measured on the CT scans and correlated to the insuffl ated air volume. Results: The mean total difference between the 131 ultrasound and CT scan lung points was 6.8 mm (SD, 7.1 mm; range, 0.0-29.3 mm). A mixed-model regression analysis showed a linear relationship between the S-LP distances and the PTX volume ( P , .001). Conclusions: In an experimental porcine model, we found a linear relation between the PTX size and the lateral position of the lung point. The accuracy of thoracic ultrasonography for identifying the lung point (and, thus, the PTX extent) was comparable to that of CT imaging. These clinically relevant results suggest that ultrasonography may be safe and accurate in monitoring PTX progression during positive pressure ventilation. CHEST 2013; 143(2):415-422 © 2013 American College of Chest Physicians.


Jones J.M.,Staffordshire University | Skaga N.O.,University of Oslo | SOvik S.,Akershus University Hospital | SOvik S.,University of Oslo | And 2 more authors.
Acta Anaesthesiologica Scandinavica | Year: 2014

Introduction Anatomic injury, physiological derangement, age, and injury mechanism are well-founded predictors of trauma outcome. We aimed to develop and validate the first Scandinavian survival prediction model for trauma. Methods Eligible were patients admitted to Oslo University Hospital Ullevål within 24 h after injury with Injury Severity Score ≥ 10, proximal penetrating injuries or received by a trauma team. The derivation dataset comprised 5363 patients (August 2000 to July 2006); the validation dataset comprised 2517 patients (August 2006 to July 2008). Exclusion because of missing data was < 1%. Outcome was 30-day mortality. Logistic regression analysis incorporated fractional polynomial modelling and interaction effects. Model validation included a calibration plot, Hosmer-Lemeshow test and receiver operating characteristic (ROC) curves. Results The new survival prediction model included the anatomic New Injury Severity Score (NISS), Triage Revised Trauma Score (T-RTS, comprising Glascow Coma Scale score, respiratory rate, and systolic blood pressure), age, pre-injury co-morbidity scored according to the American Society of Anesthesiologists Physical Status Classification System (ASA-PS), and an interaction term. Fractional polynomial analysis supported treating NISS and T-RTS as linear functions and age as cubic. Model discrimination between survivors and non-survivors was excellent. Area (95% confidence interval) under the ROC curve was 0.966 (0.959-0.972) in the derivation and 0.946 (0.930-0.962) in the validation dataset. Overall, low mortality and skewed survival probability distribution invalidated model calibration using the Hosmer-Lemeshow test. Conclusions The Norwegian survival prediction model in trauma (NORMIT) is a promising alternative to existing prediction models. External validation of the model in other trauma populations is warranted. © 2014 The Authors. The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.


Staff T.,Norwegian Air Ambulance Foundation | Staff T.,University of Oslo | Sovik S.,University of Oslo
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine | Year: 2011

Background: Few studies have evaluated pre-hospital documentation quality. We retrospectively assessed emergency medical service (EMS) documentation of key logistic, physiologic, and mechanistic variables in motor vehicle accidents (MVAs).Methods: Records from police, Emergency Medical Communication Centers (EMCC), ground and air ambulances were retrospectively collected for 189 MVAs involving 392 patients. Documentation of Glasgow Coma Scale (GCS), respiratory rate (RR), and systolic blood pressure (SBP) was classified as exact values, RTS categories, clinical descriptions enabling post-hoc inference of RTS categories, or missing. The distribution of values of exact versus inferred RTS categories were compared (Chi-square test for trend).Results: 25% of ground and 11% of air ambulance records were unretrieveable. Patient name, birth date, and transport destination was documented in >96% of ambulance records and 81% of EMCC reports. Only 54% of patient encounter times were transmitted to the EMCC, but 77% were documented in ground and 96% in air ambulance records. Ground ambulance records documented exact values of GCS in 48% and SBP in 53% of cases, exact RR in 10%, and RR RTS categories in 54%. Clinical descriptions made post-hoc inference of RTS categories possible in another 49% of cases for GCS, 26% for RR, and 20% for SBP. Air ambulance records documented exact values of GCS in 89% and SBP in 84% of cases, exact RR in 7% and RR RTS categories in 80%. Overall, for lower RTS categories of GCS, RR and SBP the proportion of actual documented values to inferred values increased (All: p < 0.001). Also, documentation of repeated assessment was more frequent for low RTS categories of GCS, RR, and SBP (All: p < 0.001). Mechanism of injury was documented in 80% of cases by ground and 92% of cases by air ambulance.Conclusion: EMS documentation of logistic and mechanistic variables was adequate. Patient physiology was frequently documented only as descriptive text. Our finding indicates a need for improved procedures, training, and tools for EMS documentation. Documentation is in itself a quality criterion for appropriate care and is crucial to trauma research. © 2011 Staff and Søvik; licensee BioMed Central Ltd.

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