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Background Selection of incidents and accurate identification of patients that require assistance from physician-staffed emergency medical services (P-EMS) remain essential. We aimed to evaluate P-EMS availability, the underlying criteria for dispatch, and the corresponding dispatch accuracy of trauma care in south-east Norway in 2015, to identify areas for improvement. Methods Pre-hospital data from emergency medical coordination centres and P-EMS medical databases were linked with data from the Norwegian Trauma Registry (NTR). Based on a set of conditions (injury severity, interventions performed, level of consciousness, incident category), trauma incidents were defined as complex, warranting P-EMS assistance, or non-complex. Incident complexity and P-EMS involvement were the main determinants when assessing the triage accuracy. Undertriage was adjusted for P-EMS availability and response and transport times. Results Among 19,028 trauma incidents, P-EMS were involved in 2506 (13.2%). The range of overtriage was 74–80% and the range of undertriage was 20–32%. P-EMS readiness in the event of complex incidents ranged from 58 to 70%. The most frequent dispatch criterion was “Police/fire brigade request immediate response” recorded in 4321 (22.7%) of the incidents. Criteria from the groups “Accidents” and “Road traffic accidents” were recorded in 10,875 (57.2%) incidents, and criteria from the groups “Transport reservations” and “Unidentified problem” in 6025 (31,7%) incidents. Among 4916 patient pathways in the NTR, 681 (13.9%) could not be matched with pre-hospital data records. Conclusions Both P-EMS availability and dispatch accuracy remain suboptimal in trauma care in south-east Norway. Dispatch criteria are too vague to facilitate accurate P-EMS dispatch, and pre-hospital data is inconsistent and insufficient to provide basic data for scientific research. Future dispatch criteria should focus on the care aspect of P-EMS. Better tools for both dispatch and incident handling for the emergency medical coordination centres are essential. In general, coordination, standardisation, and integration of existing data systems should enhance the quality of trauma care and increase patient safety.

Background Efficient and timely airway management is universally recognised as a priority for major trauma patients, a proportion of whom require emergency intubation in the pre-hospital setting. Adverse events occur more commonly in emergency airway management, and hypoxia is relatively frequent. The aim of this study was to establish whether passive apnoeic oxygenation was effective in reducing the incidence of desaturation during pre-hospital emergency anaesthesia. Methods A prospective before-after study was performed to compare patients receiving standard care and those receiving additional oxygen via nasal prongs. The primary endpoint was median oxygen saturation in the peri-rapid sequence induction period, (2 minutes pre-intubation to 2 minutes post-intubation) for all patients. Secondary endpoints included the incidence of hypoxia in predetermined subgroups. Results Of 725 patients included; 188 patients received standard treatment and 537 received the intervention. The overall incidence of hypoxia (first recorded SpO2 2 2 Median SpO2 was 100% vs. 99% for the standard vs. intervention group. There was a statistically significant benefit from apnoeic oxygenation in reducing the frequency of peri-intubation hypoxia (SpO2 2 > 95%, p = 0.0001. The other significant benefit was observed in the recovery phase for patients with severe hypoxia prior to intubation. Conclusion Apnoeic oxygenation did not influence peri-intubation oxygen saturations, but it did reduce the frequency and duration of hypoxia in the post-intubation period. Given that apnoeic oxygenation is a simple low-cost intervention with a low complication rate, and that hypoxia can be detrimental to outcome, application of nasal cannulas during the drug-induced phase of emergency intubation may benefit a subset of patients undergoing emergency anaesthesia.

The European HEMS and Air ambulance Committee’s Medical working group recently published Best Practice advice on pre-hospital emergency anaesthesia and advanced airway management. We believe that this initiative is important. In our opinion however, the competence requirements recommended by the authors do not meet the standards that we should aim for in HEMS services. We argue that pre-hospital emergency anaesthesia should be delivered with a competence level approximating in-hospital standard. In our experience, our patients benefit from pre-hospital emergency anaesthesia delivered by consultants with regular in-hospital rotations and a sound clinical governance system.

Background Helicopter EMS (HEMS) teams may perform a variety of clinical, managerial and transport functions during major incident management. Despite national and international variations in HEMS systems, the rapid delivery of HEMS personnel with advanced skills in major incident management and clinical scene leadership has been crucial to the delivery of an effective medical response at previous incidents. This document outlines the Best Practice Advice of the European HEMS and Air Ambulance Committee (EHAC) Medical Working Group on how HEMS and Pre Hospital Critical Care teams may maximise the positive impact of their resources in the event of Major Incidents. Methods Narrative literature review and expert consensus. Results To ensure a safe, coordinated and effective response, HEMS teams require suitable, proportionate and up to date major incident plans that are integrated into the major incident plans of other regional emergency and healthcare services. Role specific protocols, training and equipment should be adapted to the expected HEMS role in the major incident plan and likely regional threats. System and incident factors will influence HEMS utilisation during the major incident response and can include patient and staff transfer, equipment resupply, aerial assessment, search and rescue, clinical leadership and advanced care. During the recovery phase of a major incident there is a need to ensure restoration of conventional service and address the welfare of involved HEMS personnel. Standardised reporting of major incidents is strongly recommended for clinical governance, legal and research reasons. Conclusions The rapid delivery of HEMS personnel with advanced skills in Major Incident management and clinical scene leadership is crucial to the delivery of an effective medical response at Major Incidents.

Background: Pre-hospital basic airway interventions can be ineffective at providing adequate oxygenation and ventilation in some severely ill or injured patients, and advanced airway interventions are then required. Controversy exists regarding the level of provider required to perform successful pre-hospital intubation. A previous meta-analysis reported pre-hospital intubation success rates of 0.849 for non-physicians versus 0.991 for physicians. The evidence base on the topic has expanded significantly in the last 10 years. This study systematically reviewed recent literature and presents comprehensive data on intubation success rates. Methods: A systematic search of MEDLINE and EMBASE was performed using PRISMA methodology to identify articles on pre-hospital tracheal intubation published between 2006 and 2016. Overall success rates were estimated using random effects meta-analysis. The relationship between intubation success rate and provider type was assessed in weighted linear regression analysis. Results: Of the 1838 identified studies, 38 met the study inclusion criteria. Intubation was performed by non-physicians in half of the studies and by physicians in the other half. The crude median (range) reported overall success rate was 0.969 (0.616–1.000). In random effects meta-analysis, the estimated overall intubation success rate was 0.953 (0.938–0.965). The crude median (range) reported intubation success rates for non-physicians were 0.917 (0.616–1.000) and, for physicians, were 0.988 (0.781–1.000) (p = 0.003). Discussion: The reported overall success rate of pre-hospital intubation has improved, yet there is still a significant difference between non-physician and physician providers. The finding that less-experienced personnel perform less well is not unexpected, but since there is considerable evidence that poorly performed intubation carries a significant risk of morbidity and mortality careful consideration should be given to the training and experience required to deliver this intervention safely.

Pre-hospital critical care is considered to be a complex intervention with a weak evidence base. In quality improvement literature, the value equation has been used to depict the inevitable relationship between resources expenditure and quality. Increased value of pre-hospital critical care involves moving a system from quality assurance to quality improvement. Agreed quality indicators can be integrated in existing quality improvement and complex intervention methodology. A QI system for pre-hospital critical care includes leadership involvement, multi-disciplinary buy-in, data collection infrastructure and long-term commitment. Further, integrating process control with governance systems allows evidence-based change of practice and publishing of results.

Introduction: Although tracheal intubation (TI) in the pre-hospital setting is regularly carried out by emergency medical service (EMS) providers throughout the world, its value is widely debated. Heterogeneity in procedures, providers, patients, systems and stated outcomes, and inconsistency in data reporting make scientific reports difficult to interpret and compare, and the majority are of limited quality. To hunt down what is really known about the value of pre-hospital TI, we determined the rate of reported Utstein airway variables (28 core variables and 12 fixed-system variables) found in current scientific publications on pre-hospital TI. Methods: We performed an all time systematic search according to the PRISMA guidelines of Medline and EMBASE to identify original research pertaining to pre-hospital TI in adult patients. Results: From 1,076 identified records, 73 original papers were selected. Information was extracted according to an Utstein template for data reporting from in-the-field advanced airway management. Fifty-nine studies were from North American EMS systems. Of these, 46 (78%) described services in which non-physicians conducted TI. In 12 of the 13 non-North American EMS systems, physicians performed the pre-hospital TI. Overall, two were randomised controlled trials (RCTs), and 65 were observational studies. None of the studies presented the complete set of recommended Utstein airway variables. The median number of core variables reported was 10 (max 21, min 2, IQR 8-12), and the median number of fixed system variables was 5 (max 11, min 0, IQR 4-8). Among the most frequently reported variables were “patient category” and “service mission type”, reported in 86% and 71% of the studies, respectively. Among the least-reported variables were “co-morbidity” and “type of available ventilator”, both reported in 2% and 1% of the studies, respectively. Conclusions: Core data required for proper interpretation of results were frequently not recorded and reported in studies investigating TI in adults. This makes it difficult to compare scientific reports, assess their validity, and extrapolate to other EMS systems. Pre-hospital TI is a complex intervention, and terminology and study design must be improved to substantiate future evidence based clinical practice. publishedVersion

Background Internal bleeding from pelvic fractures is difficult to stop with external compression and necessitates other resuscitation techniques such as endovascular balloon occlusion of the aorta (REBOA). This minimally invasive procedure stops the bleeding by inflating a balloon in the aorta, and has been used successfully in emergency departments and operations theaters. If REBOA also is feasible in the pre-hospital environment is unknown.

Methods A systematic review was conducted according to the PRISMA guidelines. The protocol for the study was registered in PROSPERO and published in BMJ Open (1). In the search strategy the first set of entry terms describes major incidents published during the last 20 years. The second set of entry terms describes templates for collecting data from such incidents. Predefined free search phases were combined with the first two sets. A modified search strategy was used for the grey literature. The articles that were included were subjected to quality analysis. Reference lists of included literature were hand searched.

Although trauma remains a significant contributor to the global burden of disease, trauma research remains uncoordinated and often of low quality. Research efforts aiming to improve trauma care are drastically underfunded and global research strategies to address core challenges are missing [1,2]. The responsibility for this state lies partially within the trauma academic community and efforts to coordinate research programmes are called for. It was therefore very welcome that Professor Karim Brohi chaired a session dedicated to trauma research on the final day of the London trauma conference 2012. The session included speakers describing activity organised by UK research centres. A common theme was how the establishment of trauma networks offers new research opportunities [3]. The trauma system has the potential to facilitate robust epidemiological and public health research necessary for evidence-based system revisions. Further, formal trauma networks bridge the gap between clinical and basic science research. Pending clearly defined relationships, the trauma networks also facilitate cooperation with the medical industry to make quality improvement initiatives more effective. London is the worlds largest single trauma system and it provides opportunities for robust data collection from the scene of injury throughout rehabilitation. Such data may facilitate long-awaited high quality observational studies and randomized controlled trials on both primary and secondary preventive measures. Contemporary trauma research is heavily influenced by the current conflict in Afghanistan. Increased military funding has enabled studies to be performed on many aspects of trauma care from pre-hospital interventions to rehabilitation several of which were described in this session. Although the populations differ with respect to age, gender and co-morbidities, some data collected from the battlefield are considered transferable to the civilian community. A feasibility study of using rotational thromboelastometry to assess coagulation status of combat casualties in a deployed setting provides an example of how military research brings science to the front line [4]. Further, the high number of soldiers returning with lost limbs has initiated research programs into reconstructive challenges. As Western involvement in the Afghanistan conflict draws to an end, the destiny of military funded trauma research remains uncertain. Civilian and military clinicians share interests in unresolved challenges pertaining to areas such as nerve tissue damage and coagulation. Hypothesis on whether minor head injury can prime inflammation in the brain that may lead to neurodegenerative diseases are currently being investigated. Further, studies on neuroprotective agents for brain and spinal cord injury aims to reduce the morbidity that traumatic brain injury carries. Neuroprotection is also an essential component to improve outcome after peripheral injury. Ongoing studies of reconstruction of nerve conduction through pharmacological intervention shows promising results [5]. Lastly, haemorrhage is a major cause of trauma deaths and translational research on coagulopathy, transfusion and pro-coagulant therapies is currently conducted on several centres. High-achieving research groups rely on not only support from within their own institution but, interdisciplinary relations as well as national and international networks. These interfaces serve to improve quality and recruit financial and human resources. Research decision-makers are required to map out the need to establish new centres or where it is more cost-effective to tap into existing research clusters. Regardless, the importance of networks was exemplified in trials such as the DRAFFT-study on distal radius fractures, where inclusion rates where good [6]. Lessons can also be learned from areas such as critical care where several randomised controlled trials on core topics such as sepsis have been conducted. However, research on time-critical emergencies remains a challenge as they deviate from planned and organized environments. High-quality data is a prerequisite to conduct high-quality trials. Optimal data collection involves automatic linkage between databases and bulk uploads to registries such as The UK Trauma Audit and Research Network (TARN). Areas for improvements in data collection include minimizing manual data collection and enabling research nurses to attend trauma meetings. Cancer registries serve as role models with their long tradition for providing reliable and valid data. The day ended with updates on large, on-going trials such as CRASH 3 [7] and CRYOSTAT [8]. Hopefully, robust international trauma networks will, in the future, attract investment funding in trauma research. Our patients deserve trials with rapid recruitment timelines with greater capacity and diversity to make an impact on clinical practice and improve outcome.