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Background Delayed hypothermia, initiated after hospital arrival, several hours after cardiac arrest with 8-10 hours to reach the target temperature, is likely to have limited impact on overall survival. However, the effect of ultrafast hypothermia, i.e., delivered intra-arrest or immediately after return of spontaneous circulation (ROSC), on functional neurologic outcome after out -of -hospital cardiac arrest (OHCA) is unclear. In two prior trials, prehospital trans -nasal evaporative intra-arrest cooling was safe, feasible and reduced time to target temperature compared to delayed cooling. Both studies showed trends towards improved neurologic recovery in patients with shockable rhythms. The aim of the PRINCESS2-study is to assess whether cooling, initiated either intra-arrest or immediately after ROSC, followed by in -hospital hypothermia, significantly increases survival with complete neurologic recovery as compared to standard normothermia care, in OHCA patients with shockable rhythms. Methods/design In this investigator -initiated, randomized, controlled trial, the emergency medical services (EMS) will randomize patients at the scene of cardiac arrest to either trans -nasal cooling within 20 minutes from EMS arrival with subsequent hypothermia at 33 degrees C for 24 hours after hospital admission (intervention), or to standard of care with no prehospital or in -hospital cooling (control). Fever ( > 37,7 degrees C) will be avoided for the first 72 hours in both groups. All patients will receive post resuscitation care and withdrawal of life support procedures according to current guidelines. Primary outcome is survival with complete neurologic recovery at 90 days, defined as modified Rankin scale (mRS) 0-1. Key secondary outcomes include survival to hospital discharge, survival at 90 days and mRS 0-3 at 90 days. In total, 1022 patients are required to detect an absolute difference of 9% (from 45 to 54%) in survival with neurologic recovery (80% power and, Funding Agencies|Region Stockholm [520403]; Swedish Heart and Lung Foundation [20220688]

Tracheal intubation (TI) is often the preferred technique to secure the airway of an unconscious patient in the prehospital setting. Prehospital TI is associated with several challenges, including limited assistance, few airway rescue devices and environmental difficulties. An example of the latter is the occasional need for TI inside the cabin of an ambulance helicopter. The Nordic countries consist of both rural and urban areas with typically cold subarctic climate. The region is characterized by almost exclusive use of airway experts, mainly anaesthetists, for prehospital TI. The overall aim was to investigate prehospital advanced airway management in Nordic countries with regard to success rates, times, providers and techniques. Study I: A retrospective observational study of all patients intubated out-of-hospital with the device Airtraq® in Stockholm 2008-2012. A total number of 2453 patients were intubated during the study period and Airtraq® was used in 28 (1.1%) cases. Sixty-eight percent (19/28) of the Airtraq® intubation attempts were successful. When used due to an anticipated or unexpected difficult airway, the success rate was 61% (14/23). Study II: An experimental prospective randomized crossover manikin study on anaesthetist TI was conducted in a military helicopter cabin in daylight or darkness with night vision goggles (NVG) or in a daylight emergency department (ED) setting. The TI success rate was 100% in all scenarios. The in-cabin helicopter TI time was shorter in daylight vs. darkness with NVG (16.5 s vs. 30.0 s; p=0.03). There was no difference in TI time between the helicopter cabin daylight and ED setting (16.5 vs. 16.8 s; p=0.91). There was no difference in either glottic visualization (CL 2.0 vs. 1.8; p=0.72) or perceived intubation difficulty (VAS 3.0 vs. 2.8; p=0.24) between the daylight helicopter and ED scenarios. Study III: A prospective observational study of advanced airway management by twelve second-tier prehospital critical care