The shootings in Oslo and Utøya island July 22, 2011: Lessons for the International EMS community

SJTREM has published an account by Sollid and colleagues of the pre-hospital medical response to the major incidents, which occurred in Oslo and Utøya island on July 22, 2011. Although very similar incidents have occurred in Europe and elsewhere, this terrible day saw the greatest loss of life recorded in this type of incident in recent times. Internationally EMS providers looked on with the certain knowledge that this type of incident is sadly one that we all have to prepare for. It is unrelated to national foreign policy, religious extremism or the existence of known terrorist activity. In short this type of incident is unpredictable and has the potential to happen in any community at any time

The performance and assessment of hospital trauma teams

The purpose of the trauma team is to provide advanced simultaneous care from relevant specialists to the seriously injured trauma patient. When functioning well, the outcome of the trauma team performance should be greater than the sum of its parts. Trauma teams have been shown to reduce the time taken for resuscitation, as well as time to CT scan, to emergency department discharge and to the operating room. These benefits are demonstrated by improved survival rates, particularly for the most severely injured patients, both within and outside of dedicated trauma centres. In order to ensure the best possible performance of the team, the leadership skills of the trauma team leader are essential and their non-technical skills have been shown to be particularly important. Team performance can be enhanced through a process of audit and assessment of the workings of the team and the evidence currently available suggests that this is best facilitated through the process of video review of the trauma resuscitation. The use of human patient simulators to train and assess trauma teams is becoming more commonplace and this technique offers a safe environment for the future education of trauma team staff

Investigating the autocatalytic self-assembly of Keggin-based polyoxometalate clusters

Many areas of chemistry strive towards the directed synthesis of complex molecules. Polyoxometalates (POMs) are discrete metal oxide clusters that span a wide area of chemistry and are often topologically complex or interesting. They can be formed from many different atom types and in many different reaction conditions and can include a range of inorganic and organic complexes within their structures. Their variable structures and functions have led to use in many areas of chemistry, most notably catalysis. The way that the formation of discrete clusters is achieved is still largely unknown and is often called “self-assembly”. An investigation into the kinetics of the Keggin type POM was looked at using a UV/Vis detection-based system in order to find the underlying kinetics of the reaction. This revealed an underlying autocatalytic formation system in which the Keggin catalyzes its own formation, providing vital further insight into how these clusters are formed in situ. Also, the synthesis of the largest known POM, the Mo368, was looked at. Notoriously difficult to synthesize based on literature conditions, the goal was to improve the synthesis in order to obtain high quality single crystals of the cluster. A better understanding of the synthesis of the largest POM cluster would allow for further clarity into the exact conditions and could provide insight into the sort of reaction equilibria needed to form even larger structures. This was achieved by employing a robotic liquid handling platform for high accuracy synthesis. Specific areas of synthesis were targeted, and the reaction conditions changed depending on the results of previous reaction runs

A consensus-based template for uniform reporting of data from pre-hospital advanced airway management

Background: Advanced airway management is a critical intervention that can harm the patient if performed poorly. The available literature on this subject is rich, but it is difficult to interpret due to a huge variability and poor definitions. Several initiatives from large organisations concerned with airway management have recently propagated the need for guidelines and standards in pre-hospital airway management. Following the path of other initiatives to establish templates for uniform data reporting, like the many Utstein-style templates, we initiated and carried out a structured consensus process with international experts to establish a set of core data points to be documented and reported in cases of advanced pre-hospital airway management. Methods: A four-step modified nominal group technique process was employed. Results: The inclusion criterion for the template was defined as any patient for whom the insertion of an advanced airway device or ventilation was attempted. The data points were divided into three groups based on their relationship to the intervention, including system-, patient-, and postintervention variables, and the expert group agreed on a total of 23 core data points. Additionally, the group defined 19 optional variables for which a consensus could not be achieved or the data were considered as valuable but not essential. Conclusion: We successfully developed an Utstein-style template for documenting and reporting pre-hospital airway management. The core dataset for this template should be included in future studies on pre-hospital airway management to produce comparable data across systems and patient populations and will be implemented in systems that are influenced by the expert panel.publishedVersio

Apnoeic oxygenation for emergency anaesthesia of pre-hospital trauma patients

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 < 90%) was 16.7%; 10.9% had SpO2 < 85%. 98/725 patients (13.5%) were hypoxic post-intubation (final SpO2 < 90% 10 minutes post-intubation). 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  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.publishedVersio

A systematic review and meta-analysis comparing mortality in pre-hospital tracheal intubation to emergency department intubation in trauma patients

Background Pre-hospital endotracheal intubation is frequently used for trauma patients in many emergency medical systems. Despite a wide range of publications in the field, it is debated whether the intervention is associated with a favourable outcome, when compared to more conservative airway measures. Methods A systematic literature search was conducted to identify interventional and observational studies where the mortality rates of adult trauma patients undergoing pre-hospital endotracheal intubation were compared to those undergoing emergency department intubation. Results Twenty-one studies examining 35,838 patients were included. The median mortality rate in patients undergoing pre-hospital intubation was 48% (range 8–94%), compared to 29% (range 6–67%) in patients undergoing intubation in the emergency department. Odds ratios were in favour of emergency department intubation both in crude and adjusted mortality, with 2.56 (95% CI: 2.06, 3.18) and 2.59 (95% CI: 1.97, 3.39), respectively. The overall quality of evidence is very low. Twelve of the twenty-one studies found a significantly higher mortality rate after pre-hospital intubation, seven found no significant differences, one found a positive effect, and for one study an analysis of the mortality rate was beyond the scope of the article. Conclusions The rationale for wide and unspecific indications for pre-hospital intubation seems to lack support in the literature, despite several publications involving a relatively large number of patients. Pre-hospital intubation is a complex intervention where guidelines and research findings should be approached cautiously. The association between pre-hospital intubation and a higher mortality rate does not necessarily contradict the importance of the intervention, but it does call for a thorough investigation by clinicians and researchers into possible causes for this finding.publishedVersio

Revisiting the value of pre-hospital tracheal intubation: an all time systematic literature review extracting the Utstein airway core variables

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

The success of pre-hospital tracheal intubation by different pre-hospital providers: a systematic literature review and meta-analysis

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.publishedVersio

The extracellular domain of two-component system sensor kinase VanS from streptomyces coelicolor binds Vancomycin at a newly identified binding site

The glycopeptide antibiotic vancomycin has been widely used to treat infections of Gram-positive bacteria including Clostridium difficile and methicillin-resistant Staphylococcus aureus. However, since its introduction, high level vancomycin resistance has emerged. The genes responsible require the action of the two-component regulatory system VanSR to induce expression of resistance genes. The mechanism of detection of vancomycin by this two-component system has yet to be elucidated. Diverging evidence in the literature supports activation models in which the VanS protein binds either vancomycin, or Lipid II, to induce resistance. Here we investigated the interaction between vancomycin and VanS from Streptomyces coelicolor (VanSSC), a model Actinomycete. We demonstrate a direct interaction between vancomycin and purified VanSSC, and traced these interactions to the extracellular region of the protein, which we reveal adopts a predominantly α-helical conformation. The VanSSC-binding epitope within vancomycin was mapped to the N-terminus of the peptide chain, distinct from the binding site for Lipid II. In targeting a separate site on vancomycin, the effective VanS ligand concentration includes both free and lipid-bound molecules, facilitating VanS activation. This is the first molecular description of the VanS binding site within vancomycin, and could direct engineering of future therapeutics