Prehospital advanced airway management in the Nordic countries

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 teams in the Nordic countries was conducted from May 2015 to November 2016. Data were collected from six ambulance helicopters and six rapid response cars using the standardized Utstein-style airway template. During the study period, 2028 patients were intubated due to cardiac arrest (53.0%), other medical conditions (26.3%) and trauma (19.1%). The majority (67.0%) of the TIs were performed by providers who had intubated >2500 patients. The overall TI success rate was 98.7%, with a first pass success rate of 84.5% and overall complication rate of 10.9%. The median TI time was 25 s (IQR 15-30 s), and the time on scene was 25 min (IQR 18-33 min). The TI success rate was higher among physicians compared with nurses (99.0% vs. 97.6%; p=0.03). Study IV: An experimental prospective randomized crossover manikin study of in-cabin vs. outside helicopter cabin TI was conducted by 14 anaesthetists. The success rate was 100%, with all TIs being successful on the first attempt. There was no difference in glottic visualization (CL 1.0 vs. 1.0), but the participants perceived the in-cabin TI to be easier than intubating outside the helicopter cabin (VAS 1 vs. VAS 2; p=0.02). The total on-scene time was significantly shorter using the in-cabin TI strategy compared with the standard outside TI (266 vs. 320 s; p=0.04). In conclusion, prehospital TI is almost exclusively performed by very experienced airway providers in the Nordic countries. In this setting, the prehospital TI success rate is high and associated with few complications, comparable to in-hospital standards. The TI procedure is fast with a short on-scene time, which may benefit patients with time-critical emergencies, such as multitrauma and traumatic brain injuries. There may be potential to further decrease on-scene times with the in-cabin TI concept. The first-pass TI success rate was higher with video laryngoscopy compared with direct laryngoscopy, but the Airtraq® is not a suitable prehospital indirect laryngoscope. There is a need for large randomized studies to better investigate different aspects of the prehospital advanced airway management

Labeling of complex III peptides in beef heart mitochondria and submitochondrial particles by diazonium benzene [35S]sulfonate

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Standardised data reporting from pre-hospital advanced airway management - a nominal group technique update of the Utstein-style airway template

Background Pre-hospital advanced airway management with oxygenation and ventilation may be vital for managing critically ill or injured patients. To improve pre-hospital critical care and develop evidence-based guidelines, research on standardised high-quality data is important. We aimed to identify which airway data were most important to report today and to revise and update a previously reported Utstein-style airway management dataset. Methods We recruited sixteen international experts in pre-hospital airway management from Australia, United States of America, and Europe. We used a five-step modified nominal group technique to revise the dataset, and clinical study results from the original template were used to guide the process. Results The experts agreed on a key dataset of thirty-two operational variables with six additional system variables, organised in time, patient, airway management and system sections. Of the original variables, one remained unchanged, while nineteen were modified in name, category, definition or value. Sixteen new variables were added. The updated dataset covers risk factors for difficult intubation, checklist and standard operating procedure use, pre-oxygenation strategies, the use of drugs in airway management, airway currency training, developments in airway devices, airway management strategies, and patient safety issues not previously described. Conclusions Using a modified nominal group technique with international airway management experts, we have updated the Utstein-style dataset to report standardised data from pre-hospital advanced airway management. The dataset enables future airway management research to produce comparable high-quality data across emergency medical systems. We believe this approach will promote research and improve treatment strategies and outcomes for patients receiving pre-hospital advanced airway management.publishedVersio

Pre-hospital advanced airway management by anaesthetist and nurse anaesthetist critical care teams: a prospective observational study of 2028 pre-hospital tracheal intubations

Background: Pre-hospital tracheal intubation success and complication rates vary considerably among provider categories. The purpose of this study was to estimate the success and complication rates of pre-hospital tracheal intubation performed by physician anaesthetist or nurse anaesthetist pre-hospital critical care teams. Methods: Data were prospectively collected from critical care teams staffed with a physician anaesthetist or a nurse anaesthetist according to the Utstein template for pre-hospital advanced airway management. The patients served by six ambulance helicopters and six rapid response vehicles in Denmark, Finland, Norway, and Sweden from May 2015 to November 2016 were included. Results: The critical care teams attended to 32 007 patients; 2028 (6.3%) required pre-hospital tracheal intubation. The overall success rate of pre-hospital tracheal intubation was 98.7% with a median intubation time of 25 s and an on-scene time of 25 min. The majority (67.0%) of the patients' tracheas were intubated by providers who had performed >2500 tracheal intubations. The success rate of tracheal intubation on the first attempt was 84.5%, and 95.9% of intubations were completed after two attempts. Complications related to pre-hospital tracheal intubation were recorded in 10.9% of the patients. Intubations after rapid sequence induction had a higher success rate compared with intubations without rapid sequence induction (99.4% vs 98.1%; P=0.02). Physicians had a higher tracheal intubation success rate than nurses (99.0% vs 97.6%; P=0.03). Conclusions: When performed by experienced physician anaesthetists and nurse anaesthetists, pre-hospital tracheal intubation was completed rapidly with high success rates and a low incidence of complications.Peer reviewe

Managed Care-Work in Progress or Stalled Experiment?

The symptomatic drugs currently on the market for Alzheimer's disease (AD) have no effect on disease progression, and this creates a large unmet medical need. The type of drug that has developed most rapidly in the last decade is immunotherapy: vaccines and, especially, passive vaccination with monoclonal antibodies. Antibodies are attractive drugs as they can be made highly specific for their target and often with few side effects. Data from recent clinical AD trials indicate that a treatment effect by immunotherapy is possible, providing hope for a new generation of drugs. The first anti-amyloid-beta (anti-A beta) vaccine developed by Elan, AN1792, was halted in phase 2 because of aseptic meningoencephalitis. However, in a follow-up study, patients with antibody response to the vaccine demonstrated reduced cognitive decline, supporting the hypothesis that A beta immunotherapy may have clinically relevant effects. Bapineuzumab (Elan/Pfizer Inc./Johnson & Johnson), a monoclonal antibody targeting fibrillar A beta, was stopped because the desired clinical effect was not seen. Solanezumab (Eli Lilly and Company) was developed to target soluble, monomeric A beta. In two phase 3 studies, Solanezumab did not meet primary endpoints. When data from the two studies were pooled, a positive pattern emerged, revealing a significant slowing of cognitive decline in the subgroup of mild AD. The Arctic mutation has been shown to specifically increase the formation of soluble A beta protofibrils, an A beta species shown to be toxic to neurons and likely to be present in all cases of AD. A monoclonal antibody, mAb158, was developed to target A beta protofibrils with high selectivity. It has at least a 1,000-fold higher selectivity for protofibrils as compared with monomers of A beta, thus targeting the toxic species of the peptide. A humanized version of mAb158, BAN2401, has now entered a clinical phase 2b trial in a collaboration between BioArctic Neuroscience and Eisai without the safety concerns seen in previous phase 1 and 2a trials. Experiences from the field indicate the importance of initiating treatment early in the course of the disease and of enriching the trial population by improving the diagnostic accuracy. BAN2401 is a promising candidate for A beta immunotherapy in early AD. Other encouraging efforts in immunotherapy as well as in the small-molecule field offer hope for new innovative therapies for AD in the future

Mutations in Acute Intermittent Porphyria Detected by ELISA Measurement of Porphobilinogen Deaminase

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