Procedural Sedation Intubation in a Paramedic-Staffed Helicopter Emergency Medical System in Northern Finland

Publisher Copyright: © 2021 The AuthorsObjective: Airway management to ensure sufficient gas exchange is of major importance in emergency care. Prehospital endotracheal intubation (ETI) by paramedics is a widely debated method to ensure a patent airway. ETI is performed with procedural sedation in comatose patients because of the regulation. The use of medications increases the rate of successful airway management compared with nonmedication ETI and may also improve outcomes in patients with traumatic brain injury. In the absence of an operative emergency physician and with long distances, paramedic-induced airway management may increase the survival of patients in selected scenarios. A paramedic-staffed helicopter emergency medical system in Northern Finland operates in a rural area without an emergency physician and paralytic medications and treats critically ill patients using basic or advanced life support ground units. The aim of this study was to evaluate the success rates of ETI performed by a small, appropriately trained, and experienced group of 8 nurse paramedics in an out-of-hospital setting. Methods: The inclusion criterion for the study was an attempted intubation in patients with medical or traumatic indication for airway management by nurse paramedic. Results: Fifty-one patients were treated with ETI. The first-pass success rate was 72.5%, the second-pass success rate was 94.1%, and the overall success rate was 100% within 4 attempts. The median on-scene time was 54 minutes, and there were no signs of aspiration during laryngoscopy or after successful ETI. The primary mortality rate was 11.7%. Conclusion: The use of a rigid standard operating procedure for paramedic rapid sequence induction, paralytics, a video laryngoscope, and a gum elastic bougie might positively affect the ETI first-pass success rate. A follow-up study after these future modifications is needed. This small study suggests that intubation might be 1 option for airway management by an experienced nonanesthesiologist in Lapland.Peer reviewe

Procedural Sedation Intubation in a Paramedic-Staffed Helicopter Emergency Medical System in Northern Finland

Publisher Copyright: © 2021 The AuthorsObjective: Airway management to ensure sufficient gas exchange is of major importance in emergency care. Prehospital endotracheal intubation (ETI) by paramedics is a widely debated method to ensure a patent airway. ETI is performed with procedural sedation in comatose patients because of the regulation. The use of medications increases the rate of successful airway management compared with nonmedication ETI and may also improve outcomes in patients with traumatic brain injury. In the absence of an operative emergency physician and with long distances, paramedic-induced airway management may increase the survival of patients in selected scenarios. A paramedic-staffed helicopter emergency medical system in Northern Finland operates in a rural area without an emergency physician and paralytic medications and treats critically ill patients using basic or advanced life support ground units. The aim of this study was to evaluate the success rates of ETI performed by a small, appropriately trained, and experienced group of 8 nurse paramedics in an out-of-hospital setting. Methods: The inclusion criterion for the study was an attempted intubation in patients with medical or traumatic indication for airway management by nurse paramedic. Results: Fifty-one patients were treated with ETI. The first-pass success rate was 72.5%, the second-pass success rate was 94.1%, and the overall success rate was 100% within 4 attempts. The median on-scene time was 54 minutes, and there were no signs of aspiration during laryngoscopy or after successful ETI. The primary mortality rate was 11.7%. Conclusion: The use of a rigid standard operating procedure for paramedic rapid sequence induction, paralytics, a video laryngoscope, and a gum elastic bougie might positively affect the ETI first-pass success rate. A follow-up study after these future modifications is needed. This small study suggests that intubation might be 1 option for airway management by an experienced nonanesthesiologist in Lapland.Peer reviewe

Medical priority dispatch codes-comparison with National Early Warning Score

Background: In Finland, calls for emergency medical services are prioritized by educated non-medical personnel into four categories-from A (highest risk) to D (lowest risk)-following a criteria-based national dispatch protocol. Discrepancies in triage may result in risk overestimation, leading to inappropriate use of emergency medical services units and to risk underestimation that can negatively impact patient outcome. To evaluate dispatch protocol accuracy, we assessed association between priority assigned at dispatch and the patient's condition assessed by emergency medical services on the scene using an early warning risk assessment tool. Methods: Using medical charts, clinical variables were prospectively recorded and evaluated for all emergency medical services missions in two hospital districts in Northern Finland during 1.1.2014-30.6.2014. Risk assessment was then re-categorized as low, medium, or high by calculating the National Early Warning Score (NEWS) based on the patients' clinical variables measured at the scene. Results: A total of 12,729 emergency medical services missions were evaluated, of which 616 (4.8%) were prioritized as A, 3193 (25.1%) as B, 5637 (44.3%) as C, and 3283 (25.8%) as D. Overall, 67.5% of the dispatch missions were correctly estimated according to NEWS. Of the highest dispatch priority missions A and B, 76.9 and 78.3%, respectively, were overestimated. Of the low urgency missions (C and D), 10.7% were underestimated; 32.0% of the patients who were assigned NEWS indicating high risk had initially been classified as low urgency C or D priorities at the dispatch. Discussion and conclusion: The present results show that the current Finnish medical dispatch protocol is suboptimal and needs to be further developed. A substantial proportion of EMS missions assessed as highest priority were categorized as lower risk according to the NEWS determined at the scene, indicating over-triage with the protocol. On the other hand, only a quarter of the high risk NEWS patients were classified as the highest priority at dispatch, indicating considerable under-triage with the protocol.Peer reviewe

Compliance with CPR quality guidelines and survival after 30 days following out-of-hospital cardiac arrest : A retrospective study

Background: Our study assessed the quality of cardiopulmonary resuscitation (CPR) given by emergency medical services in Southern Ostrobothnia Finland, as is advised in the international guidelines. The goal was to evaluate the current quality of CPR given to patients who suffered an out-of-hospital cardiac arrest and to examine possible measures for improving emergency medical services. Methods: A retrospective study was conducted on out-of-hospital cardiac arrest patients in Southern Ostrobothnia, Finland, during a three-year period. Confounding caused by each patient's individual medical history was addressed by calculating Charlson Comorbidity Index (CCI), a score describing individual's risk for death in 10 years. The Utstein analysis and the CPR metrics were acquired from the medical records hospital district in question and analysed in an orderly manner using SPSS. Descriptive statistics are presented as mean (SD) and median [IQR]. Results: We found that of the 349 patients, 144 (41%) received ROSC, 96 (28%) survived to the hospital and 51 (15%) survived for at least 30 days. CPR metrics data were available for 181 patients. CCIs were 3.0 versus 5.0 (p =.157) for the ones who did and those who did not survive at least 30 days. Correspondingly, following metrics were as follows: Mean compression depth was 5.1 (1.3) versus 5.6 (0.8) cm (p =.088), median 28 [18;40] versus 40 [26;54]% of the compressions were in target depth (p =.015) and median compression rate was 113 [109;119] versus 112 [108;120] min−1 (p =.757). The median no-flow fraction was 5.1 [2.8;7.1] versus 3.7 [2.5;5.5] s (p =.073). Ventricular fibrillation (OR 8.74, 95% CI 2.89–26.43, p <.001), public location (OR 3.163, 95% CI 1.03–9.69, p =.044) and compression rate of 100–110/min (OR 7.923, 95% CI 2.11–29.82, p =.002) were related to survival. Conclusion: Patients who suffered out-of-hospital cardiac arrest in Southern Ostrobothnia received CPR that met the international CPR quality target values. The proportion of unintentional pauses during CPR was low and the 30-day survival rate exceeded the international average.Peer reviewe

EuReCa ONE—27 Nations, ONE Europe, ONE Registry A prospective one month analysis of out-of-hospital cardiac arrest outcomes in 27 countries in Europe

AbstractIntroductionThe aim of the EuReCa ONE study was to determine the incidence, process, and outcome for out of hospital cardiac arrest (OHCA) throughout Europe.MethodsThis was an international, prospective, multi-centre one-month study. Patients who suffered an OHCA during October 2014 who were attended and/or treated by an Emergency Medical Service (EMS) were eligible for inclusion in the study. Data were extracted from national, regional or local registries.ResultsData on 10,682 confirmed OHCAs from 248 regions in 27 countries, covering an estimated population of 174 million. In 7146 (66%) cases, CPR was started by a bystander or by the EMS. The incidence of CPR attempts ranged from 19.0 to 104.0 per 100,000 population per year. 1735 had ROSC on arrival at hospital (25.2%), Overall, 662/6414 (10.3%) in all cases with CPR attempted survived for at least 30 days or to hospital discharge.ConclusionThe results of EuReCa ONE highlight that OHCA is still a major public health problem accounting for a substantial number of deaths in Europe.EuReCa ONE very clearly demonstrates marked differences in the processes for data collection and reported outcomes following OHCA all over Europe. Using these data and analyses, different countries, regions, systems, and concepts can benchmark themselves and may learn from each other to further improve survival following one of our major health care events

Prehospital airway management in Finnish emergency medical service by non-physicians

Abstract Prehospital advanced airway management is one of the most demanding procedures in the out-of-hospital scene. Prehospital advanced airway management is indicated based on patient assessment and suspected underlying illness or trauma. Prehospital emergency airway management can be performed using various methods. Endotracheal intubation (ETI) has been described as the ‘gold standard’ in emergency airway management to ensure sufficient ventilation and oxygenation. In previous years, critical questions have been raised regarding the use of ETI by providers not sufficiently experienced in performing this procedure. In the Finnish emergency medical service (EMS) system, ETI is rare and therefore often difficult for non-physician care providers. Previous studies have shown SADs to be easy to insert and to provide effective ventilation in manikins, anaesthetized patients and OHCA cases. The aim of this thesis was to study different airway devices used by non-physicians in prehospital care. After manikin training, first responders inserted a disposable laryngeal tube (LT-D) in OHCA patients with reasonable success and insertion time (I). A questionnaire completed by EMS providers in Northern Finland revealed a low frequency of prehospital advanced airway management procedures and the need for improvement in maintaining airway management skills (II). A laryngeal mask airway (LMA) Supreme (LMA-S) was used by trained advanced life support paramedics in unconscious patients with a high success rate, but ventilation-related problems due to air leakage were noticed (III). ETI provided by an experienced and well-trained small group of helicopter emergency medical service (HEMS) paramedics had a high success rate after a second attempt (IV). In conclusion, the devices studied were used in patients with OHCA or altered consciousness with reasonable success. The best option for pre-hospital airway management may be an individualized process where the intervention chosen depends on the EMS provider’s skills, the patient and the environmental and organizational circumstances. SADs can also be used by non-experienced providers and as bailout devices by more experienced providers.Tiivistelmä Ensihoidossa hengitysteiden hallinta on yksi vaativimmista toimenpiteistä. Hengitysteiden hallinnan indikaatiot rakentuvat tarkasta potilaan tutkimisesta, sekä kriittisen vamman tai sairauden epäilystä ja siihen liittyvästä päätöksenteosta. Hengitysteiden hallinta ensihoidossa voidaan toteuttaa käyttäen useita erilaisia välineitä tai tekniikoita. Riittävän happeutumisen ja ventilaation mahdollistaa intubaatio, jota voidaan pitää standarditoimenpiteenä hengitysteiden hallinnassa. Viime vuosina on herännyt kriittisiä kysymyksiä intubaation suorittamisesta, kun toimenpiteen toteuttajana on vähäisen intubaatiokokemuksen omaava ei-anestesiologi. Intubaatio suomalaisessa ensihoidossa on harvinainen toimenpide ja siksi usein haasteellinen, jos toimenpiteen suorittajana on muu kuin ensihoitolääkäri. Supraglottiset hengitystievälineet (SAD) ovat yleistyneet intubaation vaihtoehtona. Aikaisemmat tutkimukset ovat todenneet supraglottiset hengitystievälineet helppokäyttöisiksi. Tämän väitöskirjan tavoitteena oli tutkia erilaisia hengitysteiden hallintamenetelmiä, kun toimenpiteen suorittaja on ensihoitaja tai pelastaja. Lyhyen simulaatioharjoittelun jälkeen ensivastehenkilöstö asetti kurkunpääputken (LT-D) sairaalan ulkopuolisille sydänpysähdyspotilaille kohtuullisella onnistumisprosentilla ja asetusajalla (I). Kyselytutkimus pohjoisen Suomen ensihoitajille paljasti matalan hengitysteiden hallinnan frekvenssin ja tarpeen kehittää tietoja ja taitoja liittyen hengitysteiden hallintaan (II). Koulutetut ensihoitajat asettivat LMA Supremen matalan tajunnan potilaille korkealla onnistumisprosentilla, vaikkakin ongelmia ventilaatiossa vuotojen vuoksi todettiin (III). Kokeneiden HEMS-ensihoitajien toimesta hengitysteiden hallinta intubaatiolla onnistui korkealla onnistumisprosentilla toisen intubaatioyrityksen jälkeen (IV). Hengitysteiden hallintavälineet, joita tässä väitöskirjassa käytettiin sydänpysähdys- ja matalan tajunnan omaaville potilaille, pystyttiin asettamaan kohtuullisella onnistumisprosentilla. Intubaation tulisi toteuttaa riittävän kokenut henkilö, jolla arvioidaan olevan riittävä tietotaito ja välineistö toimenpiteen turvalliseen suorittamiseen. Supraglottisia hengitystievälineitä voidaan käyttää hengitysteiden turvaamiseksi kokemattomampien toimenpiteen suorittajien toimesta ja vaihtoehtoisena menetelmänä kokeneempien toimenpiteen suorittajien toimesta

To ventilate or not to ventilate during bystander CPR — A EuReCa TWO analysis

Background: Survival after out-of-hospital cardiac arrest (OHCA) is still low. For every minute without resuscitation the likelihood of survival decreases. One critical step is initiation of immediate, high quality cardiopulmonary resuscitation (CPR). The aim of this subgroup analysis of data collected for the European Registry of Cardiac Arrest Study number 2 (EuReCa TWO) was to investigate the association between OHCA survival and two types of bystander CPR namely: chest compression only CPR (CConly) and CPR with chest compressions and ventilations (FullCPR). Method: In this subgroup analysis of EuReCa TWO, all patients who received bystander CPR were included. Outcomes were return of spontaneous circulation and survival to 30-days or hospital discharge. A multilevel binary logistic regression analysis with survival as the dependent variable was performed. Results: A total of 5884 patients were included in the analysis, varying between countries from 21 to 1444. Survival was 320 (8%) in the CConly group and 174 (13%) in the FullCPR group. After adjustment for age, sex, location, rhythm, cause, time to scene, witnessed collapse and country, patients who received FullCPR had a significantly higher survival rate when compared to those who received CConly (adjusted odds ration 1.46, 95% confidence interval 1.17–1.83). Conclusion: In this analysis, FullCPR was associated with higher survival compared to CConly. Guidelines should continue to emphasise the importance of compressions and ventilations during resuscitation for patients who suffer OHCA and CPR courses should continue to teach both