Anders Rostrup Nakstad

Oslo government district bombing and Utøya island shooting July 22, 2011: The immediate prehospital emergency medical service response

BackgroundOn July 22, 2011, a single perpetrator killed 77 people in a car bomb attack and a shooting spree incident in Norway. This article describes the emergency medical service (EMS) response elicited by the two incidents.MethodsA retrospective and observational study was conducted based on data from the EMS systems involved and the public domain. The study was approved by the Data Protection Official and was defined as a quality improvement project.ResultsWe describe the timeline and logistics of the EMS response, focusing on alarm, dispatch, initial response, triage and evacuation. The scenes in the Oslo government district and at Utøya island are described separately.ConclusionsMany EMS units were activated and effectively used despite the occurrence of two geographically separate incidents within a short time frame. Important lessons were learned regarding triage and evacuation, patient flow and communication, the use of and need for emergency equipment and the coordination of helicopter EMS.

Emergency cricothyrotomy--a systematic review.

BackgroundAn emergency cricothyrotomy is the last-resort in most airway management protocols and is performed when it is not possible to intubate or ventilate a patient. This situation can rapidly prove fatal, making it important to identify the best method to establish a secure airway. We conducted a systematic review to identify whether there exists superiority between available commercial kits versus traditional surgical and needle techniques.MethodsMedline, EMBASE and other databases were searched for pertinent studies. The inclusion criteria included manikin, animal and human studies and there were no restrictions regarding the professional background of the person performing the procedure.ResultsIn total, 1,405 unique references were identified; 108 full text articles were retrieved; and 24 studies were included in the review. Studies comparing kits with one another or with various surgical and needle techniques were identified. The outcome measures included in this systematic review were success rate and time consumption. The investigators performing the studies had chosen unique combinations of starting and stopping points for time measurements, making comparisons between studies difficult and leading to many conflicting results. No single method was shown to be better than the others, but the size of the studies makes it impossible to draw firm conclusions.ConclusionsThe large majority of the studies were too small to demonstrate statistically significant differences, and the limited available evidence was of low or very low quality. That none of the techniques in these studies demonstrated better results than the others does not necessarily indicate that each is equally good, and these conclusions will likely change as new evidence becomes available.

Incidence of desaturation during prehospital rapid sequence intubation in a physician-based helicopter emergency service

BACKGROUND Hypoxemia may occur during rapid sequence intubation (RSI). This study establishes the incidence of this adverse event in patients intubated by physicians in a helicopter emergency service in Norway. METHODS This was a prospective, observational study of all RSIs performed by helicopter emergency service physicians during a 12-month period. Hypoxemia was defined as a decrease in Spo(2) values to below 90% or a decrease of more than 10% if the initial Spo(2) was less than 90%. RESULTS A total of 122 prehospital intubations were performed during the study period. Spo(2) data were available for 101 (82.8%) patients. Hypoxemia was present in 11 (10.9%) patients. CONCLUSIONS Prehospital, RSI-related hypoxemia rates in this study are lower than reported rates in similar studies and are comparable with in-hospital rates. Prehospital RSI may accordingly be considered a safe procedure when performed by experienced physicians with appropriate field training.

Trends in transfusion of trauma victims - evaluation of changes in clinical practice

BackgroundThe present study was performed to compare blood product consumption and clinical results in consecutive, unselected trauma patients during the first 6 months of year 2002, 2004 and 2007.MethodsClinical data, blood product consumption, lowest haemoglobin values on day 1-10 after admission, and 30-day mortality were extracted from in-hospital trauma registry and the blood bank data base. The subpopulation of massively transfused patients was identified and analysed separately.ResultsThe total number of admitted trauma patients increased by 48% from 2002 to 2007, but the clinical data remained essentially unchanged. The mean number of erythrocyte units given day 1-10 decreased insignificantly from 9.4 in 2002 to 6.8 in 2007. New Injury Severity Score (NISS) increased in transfused and massively transfused patients, but not significantly. The number of patients transfused with plasma increased and the mean ratio of erythrocyte to plasma units transfused decreased by about 50%. The mean haemoglobin value in transfused patients on day 2 after admittance was significantly lower in 2007 than in 2002, while that on day 10 was significantly higher in 2007 than in 2002 and 2004. There was no change of 30-day survival from 2002 to 2007.ConclusionsSignificant changes of transfusion practice occurred during the past decade, probably as a result of increased focus on haemostasis and more precise criteria for transfusion. Despite a lower consumption of erythrocytes in 2007 than in 2002 and 2004, the mean haemoglobin level of transfused patients was higher on day 10 in 2007. The low number of transfused patients in this material makes evaluation of effect on survival difficult. Larger studies with strict control of all influencing factors are needed.

Medical emergency motorcycle – is it useful in a Scandinavian Emergency Medical Service?

BackgroundMedical emergency motorcycles (MEM) can be used in time-critical conditions like cardiac arrest and multi-traumatized patients in an attempt to reduce the response time. Other potential benefits with MEM are more efficient patient evaluation, reduction of unnecessary EMS car ambulance missions and reduced cost. The potential benefits have been evaluated in this study. The incidence of accidents when operating the vehicle was also of interest.MethodsA prospective study was performed when MEM was introduced as a trial in an urban ambulance service in Norway.ResultsA total of 703 MEM missions were registered in the period. The mean emergency driving time was significantly shorter for the MEM than for the ambulance car located at the same station (6 min 24 seconds vs. 6 min 54 seconds). In addition to time-critical conditions, the MEM was used to evaluate patients when the need for emergency medical assistance was uncertain, and this practice lead to a reduced number of unnecessary car ambulance missions. No accidents involving the MEM were registered in the study period. The hourly cost of running the MEM was € 29 vs. € 75 for a car ambulance. However, the actual cost benefit is smaller since the weather conditions make it impossible to run a MEM in wintertime.ConclusionThe small reduction in driving time when using a MEM instead of a car ambulance was statistically significant but probably of little clinical importance. The number of unnecessary car ambulance missions was reduced. It was cheaper to operate a MEM than a car ambulance, but the cost-effectiveness was reduced since the MEM could not operate 12 months a year. The lack of accidents may be contributed to the extensive training of the drivers and the fact that the vehicle was operated in daylight only.

Airway management in simulated restricted access to a patient - can manikin-based studies provide relevant data?

BackgroundAlternatives to endotracheal intubation (ETI) are required when access to the cranial end of the patient is restricted. In this study, the success rate and time duration of standard intubation techniques were compared with two different supraglottic devices. Two different manikins were used for the study, and the training effect was studied when the same manikin was repeatedly used.MethodsTwenty anaesthesiologists from the Air Ambulance Department used iGEL™, laryngeal tube LTSII™ and Macintosh laryngoscopes in two scenarios with either unrestricted (scenario A) or restricted (scenario B) access to the cranial end of the manikin. Different manikins were used for ETI and placement of the supraglottic devices. The technique selected by the physicians, the success rates and the times to completion were the primary outcomes measured. A secondary outcome of the study was an evaluation of the learning effect of using the same manikin or device several times.ResultsIn scenario A, all anaesthesiologists secured an airway using each device within the maximum time limit of 60 seconds. In scenario B, all physicians secured the airway on the first attempt with the supraglottic devices and 16 (80%) successfully performed an ETI with either the Macintosh laryngoscope (n = 13, 65%) or with digital technique (n = 3, 15%). It took significantly longer to perform ETI (mean time 28.0 sec +/- 13.0) than to secure an airway with the supraglottic devices (iGel™: mean 12.3 sec +/- 3.6, LTSII™: mean 10.6 sec +/- 3.2). When comparing the mean time required for the two scenarios for each supraglottic device, there was a reduction in time for scenario B (significant for LTSII™: 12.1 versus 10.6 seconds, p = 0.014). This may be due to a training effect using same manikin and device several times.ConclusionsThe amount of time used to secure an airway with supraglottic devices was low for both scenarios, while classic ETI was time consuming and had a low success rate in the simulated restricted access condition. This study also demonstrates that there is a substantial training effect when simulating airway management with airway manikins. This effect must be considered when performing future studies.

Risk assessment of pre-hospital trauma airway management by anaesthesiologists using the predictive Bayesian approach

IntroductionEndotracheal intubation (ETI) has been considered an essential part of pre-hospital advanced life support. Pre-hospital ETI, however, is a complex intervention also for airway specialist like anaesthesiologists working as pre-hospital emergency physicians. We therefore wanted to investigate the quality of pre-hospital airway management by anaesthesiologists in severely traumatised patients and identify possible areas for improvement.MethodWe performed a risk assessment according to the predictive Bayesian approach, in a typical anaesthesiologist-manned Norwegian helicopter emergency medical service (HEMS). The main focus of the risk assessment was the event where a patient arrives in the emergency department without ETI despite a pre-hospital indication for it.ResultsIn the risk assessment, we assigned a high probability (29%) for the event assessed, that a patient arrives without ETI despite a pre-hospital indication. However, several uncertainty factors in the risk assessment were identified related to data quality, indications for use of ETI, patient outcome and need for special training of ETI providers.ConclusionOur risk assessment indicated a high probability for trauma patients with an indication for pre-hospital ETI not receiving it in the studied HEMS. The uncertainty factors identified in the assessment should be further investigated to better understand the problem assessed and consequences for the patients. Better quality of pre-hospital airway management data could contribute to a reduction of these uncertainties.

Survival after prolonged resuscitation with 99 defibrillations due to Torsade De Pointes cardiac electrical storm: a case report

A 48-year-old previously healthy woman suffered witnessed cardiac arrest in hospital. She achieved return of spontaneous circulation and was transferred to the intensive care unit. During the following 3 hours, she suffered a cardiac electrical storm with 98 episodes of Torsade de Pointes ventricular tachycardia rapidly degenerating to ventricular fibrillation. She was converted with a total of 99 defibrillations. There was no response to the use of any recommended anti arrhythmic drugs. However, the use of bretylium surprisingly stabilized her heart rhythm and facilitated placing of a temporary pacemaker. Overdrive pacing prevented further arrhythmias and was life saving. A number of beneficial factors may have contributed to the good neurological outcome. Further investigations gave no explanation for her cardiac electrical storm.

Landing Sites and Intubation May Influence Helicopter Emergency Medical Services On-scene Time

BACKGROUND Reduced transport time of patients from the scene of an accident to definitive surgical treatment is one important reason to employ ambulance helicopters on trauma missions. However, if the helicopter is unable to land close to the scene, the transport time may be increased compared to transport with ground ambulance, due to time-consuming transfer of the patient between vehicles. OBJECTIVE The objective of this study was to evaluate how the landing site, as determined by distance from the scene, and rapid sequence intubation (RSI) affected on-scene time (OST). METHODS This was a prospective observational study performed during a 12-month period in a mixed urban and rural anesthesiologist-staffed Helicopter Emergency Medical Service in Norway. Data regarding the landing sites, the accident, and patient treatment were recorded. RESULTS A total of 252 primary trauma missions were included in the study. In 75% of the missions, the aircraft landed<50 meters from the scene, and in 7% the distance exceeded 200 meters. Mean OST when the patient was not intubated was 14.5 min (median 14 min). When an RSI was performed, the mean OST was significantly higher (22.7 min, median 20 min; p<0.001). CONCLUSION Usually, a helicopter can land close to the accident scene and the location of the landing site does not contribute to a delay in arrival of the patient at the hospital. The OST is significantly higher, however, in those patients who receive endotracheal intubation before take-off. This reflects the time needed for intubation, as well as the increased complexity and workload when the patient is severely injured.

Do anaesthesiologists in pre-hospital care need concomitant clinical practice?

Background Previous studies have documented that advanced life support (ALS) provided by anaesthesiologists in emergency medical service (EMS) leads to life years gained [1]. Especially interventions legally and formally related to anaesthesiology were judged as crucial: endotracheal intubation (ETI), chest tube insertion and anaesthesia induction. These interventions require extensive training and experience, and probably retraining and regular practice, to be performed safely. The need for retraining and practice is probably related to actual exposure to these interventions in clinical practice. To explore if there is a need for retraining and practice, we have investigated how often these interventions are performed by individual anaesthesiologists in a typical Norwegian physician manned EMS.