Søren Mikkelsen

Outcome following physician supervised prehospital resuscitation: a retrospective study

Background Prehospital care provided by specially trained, physician-based emergency services (P-EMS) is an integrated part of the emergency medical systems in many developed countries. To what extent P-EMS increases survival and favourable outcomes is still unclear. The aim of the study was thus to investigate ambulance runs initially assigned ‘life-saving missions’ with emphasis on long-term outcome in patients treated by the Mobile Emergency Care Unit (MECU) in Odense, Denmark Methods All MECU runs are registered in a database by the attending physician, stating, among other parameters, the treatment given, outcome of the treatment and the patients diagnosis. Over a period of 80 months from May 1 2006 to December 31 2012, all missions in which the outcome of the treatment was registered as ‘life saving’ were scrutinised. Initial outcome, level of competence of the caretaker and diagnosis of each patient were manually established in each case in a combined audit of the prehospital database, the discharge summary of the MECU and the medical records from the hospital. Outcome parameters were final outcome, the aetiology of the life-threatening condition and the level of competences necessary to treat the patient. Results Of 25 647 patients treated by the MECU, 701 (2.7%) received prehospital ‘life saving treatment’. In 596 (2.3%) patients this treatment exceeded the competences of the attending emergency medical technician or paramedic. Of these patients, 225 (0.9%) were ultimately discharged to their own home. Conclusions The present study demonstrates that anaesthesiologist administrated prehospital therapy increases the level of treatment modalities leading to an increased survival in relation to a prehospital system consisting of emergency medical technicians and paramedics alone and thus supports the concept of applying specialists in anaesthesiology in the prehospital setting especially when treating patients with cardiac arrest, patients in need of respiratory support and trauma patients.

Nontraumatic Hypotension and Shock in the Emergency Department and the Prehospital setting, Prevalence, Etiology, and Mortality: A Systematic Review

Background Acute patients presenting with hypotension in the prehospital or emergency department (ED) setting are in need of focused management and knowledge of the epidemiology characteristics might help the clinician. The aim of this review was to address prevalence, etiology and mortality of nontraumatic hypotension (SBP ≤ 90 mmHg) with or without the presence of shock in the prehospital and ED setting. Methods We performed a systematic literature search up to August 2013, using Medline, Embase, Cinahl, Dare and The Cochrane Library. The analysis and eligibility criteria were documented according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA-guidelines) and The Cochrane Collaboration. No restrictions on language, publication date, or status were imposed. We used the Newcastle-Ottawa quality assessment scale (NOS-scale) and the Strengthening the Reporting of Observational studies in Epidemiology (STROBE-statement) to assess the quality. Results Six observational studies were considered eligible for analysis based on the evaluation of 11,880 identified papers. Prehospital prevalence of hypotension was 19.5/1000 emergency medicine service (EMS) contacts, and the prevalence of hypotensive shock was 9.5-19/1000 EMS contacts with an inhospital mortality of shock between 33 to 52%. ED prevalence of hypotension was 4-13/1000 contacts with a mortality of 12%. Information on mortality, prevalence and etiology of shock in the ED was limited. A meta-analysis was not feasible due to substantial heterogeneity between studies. Conclusion There is inadequate evidence to establish concise estimates of the characteristics of nontraumatic hypotension and shock in the ED or in the prehospital setting. The available studies suggest that 2% of EMS contacts present with nontraumatic hypotension while 1-2% present with shock. The inhospital mortality of prehospital shock is 33-52%. Prevalence of hypotension in the ED is 1% with an inhospital mortality of 12%. Prevalence, etiology and mortality of shock in the ED are not well described.

Systolic blood pressure and short-term mortality in the emergency department and prehospital setting: a hospital-based cohort study

IntroductionSystolic blood pressure is a widely used tool to assess circulatory function in acutely ill patients. The systolic blood pressure limit where a given patient should be considered hypotensive is the subject of debate and recent studies have advocated higher systolic blood pressure thresholds than the traditional 90 mmHg. The aim of this study was to identify the best performing systolic blood pressure thresholds with regards to predicting 7-day mortality and to evaluate the applicability of these in the emergency department as well as in the prehospital setting.MethodsA retrospective, hospital-based cohort study was performed at Odense University Hospital that included all adult patients in the emergency department between 1995 and 2011, all patients transported to the emergency department in ambulances in the period 2012 to 2013, and all patients serviced by the physician-staffed mobile emergency care unit (MECU) in Odense between 2007 and 2013. We used the first recorded systolic blood pressure and the main outcome was 7-day mortality. Best performing thresholds were identified with methods based on receiver operating characteristics (ROC) and multivariate regression. The performance of systolic blood pressure thresholds was evaluated with standard summary statistics for diagnostic tests.ResultsSeven-day mortality rates varied from 1.8 % (95 % CI (1.7, 1.9)) of 112,727 patients in the emergency department to 2.2 % (95 % CI (2.0, 2.5)) of 15,862 patients in the ambulance and 5.7 % (95 % CI (5.3, 6.2)) of 12,270 patients in the mobile emergency care units. Best performing thresholds ranged from 95 to 119 mmHg in the emergency department, 103 to 120 mmHg in the ambulance, and 101 to 115 mmHg in the MECU but area under the ROC curve indicated poor overall discriminatory performance of SBP thresholds in all cohorts.ConclusionsSystolic blood pressure alone is not sufficient to identify patients at risk regardless of the defined threshold for hypotension. If, however, a threshold is to be defined, a systolic blood pressure threshold of 100 to 110 mmHg is probably more relevant than the traditional 90 mmHg.

The effects of gabapentin in human experimental pain models

Abstract Background The antidepressant drugs imipramine and venlafaxine relieve clinical neuropathic pain and have been shown to increase pain thresholds in healthy volunteers during repetitive electrical sural nerve stimulation causing temporal pain summation, whereas pain during the cold pressor test is unaltered by these drugs. If this pattern of effect in experimental pain models reflects potential efficacy in clinical neuropathic pain, the pain summation model may potentially be used to identify new drugs for such pain conditions. Gabapentinoids are evidence-based treatments of clinical neuropathic pain and could contribute with additional knowledge of the usefulness of the pain summation model. The aim of this study To test the analgesic effect of the gabapentinoid gabapentin in a sural nerve stimulation pain model including temporal pain summation and the cold pressor test. Method 18 healthy volunteers completed a randomized, double-blind, cross-over trial with medication of 600 mg gabapentin orally dosed 3 times over 24 h against placebo. Pain tests were performed before and 24 h after medication including pain detection and tolerance to single sural nerve stimulation and pain summation threshold to repetitive stimulation (3 Hz). Peak pain intensity and discomfort were rated during a cold pressor test. Results Compared to placebo, gabapentin had a highly significant effect on the threshold of pain summation to repetitive electrical sural nerve stimulation (P = 0.009). Gabapentin significantly increased the pain tolerance threshold to single electrical sural nerve stimulation (P = 0.04), whereas the pain detection threshold to single electrical sural nerve stimulation tended to be increased (P = 0.06). No significant differences were found on pain ratings during the cold pressor test. Conclusion Gabapentin had a selective hypoalgesic effect in a human experimental pain model of temporal pain summation and the results lend further support to the usefulness of the pain summation model to identify drugs for neuropathic pain.

Emergency patients receiving anaesthesiologist-based pre-hospital treatment and subsequently released at the scene

The Mobile Emergency Care Unit in Odense, Denmark consists of a rapid response car, manned with an anaesthesiologist and an emergency medical technician. Eleven per cent of the patients are released at the scene following treatment. The aim of the study was to investigate which diagnoses were assigned to patients released at the scene following treatment, to investigate the need for secondary contact with the hospital and to assess mortality in patients released at the scene.

Pre-hospital treatment of bee and wasp induced anaphylactic reactions: a retrospective study

BackgroundBee and wasp stings are among the most common triggers of anaphylaxis in adults representing around 20% of fatal anaphylaxis from any cause. Data of pre-hospital treatment of bee and wasp induced anaphylactic reactions are sparse. This study aimed to estimate the incidence of bee and wasp induced anaphylactic reactions, the severity of the reactions and to correlate the pre-hospital treatment with the severity of the anaphylactic reaction.MethodsRetrospective and descriptive study based on data from the Mobile Emergency Care Units (MECUs) in the Region of Southern Denmark (2008 only for Odense and 2009–2014 for the whole region). Discharge summaries with diagnosis related to anaphylaxis according to the International Classification of Diseases 10 (ICD-10) were reviewed to identify bee and wasp induced anaphylactic reactions. The severity of the anaphylactic reaction was assessed according to Sampson’s severity score and Mueller’s severity score. Treatment was evaluated in relation to administration of adrenaline, glucocorticoids and antihistamine.ResultsWe identified 273 cases (Odense 2008 n = 14 and Region of Southern Denmark 2009–2014 n = 259) of bee and wasp induced anaphylaxis. The Incidence Rate was estimated to 35.8 cases per 1,000,000 person year (95% CI 25.9–48.2) in the Region of Southern Denmark during 2009–2014. According to Sampson’s severity score, 65% (n = 177) of the cases were graded as moderate to severe anaphylaxis (grade 3–5). Almost one third of cases could not be graded according to Mueller’s severity score. Adrenaline was administrated in 54% (96/177) of cases with moderate to severe anaphylaxis according to Sampson’s severity score, compared to 88% receiving intravenous glucocorticoids (p < 0.001) and 91% receiving intravenous antihistamines (p < 0.001). Even in severe anaphylaxis (grade 5) adrenaline was administered in only 80% of the cases.ConclusionTreatment with adrenaline is not administered in accordance with international guidelines. However, making an assessment of the severity of the anaphylactic reaction is difficult in retrospective studies.

Characteristics and prognoses of patients treated by an anaesthesiologist-manned prehospital emergency care unit: A retrospective cohort study

Objective When planning and dimensioning an emergency medical system, knowledge of the population serviced is vital. The amount of literature concerning the prehospital population is sparse. In order to add to the current body of literature regarding prehospital treatment, thus aiding future public health planning, we describe the workload of a prehospital anaesthesiologist-manned mobile emergency care unit (MECU) and the total population it services in terms of factors associated with mortality. Participants The study is a register-based study investigating all missions carried out by a MECU operating in a mixed urban/rural area in Denmark from 1 May 2006 to 31 December 2014. Information on missions was extracted from the local MECU registry and linked at the individual level to the Danish population-based databases, the National Patient Registry and the Civil Registration System. Primary and secondary outcome measures Primary outcome measures were number of missions and number of patient contacts. Secondary patient variables were mortality and association between mortality and age, sex, comorbidity, prior admission to hospital and response time. Results The MECU completed 41 513 missions (mean 13.1 missions/day) having 32 873 patient contacts, corresponding to 19.2 missions and 15.2 patient encounters per 1000 patient years. Patient variables: the median age was 57 years (range 0–108 years), 42.8% (42.3% to 43.4%) were women. For patients admitted to hospital alive, 30-day mortality was 5.7% (5.4% to 6.0%); 90-day mortality was 8.1% (7.8% to 8.5%) while 2-year mortality was 16.4% (16.0% to 16.8%). Increasing age, male sex, comorbidity and prior admission to hospital but not response time were associated with mortality. Conclusions Mortality following an incident requiring the assistance of a MECU was high in the first 2 years following the incident. MECU response time assessed as a continuous parameter was not associated with patient outcome.

Termination of pre-hospital resuscitation by anaesthesiologists - causes and consequences. A retrospective study.

Differentiating between a newly deceased patient and the lifeless patient in whom immediate resuscitation is required may be facilitated by a pre‐hospital anaesthesiologist. The purpose of our study was to investigate to what extent and why the pre‐hospital anaesthesiologist pronounced life extinct in situations where an emergency medical technician (EMT) would have been required to resuscitate.

Reporting Helicopter Emergency Medical Services in Major Incidents: A Delphi Study.

OBJECTIVE Research on helicopter emergency medical services (HEMS) in major incidents is predominately based on case descriptions reported in a heterogeneous fashion. Uniform data reported with a consensus-based template could facilitate the collection, analysis, and exchange of experiences. This type of database presently exists for major incident reporting at www.majorincidentreporting.net. This study aimed to develop a HEMS-specific major incident template. METHODS This Delphi study included 17 prehospital critical care physicians with current or previous HEMS experience. All participants interacted through e-mail. We asked these experts to define data variables and rank which were most important to report during an immediate prehospital medical response to a major incident. Five rounds were conducted. RESULTS In the first round, the experts suggested 98 variables. After 5 rounds, 21 variables were determined by consensus. These variables were formatted in a template with 4 main categories: HEMS background information, the major incident characteristics relevant to HEMS, the HEMS response to the major incident, and the key lessons learned. CONCLUSION Based on opinions from European experts, we established a consensus-based template for reporting on HEMS responses to major incidents. This template will facilitate uniformity in the collection, analysis, and exchange of experience.

Implementation of the ABL-90 blood gas analyzer in a ground-based mobile emergency care unit

Point-of Care analysis is increasingly being applied in the prehospital scene. Arterial blood gas analysis is one of many new initiatives adding to the diagnostic tools of the prehospital physician. In this paper we present a study on the feasibility of the Radiometer ABL-90 in a ground-based Mobile Emergency Care Unit and report on some clinical situations in which the apparatus has proven beneficial.