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The therapy of brain-dead pregnant women is an extreme example not only of the possibilities in current critical care, but also of resulting ethical, social and legal controversies, an area not familiar to most clinicians. Based on the case of a patient with fatal traumatic brain injury, a previously unknown early pregnancy and stated will to donate organs, we will discuss several aspects using published case reports: therapeutic goals, especially palliative care vs. continuation; implications of brain death diagnosis; considerations on legal care; involvement of relatives, especially the child's father; dynamics within the care team; and finally the issue of putative organ donation. This complex case once more depicts that even facing such highly unfavourable framework and seemingly irreconcilable factors, pregnancy can prevail. The researched facts and considerations in this article are intended to give an overview of potential dilemmas and might serve as a starting point in similar situations., Competing Interests: Die Autorinnen/Autoren erklären, dass kein Interessenkonflikt vorliegt., (Thieme. All rights reserved.)

A 29-year-old woman suffered major traumatic brain injury caused by a car accident. As diagnostic measures had revealed an early pregnancy (9th week), treatment on the intensive care unit was continued for 5 months, after unfavourable cerebral prognosis was followed by an irreversible loss of brain function in the 10th week of pregnancy. After assisted vaginal delivery of a healthy child in the 31th week of pregnancy on the critical care unit, organ procurement took place according to the presumed will of the patient. The article presents the details of the critical care therapy and discusses the supportive medical measures. Those measures served primarily to uphold the pregnancy und support the healthy development and delivery of the fetus and only in second instance the organ preservation aiming on organ donation. Necessary measures included maintenance of vital functions, hemostasis of electrolytes, nutrition, treatment of infection, prevention of adverse effects on the fetus, substitution of hormones and vitamins as well as the preparation of a planned or an unplanned delivery., Competing Interests: Die Autorinnen/Autoren erklären, dass kein Interessenkonflikt vorliegt., (Thieme. All rights reserved.)

Background: Data on RAS testing practices prior to metastatic colorectal cancer (mCRC) treatment initiation are lacking in the USA. Materials & methods: Flatiron data were utilized for patients diagnosed with mCRC between 2011 and 2017. Flatiron is a longitudinal, demographically and geographically diverse database representing data from over 1.5 million active US patients treated at 255 community and hospital-affiliated oncology clinics. Results: Among 17,387 mCRC patients 69% were RAS tested and 31% were never tested. Timing of RAS testing was as follows: 23% were tested at the time of their initial CRC diagnosis, 60% following mCRC diagnosis but prior to first line of treatment, 3% prior to third line, the remaining 14% were tested following third line. Conclusion: A third (31%) of patients failed to receive RAS testing, therefore all treatment options were unavailable to them. These data highlight how universal testing has not been achieved.

The Scandinavian Society of Anaesthesiology and Intensive Care Medicine Clinical practice Committee endorses the BMJ Rapid Recommendation Gastrointestinal bleeding prophylaxis for critically ill patients-a clinical practice guideline. The guideline serves as a useful decision aid for clinicians caring for critically ill patients, and can be used together with clinical experience to decide whether a specific critically ill patient may benefit from gastrointestinal bleeding prophylaxis., (© 2020 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

Objective: Despite critical hypoxemia, Covid-19 patients may present without proportional signs of respiratory distress. We report three patients with critical respiratory failure due to Covid-19, in which all presented with severe hypoxemia refractory to supplemental oxygen therapy. We discuss possible strategies for ventilatory support in the emergency pre-hospital setting, and point out some pitfalls regarding the management of these patients. Guidelines for pre-hospital care of critically ill Covid-19 patients cannot be established based on the current evidence base, and we have to apply our understanding of respiratory physiology and mechanics in order to optimize respiratory support., Methods: Three cases with similar clinical presentation were identified within the Norwegian national helicopter emergency medical service (HEMS) system. The HEMS units are manned by a consultant anaesthesiologist. Patient's next of kin and the Regional committee for medical and health research ethics approved the publication of this report., Conclusion: Patients with Covid-19 and severe hypoxemia may pose a considerable challenge for the pre-hospital emergency medical services. Intubation may be associated with a high risk of complications in these patients and should be carried out with diligence when considered necessary. The following interventions are worth considering in Covid-19 patients with refractory hypoxemia before proceeding to intubation. First, administering oxygen via a tight fitting BVM with an oxygen flow rate that exceeds the patient's ventilatory minute volume. Second, applying continuous positive airway pressure, while simultaneously maintaining a high FiO 2 . Finally, assuming the patient is cooperative, repositioning to prone position.

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 SpO 2  < 90%) was 16.7%; 10.9% had SpO 2  < 85%. 98/725 patients (13.5%) were hypoxic post-intubation (final SpO 2  < 90% 10 minutes post-intubation). Median SpO 2 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 (SpO 2  < =90%) for patients with initial SpO 2  > 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.

Background: Few publications have addressed prehospital use of ketamine in analgesic doses. We aimed to assess the effect and safety profile of ketamine compared with other analgesic drugs (or no drug) in adult prehospital patients with acute pain., Methods: A systematic review of clinical trials assessing prehospital administration of ketamine in analgesic doses compared with other analgesic drugs or no analgesic treatment in adults. We searched PubMed, EMBASE, Cochrane Library and Epistemonikos from inception until 15 February 2020, including relevant articles in English and Nordic languages. We used the Cochrane and Grading of Recommendations Assessment, Development and Evaluation methodologies and exclusively assessed patient-centred outcomes. Two independent authors screened trials for eligibility, extracted data and assessed risk of bias., Results: We included eight studies (2760 patients). Ketamine was compared with various opioids given alone, and intranasal ketamine given with nitrous oxide was compared with nitrous oxide given alone. Four randomised controlled trials (RCTs) and one cluster randomised trial included 699 patients. One prospective cohort included 27 patients and two retrospective cohorts included 2034 patients. Five of the eight studies had high risks of bias. Pain score with ketamine is probably lower than after opioids as demonstrated in a cluster-RCT (308 patients) and a retrospective cohort (158 patients) study, Δ visual analogue scale -0.4 (-0.8 to 0.0) and Δ numeric pain rating scale -3.0 (-3.86 to -2.14), respectively. Ketamine probably leads to less nausea and vomiting (risk ratio (RR) 0.24 (0.11 to 0.52)) but more agitation (RR 7.81 (1.85 to 33)) than opioids., Conclusions: This systematic literature review finds that ketamine probably reduces pain more than opioids and with less nausea and vomiting but higher risk of agitation. Risk of bias in included studies is high., Other: Scandinavian society of anaesthesiology and intensive care medicine funded meetings and software. The Norwegian Air Ambulance Foundation funded publication. Otherwise this research received no grant from any agency in the public, commercial or not-for-profit sectors., Prospero Registration Number: CRD42018114399., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Pain management is one of the most important interventions in the emergency medical services. The femoral nerve block (FNB) is, among other things, indicated for pre- and post-operative pain management for patients with femoral fractures but its role in the pre-hospital setting has not been determined. The aim of this review was to assess the effect and safety of the FNB in comparison to other forms of analgesia (or no treatment) for managing acute lower extremity pain in adult patients in the pre-hospital setting., Methods: A systematic review (PROSPERO registration (CRD42018114399)) was conducted. The Cochrane and GRADE methods were used to assess outcomes. Two authors independently reviewed each study for eligibility, extracted the data and performed risk of bias assessments., Results: Four studies with a total of 252 patients were included. Two RCTs (114 patients) showed that FNB may reduce pain more effectively than metamizole (mean difference 32 mm on a 100 mm VAS (95% CI 24 to 40)). One RCT (48 patients) compared the FNB with lidocaine and magnesium sulphate to FNB with lidocaine alone and was only included here for information regarding adverse effects. One case series included 90 patients. Few adverse events were reported in the included studies. The certainty of evidence was very low. We found no studies comparing FNB to inhaled analgesics, opioids or ketamine., Conclusions: Evidence regarding the effectiveness and adverse effects of pre-hospital FNB is limited. Studies comparing pre-hospital FNB to inhaled analgesics, opioids or ketamine are lacking., (© 2020 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

Background: Helicopter emergency medical services (HEMS) and search and rescue helicopters (SAR) aim to bring specialized personnel to major incidents and transport patients to definite care, but their operational pattern remains poorly described. We aim to describe the use of HEMS and SAR in major incidents in Norway and investigate the feasibility of retrospectively collecting uniform data from incident reports., Methods: We searched HEMS medical databases from three HEMS and one SAR base in south-east Norway for the written reports of incidents from 2000 to 2016. After incidents were included through consensus in the author group, we collected data as described in majorincidentreporting.org and a previous cross-sectional study and rated availability of the variables., Results: From a total of 31 803 missions, we identified 50 (0.16%) major incidents with HEMS/SAR involvement where road traffic accidents were the most common type of incident (n = 28, 56%), and rural area was the most prevalent location (n = 35, 70%). Inter-agency cooperation was common and HEMS contributed most often with treatment and transport. The majority of information was found in the free-text area in the medical records hereby increasing the risk for rater variability., Conclusion: Major incidents are rare in Norway. HEMS and SAR play an important role in incident logistics, cooperation with other agencies, treatment and transport of patients and should be included in major incident plans. Retrospective data collection is challenging as data variables are not systematically integrated into the database. Future research should focus on systematic data gathering and a system for sharing lessons learned., (© 2020 The Authors. Acta Anaesthesiologica Scandinavica published by John Wiley & Sons Ltd on behalf of Acta.)

Background: Emergency physicians on-scene provide highly specialized care to severely sick or injured patients. High-quality research relies on the quality of data, but no commonly accepted definition of EMS data quality exits. Glasgow Coma Score (GCS) and Systolic Blood Pressure (SBP) are core physiological variables, but little is known about the quality of these data when reported in p-EMS research. This systematic review aims to describe the quality of pre-hospital reporting of GCS and SBP data in studies where emergency physicians are present on-scene., Methods: A systematic literature search was performed using CINAHL, Cochrane, Embase, Medline, Norart, Scopus, SweMed + and Web of Science, in accordance with the PRISMA guidelines. Reported data on accuracy of reporting, completeness and capture were extracted to describe the quality of documentation of GCS and SBP. External and internal validity assessment was performed by extracting a set of predefined variables., Results: We included 137 articles describing data collection for GCS, SBP or both. Most studies (81%) were conducted in Europe and 59% of studies reported trauma cases. Reporting of GCS and SBP data were not uniform and may be improved to enable comparisons. Of the predefined external and internal validity data items, 26%-45% of data were possible to extract from the included papers., Conclusions: Reporting of GCS and SBP is variable in scientific papers. We recommend standardized reporting to enable comparisons of p-EMS., (© 2020 The Authors. Acta Anaesthesiologica Scandinavica published by John Wiley & Sons Ltd on behalf of Acta Anaesthesiologica Scandinavica Foundation.)

Background: Individualized treatment is a common principle in hospitals. Treatment decisions are made based on the patient's condition, including comorbidities. This principle is equally relevant out-of-hospital. Furthermore, comorbidity is an important risk-adjustment factor when evaluating pre-hospital interventions and may aid therapeutic decisions and triage. The American Society of Anesthesiologists Physical Status (ASA-PS) classification system is included in templates for reporting data in physician-staffed pre-hospital emergency medical services (p-EMS) but whether an adequate full pre-event ASA-PS can be assessed by pre-hospital physicians remains unknown. We aimed to explore whether pre-hospital physicians can score an adequate pre-event ASA-PS with the information available on-scene., Methods: The study was an inter-rater reliability study consisting of two steps. Pre-event ASA-PS scores made by pre- and in-hospital physicians were compared. Pre-hospital physicians did not have access to patient records and scores were based on information obtainable on-scene. In-hospital physicians used the complete patient record (Step 1). To assess inter-rater reliability between pre- and in-hospital physicians when given equal amounts of information, pre-hospital physicians also assigned pre-event ASA-PS for 20 of the included patients by using the complete patient records (Step 2). Inter-rater reliability was analyzed using quadratic weighted Cohen's kappa (κ w )., Results: For most scores (82%) inter-rater reliability between pre-and in-hospital physicians were moderate to substantial (κ w 0,47-0,89). Inter-rater reliability was higher among the in-hospital physicians (κ w 0,77 to 0.85). When all physicians had access to the same information, κ w increased (κ w 0,65 to 0,93)., Conclusions: Pre-hospital physicians can score an adequate pre-event ASA-PS on-scene for most patients. To further increase inter-rater reliability, we recommend access to the full patient journal on-scene. We recommend application of the full ASA-PS classification system for reporting of comorbidity in p-EMS.

Introduction: Out of hospital cardiac arrest (OHCA) carries an 86% mortality rate in Norway. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a potential adjunct in management of non-traumatic cardiac arrest and is feasible in pre-hospital setting without compromising standard cardiopulmonary resuscitation (CPR). However, number of patients potentially eligible for REBOA remain unknown. In preparation for a clinical trial to investigate any benefit of pre-hospital REBOA, we sought to assess the need for REBOA in Norway as an adjunct treatment in OHCA., Methods: Retrospective observational cohort study of data from the Norwegian Cardiac Arrest Registry in the 3-year period 2016-2018. We identified number of patients potentially eligible for pre-hospital REBOA during CPR, defined by suspected non-traumatic origin, age 18-75 years, witnessed arrest, ambulance response time less than 15 min, treated by ambulance personnel and resuscitation effort over 30 min., Results: In the 3-year period, ambulance personnel resuscitated 8339 cases. Of these, a group of 720 patients (8.6%) were eligible for REBOA. Only 18% in this group achieved return of spontaneous circulation and 7% survived for 30 days or more., Conclusion: This national registry data analysis constitutes a needs assessment of REBOA in OHCA. We found that each year approximately 240 patients, or nearly 9% of ambulance treated OHCA, in Norway is potentially eligible for pre-hospital REBOA as an adjunct treatment to standard resuscitation. This needs assessment suggests that there is sufficient patient population in Norway to study REBOA as an adjunct treatment in OHCA.

Background: Physician-staffed emergency medical services (p-EMS) are resource demanding, and research is needed to evaluate any potential effects of p-EMS. Templates, designed through expert agreement, are valuable and feasible, but they need to be updated on a regular basis due to developments in available equipment and treatment options. In 2011, a consensus-based template documenting and reporting data in p-EMS was published. We aimed to revise and update the template for documenting and reporting in p-EMS., Methods: A Delphi method was applied to achieve a consensus from a panel of selected European experts. The experts were blinded to each other until a consensus was reached, and all responses were anonymized. The experts were asked to propose variables within five predefined sections. There was also an optional sixth section for variables that did not fit into the pre-defined sections. Experts were asked to review and rate all variables from 1 (totally disagree) to 5 (totally agree) based on relevance, and consensus was defined as variables rated ≥4 by more than 70% of the experts., Results: Eleven experts participated. The experts generated 194 unique variables in the first round. After five rounds, a consensus was reached. The updated dataset was an expanded version of the original dataset and the template was expanded from 45 to 73 main variables. The experts approved the final version of the template., Conclusions: Using a Delphi method, we have updated the template for documenting and reporting in p-EMS. We recommend implementing the dataset for standard reporting in p-EMS.

Introduction: Optimal dispatch of emergency medical services relies on accurate time estimates of the various prehospital stages. Hoist rescue work time intervals performed by the search and rescue (SAR) helicopter service in Norway have not been studied to date. We aimed to describe the epidemiologic, operational, and medical aspects of the SAR service in southeast Norway. To complement the prehospital timeline, we performed simulated hoist operations., Methods: We reviewed time and patient descriptors and medical interventions in hoist operations performed at a SAR base over 5 y. In addition, a simulation study measuring hoist rescue time intervals was performed. Data are presented as mean±SD, except National Advisory Committee for Aeronautics (NACA) scores, which are presented as modes., Results: There were 148 hoist operations performed during the study period, involving 180 patients. Time to take-off was 13±7 min. There were 88 patients (49%) who were injured; 53 (29%) had a medical condition, and 39 (22%) were evacuees. The mode of the NACA score was 3. Forty-five patients (25%) had an NACA score of 4 to 6. Medical interventions were performed on 77 patients (43%) in 73 operations (49%). Nine patients (5%) were endotracheally intubated, and 1 thoracostomy was performed. The simulated rescuer access time was 4±2 min, the simulated anesthesiologist access time was 6±2 min, and the simulated hoist extrication time was 13±2 min., Conclusions: Hoist rescue was performed in 10% (n=148) of the SAR operations. New information about hoist extrication time intervals can improve rescue helicopter dispatch accuracy., (Copyright © 2019 The Authors. Published by Elsevier Inc. All rights reserved.)

B cell development depends on the coordinated expression and cooperation of several transcription factors. Here we show that the transcription factor ETS-related gene (ERG) is crucial for normal B cell development and that its deletion results in a substantial loss of bone marrow B cell progenitors and peripheral B cells, as well as a skewing of splenic B cell populations. We find that ERG-deficient B lineage cells exhibit an early developmental block at the pre-B cell stage and proliferate less. The cells fail to express the immunoglobulin heavy chain due to inefficient V-to-DJ recombination, and cells that undergo recombination display a strong bias against incorporation of distal V gene segments. Furthermore, antisense transcription at PAX5-activated intergenic repeat (PAIR) elements, located in the distal region of the Igh locus, depends on ERG. These findings show that ERG serves as a critical regulator of B cell development by ensuring efficient and balanced V-to-DJ recombination., (Copyright © 2019 The Author(s). Published by Elsevier Inc. All rights reserved.)

Sweden is investigating an outbreak of monophasic Salmonella Typhimurium. Eighty-two nationally-distributed cases have been confirmed, with date of symptom onset between 28 August and 29 October. Cases were 51 years of age on average (range: 0-89) and the majority of cases were female (62%). A case-control study was conducted and suggested small tomatoes as source of the outbreak (adjusted odds ratio (OR): 10.8, 95% confidence interval (CI): 4.15-112.68, p value < 0.001), and a trace-back investigation led to a single, non-Swedish producer in Europe. Both the Salmonella strain and the source of the outbreak are rarely encountered in Europe. Results from investigation at the producer are pending.

The Scandinavian Society of Anaesthesiology and Intensive Care Medicine Clinical Practice Committee endorses the recent DASAIM/DSIT guideline for prevention of rhabdomyolysis-induced acute kidney injury. However, we emphasize the low quality of evidence with only weak recommendations for all interventions, highlighting that further research is very likely to have an important impact on the confidence in the estimate of effect and is likely to change the estimates., (© 2019 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

The importance of Vesicular Glutamate Transporter 2 (VGLUT2)-mediated neurotransmission has been highlighted in studies on addiction-related phenotypes. The single nucleotide polymorphism rs2290045 in VGLUT2 has been associated with alcohol dependence, but it is unknown whether or how this association is affected by environmental factors. The present study determined whether the association of alcohol-related problems with the rs2290045 in the VGLUT2 gene was modified by negative and positive environmental factors. Three samples were included: a clinical sample of 131 adolescents followed from age 17 to 22; a general population sample of 1794 young adults; and a general population sample of 1687 adolescents followed from age 14 to 17. DNA was extracted from saliva and the rs2290045 (T/C) was genotyped. Alcohol-related problems were assessed using the Alcohol Use Disorders Identification Test. Stressful life events (SLE) and parenting were assessed by questionnaires. Gene-environment interactions were investigated using a dual statistical approach. In all samples (effect sizes 0.6-6.2%), and consistent with the differential susceptibility framework, T carriers exposed to SLE reported more alcohol-related problems if they had experienced poor parenting, and lower alcohol-related problems if they had received supportive parenting. T carriers not exposed to SLE reported higher alcohol-related problems if they had received supportive parenting and lower alcohol-related problems if they had received poor parenting. Among CC carriers, alcohol-related problems did not vary as a function of negative and positive environmental factors. In conclusion, in three samples of youths, alcohol-related problems were associated with an interaction of VGLUT2 rs2290045, SLE, and parenting.

Introduction: Helicopter emergency medical services (HEMS) contribute to and complement other specialized search and rescue (SAR) services. Conversely, traditional SAR services perform medical evacuation (medevac), depending on crew, training, medical equipment, and procedures for interdisciplinary cooperation. We aim to describe and compare SAR and remote medevac mission characteristics in a military SAR helicopter system to a civilian HEMS operating in the same region., Methods: Retrospective, observational study of SAR and remote medevac missions performed at a Norwegian military SAR helicopter and civilian HEMS base in the 5-y period from January 1, 2013 to December 31, 2017. Descriptive statistics and median values with interquartile range (IQR) were applied where appropriate. Comparisons were performed with the Mann-Whitney U test., Results: We included 721 missions. The SAR service performed 359 (50%) missions, of which 237 (33%) were SAR and 122 (17%) were remote medevac missions. The HEMS service performed 85 (12%) SAR and 277 (38%) remote medevac missions. Median mission time for SAR missions was 152 (IQR 100-235) min for the SAR service and 57 (IQR 34-89) min for the HEMS service. Trauma was the dominating mechanism in 48% of patients, followed by medical conditions (21%) and psychiatric disorders (9%). Medevac patients in both services had a higher median National Advisory Committee for Aeronautics score of 3 (IQR 2-4) compared to 1 (IQR 0-3) in SAR missions (P<0.05)., Conclusions: Both SAR and HEMS services perform SAR and remote medevac missions extensively and mission profiles vary., (Copyright © 2019 Wilderness Medical Society. Published by Elsevier Inc. All rights reserved.)

The Scandinavian Society of Anaesthesiology and Intensive Care Medicine Clinical Practice Committee endorses the BMJ Rapid Recommendation clinical practice guideline on atraumatic (pencil-point) vs conventional needles for lumbar puncture. This includes the strong recommendation for the use of atraumatic needles for lumbar puncture in all patients regardless of age or indication., (© 2019 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

Background: Comparison of services and identification of factors important for favourable patient outcomes in emergency medical services (EMS) is challenging due to different organization and quality of data. The purpose of the present study was to evaluate the feasibility of physician-staffed EMS (p-EMS) to collect patient and system level data by using a consensus-based template., Methods: The study was an international multicentre observational study. Data were collected according to a template for uniform reporting of data from p-EMS using two different data collection methods; a standard and a focused data collection method. For the standard data collection, data were extracted retrospectively for one year from all FinnHEMS bases and for the focused data collection, data were collected prospectively for six weeks from four selected Norwegian p-EMS bases. Completeness rates for the two data collection methods were then compared and factors affecting completeness rates and template feasibility were evaluated. Standard Chi-Square, Fisher's Exact Test and Mann-Whitney U Test were used for group comparison of categorical and continuous data, respectively, and Kolomogorov-Smirnov test for comparison of distributional properties., Results: All missions with patient encounters were included, leaving 4437 Finnish and 128 Norwegian missions eligible for analysis. Variable completeness rates indicated that physiological variables were least documented. Information on pain and respiratory rate were the most frequently missing variables with a standard data collection method and systolic blood pressure was the most missing variable with a focused data collection method. Completeness rates were similar or higher when patients were considered severely ill or injured but were lower for missions with short patient encounter. When a focused data collection method was used, completeness rates were higher compared to a standard data collection method., Conclusions: We found that a focused data collection method increased data capture compared to a standard data collection method. The concept of using a template for documentation of p-EMS data is feasible in physician-staffed services in Finland and Norway. The greatest deficiencies in completeness rates were evident for physiological parameters. Short missions were associated with lower completeness rates whereas severe illness or injury did not result in reduced data capture.

Background: Current management principles of hemorrhagic shock after trauma emphasize earlier transfusion therapy to prevent dilution of clotting factors and correct coagulopathy. London's Air Ambulance (LAA) was the first UK civilian prehospital service to routinely offer prehospital red blood cell (RBC) transfusion (phRTx). We investigated the effect of phRTx on mortality., Methods: Retrospective trauma database study comparing mortality before implementation with after implementation of phRTx in exsanguinating trauma patients. Univariate logistic regression was performed for the unadjusted association between phRTx and mortality was performed, and multiple logistic regression adjusting for potential confounders., Results: We identified 623 subjects with suspected major hemorrhage. We excluded 84 (13.5%) patients due to missing data on survival status. Overall 187 (62.3%) patients died in the before phRTx period and 143 (59.8%) died in the after phRTx group. There was no significant improvement in overall survival after the introduction of phRTx (P = 0.554). Examination of prehospital mortality demonstrated 126 deaths in the pre-phRTx group (42.2%) and 66 deaths in the RBC administered group (27.6%). There was a significant reduction in prehospital mortality in the group who received RBC (P < 0.001)., Conclusions: phRTx was associated with increased survival to hospital, but not overall survival. The "delay death" effect of phRTx carries an impetus to further develop inhospital strategies to improve survival in severely bleeding patients.

Purpose: Quality measurement of physician-staffed emergency medical services (P-EMS) is necessary to improve service quality. Knowledge and consensus on this topic are scarce, making quality measurement of P-EMS a high-priority research area. The aim of this review was to identify, describe and evaluate studies of quality measurement in P-EMS., Data Sources: The databases of MEDLINE and Embase were searched initially, followed by a search for included article citations in Scopus., Study Selection: The study eligibility criteria were: (1) articles describing the use of one quality indicator (QI) or more in P-EMS, (2) original manuscripts, (3) articles published from 1 January 1968 until 5 October 2016. The literature search identified 4699 records. 4543 were excluded after reviewing title and abstract. An additional 129 were excluded based on a full-text review. The remaining 27 papers were included in the analysis. Methodological quality was assessed using an adapted critical appraisal tool., Data Extraction: The description of used QIs and methods of quality measurement was extracted. Variables describing the involved P-EMSs were extracted as well., Results of Data Synthesis: In the included papers, a common understanding of which QIs to use in P-EMS did not exist. Fifteen papers used only a single QI. The most widely used QIs were 'Adherence to medical protocols', 'Provision of advanced interventions', 'Response time' and 'Adverse events'., Conclusion: The review demonstrated a lack of shared understanding of which QIs to use in P-EMS. Moreover, papers using only one QI dominated the literature, thus increasing the risk of a narrow perspective in quality measurement. Future quality measurement in P-EMS should rely on a set of consensus-based QIs, ensuring a comprehensive approach to quality measurement., (© The Author(s) 2018. Published by Oxford University Press in association with the International Society for Quality in Health Care.)

Clinical practice guidelines from other organizations or societies with assumed clinical and contextualized relevance for Scandinavian Society of Anaesthesiology and Intensive Care Medicine (SSAI) members, may trigger a formal evaluation by The Clinical Practice Committee (CPC) for possible SSAI endorsement. This avoids unnecessary duplicate processes and minimizes resource-waste. Identified guidelines are assessed for endorsement using the Appraisal of Guidelines for REsearch and Evaluation (AGREE) II instrument. The SSAI CPC utilizes the AGREE II online coordinated group appraisal platform to assess the methodological rigor and transparency in which the guideline was developed. The results of the assessment, including the decision to endorse or not, are presented to the SSAI Board for sanctioning. This document briefly outlines the process for evaluation of non-SSAI guidelines by the CPC for possible SSAI endorsement., (© 2018 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

Psittacosis is a zoonotic disease transmitted by birds. In Sweden, where psittacosis is notifiable, an average of eight cases per year were reported between 2002 and 2012. In 2013, an unusual increase in cases in southern Sweden was associated with exposure to wild birds. To further explore specific risk factors connected to wild birds and identify other risk factors for sporadic psittacosis, we conducted a case-control study including all domestically acquired psittacosis cases reported between December 2014 and April 2016 in Sweden. Cases were age-, sex- and geo-matched to controls randomly selected from a population register. Cases and controls completed a questionnaire investigating detailed exposures to wild and domestic birds. We compared cases to controls, calculating adjusted matched odds ratios (amOR) using conditional logistic regression. Thirty-one cases were notified: all cases lived in southern Sweden and 26 were ill during winter season. Two risk factors were independently associated with psittacosis infection: cleaning a wild bird feeder (amOR = 18.95; 95% CI: 2.11-170.03) and owning domestic birds (amOR = 5.55, 95% CI: 1.16-26.61). Our results suggest that exposure to bird faeces, for example when cleaning a wild bird feeder, was the main route of transmission. Following this study, the Public Health Agency of Sweden published recommendations on good practices when cleaning surfaces contaminated with bird faeces and recommended use of bird feeders with a design limiting faeces accumulation., (© 2018 Blackwell Verlag GmbH.)

The conduct and benefit of pre-hospital advanced airway management and pre-hospital emergency anaesthesia have been widely debated for many years. In 2011, prehospital advanced airway management was identified as a 'top five' in physician-provided pre-hospital critical care. This article summarises the evidence for and against this intervention since 2011 and attempts to address some of the more controversial areas of this topic.

Introduction: Physician-staffed helicopter emergency medical services (HEMS) in Norway are an adjunct to existing search and rescue services. Our aims were to study the epidemiological, operational, and medical aspects of HEMS daylight static rope operations performed in the southeastern part of the country and to examine several quality dimensions that are characteristic of this service., Methods: We reviewed the static rope operations performed at 3 HEMS bases during a 3-y period and applied a set of quality indicators designed for physician-staffed emergency medical services to evaluate the quality of care. Data are presented as medians with quartiles, except National Advisory Committee for Aeronautics (NACA) scores, which are presented as mean (SD)., Results: Fifty-nine static rope operations were identified, involving 60 patients. Median (quartiles) age was 43 (27-55) y. Median (quartiles) take-off time was 9 (5-13) min. Trauma-related injuries were found in 48 patients. The main conditions were lower limb injuries, found in 32 patients. Ten patients experienced medical conditions. Mean (SD) NACA score was 3.3 (1.3). A potential or actual life-threatening diagnosis (NACA score: 4-6) was reported among 15 patients. The main interventions were intravenous lines (19 patients), analgesics (17), and oxygen treatment (14). Four patients were intubated, and 1 thoracostomy was performed., Conclusions: Static rope operations are rarely performed. The quality indicators suggest that the service is safe, available, and equitable. Its main benefit seems to be evacuation and the maintenance of readiness before rapid transport of the physician to the scene or the patient to the hospital., (Copyright © 2018 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Helicopter EMS (HEMS) teams may perform a variety of clinical, managerial and transport functions during major incident management. Despite national and international variations in HEMS systems, the rapid delivery of HEMS personnel with advanced skills in major incident management and clinical scene leadership has been crucial to the delivery of an effective medical response at previous incidents. This document outlines the Best Practice Advice of the European HEMS and Air Ambulance Committee (EHAC) Medical Working Group on how HEMS and Pre Hospital Critical Care teams may maximise the positive impact of their resources in the event of Major Incidents., Methods: Narrative literature review and expert consensus., Results: To ensure a safe, coordinated and effective response, HEMS teams require suitable, proportionate and up to date major incident plans that are integrated into the major incident plans of other regional emergency and healthcare services. Role specific protocols, training and equipment should be adapted to the expected HEMS role in the major incident plan and likely regional threats. System and incident factors will influence HEMS utilisation during the major incident response and can include patient and staff transfer, equipment resupply, aerial assessment, search and rescue, clinical leadership and advanced care. During the recovery phase of a major incident there is a need to ensure restoration of conventional service and address the welfare of involved HEMS personnel. Standardised reporting of major incidents is strongly recommended for clinical governance, legal and research reasons., Conclusions: The rapid delivery of HEMS personnel with advanced skills in Major Incident management and clinical scene leadership is crucial to the delivery of an effective medical response at Major Incidents.

Background: On-scene management of pre-hospital emergencies is often inter-disciplinary, involving ground-emergency medical services (EMS), police- and fire services, and in Norway general practitioners on-call. This can also be supplemented by physician-staffed EMS (P-EMS), utilizing helicopters or rapid response vehicles. We hypothesized that P-EMS cooperates extensively with other emergency services, and therefore the primary aim of this study was to investigate the fraction of inter-disciplinary cooperation between P-EMS and other emergency services., Methods: Retrospective, observational study of primary pre-hospital missions with patient contact performed at a Norwegian P-EMS base from 01.01.06 to 31.12.15. Descriptive statistics, comparisons using Student`s t-test, and chi-squared test for trend were applied., Results: Inter-disciplinary cooperation occurred in 94.3% of the 8580 missions, of which physician-staffed EMS cooperated with ground EMS in 92.4%, general practitioner 32.9%, police service 11.6% and fire service 11.8%. Trauma constituted 34.4 and cardiac arrest 14.1% of missions. The mean National Advisory Committee for Aeronautics score was 4.21 (95% Confidence Interval 4.18-4.24). There was an overall decrease in cooperation with general practitioners and the police service (P < 0.001). During helicopter missions, we reported a decrease in general practitioner cooperation compared to an increase during rapid response car missions (P < 0.001). In cardiac arrest cases, cooperation with both general practitioners and the fire service increased (P < 0.001)., Conclusion: Physician-staffed EMS cooperates extensively with other professional emergency services, especially ground-EMS. On-scene cooperation with general practitioners decreased, whereas there was an increased cooperation with the fire service in a "first-responder" role during cardiac arrest missions., (© 2018 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

Introduction: The current management of severely injured patients includes damage control resuscitation strategies that minimise the use of crystalloids and emphasise earlier transfusion of red blood cells (RBC) to prevent coagulopathy. In 2012, London's air ambulance (LAA) became the first UK civilian pre-hospital service to routinely carry RBC to the trauma scene., Objective: To investigate the effect of pre-hospital RBC transfusion (phRTx) on overall blood product consumption., Methods: A retrospective trauma database study compares before implementation with after implementation of phRTx in exsanguinating trauma patients transported directly to one major trauma centre. Pre-hospital deaths were excluded. Univariate and multivariate Poisson regression analyses on data subject to multiple imputation were conducted., Results: We included 137 and 128 patients in the before and after the implementation of phRTx groups, respectively. LAA transfused 304 RBC units (median 2, inter quartile range 1-3). We found a significant reduction in total RBC usage and reduced early use of platelets and fresh-frozen plasma (FFP) after the implementation of phRTx in both univariate (P < 0·001) and multivariate analyses (P < 0·001). No immediate adverse transfusion reactions were identified., Conclusion: Pre-hospital trauma transfusion practice is feasible and associated with overall reduced RBC, platelets and FFP consumption., (© 2017 British Blood Transfusion Society.)

Hematopoietic stem cells (HSCs) are considered a heterogeneous cell population. To further resolve the HSC compartment, we characterized a retinoic acid (RA) reporter mouse line. Sub-fractionation of the HSC compartment in RA-CFP reporter mice demonstrated that RA-CFP-dim HSCs were largely non-proliferative and displayed superior engraftment potential in comparison with RA-CFP-bright HSCs. Gene expression analysis demonstrated higher expression of RA-target genes in RA-CFP-dim HSCs, in contrast to the RA-CFP reporter expression, but both RA-CFP-dim and RA-CFP-bright HSCs responded efficiently to RA in vitro. Single-cell RNA sequencing (RNA-seq) of >1,200 HSCs showed that differences in cell cycle activity constituted the main driver of transcriptional heterogeneity in HSCs. Moreover, further analysis of the single-cell RNA-seq data revealed that stochastic low-level expression of distinct lineage-affiliated transcriptional programs is a common feature of HSCs. Collectively, this work demonstrates the utility of the RA-CFP reporter line as a tool for the isolation of superior HSCs., (Copyright © 2018 The Author(s). Published by Elsevier Inc. All rights reserved.)

Once an incidental finding (IF) is discovered in the course of genomic research, the researchers are faced with the question of whether or not that finding should be reported back to the study participant. A large number of hypothetical studies and policy documents on this issue have been published, but there are very few empirical studies to inform the bioethics debate. Within a biobank research study of somatic mutations in breast carcinomas, ten germline BRCA1/2 mutations were incidentally detected. After thorough discussions within a group of experts, the mutation carriers (n = 7) or relatives of deceased carriers (n = 3) were re-contacted and informed about the findings. Eight out of ten accepted to receive the information and underwent confirmatory testing. One year later, semi-structured interviews were undertaken with three of the study participants. All of them felt that BRCA mutations discovered in the course of research should be reported back to the individual study participants. In this paper, we report our step-by-step experiences of the re-contacting process. We hope that our detailed reporting will be helpful for other researchers and clinicians that are faced with similar situations. The results of our study lend empirical support to opinion that IFs that meet the three baseline criteria of analytic validity, clinical significance, and actionability should be reported back to the individual study participants.

Background: The benefits of pre-hospital emergency anaesthesia (PHEA) are controversial. Patients who are hypovolaemic prior to induction of anaesthesia are at risk of severe cardiovascular instability post-induction. This study compared mortality for hypovolaemic trauma patients (without major neurological injury) undergoing PHEA with a patient cohort with similar physiology transported to hospital without PHEA., Methods: A retrospective database review was performed to identify patients who were hypotensive on scene [systolic blood pressure (SBP) < 90 mmHg], and GCS 13-15. Patient records were reviewed independently by two pre-hospital clinicians to identify the likelihood of hypovolaemia. Primary outcome measure was mortality defined as death before hospital discharge., Results: Two hundred and thirty-six patients were included; 101 patients underwent PHEA. Fifteen PHEA patients died (14.9%) compared with six non-PHEA patients (4.4%), P = 0.01; unadjusted OR for death was 3.73 (1.30-12.21; P = 0.01). This association remained after adjustment for age, injury mechanism, heart rate and hypovolaemia (adjusted odds ratio 3.07 (1.03-9.14) P = 0.04). Fifty-eight PHEA patients (57.4%) were hypovolaemic prior to induction of anaesthesia, 14 died (24%). Of 43 PHEA patients (42.6%) not meeting hypovolaemia criteria, one died (2%); unadjusted OR for mortality was 13.12 (1.84-578.21). After adjustment for age, injury mechanism and initial heart rate, the odds ratio for mortality remained significant at 9.99 (1.69-58.98); P = 0.01., Conclusion: Our results suggest an association between PHEA and in-hospital mortality in awake hypotensive trauma patients, which is strengthened when hypotension is due to hypovolaemia. If patients are hypovolaemic and awake on scene it might, where possible, be appropriate to delay induction of anaesthesia until hospital arrival., (© 2018 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

Introduction: Improved physiologic status can be seen as a surrogate measure of improved outcome and a field-friendly prognostic model such as the Mainz Emergency Evaluation Score (MEES) could quantify the effect on physiological response. We aim to examine the dynamic physiological profile as measured by this score on patients managed by physician-manned helicopter emergency medical services and how this profile was related to on-scene time expenditure and critical care interventions., Materials and Methods: Data including patient characteristics, physiological data, and description of diagnostic and therapeutic interventions were prospectively collected over two 14-day periods, summer and winter, at six participating Norwegian bases. The MEES score was utilized to examine the difference between a score measured at first patient contact (MEES 1) and end-of-care (MEES 2), (MEES 2-MEES 1=[INCREMENT]MEES)., Results: A total of 240 primary missions with patient-on-scene form the basis of the study. In total, 43% were considered severely ill or injured, of whom 59% were medical patients. Twenty-nine percent were severely deranged physiologically. The most common advanced procedure performed was advanced airway management (15%), followed by defibrillation (8.8%). Using [INCREMENT]MEES as an indicator, 1% deteriorated under care, whereas 66% remained unchanged and 33% showed an improvement in their physiological status. With increasing on-scene time, fewer patients deteriorated and a greater proportion of patients improved., Conclusion: Restoring deranged physiology remains a mantra for all critical care practitioners. We have shown that this is also possible in the prehospital context, even when prolonging on-scene time, and after initiating advanced procedures.

Objectives: Hanging may inflict laryngotracheal injuries and increase the potential for difficult airway management. We describe the management of pediatric hangings attended by an urban physician-led prehospital trauma service to provide information on a clinical situation encountered infrequently by most acute care clinicians., Methods: Retrospective trauma registry-based observational study of all children younger than 16 years attended with hanging as mechanism of injury in the period between 2000 and 2014., Results: Twenty-three thousand one hundred thirty patients were attended; 2415 (10%) of which were children. Of these, 32 cases (<1%) were pediatric hanging (1 case excluded due to missing data). There were 22 (71%) boys and 9 (29%) girls. Median age was 13 years. There was suicidal intent in 23 (74%) cases, and in 8 (26%) cases, hanging was accidental. There were 17 (55%) deaths, of which 14 (82%) were suicides.The doctor-paramedic team intubated 25 (80%) patients, with a 100% success rate. One (3%) patient was managed with a supraglottic airway device, and 5 (16%) patients did not require any advanced airway management., Conclusions: Pediatric hanging is rare, but has a high mortality rate. Attempted suicide is the leading cause of hangings in children and preventive measures should target psychiatric morbidity. Despite concerns about airway edema or laryngeal injury, experienced doctor-paramedic teams had no failed airway attempts.

Erratum: The original article [1] contains an error whereby all authors' names were mistakenly interchanged. The original article has now been corrected to present the authors' names correctly.

Background: Major incidents affect us globally, and are occurring with increasing frequency. There is still no evidence-based standard regarding the best medical emergency response to major incidents. Currently, reports on major incidents are non-standardised and variable in quality. This pilot study examines the first systematic reports from a consensus-based, freely accessible database, aiming to identify how descriptive analysis of reports submitted to this database can be used to improve the major incident response., Methods: Majorincidentreporting.net is a website collecting reports on major incidents using a standardised template. Data from these reports were analysed to compare the emergency response to each incident., Results: Data from eight reports showed that effective triage by experienced individuals and the use of volunteers for transport were notable successes of the major incident response. Inadequate resources, lack of a common triage system, confusion over command and control and failure of communication were reported failures. The following trends were identified: Fires had the slowest times for several aspects of the response and the only three countries to have a single dialling number for all three emergency services had faster response times. Helicopter Emergency Medical services (HEMS) were used for transport and treatment in rural locations and for triage and treatment in urban locations. In two incidents, a major incident was declared before the arrival of the first Emergency Medical Services (EMS) personnel., Conclusion: This study shows that we can obtain relevant data from major incidents by using systematic reporting. Though the sample size from this pilot study is not large enough to draw any specific conclusions it illustrates the potential for future analyses. Identified lessons could be used to improve the emergency medical response to major incidents.

Objective: The potential increased risk of an emergency response using a rapid response vehicle (RRV) should only be accepted when it allows a clinically significant time saving for management of patients who are critically injured or sick. Air ambulance services often use an RRV to maintain operational resilience. We compared the RRV response time on emergency versus standard driving to inform emergency services of time efficacy of emergency response in an urban environment., Methods: Prospective observational controlled study of response data of emergency and standard driving. An identical RRV shadowed the medical team until the team was dispatched to a job (emergency driving). The shadow RRV then drove to the same given location from the same origin location in equal traffic conditions being compliant with all traffic signals, road signs and speed limits (standard driving)., Results: The emergency response resulted in an estimated reduction in median response time of 14 min (95% CI 9 to 19) which represented a time saving of 54.9%. The estimated difference in distance travelled (0.6 km) was not statistically significant. Median speed was significantly higher when using an emergency response (46.1 IQR 39-53.4 km/hour) versus standard response (20.1 IQR 16.3-24.7 km/hour), with an estimated difference of -24.5 km/hour (95% CI -28.8 to -20.5)., Conclusions: The current study found RRVs to be significantly quicker when responding with lights, sirens and traffic rule exemptions compared with a response being compliant with all traffic signals, road signs and speed limits., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Introduction Fetal exposition to valproate can lead to a cluster of facial dysmorphism, congenital anomalies and neurodevelopmental retardation. Case Report In this report we describe 2 cases of fetal valproate syndrome. In the first case, the gravida had a valproate medication before and during pregnancy with additional folic acid. She delivered a male premature infant at 25+2 weeks of gestation due to preterm labor and rupture of the membranes. Physical examination showed even in the premature infant typical signs of fetal valproate syndrome with trigonocephaly, epicanthal folds, broad root of the nose, low-set ears, thin upper lip and anteverted nares. In the second case, the gravida was under antiepileptic therapy with valproate and lamotrigine before and during pregnancy without any prophylaxis with folic acid. Sonographic examination during pregnancy diagnosed a spina bifida, Chiari II malformation and clubfeet. A female newborn was delivered at 39+4 weeks of gestation. Besides the prenatally detected anomalies, facial dysmorphism including microcephaly, low-set ears, thin upper lip and shallow philtrum were seen after birth. Conclusion Valproate, a widely used anticonvulsant medication, is known for its teratogenic effects. The risk of congenital anomalies is even higher in combination with other antiepileptic drugs. Therefore, the avoidance of valproate or at least supplementation with a high dose prophylactic folic acid before and during pregnancy is highly recommended for women with epilepsy., Competing Interests: Conflict of Interest: The authors declare that they have no conflict of interest., (© Georg Thieme Verlag KG Stuttgart · New York.)

Objective: The transfer of experiences gained after prehospital medical responses to major incidents has largely been nonsystematic, and better-structured reporting methods have been advocated. A consensus-based template was recently created and implemented as an open-access website. This qualitative study assessed the feasibility of using the template and reporting site., Methods: Informants who had used or who had been asked to use the template were interviewed. The semi-structured interviews were transcribed verbatim, and the transcripts were analyzed by using an inductive approach based on grounded theory methodology., Results: The major theme identified was a need for "defining purpose" as explained by the minor themes "relevance," "scope," "resources," and "usefulness." Informants reported that the template content needed to be revised and that the scope and rationale behind each question should be conveyed to the user. Resources necessary for reporting and clarity regarding the aim and outcome also need to be communicated to users and policy-makers. The interface between informants and the template is critical., Conclusions: Informants considered the template and website useful but reported that the workload exceeded their expectations. Despite pilot testing of the template before implementation, early revision of the template is recommended. (Disaster Med Public Health Preparedness. 2017;11:403-406).