Mountain Rescue Services (MRS) are a vital link in the chain of survival when it comes to emergencies at high altitudes. Cognitive impairment in hypobaric hypoxic conditions is known, and previous studies have shown suboptimal performance of MRS members after a steep ascent. These impairments may be linked to regional cerebral oxygenation (rSO2). Therefore, this study aimed to investigate whether there are dynamics in rSO2 between “baseline” and “working” altitudes after climbing up to a potential patient.

In this alpine proof-of-concept field study, experienced mountaineers of the Austrian MRS had to perform an active rapid ascent of 1,200 meters on foot to 3,454 meters above sea level. Near-infrared spectroscopy (NIRS) was used to measure rSO2 before and after the climb. Continuous data were compared among subgroups using Mann-Whitney-U tests, and categorical data were compared with χ2-square tests. Statistical significance was defined by two-tailed P values of <.05.

Twenty MRS members were assessed. Their rSO2 values at baseline altitude were significantly higher than at working altitude (70 [SD = 1]% versus 60 [SD = 1]%; absolute difference 10 [95% CI, 6-15]; P <.001). When assessing the single dynamics of each mountain rescuer, there was a wide variability in delta rSO2, ranging from a minimum of 0% to a maximum of 32% (mean 10 [SD = 8]%).

Overall, low rSO2 values were found in mountain rescuers at high altitudes, and there were considerable interpersonal differences of changes in cerebral oxygenation after an ascent. Using rSO2 to assess performance-readiness in mountain rescuers and individual proneness to potential cognitive dysfunction or acute mountain sickness (AMS) could be further research goals.

Airport emergencies are rare but potentially catastrophic; therefore, system preparedness is crucial. Airport emergency plans include the organization of emergency drills on a regular basis, including full-scale exercises, to train and test the entire rescue organization.

This report describes a full-scale simulation at Bologna International Airport, Italy, in October 2022, involving local EMS resources.

A full-scale aeroplane crash was simulated on the airport ground, activating the Airport emergency plan, and requiring the intervention of supplementary resources (ambulances, medical cars, and other emergency vehicles).

Twenty-seven simulated patients were evaluated by EMS: START triage assessment was correct for 81.48% of patients; 11.11% were over-triaged and 7.41% were under-triaged. All patients were transported to the hospitals of the area. The simulation ended 2 hours and 28 minutes after the initial alarm.

The response time proved a good response. Triage accuracy was correct in more than 80% of simulated patients. The availability of a trauma centre within 6 kilometres allowed the transportation of a quota of patients directly from the event, without affecting transportation times. Areas for improvement were identified in the communication within the different agencies and in moving ambulances within the airport runway without airport personnel guidance.

Structured review of video laryngoscopy recordings from physician team prehospital rapid sequence intubations (RSIs) may provide new insights into why prehospital intubations are difficult. The aim was to use laryngoscope video recordings to give information on timings, observed features of the airway, laryngoscopy technique, and laryngoscope performance. This was to both describe prehospital airways and to investigate which factors were associated with increased time taken to intubate.

Sydney Helicopter Emergency Medical Service (HEMS; the aeromedical wing of New South Wales Ambulance, Australia) has a database recording all intubations. The database comprises free-text case detail, airway dataset, scanned case sheet, and uploaded laryngoscope video. The teams of critical care paramedic and doctor use protocol-led intubations with a C-MAC Macintosh size four laryngoscope and intubation adjunct. First-pass intubation rate is approximately 97%. Available video recordings and their database entries were retrospectively analyzed for pre-specified qualitative and quantitative factors.

Prehospital RSI video recordings were available for 385 cases from January 2018 through July 2020. Timings revealed a median of 58 seconds of apnea from laryngoscope entering mouth to ventilations. Median time to intubate (laryngoscope passing lips until tracheal tube inserted) was 35 seconds, interquartile range 28-46 seconds. Suction was required prior to intubation in 29% of prehospital RSIs. Fogging of the camera lens at time of laryngoscopy occurred in 28%. Logistic regression revealed longer time to intubate was associated with airway soiling, Cormack-Lehane Grade 2 or 3, multiple bougie passes, or change of bougie.

Video recordings averaging 35 seconds for first-pass success prehospital RSI with an adjunct give bed-side “definitions of difficulty” of 30 seconds for no glottic view, 45 seconds for no bougie placement, and 60 seconds for no endotracheal tube placement. Awareness of apnea duration can help guide decision making for oxygenation. All emergency intubators need to be cognizant of the need for suctioning. Improving the management of bloodied airways and bougie usage may reduce laryngoscopy duration and be a focus for training. Video screen fogging and missed recordings from some patients may be something manufacturers can address in the future.

Trauma is the leading cause of death in the Western world. Trauma systems have been paramount in opposing this problem. Commonly, Level 1 Trauma Centers are staffed by in-house (IH) attending trauma surgeons available 24/7, whereas other institutions function on an on-call (OC) basis with defined response times. There is on-going debate about the value of an IH attending trauma surgeon compared to OC trauma surgeons regarding clinical outcome.

This study was performed at a tertiary care facility complying with all requirements to be a designated Level 1 Trauma Center as defined by the American College of Surgeons Committee on Trauma (ACSCOT). Inclusion occurred from January 1, 2012 through December 31, 2013. Patients were assigned an identifier for IH trauma surgeon attendance versus OC attendance. The primary outcome variable studied was overall mortality in relation to IH or OC attending trauma surgeons. Additionally, time to operating theater, hospital length-of-stay (HLOS), and intensive care unit (ICU) admittance were investigated.

A total of 1,287 unique trauma cases in 1,285 patients were presented to the trauma team. Of all cases, 712 (55.3%) occurred between 1700h and 0800h. These 712 cases were treated by an IH attending in 66.3% (n = 472) and an OC attending in 33.7% (n = 240). In the group of patients treated by an IH attending trauma surgeon, the overall mortality rate was 5.5% (n = 26); in the group treated by an OC attending, the overall mortality rate was 4.6% (n = 11; P = .599). Cause of death was traumatic brain injury (TBI) in 57.6%. No significant difference was found in the time between initial presentation at the trauma room and arrival in the operating theater.

In terms of trauma-related mortality during non-office hours, no benefit was demonstrated through IH trauma surgeons compared to OC trauma surgeons.

Prehospital ultrasound (PHUS) assessments by physicians and non-physicians are performed on medical and trauma patients with increasing frequency. Prehospital ultrasound has been shown to be of benefit by supporting interventions.

Which patients may benefit from PHUS has not been clearly identified.

A multi-variable logistic regression analysis was performed on a previously created retrospective dataset of five years of physician- and non-physician-performed ultrasound scans in a Canadian critical care Helicopter Emergency Medical Service (HEMS). For separate medical and trauma patient groups, the a-priori outcome assessed was patient characteristics associated with the outcome variable of “PHUS-supported intervention.”

Both models were assessed (Likelihood Ratio, Score, and Wald) as a good fit. For medical patients, the characteristics of heart rate (HR) and shock index (SI) were found to be most significant for an intervention being supported by PHUS. An extremely low HR was found to be the most significant (OR=15.86 [95% confidence interval (CI), 1.46-171.73]; P=.02). The higher the SI, the more likely that an intervention was supported by PHUS (SI 0.9 to<1.3: OR=9.15 [95% CI, 1.36-61.69]; P=.02; and SI 1.3+: OR=8.37 [95% CI, 0.69-101.66]; P=.09). For trauma patients, the characteristics of Prehospital Index (PHI) and SI were found to be most significant for PHUS support. The greatest effect was PHI, where increasing ORs were seen with increasing PHI (PHI 14-19: OR=13.36 [95% CI, 1.92-92.81]; P=.008; and PHI 20-24: OR=53.10 [95% CI, 4.83-583.86]; P=.001). Shock index was found to be similar, though, with lower impact and significance (SI 0.9 to<1.3: OR=9.11 [95% CI, 1.31-63.32]; P=.025; and SI 1.3+: OR=35.75 [95% CI, 2.51-509.81]; P=.008).

In a critical care HEMS, markers of higher patient acuity in both medical and trauma patients were associated with occurrences when an intervention was supported by PHUS. Prospective study with in-hospital follow-up is required to confirm these hypothesis-generating results.

O’DochartaighD, DoumaM, AlexiuC, RyanS, MacKenzieM. Utilization Criteria for Prehospital Ultrasound in a Canadian Critical Care Helicopter Emergency Medical Service: Determining Who Might Benefit. Prehosp Disaster Med. 2017;32(5):536–540.

Early identification of traumatic brain injury (TBI) is essential. Near-infrared spectroscopy (NIRS) can be used in prehospital settings for non-invasive monitoring and the diagnosis of patients who may require surgical intervention.

The handheld NIRS Infrascanner (InfraScan Inc.; Philadelphia, Pennsylvania USA) uses eight symmetrical scan points to detect intracranial bleeding. A scanner was tested in a physician-staffed helicopter Emergency Medical Service (HEMS). The results were compared with those obtained using in-hospital computed tomography (CT) scans. Scan time, ease-of-use, and change in treatment were scored.

A total of 25 patients were included. Complete scans were performed in 60% of patients. In 15 patients, the scan was abnormal, and in one patient, the scan resulted in a treatment change. Compared with the results of CT scanning, the Infrascanner obtained a sensitivity of 93.3% and a specificity of 78.6%. Most patients had severe TBI with indication for transport to a trauma center prior to scanning. In one patient, the scan resulted in a treatment change. Evaluation of patients with less severe TBI is needed to support the usefulness of the Infrascanner as a prehospital triage tool.

Promising results were obtained using the InfraScan NIRS device in prehospital screening for intracranial hematomas in TBI patients. High sensitivity and good specificity were found. Further research is necessary to determine the beneficial effects of enhanced prehospital screening on triage, survival, and quality of life in TBI patients.

PetersJ, Van WageningenB, HoogerwerfN, TanE. Near-Infrared Spectroscopy: A Promising Prehospital Tool for Management of Traumatic Brain Injury. Prehosp Disaster Med. 2017;32(4):414–418.

Non-invasive positive pressure ventilation (NIPPV) is used to treat severe acute respiratory distress. Prehospital NIPPV has been associated with a reduction in both in-hospital mortality and the need for invasive ventilation.

The authors of this study examined factors associated with NIPPV failure and evaluated the impact of NIPPV on scene times in a critical care helicopter Emergency Medical Service (HEMS). Non-invasive positive pressure ventilation failure was defined as the need for airway intervention or alternative means of ventilatory support.

A retrospective chart review of consecutive patients where NIPPV was completed in a critical care HEMS was conducted. Factors associated with NIPPV failure in univariate analyses and from published literature were included in a multivariable, logistic regression model.

From a total of 44 patients, NIPPV failed in 14 (32%); a Glasgow Coma Scale (GCS) <15 at HEMS arrival was associated independently with NIPPV failure (adjusted odds ratio 13.9; 95% CI, 2.4-80.3; P=.003). Mean scene times were significantly longer in patients who failed NIPPV when compared with patients in whom NIPPV was successful (95 minutes vs 51 minutes; 39.4 minutes longer; 95% CI, 16.2-62.5; P=.001).

Patients with a decreased level of consciousness were more likely to fail NIPPV. Furthermore, patients who failed NIPPV had significantly longer scene times. The benefits of NIPPV should be balanced against risks of long scene times by HEMS providers. Knowing risk factors of NIPPV failure could assist HEMS providers to make the safest decision for patients on whether to initiate NIPPV or proceed directly to endotracheal intubation prior to transport.

LeeJS , O’DochartaighD , MacKenzieM , HudsonD , CouperthwaiteS , Villa-RoelC , RoweBH . Factors Associated with Failure of Non-invasive Positive Pressure Ventilation in a Critical Care Helicopter Emergency Medical Service. Prehosp Disaster Med2015; 30(2): 1–5

Prehospital anaesthesia in the United Kingdom (UK) is provided by Helicopter Emergency Medical Service (HEMS) and British Association for Immediate Care (BASICS), a road-based service. Muscle relaxation in rapid sequence induction (RSI) has been traditionally undertaken with the use of suxamethonium; however, rocuronium at higher doses has comparable intubating conditions with fewer side effects.

The aim of this survey was to establish how many prehospital services in the UK are now using rocuronium as first line in RSI.

An online survey was constructed identifying choice of first-line muscle relaxant for RSI and emailed to lead clinicians for BASICS and HEMS services across the UK. If rocuronium was used, further questions regarding optimal dose, sugammadex, contraindications, and difference in intubating conditions were asked.

A total of 29 full responses (93.5%) were obtained from 31 services contacted. Suxamethonium was used first line by 17 prehospital services (58.6%) and rocuronium by 12 (41.4%). In 11 services (91.7%), a dose of 1 mg/kg of rocuronium was used, and in one service, 1.2 mg/kg (8.3%) was used. No services using rocuronium carried sugammadex. In five services, slower relaxation time was found using rocuronium (41.7%), and in seven services, no difference in intubation conditions were noted (58.3%). Contraindications to rocuronium use included high probability of difficult airway and anaphylaxis.

Use of rocuronium as first-line muscle relaxant in prehospital RSI is increasing. Continued auditing of practice will ascertain which services have adopted change and identify if complications of failed intubation increase as a result.

HartleyEL , AlcockR . Rocuronium Versus Suxamethonium: A Survey of First-line Muscle Relaxant Use in UK Prehospital Rapid Sequence Induction. Prehosp Disaster Med. 2015;30(2):1-3.

Since 2001, a Japanese national project has developed a helicopter emergency medical service (HEMS) system (“doctor-helicopter”) and a central Disaster Medical Assistance Team (DMAT) composed of mobile and trained medical teams for rapid deployment during the response phase of a disaster.

In Japan, the DMAT Research Group has focused on command and control of doctor-helicopters in future disasters. The objective of this study was to investigate the effectiveness of such planning, as well as the problems encountered in deploying the doctor-helicopter fleet with DMAT members following the March 11, 2011 Great East Japan Earthquake.

This study was undertaken to examine the effectiveness of aeromedical disaster relief activities following the Great East Japan Earthquake and to evaluate the assembly and operations of 15 doctor-helicopter teams dispatched for patient evacuation with medical support.

Fifteen DMATs from across Japan were deployed from March 11th through March 13th to work out of two doctor-helicopter base hospitals. The dispatch center at each base hospital directed its own doctor-helicopter fleet under the command of DMAT headquarters to transport seriously injured or ill patients out of hospitals located in the disaster area. Disaster Medical Assistance Teams transported 149 patients using the doctor-helicopters during the first five days after the earthquake. The experiences and problems encountered point to the need for DMATs to maintain direct control over 1) communication between DMAT headquarters and dispatch centers; 2) information management concerning patient transportation; and 3) operation of the doctor-helicopter fleet during relief activities. As there is no rule of prioritization for doctor-helicopters to refuel ahead of other rotorcraft, many doctor-helicopters had to wait in line to refuel.

The “doctor-helicopter fleet” concept was vital to Japan's disaster medical assistance and rescue activities. The smooth and immediate dispatch of the doctor-helicopter fleet must occur under the direct control of the DMAT, independent from local government authority. Such a command and control system for dispatching the doctor-helicopter fleet is strongly recommended, and collaboration with local government authorities concerning refueling priority should be addressed.

MatsumotoH, MotomuraT, HaraY, MasudaY, MashikoK, YokotaH, KoidoY. Lessons Learned from the Aeromedical Disaster Relief Activities Following the Great East Japan Earthquake. Prehosp Disaster Med. 2013;28(2):1-4.