Neurosurgical Admission Later Than 4 h After the Emergency Call Does Not Result in Worse Long-Term Outcome in Subarachnoid Haemorrhage

Background: Few studies have investigated the importance of the time interval between contact to the emergency medical service and neurosurgical admission in patients with spontaneous subarachnoid haemorrhage. We hypothesised that longer time to treatment would be associated with an increased risk of death or early retirement.

Methods: This was a retrospective observational study with 4 years follow-up. Those who reached a neurosurgical department in fewer than 4 h were compared with those who reached it in more than 4 h. Individual level data were merged from the Danish National Patient Register, medical records, the Copenhagen Emergency Medical Dispatch Centre, the Civil Registration System, and the Ministry of Employment and Statistics Denmark. Patients were ≥18 years and had a verified diagnosis of spontaneous subarachnoid haemorrhage. The primary outcome was death or early retirement after 4 years.

Results: Two hundred sixty-two patients admitted within a three-and-a-half-year time period were identified. Data were available in 124 patients, and 61 of them were in their working age. Four-year all-cause mortality was 25.8%. No significant association was found between time to neurosurgical admission and risk of death or early retirement (OR = 0.35, 95% confidence interval [CI]: 0.10–1.23, p = 0.10).

Conclusion: We did not find an association between the time from emergency telephone call to neurosurgical admission and the risk of death or early retirement.

Criteria-based dispatch of emergency medical services in non-traumatic subarachnoid haemorrhage

INTRODUCTION

Timely admission to a facility capable of providing highly specialised treatment is key in patients with spontaneous subarachnoid haemorrhage. We aimed to determine the time elapsed from the initial emergency telephone call to arrival at a neurosurgical department. Also, we aimed to determine the ambulance dispatch criteria used and the activated prehospital responses.

METHODS

This was a retrospective study. Patients admitted in the Capital Region of Denmark within a 3.5-year period were identified in the Danish National Patient Register. Data were extracted from medical records and from automated telephone logs at the Emergency Medical Dispatch Centre.

RESULTS

Time intervals were available in 124 out of 262 patients and ambulance dispatch criteria in 98 patients. The median time from call to neurosurgical admission was 207.5 minutes. The dispatch criterion sudden severe headache had a sensitivity of 17.4%. An ambulance with lights and sirens was dispatched to 77% of patients and 28% were brought directly to a hospital with neurosurgical facilities.

CONCLUSIONS

The median time from emergency call to neurosurgical admission was 3.5 hours. No single dispatch criterion detected the condition with an acceptable sensitivity. A high proportion of patients received an ambulance with lights and sirens, but more than two out of three were not initially brought to a hospital with neurosurgical facilities.

FUNDING

the non-profit organisation Trygfonden Trial registration: NCT03786068 - www.clinicaltrials.gov.

Symptoms presented during emergency telephone calls for patients with spontaneous subarachnoid haemorrhage

Background

A spontaneous subarachnoid haemorrhage (SAH) is one of the most critical neurological emergencies a dispatcher can face in an emergency telephone call. No study has yet investigated which symptoms are presented in emergency telephone calls for these patients. We aimed to identify symptoms indicative of SAH and to determine the sensitivity of these and their association (odds ratio, OR) with SAH.

Methods

This was a nested case–control study based on all telephone calls to the medical dispatch center of Copenhagen Emergency Medical Services in a 4-year time period. Patients with SAH were identified in the Danish National Patient Register; diagnoses were verified by medical record review and their emergency telephone call audio files were extracted. Audio files were replayed, and symptoms extracted in a standardized manner. Audio files of a control group were replayed and assessed as well.

Results

We included 224 SAH patients and 609 controls. Cardiac arrest and persisting unconsciousness were reported in 5.8% and 14.7% of SAH patients, respectively. The highest sensitivity was found for headache (58.9%), nausea/vomiting (46.9%) and neck pain (32.6%). Among conscious SAH patients these symptoms were found to have the strongest association with SAH (OR 27.0, 8.41 and 34.0, respectively). Inability to stand up, speech difficulty, or sweating were reported in 24.6%, 24.2%, and 22.8%. The most frequent combination of symptoms was headache and nausea/vomiting, which was reported in 41.6% of SAH patients. More than 90% of headaches were severe, but headache was not reported in 29.7% of conscious SAH patients. In these, syncope was described by 49.1% and nausea/vomiting by 37.7%.

Conclusion

Headache, nausea/vomiting, and neck pain had the highest sensitivity and strongest association with SAH in emergency telephone calls. Unspecific symptoms such as inability to stand up, speech difficulty or sweating were reported in 1 out of 5 calls. Interestingly, 1 in 3 conscious SAH patients did not report headache.

Trial registration NCT03980613 (www.clinicaltrials.gov).

Search and Rescue Helicopters for Emergency Medical Service Assistance: A Retrospective Study

OBJECTIVE

The time until treatment is a crucial factor for the outcome after medical emergencies. One way of reducing transportation time is the use of helicopter-based emergency medical services, but poor weather conditions, commitment to another mission, or technical problems may limit the availability. In these cases, military search and rescue (SAR) helicopters can be used. The aim of this study was to investigate the role of SAR helicopters in the civilian emergency medical system.

METHODS

We conducted a retrospective study of SAR mission reports and SAR medical records collected from the archives of the Royal Danish Air Force for the years 2016 and 2017.

RESULTS

A total of 1,262 mission reports were included with a total of 628 medical records available in the study period. There were 490 of 1,246 (39.3%) missions involving patients. Interhospital transfers accounted for 306 of 604 (50.7%) of cases, whereas island evacuation constituted 110 of 604 (18.2%) cases. The most prevalent suspected diagnosis was acute coronary syndrome (14.4%). The 30-day survival rate was 87.6%.

CONCLUSION

The military SAR helicopters were most commonly activated for civilian emergency medical service mission assistance due to poor weather conditions. The most frequent medical condition was acute coronary syndrome.

Spontaneous Subarachnoid Haemorrhage as a Cause of Out-of-Hospital Death

BACKGROUND

There are no recent studies on the incidence rate of out-of-hospital death due to spontaneous subarachnoid haemorrhage (SAH). The primary aim of this study was to determine how often SAH was the cause of out-of-hospital death. The secondary aim was to determine if decedents had contacted any health care services within the last 72 h prior to the time of death.

METHODS

This was a retrospective cohort study. The reports of all autopsies carried out at the Department of Forensic Medicine in the Capital Region of Denmark in a ten-year period were read. Police records and Emergency Medical Services (EMS) telephone records were searched for health care contacts within the last 72 h prior to the time of death. Descriptive statistics were used, and to analyse the incidence rates for trend Poisson regression was used.

RESULTS

In total, 6,903 decedents underwent autopsy. Out-of-hospital SAH was the cause of death in 58 decedents, resulting in an average incidence rate of 0.34 per 100.000 persons per year. No significant change in the incidence rate over time was found (p = 0.52). No EMS data were available for eleven decedents in the first part of the study period. Of the remaining 47 decedents, 2 (3.5%, 95% CI: 0.4-11.9) had called the EMS, and in regards to 27 of the 58 decedents, the police records contained information on health care system contacts. Five (8.6%, 95% CI: 2.9-18.9) patients had contacted a general practitioner and three (5.2%, 95% CI: 1.1-14.4) patients had been admitted to hospital but were discharged again within 72 h prior to their death.

CONCLUSION

The incidence rate of out-of-hospital death from SAH was 0.34 per 100.000 persons per year and remained stable across the years 2009-2018. Several patients had sought medical attention shortly before their death, emphasizing the vital importance of recognizing the early symptoms of SAH.

The positive predictive value of spontaneous subarachnoid hemorrhage diagnoses in the Danish National Patient Register

Introduction: Spontaneous (non-traumatic) subarachnoid hemorrhage (ntSAH) is frequently suspected in the emergency department, but the incidence rate is low. Diagnosis registers can provide valuable data for research in uncommon conditions like ntSAH. Unfortunately, validity vary in the registers. We aimed to assess the validity of the ntSAH diagnosis in the Danish National Patient Register (DNPR) and secondly to describe patients misclassified as ntSAH and to calculate the incidence rate of ntSAH. Methods: From the DNPR we extracted information on patients at least 18 years of age on admission registered with a diagnosis of ntSAH and admitted to a hospital in the Capital Region of Denmark between January 1, 2008 and December 31, 2014. Two independent investigators reviewed the medical records to assess if the diagnosis could be confirmed. Those not confirmed were categorized according to a predeveloped case report form. Results: We identified 1101 patients with a diagnosis of ntSAH; medical records were accessible for 1069 (97.7%) and 842 (78.8%) met the inclusion criteria. The diagnosis was confirmed in 537 patients (63.8% (95% confidence interval: 60.5-67.0%)). Among patients where ntSAH was not confirmed, 122 (40.0%) had a traumatic subarachnoid hemorrhage (tSAH), ntSAH had been suspected in 57 (18.9%) patients but was not substantiated during admission, while parenchymal hemorrhages were identified in 45 (14.5%) patients. The incidence rate was 5.5 (95% CI: 4.9-6.1) per 100,000 persons per year. Conclusion: We found a positive predictive value (PPV) of 63.8% for the diagnosis of non-traumatic subarachnoid hemorrhage in the Danish National Patient Register. The low PPV suggests that care should be taken if unvalidated data are used for research and that results of previous studies should be interpreted with caution.

Prehospital interventions before and after implementation of a physician-staffed helicopter

INTRODUCTION

Implementation of a physician-staffed helicopter emergency medical service (HEMS) in eastern Denmark was associated with increased survival for severely injured patients. This study aimed to assess the potential impact of advanced prehospital interventions by comparing the proportion of patients who received those interventions before and after the HEMS implementation.

METHODS

A post-hoc analysis of a prospective before-after study. We included trauma patients with Injury Severity Scores above three who had been admitted to seven emergency departments or one level 1 trauma centre in the course of a five-month period before and a 12-month period after the HEMS implementation. We compared the proportion of patients receiving at least one of 14 predefined advanced interventions between the two periods.

RESULTS

We included 189 patients before and 548 patients after the implementation. The proportion of patients who had interventions done increased from 24.3% to 36.1% (difference (95% confidence limits (CL)): 11.9% (4.6-19.3%); p = 0.003). In patients with a Glasgow Coma Scale score below nine and/or an Abbreviated Injury Score above three in the head region, endotracheal intubation was done prior to hospital arrival in 28.1% (9/32) before versus 48.6% (35/72) after (difference (CL): 20.5% (1.1-39.9%)). The proportion of patients who received opioids increased from 11.1% to 21.8% (p < 0.01).

CONCLUSIONS

A higher proportion of trauma patients received advanced prehospital interventions after the implementation of a physician-staffed HEMS.

FUNDING

Funding for this study was received from TrygFonden.

TRIAL REGISTRATION

not relevant.

Quality of life following trauma before and after implementation of a physician-staffed helicopter

Background

Implementation of a physician‐staffed helicopter emergency medical service (PS‐HEMS) in Denmark was associated with lower 30‐day mortality in severely injured trauma patients and less time on social subsidy. However, the reduced 30‐day mortality in severely injured patients might be at the expense of a worse functional outcome and quality of life (QoL) in those who survive. The aim of this study was to investigate the effect of a physician‐staffed helicopter on long‐term QoL in trauma patients.

Methods

Prospective, observational study including trauma patients who survived at least 3 years after injury. A 5‐month period prior to PS‐HEMS implementation was compared with the first 12 months after PS‐HEMS implementation. QoL was assessed 4.5 years after trauma by the SF‐36 questionnaire. Primary endpoint was the Physical Component Summary score.

Results

Of the 1994 patients assessed by a trauma team, 1521 were eligible for inclusion in the study. Of these, 566 (37%) gave consent to participate and received a questionnaire by mail, and 402 (71%) of them returned the questionnaire (n = 114 before PS‐HEMS; n = 288 after PS‐HEMS implementation). Older patients, women and patients with trauma in the after PS‐HEMS period were more likely to return the questionnaire. No significant association between QoL and period (before vs. after PS‐HEMS) was found; the Physical Component Summary scores were 50.0 and 50.9 in the before and after PS‐HEMS periods, respectively (P = 0.47). We also found no difference on multivariable analysis with adjustment for sex, age and injury severity score.

Conclusion

No significant difference in QoL among trauma patients was found after implementation of a PS‐HEMS.

London Trauma Conference 2015

I1: Trauma, Pre-hospital and Cardiac Arrest Care 2015

Pascale Avery, Leopold Salm, Flora Bird

A1: Retrospective evaluation of HEMS ‘Direct to CT’ protocol

Anja Hutchinson, Ashley Matthies, Anthony Hudson, Heather Jarman

A2 Rush hour – Crush hour: temporal relationship of cyclist vs. HGV trauma admissions. A single site observational study

Maria Bergman Nilsson, Tom Konig, Nigel Tai

A3 Semiprone position endotracheal intubation during continuous cardiopulmonary resuscitation in drowned children with regurgitation: a case report and experimental manikin study

Espen Fevang, Børge Hognestad, Håkon B. Abrahamsen

A4 An audit of CO2 A-a gradient in non-trauma patients receiving pre-hospital anaesthesia

Olivia V Cheetham, Matthew JC Thomas, Kieron D Rooney

A5 Can the use of c-spine immobilisation collars be avoided in non-trauma patients presenting to the Emergency Department?

Josephine Murray, Malcolm Tunnicliff

A6 Curriculum mapping in ED point of care simulation

Joseph W Collinson, Thomas Brown, Christopher Pritchett

A7 Point of care multidisciplinary trauma team simulation & participant satisfaction in a geographically remote trauma unit in Cornwall

Christopher SA Pritchett, Mark Jadav, Gareth Meredith, Jamie Plumb, Steve Harris, Roger Langford

A8 Conservative management of head injury inpatients - the challenge of simplifying injury management in a non-neurosurgical hospital

JG Hunter, A Sage, R Madden, O Flamank, B Broadbent, S Marsh, H Lewis, E Daniels, N Roberts

A9 Improving the care of traumatic brain injury at non-neurosurgical hospitals: Introducing a head injury pathway and single place of care is associated with significant improvements in neurological observation

JG Hunter, A Sage, R Madden, O Flamank, B Broadbent, S Marsh, H Lewis, E Daniels, N Lin, N Roberts

A10 The experience of inter-disciplinary students undertaking cardiac arrest moulage training

Samuel Bulford, Silas Houghton-Budd, Sam Pearson, Megan Clear-Hill

A11 Impact brain apnoea – nine cases

David J Menzies, James P Leonard, Conor Keogh, Ray Quinn, John D Hinds

A12 Time well spent? Improving the performance improvement programme in a busy Trauma Unit

N Roberts, D Ashton-Cleary, M Jadav

A14 Clinical significant and outcome of pulmonary contusions in patients with blunt chest trauma

Ismail Mahmood, Ayman El-Menyar, Basil Younis, Ahmed Khalid, Syed Nabir, Mohamed Nadeem Ahmed, Omer Al-Yahri, Hassan Al-Thani

A15 Plastics operative workload in major trauma centres: a national prospective survey

Katie Young, Susan A. Hendrickson, Georgina Phillips, Matthew D. Gardiner, Shehan Hettiaratchy

A16 A survey to assess the accuracy of estimating height by pre-hospital clinicians: can we reliably predict those most at risk of serious injury?

Alexandra Alice Crossland, Anthony Hudson

A17 An audit of the cause, outcome and adherence to treatment Standard Operating Procedure (SOP) for all traumatic cardiac arrests at a Helicopter Emergency Medical Service over a 12-month period

Nicholas C Brassington, Anthony Hudson, Emily McWhirter

A18 Should we “stay-and-play? A study of patient physiology in Norwegian Helicopter Emergency Services

Bjørn O Reid, Marius Rehn, Oddvar Uleberg, Andreas J Krüger

A19 Training in resuscitative thoracotomy: have we cracked it? A survey of higher Emergency Medicine trainees in London

Cara Jennings, Yasmin Kapadia, Duncan Bew

A20 London’s Air Ambulance (LAA): 25-years of drownings in an urban environment

Jenny Townsend, Tom P Hurst, Elizabeth A Foster

A21 Live patients in trauma simulation – more than just simulation on a shoestring?

Thomas B Brown, Joseph Collinson, Christopher Pritchett, Toby Slade

A22 Collecting core data in pre-hospital critical care using a consensus based template

Kristin Tønsager, Marius Rehn, Kjetil G.Ringdal, Andreas J.Krüger

A23 Prehospital interventions before and after implementation of a physician staffed helicopter

Rasmus Hesselfeldt, Sandra Wulffeld, Asger Sonne, Lars S. Rasmussen, Jacob Steinmetz

A24 Duration of ventilation following prehospital drug assisted intubation; a retrospective review

Thomas J Renninson, Nadine Thomson, Harvey Pynn, Timothy J Hooper

A25 Non-haemorrhagic shock in trauma: a novel guideline for management in ED

Anthony Hudson, Jacinta Dawson, Ashley Matthies

A26 Patient-tailored triage decisions by anaesthetist-staffed pre-hospital critical care teams

Morten Langfeldt Friberg, Leif Rognås

A27 Anatomical accuracy and appropriate sizing of pre-hospital thoracostomies

Jessica FG Wills, Anthony Hudson

A28 Pre-hospital management of mass casualty civilian shootings

Conor DA Turner, Marius Rehn

A30 The prevalence of alcohol-related trauma recidivism: a systematic review

James Nunn, Mete Erdogan, Robert S. Green

A31 Development of a hospital-wide program for simulation-based training in trauma care and management

Samuel Minor, Mete Erdogan, Kathy Hartlen, Robert S. Green

A32 Out of Hospital Cardiac Arrests (OOHCA); lessons from Hollywood

Ruth Bird, Rachael L. Grupping

A33 Mechanism of injury as a predictor of severity of injury in road traffic collisions: a literature review

Amelia M. Stacey, Marius Rehn, David J. Lockey

A34 Lessons to be learned from prehospital airway intervention documentation? Are airway intervention documentation templates as successful in-hospital as prehospitally?

S. Abiks, L. Cutler, K. Monaghan, A. Al-Rais, C. Hymers, R. Bloomer, Y. Kapadia

A35 Novel biomarkers in prehospital management of traumatic brain injury (the PreTBI study protocol)

Sophie-Charlott Seidenfaden, Ingunn S. Riddervold, Hans Kirkegaard, Niels Juul, Morten T. Bøtker

A36 Hospital outcomes of traumatic railway incidents: a seven-year observational retrospective study of a major trauma centre

Alice Gao, Zane Perkins; Gareth Grier, Alex Tzannes

A37 Does taking a third crew member affect the on-scene time of HEMS jobs?

Nathan Hudson-Peacock, Quentin Otto, Laurie Phillipson, Rik Thomas, Ainsley Heyworth

A38 Does pre-hospital rapid sequence induction affect on-scene time of HEMS jobs?

Quentin Otto, Nathan Hudson-Peacock, Laurie Phillipson, Ainsley Heyworth, Erica Ley

A39 Code red: shock index as a prehospital indicator of massive haemorrhage

Daniel Banner, Ainsley Heyworth, Erica Ley

A40 Air ambulance tasking: how accurate are our current methods?

Madeleine Benson, Nathan Hudson-Peacock, Tony Stone, Erica Ley, Louise Rousson, Ainsley Heyworth

A41 Modern trauma burden in a district general hospital

Beth A Lineham, Matthew J Lee, Martin Gough

A42 Establishing a legal service for major trauma patients in two UK major trauma centres

William H Seligman, Hannah E Thould, Andrew Dinsmore, Charlotte Tan, Julian Thompson, C Andy Eynon, David J Lockey

A43 Prehospital assessment and care of patients – a study of the use of guidelines when assessing head trauma

Rebecka M Rubenson Wahlin, Veronica Lindström, Sari Ponzer, Veronica Vicente

A44 An audit of pre-hospital blood pressure management resulting from head injury

Pamela Eligio, Anthony Hudson

A45 The surgical contribution of surface shading volumetric rendering techniques in rib fracture management

Robert Young, Dimitri Amiras, Ian Sinha

Registration of randomized clinical trials--a challenge

BACKGROUND

Registration of interventional studies is necessary according to the Declaration of Helsinki but implementation has been a challenge for many journals. Acta Anaesthesiologica Scandinavica (Acta) requires registration for studies conducted after January 1(st) 2010. We aimed to assess the proportion of correctly registered randomized controlled trials (RCTs) published in Acta from 2009 to 2014.

METHODS

We manually searched all Acta issues from 2009 to 2014 for RCTs. Information about timing of data collection and registration in trial registries was extracted. We classified RCTs as correctly registered when it could be verified that patient enrolment was started after registration in a trial registry.

RESULTS

We identified 200 RCTs. Dates for patient enrolment were not specified in 51 (25.5%). The proportion of correctly registered trials increased significantly from 17.1% (19/111) for trials starting enrolment before 2010 to 63.2% after 2010 (24/38, P < 0.01). Most clinical trials were registered at clinicaltrials.gov.

CONCLUSION

Many published randomized controlled trials from Acta Anaesthesiologica Scandinavica were not adequately registered but the requirement of trial registration has resulted in a significant increase in the proportion of correctly registered trials.