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Early definitive airway protection and normoventilation are key principles in the treatment of severe traumatic brain injury. These are currently guided by end tidal CO 2 as a proxy for PaCO 2 . We assessed whether the difference between end tidal CO 2 and PaCO 2 at hospital admission is associated with in-hospital mortality. We conducted a retrospective observational cohort study of consecutive patients with traumatic brain injury who were intubated and transported by Helicopter Emergency Medical Services to a Level 1 trauma center between January 2014 and December 2019. We assessed the association between the CO 2 gap—defined as the difference between end tidal CO 2 and PaCO 2 —and in-hospital mortality using multivariate logistic regression models. 105 patients were included in this study. The mean ± SD CO 2 gap at admission was 1.64 ± 1.09 kPa and significantly greater in non-survivors than survivors (2.26 ± 1.30 kPa vs. 1.42 ± 0.92 kPa, p < .001). The correlation between EtCO 2 and PaCO 2 at admission was low (Pearson's r = .287). The mean CO 2 gap after 24 h was only 0.64 ± 0.82 kPa, and no longer significantly different between non-survivors and survivors. The multivariate logistic regression model showed that the CO 2 gap was independently associated with increased mortality in this cohort and associated with a 2.7-fold increased mortality for every 1 kPa increase in the CO 2 gap (OR 2.692, 95% CI 1.293 to 5.646, p = .009). This study demonstrates that the difference between EtCO 2 and PaCO 2 is significantly associated with in-hospital mortality in patients with traumatic brain injury. EtCO 2 was significantly lower than PaCO 2 , making it an unreliable proxy for PaCO 2 when aiming for normocapnic ventilation. The CO2 gap can lead to iatrogenic hypoventilation when normocapnic ventilation is aimed and might thereby increase in-hospital mortality.

Background The current COVID-19 pandemic highlights the challenges air ambulance services are facing when transporting highly infectious patients for several hours in enclosed spaces. This overview provides an example of a standard operating procedure (SOP) for infection prevention measures in HEMS missions during the COVID-19 pandemic. Furthermore, we describe different methods used by several organizations in Europe and the experience of the Swiss air rescue organization Rega in transporting these patients. Possible benefits of the use of small patient isolation units (PIU) are discussed, including the fact that accompanying medical personnel do not need to wear personal protective equipment (PPE) during the transport but can still maintain full access to the patient. Rega has developed and patented its own PIU. This device allows spontaneously breathing or mechanically ventilated patients to be transported in pressurized jet cabins, small helicopters and ambulance vehicles, without the need to change between transport units. This PIU is unique, as it remains air-tight even when there is a sudden loss of cabin pressure. Conclusion A wide variety of means are being used for the aeromedical transport of infectious patients. These involve isolating either the patient or the medical crew. One benefit of PIUs is that the means of transport can be easily changed without contaminating the surroundings and while still allowing access to the patient.

Background Tracheal intubation remains the gold standard of airway management in emergency medicine and maximizing safety, intubation success, and especially first-pass intubation success (FPS) in these situations is imperative. Methods We conducted a prospective observational study on all 12 helicopter emergency medical service (HEMS) bases of the Swiss Air Rescue, between February 15, 2018, and February 14, 2019. All 428 patients on whom out-of-hospital advanced airway management was performed by the HEMS crew were included. The C-MAC video laryngoscope was used as the primary device for tracheal intubation. Intubation procedures were recorded by the video laryngoscope and precise time points were recorded to verify the time necessary for each attempt and the overall procedure time until successful intubation. The videos were further analysed for problems and complications during airway management by an independent reviewer. Additionally, a questionnaire about the intubation procedure, basic characteristics of the patient, circumstances, environmental factors, and the provider’s level of experience in airway management was filled out. Main outcome measures were FPS of tracheal intubation, overall success rate, overall intubation time, problems and complications of video laryngoscopy. Results FPS rate was 87.6% and overall success rate 98.6%. Success rates, overall time to intubation, and subjective difficulty were not associated to the providers’ expertise in airway management. In patients undergoing CPR FPS was 84.8%, in trauma patients 86.4% and in non-trauma patients 93.3%. FPS in patients with difficult airway characteristics, facial trauma/burns or obesity ranges between 87 and 89%. Performing airway management indoors or inside an ambulance resulted in a significantly higher FPS of 91.1% compared to outdoor locations ( p  < 0.001). Direct solar irradiation on the screen, fogging of the lens, and blood on the camera significantly impaired FPS. Several issues for further improvements in the use of video laryngoscopy in the out-of-hospital setting and for quality control in airway management were identified. Conclusion Airway management using the C-MAC video laryngoscope with Macintosh blade in a group of operators with mixed experience showed high FPS and overall rates of intubation success. Video recording emergency intubations may improve education and quality control.

Background For helicopter emergency service systems (HEMS), the prehospital time consists of response time, on-scene time and transport time. Little is known about the factors that influence on-scene time or about differences between adult and paediatric missions in a physician-staffed HEMS. Methods We analysed the HEMS electronic database of Swiss Air-Rescue from 01-01-2011 to 31-12-2021 (N = 110,331). We included primary missions and excluded missions with National Advisory Committee for Aeronautics score (NACA) score 0 or 7, resulting in 68,333 missions for analysis. The primary endpoint ‘on-scene time’ was defined as first physical contact with the patient until take-off to the hospital. A multivariable linear regression model was computed to examine the association of diagnosis, type and number of interventions and monitoring, and patient's characteristics with the primary endpoint. Results The prehospital time and on-scene time of the missions studied were, respectively, 50.6 [IQR: 41.0–62.0] minutes and 21.0 [IQR: 15.0–28.6] minutes. Helicopter hoist operations, resuscitation, airway management, critical interventions, remote location, night-time, and paediatric patients were associated with longer on-scene times. Conclusions Compared to adult patients, the adjusted on-scene time for paediatric patients was longer. Besides the strong impact of a helicopter hoist operation on on-scene time, the dominant factors contributing to on-scene time are the type and number of interventions and monitoring: improving individual interventions or performing them in parallel may offer great potential for reducing on-scene time. However, multiple clinical interventions and monitoring interact and are not single interventions. Compared to the impact of interventions, non-modifiable factors, such as NACA score, type of diagnosis and age, make only a minor contribution to overall on-scene time.

Dear Editor, The recent advancements in paediatric out-of-hospital cardiac arrest (OHCA) management underscore the importance of understanding age-specific aetiologies and their influence on neurological outcomes. (docum.) No (CPC > 2) Yes (CPC 1/2) P-value Patient & mission characteristics  Age group    < 1y 56 (100.0) 45 (100.0) 11 (100.0) -  Late/night mission (20:00–07:59) 10 (17.9) 10 (22.2) 0 (0.0) 0.085 Activity  Transport   Car 1 (1.8) 1 (2.2) 0 (0.0) 0.618  Watersport   Swimming 1 (1.8) 1 (2.2) 0 (0.0) 0.618  Other   In and around the house 44 (78.6) 38 (84.4) 6 (54.5)  No activity or unknown 10 (17.9) 5 (11.1) 5 (45.5) 0.026 Aetiology detail Non-traumatic 54 (96.4) 43 (95.6) 11 (100.0) 0.476 Asphyxia—total 18 (32.1) 15 (33.3) 3 (27.3) 0.700  Asphyxia—drowning 4 (7.1) 4 (8.9) 0 (0.0) 0.305  Asphyxia—aspiration 14 (25.0) 11 (24.4) 3 (27.3) 0.846  Asphyxia—strangulation 0 [0.0] 0 [0.0] 0 [0.0] -  Asphyxia—burial 0 [0.0] 0 [0.0] 0 [0.0] - Other pulmonary 2 (3.6) 0 (0.0) 2 (18.2) 0.004 Cardiac 3 (5.4) 2 (4.4) 1 (9.1) 0.540 SIDS 21 (37.5) 21 (46.7) 0 (0.0) 0.004 Anaphylactic 0 [0.0] 0 [0.0] 0 [0.0] - Intoxication 0 [0.0] 0 [0.0] 0 [0.0] - Non-traumatic, reason unknown 6 (10.7) 3 (6.7) 3 (27.3) 0.048 Other non-traumatic 4 (7.1) 2 (4.4) 2 (18.2) 0.113 Traumatic 2 (3.6) 2 (4.4) 0 (0.0) 0.476 Traffic accident 1 (1.8) 1 (2.2) 0 (0.0) 0.618 Fall from a height 0 [0.0] 0 [0.0] 0 [0.0] - Burning/scalding 0 [0.0] 0 [0.0] 0 [0.0] - Other traumatic 1 (1.8) 1 (2.2) 0 (0.0) 0.618 First rhythm Non-shockable 54 (96.4) 43 (95.6) 11 (100.0) 0.476  Pulseless Electrical Activity 8 (14.3) 6 (13.3) 2 (18.2) 0.680  Asystole 31 (55.4) 31 (68.9) 0 (0.0)  < 0.001 Shockable initial rhythm 2 (3.6) 2 (4.4) 0 (0.0) 0.476  Pulseless Ventricular Tachycardia 0 [0.0] 0 [0.0] 0 [0.0] -  Pulseless Ventricular Fibrillation 2 (3.6) 2 (4.4) 0 (0.0) 0.476 Normal Sinus rhythm / ROSC 5 (8.9) 0 (0.0) 5 (45.5)  < 0.001 Unknown 10 (17.9) 6 (13.3) 4 (36.4) 0.074 No measures taken (obviously dead) 0 [0.0] 0 [0.0] 0 [0.0] - Injuries  Traumatic brain injury 2 (3.6) 2 (4.4) 0 (0.0) 0.476  Chest trauma 0 [0.0] 0 [0.0] 0 [0.0] -  Abdominal trauma 0 [0.0] 0 [0.0] 0 [0.0] -  Pelvic trauma 0 [0.0] 0 [0.0] 0 [0.0] -  Upper extremity trauma 0 [0.0] 0 [0.0] 0 [0.0] -  Lower extremity trauma 0 [0.0] 0 [0.0] 0 [0.0] - Outcome  Favor. neurol. outcome, 30d (CPC 1/2) 11 (19.6) 0 (0.0) 11 (100.0)  < 0.001 Depending on normality testing (Shapiro Wilk) median (IQR) respectively mean (SD) are shown for continuous variables, p-values obtained by Wilcoxon rank sum test respectively unpaired T-test. Categorical variables are shown with number (%) in each category, p-values obtained by Chi-squared test Abbreviations: CPC Cerebral Performance Category, ROSC Return of Spontaneous Circulation, SIDS Sudden Infant Death Syndrome Preschoolers (1–6 Years): drowning as the leading cause In preschool-aged children, drowning was the predominant cause of cardiac arrest, responsible for 37.7% of cases. (docum.) No (CPC > 2) Yes (CPC 1/2) P-value Patient & mission characteristics  Age group   1-6y 114 (100.0) 86 (100.0) 28 (100.0) -  Late/night mission (20:00–07:59) 8 (7.0) 8 (9.3) 0 (0.0) 0.094 Activity  Transport   Car 3 (2.6) 3 (3.5) 0 (0.0)   Bicycle 1 (0.9) 1 (1.2) 0 (0.0)   Pedestrian 8 (7.0) 8 (9.3) 0 (0.0)   Other means of transport 3 (2.6) 3 (3.5) 0 (0.0) 0.229  Watersport   Swimming 21 (18.4) 7 (8.1) 14 (50.0)  < 0.001  Summersport   Hiking 5 (4.4) 4 (4.7) 1 (3.6) 0.809  Wintersport   Skiing/Carving 3 (2.6) 2 (2.3) 1 (3.6)   Other winter sports 1 (0.9) 1 (1.2) 0 (0.0) 0.798  Work   In agriculture 1 (0.9) 1 (1.2) 0 (0.0) 0.567  Other   No other activity 46 (40.4) 30 (34.9) 16 (57.1)   In and around the house 60 (52.6) 48 (55.8) 12 (42.9)   Relocation (secondary deployment) 1 (0.9) 1 (1.2) 0 (0.0)  No activity or unknown 7 (6.1) 7 (8.1) 0 (0.0) 0.118 Aetiology detail Non-traumatic 76 (66.7) 49 (57.0) 27 (96.4)  < 0.001 Asphyxia – total 55 (48.2) 32 (37.2) 23 (82.1)  < 0.001  Asphyxia – drowning 43 (37.7) 24 (27.9) 19 (67.9)  < 0.001  Asphyxia – aspiration 6 (5.3) 5 (5.8) 1 (3.6) 0.644  Asphyxia – strangulation 6 (5.3) 3 (3.5) 3 (10.7) 0.137  Asphyxia – burial 0 [0.0] 0 [0.0] 0 [0.0] - Other pulmonary 7 (6.1) 6 (7.0) 1 (3.6) 0.514 Cardiac 2 (1.8) 2 (2.3) 0 (0.0) 0.416 SIDS 2 (1.8) 2 (2.3) 0 (0.0) 0.416 Anaphylactic 0 [0.0] 0 [0.0] 0 [0.0] - Intoxication 1 (0.9) 0 (0.0) 1 (3.6) 0.078 Non-traumatic, reason unknown 5 (4.4) 4 (4.7) 1 (3.6) 0.809 Other non-traumatic 4 (3.5) 3 (3.5) 1 (3.6) 0.983 Traumatic 38 (33.3) 37 (43.0) 1 (3.6)  < 0.001 Traffic accident 24 (21.1) 24 (27.9) 0 (0.0) 0.002 Fall from a height 5 (4.4) 4 (4.7) 1 (3.6) 0.809 Burning/scalding 0 [0.0] 0 [0.0] 0 [0.0] - Other traumatic 9 (7.9) 9 (10.5) 0 (0.0) 0.074 First rhythm Non-shockable 109 (95.6) 81 (94.2) 28 (100.0) 0.192  Pulseless Electrical Activity 18 (15.8) 16 (18.6) 2 (7.1) 0.149  Asystole 57 (50.0) 56 (65.1) 1 (3.6)  < 0.001 Shockable initial rhythm 5 (4.4) 5 (5.8) 0 (0.0) 0.192  Pulseless Ventricular Tachycardia 0 [0.0] 0 [0.0] 0 [0.0] -  Pulseless Ventricular Fibrillation 5 (4.4) 5 (5.8) 0 (0.0) 0.192 Normal Sinus rhythm / ROSC 23 (20.2) 1 (1.2) 22 (78.6)  < 0.001 Unknown 9 (7.9) 6 (7.0) 3 (10.7) 0.524 No measures taken (obviously dead) 2 (1.8) 2 (2.3) 0 (0.0) 0.416 Injuries  Traumatic brain injury 29 (25.4) 28 (32.6) 1 (3.6) 0.002  Chest trauma 10 (8.8) 10 (11.6) 0 (0.0) 0.059  Abdominal trauma 7 (6.1) 7 (8.1) 0 (0.0) 0.119  Pelvic trauma 1 (0.9) 1 (1.2) 0 (0.0) 0.567  Upper extremity trauma 1 (0.9) 1 (1.2) 0 (0.0) 0.567  Lower extremity trauma 4 (3.5) 4 (4.7) 0 (0.0) 0.245

Background Traumatic brain injury (TBI) remains one of the main causes of mortality and long-term disability worldwide. Maintaining physiology of brain tissue to the greatest extent possible through optimal management of blood pressure, airway, ventilation, and oxygenation, improves patient outcome. We studied the quality of prehospital care in severe TBI patients by analyzing adherence to recommended target ranges for ventilation and blood pressure, prehospital time expenditure, and their effect on mortality, as well as quality of prehospital ventilation assessed by arterial partial pressure of CO 2 (PaCO 2 ) at hospital admission. Methods This is a retrospective cohort study of all TBI patients requiring tracheal intubation on scene who were transported to one of two major level 1 trauma centers in Switzerland between January 2014 and December 2019 by Swiss Air Rescue (Rega). We assessed systolic blood pressure (SBP), end-tidal partial pressure of CO 2 (PetCO 2 ), and PaCO 2 at hospital admission as well as prehospital and on-scene time. Quality markers of prehospital care (PetCO 2 , SBP, prehospital times) and prehospital ventilation (PaCO 2 ) are presented as descriptive analysis. Effect on mortality was calculated by multivariable regression analysis and a logistic general additive model. Results Of 557 patients after exclusions, 308 were analyzed. Adherence to blood pressure recommendations was 89%. According to PetCO 2, 45% were normoventilated, and 29% had a SBP ≥ 90 mm Hg and were normoventilated. Due to the poor correlation between PaCO 2 and PetCO 2 , only 33% were normocapnic at hospital admission. Normocapnia at hospital admission was strongly associated with reduced probability of mortality. Prehospital and on-scene times had no impact on mortality. Conclusions PaCO 2 at hospital admission is strongly associated with mortality risk, but normocapnia is achieved only in a minority of patients. Therefore, the time required for placement of an arterial cannula and prehospital blood gas analysis may be warranted in severe TBI patients requiring on-scene tracheal intubation.

Background Mountain sport activities are being practiced by an increasing number of people: The number of tourists visiting altitudes greater than 2,500 m above sea level in the Alps has been estimated at around 40 million people per year. For this reason, however, the number of emergencies in remote areas, which can be reached most rapidly by helicopter, has also increased. Methods We retrospectively reviewed all rescue missions conducted by the Swiss Air Ambulance (Rega) in the period 2011–2021 that were carried out at an altitude of more than 2,500 m above sea level. Demographic and epidemiological data, medical measures implemented on scene, and the on-scene time were then analyzed for both trauma and non-trauma patients. Patients were categorized based on the National Advisory Committee for Aeronautics (NACA) score into non-injured (NACA 0), minor injured (NACA 0–3), seriously injured (NACA 4–6), deceased during mission (NACA 7), and already deceased on arrival of the HEMS team. Results A total of 3,564 rescue missions were analyzed. Of the patients, 66.8% were male and the vast majority (88.4%) were adults. In terms of injury level, 88.1% of the patients were minor injured, with an NACA score of 0–3, while 9.4% were seriously injured, with a score of 4–6. Patients who died in scene (NACA 7) accounted for 2.5% of cases. We observed a significant increase in the number of minor injured patients with traumatic injuries over the period of observation. Factors that significantly influenced the on-scene time included the NACA score, hoist missions, and traumatic injuries in summer. Conclusion Over the last ten years, the number of HEMS missions conducted at more than 2,500 m above sea level with non-injured and slightly injured patients has increased. The large number of HEMS missions with uninjured patients are of a preventive nature. Only around 9% of all rescue missions involved the medical treatment and rescue of seriously injured patients who required advanced medical interventions. Trial registration Ethics approval and consent to participate BASEC Nr. Req202200189.

Background The goal of improving quality through centralisation of specialised medical services must be balanced against potential harm caused by delayed access to emergency treatments in rural areas. This study aims to assess the duration of transfers of critically ill patients with cardiovascular emergencies from smaller hospitals to major medical centres by a helicopter emergency medical service (HEMS) in Switzerland. Methods This retrospective observational cohort study includes all consecutive emergency interfacility transfers (IFTs) conducted by Switzerland’s largest HEMS provider between July 3rd, 2019, and March 31st, 2021. All patients with acute myocardial infarction, non-traumatic strokes, ruptured aortic aneurysms, and other acute vascular emergencies were included. The duration and distance of each HEMS IFT were compared to calculated distances and duration of travel for the same missions using ground-based transportation (GEMS). The ground-based mission distance beyond which the total mission duration of HEMS is expected to be faster than GEMS was calculated. Findings A total of 645 patients were transferred for stroke (n = 364), myocardial infarction (n = 252) and other acute vascular emergencies (n = 29). The median total mission duration from emergency call to landing at the destination was 59.9 (IQR 51.5 to 70.5) minutes. The median road distance for the same missions was 60 (IQR 43 to 72) km. Regression analysis revealed that HEMS is expected to be faster if the road distance is more than 51.3 km. Interpretation Centralisation of specialised medical services should be accompanied by a comprehensive and specialised rescue chain. HEMS in Switzerland ensures time-sensitive IFT in medical emergencies, even in topographically challenging terrain. Graphical Abstract

Background Human external cargo (HEC) extrication during helicopter rescue missions is commonly used in mountain emergency medical services. Furthermore, longline or winch operations offer the opportunity to deliver professional medical care onsite. As the safety and quality of emergency medical care depends on training and experience, we aimed to investigate characteristics of mountain rescue missions with HEC. Methods We retrospectively reviewed all rescue missions conducted by Air Zermatt (a commercial rescue service in the high-alpine region of Switzerland) from January 2010 to September 2016. Results Out of 11,078 rescue missions 1137 (10%) required a HEC rescue. In 3% ( n  = 29) rapid sequence induction and endotracheal intubation, in 2% ( n  = 14) cardiopulmonary resuscitation, and in 0.4% ( n  = 3) a chest tube insertion had to be performed onsite prior to HEC extraction. The most common medical intervention onsite is analgesia or analgosedation, in 17% ( n  = 142) fentanyl or ketamine was used in doses of ≥ 0.2 mg or ≥ 50 mg, respectively. Conclusions As these interventions have to be performed in challenging terrain, with reduced personnel resources, and limited monitoring, our results point out the need for physicians onsite who are clinically experienced in these procedures and specially and intensively trained for the specific characteristics and challenges of HEC rescue missions.

The very brief chapter on Traumatic CA in the ERC Paediatric Life Support guidelines [6] recommends starting standard CPR while searching for and treating reversible causes. [...]we highly appreciate the awareness campaign ‘Aaron’s Heart’ of the Resuscitation Council United Kingdom to improve outcomes for paediatric CA patients. Characteristics and neurological survival following intraoperative cardiac arrest in a Swiss University Hospital: a 7-year retrospective observational cohort study.