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BackgroundScotland has three prehospital critical care teams (PHCCTs) providing enhanced care support to a usually paramedic-delivered ambulance service. The effect of the PHCCTs on patient survival following trauma in Scotland is not currently known nationally.MethodsNational registry-based retrospective cohort study using 2011–2016 data from the Scottish Trauma Audit Group. 30-day mortality was compared between groups after multivariate analysis to account for confounding variables.ResultsOur data set comprised 17 157 patients, with a mean age of 54.7 years and 8206 (57.5%) of male gender. 2877 patients in the registry were excluded due to incomplete data on their level of prehospital care, leaving an eligible group of 14 280. 13 504 injured adults who received care from ambulance clinicians (paramedics or technicians) were compared with 776 whose care included input from a PHCCT. The median Injury Severity Score (ISS) across all eligible patients was 9; 3076 patients (21.5%) met the ISS>15 criterion for major trauma. Patients in the PHCCT cohort were statistically significantly (all p<0.01) more likely to be male; be transported to a prospective Major Trauma Centre; have suffered major trauma; have suffered a severe head injury; be transported by air and be intubated prior to arrival in hospital. Following multivariate analysis, the OR for 30-day mortality for patients seen by a PHCCT was 0.56 (95% CI 0.36 to 0.86, p=0.01).ConclusionPrehospital care provided by a physician-led critical care team was associated with an increased chance of survival at 30 days when compared with care provided by ambulance clinicians.

Prehospital identification of shock in trauma patients lacks accurate markers. Low end tidal carbon dioxide (ETCO2) correlates with mortality in intubated patients. The predictive value of ETCO2 obtained by nasal capnography cannula (NCC) is unknown. We hypothesized that prehospital ETCO2 values obtained by NCC and in-line ventilator circuit (ILVC) would be predictive of mortality. This was a prospective, observational, multicenter study. ETCO2 values were collected by a NCC or through ILVC. AUROCs were compared with prehospital systolic blood pressure (SBP) and shock index (SI). The Youden index defined optimal cutoffs. Of 550 enrolled patients, 487 (88.5%) had ETCO2 measured through an NCC. Median age was 37 (27–52) years; 76.5% were male; median ISS was 13 (5–22). Mortality was 10.4%. Minimum prehospital ETCO2 significantly predicted mortality with an AUROC of 0.76 (CI 0.69–0.84; Youden index ​= ​22 ​mmHg), outperforming SBP with an AUROC of 0.68; (CI 0.62–0.74, p ​= ​0.04) and shock index with an AUROC of 0.67 (CI 0.59–0.74, p ​= ​0.03). Prehospital ETCO2 measured by non-invasive NCC or ILVC may be predictive of mortality in injured patients. •Lowest prehospital ETCO2 value predicts mortality in trauma patients.•Lowest prehospital ETCO2 value predicts massive transfusion in trauma patients.•Values were obtained via nasal capnography cannula and in-line ventilator circuit.

Background Out-of-hospital emergency care (OHEC), also known as prehospital care, has been shown to reduce morbidity and mortality from serious illness. We sought to summarize literature for low and low-middle income countries to identify barriers to and key interventions for OHEC delivery. Methods We performed a systematic review of the peer reviewed literature from January 2005 to March 2015 in PubMed, Embase, Cochrane, and Web of Science. All articles referencing research from low and low-middle income countries addressing OHEC, emergency medical services, or transport/transfer of patients were included. We identified themes in the literature to form six categories of OHEC barriers. Data were collected using an electronic form and results were aggregated to produce a descriptive summary. Results A total 1927 titles were identified, 31 of which met inclusion criteria. Barriers to OHEC were divided into six categories that included: culture/community, infrastructure, communication/coordination, transport, equipment and personnel. Lack of transportation was a common problem, with 55% (17/31) of articles reporting this as a hindrance to OHEC. Ambulances were the most commonly mentioned (71%, 22/31) mode of transporting patients. However, many patients still relied on alternative means of transportation such as hired cars, and animal drawn carts. Sixty-one percent (19/31) of articles identified a lack of skilled personnel as a key barrier, with 32% (10/31) of OHEC being delivered by laypersons without formal training. Forty percent (12/31) of the systems identified in the review described a uniform access phone number for emergency medical service activation. Conclusions Policy makers and researchers seeking to improve OHEC in low and low-middle income countries should focus on increasing the availability of transport and trained providers while improving patient access to the OHEC system. The review yielded articles with a primary focus in Africa, highlighting a need for future research in diverse geographic areas.

Background Workplace violence against healthcare workers has been a well-known problem for more than 40 years. This problem is also relevant for prehospital personnel who are at risk of physical and/or psychological violence during work. Violence and threats of violence can have physical and psychological consequences, including personal challenges in their everyday life, use of sick days, reports, and the need for professional help. Therefore, this study aimed to describe the extent of and subsequent reporting of physical and psychological workplace violence toward the prehospital healthcare workers in Denmark in a two-year period. Moreover, we wanted to elucidate any possible effect of workplace violence on the private and professional lives of the prehospital healthcare personnel. Methods A nation-wide survey where a validated anonymised questionnaire was directed to all of the approximately 4500 Danish prehospital healthcare workers. Results Out of 584 complete responses we found that 47.4% had experienced psychological violence on the job whereas 25.7% had experienced physical violence on the job within the past two years. The perpetrators were mainly patients or relatives of the patients. Physical violence was mostly reported as punching, pushing, and kicking, while psychological violence included threats of violence and other intimidation. After experiencing violence the respondents reported both physical and psychological harm, which for some prehospital healthcare workers had consequences for their professional and/or personal life. Furthermore, some prehospital healthcare workers reported that the violence had resulted in some patients receiving worse treatment afterwards. We found that violence was rarely reported to either employers or the police, because respondents believed the events were not important enough to merit reporting, or because a report was not considered to make any difference to the healthcare worker. The survey demonstrates that, as a minimum, at least one healthcare worker in 30 and one healthcare worker in 16 has been exposed to episodes of violence and threats of violence within the last two years. Conclusion We suggest that the prehospital organisations emphasise reporting future episodes of physical and/or psychological violence. Knowing the extent of the problem is a prerequisite for addressing, debriefing, and/or other psychological follow-up. Trial registration N/A.

Background In 2011, the role of Point of Care Ultrasound (POCUS) was defined as one of the top five research priorities in physician-provided prehospital critical care and future research topics were proposed; the feasibility of prehospital POCUS, changes in patient management induced by POCUS and education of providers. This systematic review aimed to assess these three topics by including studies examining all kinds of prehospital patients undergoing all kinds of prehospital POCUS examinations and studies examining any kind of POCUS education in prehospital critical care providers. Methods and results By a systematic literature search in MEDLINE, EMBASE, and Cochrane databases, we identified and screened titles and abstracts of 3264 studies published from 2012 to 2017. Of these, 65 studies were read in full-text for assessment of eligibility and 27 studies were ultimately included and assessed for quality by SIGN-50 checklists. No studies compared patient outcome with and without prehospital POCUS. Four studies of acceptable quality demonstrated feasibility and changes in patient management in trauma. Two studies of acceptable quality demonstrated feasibility and changes in patient management in breathing difficulties. Four studies of acceptable quality demonstrated feasibility, outcome prediction and changes in patient management in cardiac arrest, but also that POCUS may prolong pauses in compressions. Two studies of acceptable quality demonstrated that short (few hours) teaching sessions are sufficient for obtaining simple interpretation skills, but not image acquisition skills. Three studies of acceptable quality demonstrated that longer one- or two-day courses including hands-on training are sufficient for learning simple, but not advanced, image acquisition skills. Three studies of acceptable quality demonstrated that systematic educational programs including supervised examinations are sufficient for learning advanced image acquisition skills in healthy volunteers, but that more than 50 clinical examinations are required for expertise in a clinical setting. Conclusion Prehospital POCUS is feasible and changes patient management in trauma, breathing difficulties and cardiac arrest, but it is unknown if this improves outcome. Expertise in POCUS requires extensive training by a combination of theory, hands-on training and a substantial amount of clinical examinations – a large part of these needs to be supervised.

Background The purpose of this study was to clarify the potentially life-saving critical interventions performed on children below the age of seven by the physician-manned mobile emergency care unit (MECU) in Odense, Denmark. We investigated critical interventions in relation to morbidity and mortality. Methods A retrospective cohort study of all MECU missions involving children below the age of seven. The study period was from October 1 2007 to December 31 2020. Data sources were the MECU Odense database, the Danish National Patient Registry, and the Danish Civil Registration System. Variables were critical interventions, the severity of injury/illness, MECU on-scene time, in-hospital diagnosis and 7-day, 30-day, and 90-day mortality. Results The MECU carried out 4,032 missions to children below 7 years. 88 patients (2.2%) received at least one critical prehospital intervention. Upper airway suction was performed in 39 cases (1.0%), endotracheal intubation (all causes) in 36 cases (0.9%), and intraosseous access in 21 cases (0.5%). General anaesthesia was induced in 29 cases (0.7%). Seventeen patients (0.4%) received cardiopulmonary resuscitation and two patients received manual defibrillation (< 0.1%). 3,278 patients were admitted to the hospital and assigned a diagnosis when discharged. The most common diagnoses were assigned within the International Statistical Classification of Diseases and Related Health Problems 10th Revision Chapter XVIII (Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified), which includes febrile convulsions. 1,437 patients (43.8%) were assigned diagnoses within this diagnosis group. The overall 7-day mortality in the cohort was 0.74%, 30-day mortality was 0.82%, and 90-day mortality was 1.02%. Conclusion Prehospital critical interventions are rarely performed in children under the age of 7 years. The low frequency of these interventions may have implications for maintaining the clinical routine of the prehospital care providers.

The prehospital interventions provided by helicopter emergency medical services are crucial for improving rescue efficiency and success rates. We aimed to assess and describe the literature on prehospital rescue interventions provided by helicopter emergency medical services personnel worldwide. A comprehensive search was conducted via PubMed, MEDLINE, Embase, Web of Science, and CINAHL from January 1, 2010, to September 30, 2025, to identify studies for patients of any age involving helicopter prehospital interventions. Two authors independently completed the data extraction and quality assessment. Among 10,731 records, 80 studies were included with a total sample size of 3,343,377 cases, of whom 963,779 were transported by helicopter emergency medical services. Of the 84 identified prehospital interventions provided by helicopter emergency medical services crews, 18 high-frequency core emergency interventions were extracted and categorized into 4 systems: circulatory, respiratory, locomotor, and other. The most frequent interventions were endotracheal intubation, drug treatment, and cardiopulmonary resuscitation. Subgroup analyses of “trauma patients only,” “cardiac arrest only,” and “trauma and non-trauma patients” indicated that advanced airway management, hemodynamic stabilization, and supportive drug therapy were consistently critical across all groups. The helicopter emergency medical services teams provided a wide spectrum of intervention services. Evaluating the interventions is important to gain insight into uniform practices, terminology, and documentation. Identifying intervention outcomes and efficacy is crucial for guiding future research and developing evidence-based, standardized helicopter emergency intervention guidelines.

Background Acute pain in the prehospital setting is frequent and prehospital pain management presents multiple challenges, especially in children. There is a lack of high-level evidence regarding prehospital pain management in the paediatric population worldwide. In Denmark, this lack of evidence particularly concerns the frequency of the prehospital use of strong analgesics. Guidelines are sparse but there is evidence that prehospital fentanyl may be administered up to 5 µg/kg. Method This register-based study investigated the prehospital analgesic treatment in the population under 15 years from January 2017 to December 2022 in the Region of Southern Denmark. Data were extracted from electronic prehospital medical records. The analgesic treatment was characterised by the type of medication, dosage, administration method, and cause of ambulance dispatch. Lastly, response- and transport times were registered. Results A total of 28,933 prehospital paediatric medical records were examined. In one in seventeen of all prehospital contacts with children, fentanyl, alfentanil, morphine and/or s-ketamine was administered. Three-quarters of the doses of strong analgesics were administered to patients older than 10 years. Fentanyl was the most frequently administered medication (96.4%). The median fentanyl-equipotent doses of opioids were 1.7 µg/kg adjusted according to standardised patient weight. In 63.4% of cases, the analgesic treatment was administered intravenously. Conclusion The doses of opioids as administered by the EMS personnel seem safe as 97% of the doses were within the recommended range and even at the lower end of the recommended range. Although apparently safe, the utilisation of strong analgesics points to a risk of under-treating pain in children.

Aggressive prehospital interventions (PHI) in trauma may not improve outcomes compared to prioritizing rapid transport. The aim of this study was to quantify temporal changes in the frequency of PHI performed by EMS. Retrospective chart review of adult patients transported by EMS to our trauma center from January 1, 2014 to 12/31/2021. PHI were recorded and annual changes in their frequency were assessed via year-by-year trend analysis and multivariate regression. Between the first and last year of the study period, the frequency of thoracostomy (6% vs. 9%, p ​= ​0.001), TXA administration (0.3% vs. 33%, p ​< ​0.001), and whole blood administration (0% vs. 20%, p ​< ​0.001) increased. Advanced airway procedures (21% vs. 12%, p ​< ​0.001) and IV fluid administration (57% vs. 36%, p ​< ​0.001) decreased. ED mortality decreased from 8% to 5% (p ​= ​0.001) over the study period. On multivariate regression, no PHI were independently associated with increased or decreased ED mortality. PHI have changed significantly over the past eight years. However, no PHI were independently associated with increased or decreased ED mortality. [Display omitted] •EMS provide basic and advanced prehospital interventions for trauma patients.•Interventions performed by our EMS changed significantly over the last eight years.•No prehospital interventions were independently associated with either increased or decreased ED mortality on multivariate logistic regression.

Background Sepsis is defined as life-threatening organ dysfunction caused by a host response to infection. The quick SOFA (qSOFA) score has been recently proposed as a new bedside clinical score to identify patients with suspected infection at risk of complication (intensive care unit (ICU) admission, in-hospital mortality). The aim of this study was to measure the sensitivity of the qSOFA score, SIRS criteria and sepsis definitions to identify the most serious sepsis cases in the prehospital setting and at the emergency department (ED) triage. Methods We performed a retrospective study of all patients transported by emergency medical services (EMS) to the Lausanne University Hospital (CHUV) over twelve months. All patients with a suspected or proven infection after the ED workup were included. We retrospectively analysed the sensitivity of the qSOFA score (≥2 criteria), SIRS criteria (≥2 clinical criteria) and sepsis definition (SIRS criteria + one sign of organ dysfunction or hypoperfusion) in the pre-hospital setting and at the ED triage as predictors of ICU admission, ICU stay of ≥3 days and early (i.e. 48 h) mortality. No direct comparison between the three tools was attempted. Results Among 11,411 patients transported to the University hospital, 886 (7.8%) were included. In the pre-hospital setting, the sensitivity of qSOFA reached 36.3% for ICU admission, 17.4% for ICU stay of three days or more and 68.0% for 48 h mortality. The sensitivity of SIRS criteria reached 68.8% for ICU admission, 74.6% for ICU stay of three days or more and 64.0% for 48 h mortality. The sensitivity of sepsis definition did not reach 60% for any outcome. At ED triage, the sensitivity of qSOFA reached 31.2% for ICU admission, 30.5% for ICU stay of ≥3 days and 60.0% for mortality at 48 h. The sensitivity of SIRS criteria reached 58.8% for ICU admission, 57.6% for ICU stay of ≥3 days 80.0% for mortality at 48 h. The sensitivity of sepsis definition reached 60.0% for 48 h mortality. Discussion Incidence of sepsis in the ED among patients transported by ambulance was 3.8 percent. This rate, associated to the mortality of sepsis, confirms the necessity to dispose of a test to early identify those patients. Conclusion The sensitivity performance of all three tools was suboptimal. The qSOFA score, SIRS criteria and sepsis definition have low identification sensitivity in selecting septic patients in the pre-hospital setting or upon arrival in the ED at risk of complication.