Early identification of hypovolemia remains challenging in emergency settings, as vital signs may remain normal during initial blood loss. Point-of-care echocardiography allows assessment of stroke volume through left ventricular outflow tract velocity–time integral (LVOT VTI), but its performance in detecting mild hypovolemia in humans is unclear. To evaluate changes in LVOT VTI following standardized mild blood loss and to assess its ability to identify early hypovolemia in spontaneously breathing adults. In this prospective study, healthy volunteers undergoing whole blood donation (≈ 6–7 mL·kg⁻¹) were assessed using transthoracic echocardiography before donation (T0), immediately after (T1), and 15 min later (T2). The primary outcome was the relative change in LVOT VTI between T0 and T1. Secondary outcomes included the proportion of participants with ≥ 10
The association between ionized calcium (iCa²⁺) levels at admission and mortality in trauma patients remains controversial, with prior studies suggesting increased mortality in both hypocalcemic and hypercalcemic states. This study aimed to characterize the relationship between admission iCa²⁺ and key clinical outcomes, including mortality, and to clarify the contribution of acidosis—particularly among patients presenting with elevated iCa²⁺ levels. We performed a retrospective multicenter cohort study using a trauma registry (2011–2021). Adult trauma patients admitted to a level-1 trauma center with measured admission iCa²⁺ were included. Hypocalcemia and hypercalcemia were defined as iCa²⁺ <1.10 mmol/L and > 1.20 mmol/L, respectively. The primary outcome was mortality at hospital discharge (MHD); secondary outcomes were massive transfusion and trauma-induced coagulopathy (TIC). Associations were evaluated using multivariable logistic regression. We additionally assessed whether incorporating pH-adjusted iCa²⁺ improved the predictive performance of the mortality model. Among 977 patients (93
Fentanyl is commonly used as an adjuvant in prehospital emergency anesthesia to reduce the sympathetic response caused by laryngoscopy. It is widely employed in patients with traumatic brain injury, a group considered particularly vulnerable to both rises and falls in blood pressure during anesthesia. Currently, there is a lack of data on the overall impact of fentanyl use on mortality in TBI patients during prehospital anesthesia. We performed a retrospective cohort study to assess the effects of using fentanyl as an anesthetic adjuvant during prehospital intubation of patients with traumatic brain injury. We collected data on patients intubated between January 2014 and December 2022 by a single helicopter emergency medical service unit and included patients diagnosed with traumatic brain injury. The primary outcome was death before discharge. The secondary outcomes were (a) exiting the favorable blood pressure zone of 130–180mmHg, and (b) a change in blood pressure of either 10
Emergency department (ED) outcomes may be influenced by two volume-related mechanisms: structural volume (large vs. smaller EDs), which may confer scale-related advantages, and relative daily workload (busy vs. quiet days). We examined associations between annual ED volume and relative daily volume with in-hospital mortality across the six most common presenting complaints (PCs). We conducted an international retrospective multicenter cohort study using the Netherlands Emergency department Evaluation Database (NEED; seven EDs) and the Danish Multicenter Cohort (DMC; five EDs), including the six most common PCs. We used mixed-effects logistic regression to examine associations of annual PC-specific volume and relative daily ED volume with in-hospital mortality, adjusted for demographics, urgency, vital signs, Glasgow Coma Scale, consultations, laboratory tests, imaging, and medication. Relative daily volume was defined as total ED visits on a given day compared with that ED’s usual daily volume and categorized as low (<–1 SD), usual-volume days (−1 to + 1 SD), or high (>+1 SD). We included 486,558 Dutch and 237,698 Danish ED visits. Annual PC-specific volume showed no association with mortality. Higher relative daily volume (busy days) was associated with lower mortality in the Netherlands (e.g. dyspnea AOR 0.89, 95
In Norway, primary care doctors (PCDs) participate in prehospital trauma care. PCDs must decide whether to call out based on limited information shortly after a trauma incident. The Emergency Medical Communication Centre (EMCC) sends a short primary voice message containing the most important information. Although this information is often limited, it is one of several important factors influencing the decision to call out. Experienced PCDs may identify cues in the available information to help them decide. This was a qualitative interview study exploring factors that influence PCDs’ decision-making on whether to call out to acute trauma incidents. Twenty PCDs who had received acute trauma alarms from the EMCC were included. Data from the interviews were analysed using systematic text condensation. The results were discussed in light of Klein’s Recognition-Primed Decision model and Kahneman and Tversky’s Heuristics-and-Biases Framework. We identified five main themes through which PCDs’ reflections provided insights into their decision to call out to a specific acute trauma incident: (1) Limited but sufficient information; (2) The dilemma of severity versus distance; (3) Managing the risk of concurrent conflicts; (4) Professional responsibility made the difference; and (5) Competence and collaboration among emergency primary care personnel. In spite of limited information in the primary voice messages the PCDs stated that the message were an important factor deciding whether to call out. Experienced doctors reported using cues for guidance, consistent with Klein’s Recognition-Primed Decision model. However, decisions may at times be influenced by heuristic-based intuition. PCDs should be aware of cognitive biases. The PCDs reported several factors influencing their decision to call out, such as the patient’s vital signs, type of trauma, and mechanism of injury. However, these considerations were often overshadowed by time constraints. Not surprisingly, long distances, uncertainty about the time required at the incident scene, and concurrent conflicts were important reasons for not calling out. Despite these challenges, the PCDs emphasised a strong professional commitment to call out when needed as part of the prehospital trauma care team.
Sepsis heterogeneity is an obstacle to therapeutic advances, which may be addressed by identifying more homogenous patient subgroups. We aimed to validate the four subgroups previously identified in the SENECA study in our cohort of patients with sepsis in the emergency department (ED) and potentially propose new subphenotypes. This was a retrospective cohort study with laboratory and clinical data from patients admitted to the ED at Oslo University hospital with sepsis according to the Sepsis-3 definition. 953 adult patients admitted between January 4, 2019 to October 09, 2023 were included. As in SENECA, Consensus clustering was used to subgroup patients, with minor methodological adjustments. Four subgroups could be identified in our dataset, but they differed from the SENECA phenotypes. Eight subgroups were stable with more granular and distinct characteristics, described as: (1) Mild young, (2) Mild older, (3) Mild respiratory failure, (4) Severe respiratory failure, (5) Inflammatory, (6) Renal and multiorgan failure, (7) Hepatic and (8) Cytopenic. When using the inclusion criteria from SENECA in the Oslo cohort, only 49
Nearly 5,000 out-of-hospital cardiac arrests occur annually in Denmark. Three in four take place in the patient’s home, often witnessed by relatives. In 60–70
Trauma is a leading cause of death in children. Paediatric patients comprise only a small fraction of HEMS missions. Little is known about the diagnostic accuracy of prehospital and in-hospital diagnoses in a large physician-staffed HEMS. This observational multicentre study included paediatric trauma patients ≤ 16 years treated by the Swiss Air-Rescue between 28/10/2021 and 20/08/2024. We included all primary missions with a National Advisory Committee for Aeronautics (NACA) score of ≥ 3 (i.e. moderate to severe trauma) transported to three paediatric trauma centres or declared dead on-scene. Data were obtained from the HEMS database and the hospital discharge report. The primary outcome was diagnostic accuracy between the prehospital and in-hospital diagnoses, measured with Cohen’s kappa. Secondary outcomes included patient characteristics, interventions, and survival. We screened 1,531 eligible missions, of which 282 met inclusion criteria. Median age was 8.3 [IQR 3.5–12.1] years, and 163 (57.8
Abstract Objective To explore and map research on workplace culture, occupational health, exposure to violence, and organizational dynamics among Emergency Medical Service (EMS) professionals in Nordic countries, focusing on studies reporting gender-related findings between 2010 and 2025. Methods A scoping review was conducted in accordance with the JBI methodological guidance and reported using the PRISMA-ScR framework. Searches were performed in CINAHL, PubMed, Scopus, Web of Science, and Google Scholar covering the period 2010–2025. Studies focusing on EMS professionals and workplace experiences related to gender, workplace culture, discrimination, leadership, or organizational factors were eligible. Data were charted descriptively, using an inductive content analysis approach. Results Seven peer-reviewed studies and five master’s theses met the inclusion criteria, comprising cross-sectional, prospective cohort, and observational designs. Three explicitly examined gender/equality; other gender-related differentiated findings were reported as secondary observations. Women reported higher physical and psychosocial work demands (43% vs. 22%; 41% vs. 20%), greater concerns about threats and violence (58% vs. 38%), and higher levels of mental health problems (29% vs. 8%) and sleep disturbances (60% vs. 39%). Despite this, women demonstrated higher physical capacity, while men had higher cardiovascular disease risk factors. Men reported greater exposure to certain critical incidents, whereas stress levels were similar between genders. Workplace violence was common, with differences between men and women observed in exposure, perception, and support-seeking behaviors. Conclusion This scoping review found that gender-related patterns are present across workplace demands, health outcomes, exposure to violence, and critical incidents, but are rarely explicitly addressed in Nordic EMS research. Rather than isolated findings, these patterns appear to be embedded in organizational processes that shape norms, expectations, and professional identities. For example, women reported higher work demands, greater concern about workplace risks, and poorer mental health outcomes, despite demonstrating high physical capacity, while men reported greater exposure to certain critical incidents. Interpreted through the lens of organizational socialization, these findings suggest unequal access to legitimacy, well-being, and career opportunities, with implications for workforce sustainability. Addressing these issues through organizational and educational strategies may improve working conditions, reduce workplace risks, and support a more equitable and sustainable Nordic EMS workforce.
Abstract Purpose The aim was to describe epidemiology, injury characteristics, in-hospital care and outcome for elderly trauma patients with thoracic injuries within the context of a large national register study. Methods Trauma patients aged ≥ 60 years from 2022 to 2024 were identified through the national Swedish Trauma Registry (SweTrau). The Abbreviated Injury Scale (AIS) was used to identify thoracic and other injuries. Data on patient and injury demographics, in-hospital care and outcome in terms of discharge destination and mortality was collected for each patient. Results A total of 11,624 patients were included. The median age for all patients was 76 years (range 60–106), and 4617 (40%) were females. A total of 3644 (31%) patients had a thoracic injury registered (TI group). Compared with patients without thoracic injury (NTI), the TI group had higher injury severity (ISS and NISS) and were more physiologically compromised on arrival (lower systolic blood pressure and a higher proportion of patients presenting with circulatory shock (SBP < 90 mmHg). TI patients had more injuries, longer hospital length of stay, required more intensive care and were less often discharged to their home, while 30day mortality did not differ between groups. Conclusion Elderly trauma patients with thoracic injuries were more severely injured, required more in-hospital care and could less often be discharged directly to their home, compared to patients without thoracic injury.
In-hospital cardiac arrest carries high mortality despite advances in monitoring, rapid response systems, and adherence to advanced life support (ALS) guidelines. Digital decision-support tools, including mobile applications, are increasingly explored to improve guideline adherence, yet their impact on cognitive workload, team performance, and ALS performance remains uncertain. We conducted a prospective, randomized, simulation-based controlled feasibility trial with 40 interprofessional teams (80 participants) comparing ALS performance with and without the use of the ‘CPR Leader’ app. Two-person teams were randomized 1:1 to intervention or control and followed standardized in-hospital cardiac arrest scenarios (asystole and ventricular fibrillation). Primary outcomes included team performance (TEAM), non-technical skills (ANTS), and subjective workload (NASA-TLX). Secondary outcomes comprised objective resuscitation metrics, including time to rhythm analysis, defibrillation, medication administration, and chest compression quality. Overall NASA-TLX scores were high but comparable between intervention and control group (mean 49.2 ± 13.6 vs. 54.1 ± 14.6; p = 0.2), with higher effort reported in the app group and higher frustration in the control group. TEAM and ANTS scores showed no evidence of meaningful between-group differences. Across the two scenarios types, ALS performance metrics—including rhythm analysis, defibrillation, medication administration, and chest compression quality—were similar between groups, with the exception of earlier chest compression initiation in the control group during ventricular fibrillation. In this exploratory randomized simulation study involving predominantly experienced in-hospital healthcare professionals, the use of a resuscitation support application did not demonstrate a clear improvement in adherence to guideline-recommended ALS algorithms or resuscitation performance compared with standard practice. These findings likely reflect the high level of participants’ clinical experience and should not be generalized to novice providers, mixed-experience teams, prehospital settings, or training environments. Further studies are warranted to evaluate the potential benefits of cognitive aids in less experienced populations and in real-world clinical practice. None.
Non-urgent emergency department (ED) visits represent a growing global challenge with significant economic and operational consequences. Despite previous reviews, important gaps remain. No review has included all commonly used terms for non-urgent ED visits, recent evidence has not been synthesised, and factors related to patients, health systems, and care contexts have rarely been examined together. This systematic review aimed to identify and categorize factors associated with non-urgent ED visits in adults. A systematic search was conducted in PubMed, Scopus, and Web of Science for articles published between January 2015 and May 2026. We included cross-sectional, cohort, and case-control studies that compared urgent and non-urgent ED visits and reported at least one associated factor. Quality assessment was performed using Joanna Briggs Institute (JBI) checklists. Because of substantial heterogeneity in definitions, the findings were synthesised narratively. Thirty-two studies from 21 countries were included. The proportion of non-urgent visits ranged from 1
Abstract Background/ aim To reduce the risk of fire, the ERC resuscitation guidelines recommend removing all oxygen-delivery devices at least 1 m away from the patient’s chest prior to defibrillation. This recommendation is based on the assumption of relevant local oxygen accumulation. The presented study aimed to characterise ambient oxygen concentrations during cardiopulmonary resuscitation (CPR) and to assess the effect of removing oxygen-delivery devices. Methods In a controlled mannequin-based simulation study, 20 resuscitation scenarios were performed under standardised conditions, varying oxygen delivery, airway management, ventilation mode, environment (room vs. ambulance), and distance of oxygen sources. Oxygen concentrations were continuously measured and recorded at 10-second intervals at three locations corresponding to typical defibrillation sites. Linear mixed-effects models were used to analyse predictors of oxygen fraction. Results A total of 6,555 oxygen measurements were recorded. Median oxygen concentration was 21.6% (IQR 21.3–22.1%). Removing oxygen delivery devices to > 1 m did not result in lower oxygen concentrations compared with leaving them in proximity of the mannequin’s head. Endotracheal intubation compared to an open airway and the use of an OxyDemand valve compared to a reservoir with 15 L/min oxygen flow were associated with slightly lower oxygen fractions, whereas other factors (handling of upper garments, site, use of mechanical CPR) showed no clinically relevant effects. Conclusion Clinically relevant oxygen accumulation at defibrillation sites was not observed. Likewise, removing oxygen-delivery devices did not result in a reduction in oxygen concentrations. Under the tested conditions, these findings do not support clinically relevant oxygen enrichment during CPR, questioning the risk of oxygen-enriched atmospheres during CPR as well as the role of routine removal of oxygen sources prior to defibrillation.
Emergency airway management in critically injured trauma patients is frequently complicated by distorted anatomy, airway contamination, cervical spine immobilisation, and prior airway manipulation. Although bougie and stylet are commonly used adjuncts for tracheal intubation, evidence comparing their effectiveness in difficult trauma airways remains limited. We aimed to compare first-pass intubation success between bougie-guided and stylet-guided tracheal intubation in critically injured trauma patients with predefined difficult airway characteristics. In this prospective randomised clinical trial, 188 adult critically injured trauma patients requiring emergency tracheal intubation and having at least one predefined difficult airway characteristic were randomised to bougie-guided intubation (Group B, n = 94) or stylet-guided intubation (Group S, n = 94). All first-attempt intubations were performed by trauma anaesthesia senior residents using video laryngoscopy and a standardised drug-assisted delayed sequence intubation protocol. The primary outcome was first-pass intubation success. Secondary outcomes included time to intubation, rescue airway interventions, need for alternate adjunct or front-of-neck access, and peri-intubation complications. First-pass intubation success was achieved in 67 of 94 patients (71.3
Evidence on trauma epidemiology and outcomes largely originates from major trauma centres, while data from regional trauma units remain limited. The aim of this study was to describe the epidemiology, management, and outcomes of patients undergoing trauma team activation in the trauma units of Region Zealand, Denmark. We conducted a prospective multicentre observational study across four regional trauma units in Region Zealand, Denmark, between 1 March 2024 and 28 February 2025. All consecutive patients undergoing trauma team activation were included. Data included demographics, injury mechanisms, injury severity, in-hospital management, and mortality. Analyses were descriptive. A total of 1611 patients were included. Median age was 38 years [IQR 20–58], and 60.5
Abstract Background The American College of Surgeons Trauma Quality Improvement Program (TQIP) relies primarily on risk-adjusted mortality benchmarking, yet mortality alone may overlook non-fatal morbidity and care-process failures, particularly in cohorts where outcomes are driven by injury severity. This study aimed to analyse and compare 30-day mortality, cause of death, functional outcomes as measured by the Glasgow Outcome Scale (GOS), and opportunities for improvement (OFIs) identified through peer review across modified TQIP cohorts. Methods Registry-based cohort study of 8,298 trauma patients at Karolinska University Hospital (2013–2023), classified into four modified TQIP cohorts: isolated severe TBI, blunt multisystem with TBI, blunt multisystem without TBI, and penetrating truncal injury. Remaining patients, of lower severity on average, formed a non-TQIP reference cohort. Cohort associations with mortality, unfavourable GOS, and OFI were assessed using cumulative sequential logistic regression (reference: non-TQIP cohort), progressively adjusting for patient characteristics, physiological status, and care processes, pooled across 20 imputed datasets. Cause of death, GOS levels, and OFI categories were compared using multinomial logistic regression. Results All TQIP cohorts had elevated odds of mortality and unfavourable GOS. The blunt multisystem cohorts had the highest OFI rates (10.6% with TBI, 16.9% without) and were the only cohorts with elevations across all OFI categories, including potentially preventable deaths and clinical judgement errors. Care-process adjustment (e.g. emergency interventions, time to radiology, care level) reduced their mortality ORs, suggesting potentially modifiable processes. Isolated severe TBI had the highest mortality (52.8%) but no OFI excess, suggesting outcomes driven by primary injury rather than care-process failures. Penetrating truncal injury showed high, potentially preventable, haemorrhage-related mortality but favourable functional recovery in survivors after care-process adjustment. Conclusions Outcome profiles differed across TQIP cohorts and were not captured by mortality alone: isolated severe TBI had the highest mortality but no OFI excess, while the blunt multisystem cohorts had the greatest OFI burden and potentially preventable deaths despite lower mortality. Penetrating truncal injury showed high haemorrhage-related mortality but favourable functional recovery in survivors. Integrating functional outcomes and structured peer review alongside mortality identifies cohorts amenable to quality improvement and reveals cohort-specific processes to target.
Blunt and penetrating trauma differ in injury patterns, management, and outcomes, but data comparing early physiological and haemostatic responses within Scandinavian trauma systems remain limited. We aimed to investigate differences in clinical characteristics, early physiology, and outcomes between blunt and penetrating trauma patients at a major Swedish trauma centre. This registry-based observational cohort study included adult trauma patients admitted to the Karolinska University Hospital, Stockholm, between November 2022 and December 2024. Detailed prospective data were collected for patients receiving blood transfusion within two hours of arrival. Patients were categorised by injury type (blunt vs. penetrating). Clinical outcomes included 30-day mortality, hospital length of stay, and functional outcome. Secondary analyses compared physiological, metabolic, and coagulation parameters. Multivariable logistic regression was used to compare 30-day mortality between groups, adjusted for age, sex, Injury Severity Score, and preinjury comorbidity. A total of 2,193 patients were included, of whom 353 (16
Mass casualty incidents (MCIs) place substantial demands on pre-hospital systems. Extended pre-hospital times are associated with adverse patient outcomes. The factors perceived as contributing to these delays are poorly characterized across different resource settings. This study aimed to identify and compare pre-hospital care providers’ perceptions of factors associated with pre-hospital delays during trauma-related mass casualty incidents across high-income and low- and middle-income countries. A cross-sectional online survey was conducted between May and August 2024. Pre-hospital care providers with experience of at least one trauma-related mass casualty incident were recruited globally via professional associations, alumni networks, and social media. The survey comprised expert-reviewed Likert-scale items and open-ended questions. Participants were stratified by national income level using World Bank classifications. Quantitative data were analyzed using the Mann–Whitney U test and chi-squared or Fisher’s exact tests. Open-text responses were analyzed using thematic analysis following the framework of Braun and Clarke. Of 225 eligible responses from 54 countries, 158 (70.2
