Marius Rehn

• Rognes, Ingrid Nygren; Morberg, Pål; Solberg, Henriette; Rehn, Marius; Stø, Kristine & Alteheld, Lars Holger [Show all 9 contributors for this article] (2026). Transcranial Ultrasound in the Helicopter Emergency Medical Services—A Feasibility Study. Journal of Neuroimaging (JON). ISSN 1051-2284. 36(4). doi: 10.1111/jon.70145. Full text in Research Archive Show summary

  ABSTRACT Background and Purpose Transcranial color‐coded Doppler (TCCD) is a noninvasive, widely available diagnostic method that may identify large vessel occlusion (LVO) in acute stroke patients. This study aimed to explore whether helicopter emergency medical services (HEMS) physicians could use TCCD in a prehospital setting to identify the proximal segment of the middle cerebral artery (M1‐MCA). Methods In a feasibility study following brief training, three HEMS physicians and a single‐reference examiner performed transtemporal TCCD examinations of four healthy volunteers, on ground and in flight a cruising helicopter. One color and one pulsed‐wave Doppler image of M1‐MCA were stored per examination, and time was recorded. TCCD images were retrospectively assessed by two raters for M1‐MCA identification success and image quality, using a 5‐point Likert scale. Results Participants performed a total of 32 bilateral M1‐MCA examinations. The HEMS physicians identified M1‐MCA in 83% of color Doppler examinations, with median (interquartile range [IQR]) time of 83 (63–130) s. Substantial inter‐examiner variability was observed. The single‐reference examiner identified M1‐MCA in 88% of color Doppler examinations using 58 (49–101) s. Median (IQR) Likert scores for successful images were high: HEMS physicians 4.5 (4.5–5.0) and single‐reference examiner 5.0 (4.5–5.0), with no significant difference between on‐ground and in‐flight examinations. Conclusion Following brief training, HEMS physicians were able to perform TCCD field examinations of M1‐MCA in healthy volunteers, with identification rates and image quality comparable to a single‐reference examiner. Substantial inter‐examiner variability was observed, highlighting the importance of tailored training and competency assessment. Research is required to evaluate TCCD use by HEMS physicians under real‐world prehospital conditions.

• Erblich, Romana; Noitz, Matthias; Knöll, Marius; Trimmel, Helmut; Voelckel, Wolfgang Georg Cornelius & Carenzo, Luca [Show all 10 contributors for this article] (2026). Timing and outcomes of out-of-hospital traumatic cardiac arrest: results of a multicentre, retrospective cohort study. Resuscitation Plus. 30. doi: 10.1016/j.resplu.2026.101393. Full text in Research Archive
• Butterfield, Emma; Wooldridge, Gavin; Asfaw, Solomon Abraha; Alhilal, Mervat; Steere, Mardi & Wachira, Benjamin W. [Show all 10 contributors for this article] (2026). Explosive Weapons Trauma Care Collective (EXTRACCT) Clinical Practice Guideline: Transfer of Critically Injured Casualties. World Journal of Surgery. ISSN 0364-2313. doi: 10.1002/wjs.70456.
• Brede, Jostein Rødseth; Farbu, Bjørn; Gamberini, Lorenzo; Thorsen, Kjetil; Rehn, Marius & Rognås, Leif Kåre [Show all 15 contributors for this article] (2026). Prehospital resuscitative endovascular balloon occlusion of the aorta in non-traumatic out-of-hospital cardiac arrest (REBOARREST): an international, multicentre, open label, pragmatic, randomised, controlled trial. Critical Care. ISSN 1364-8535. 30(1). doi: 10.1186/s13054-026-06057-y. Full text in Research Archive
• Amer, Marwa; Alhazzani, Waleed; Alshamsi, Fayez; Granholm, Anders; Arabi, Yaseen M. & Olkkola, Klaus T. [Show all 28 contributors for this article] (2026). Recommendations for Stress Ulcer Prophylaxis in Critically Ill Adults: A Contextualized Clinical Practice Guideline From the Saudi Critical Care Society and the Scandinavian Society of Anaesthesiology and Intensive Care Medicine, Endorsed by the Kuwait Anesthesia and Critical Care Society. Acta Anaesthesiologica Scandinavica. ISSN 0001-5172. 70(3). doi: 10.1111/aas.70201. Full text in Research Archive
• Koistinaho, Aura; Lie, Sole Lindvåg; Landsverk, Svein Aslak; Lenz, Harald; Rehn, Marius & Hisdal, Jonny [Show all 7 contributors for this article] (2026). Peripheral intravenous waveform analysis for evaluating volume status in healthy volunteers and mechanically ventilated patients. Journal of clinical monitoring and computing. ISSN 1387-1307. doi: 10.1007/s10877-025-01408-6. Full text in Research Archive
• Jagtenberg, Caroline J.; Boer, Annemijn M.; Rehn, Marius; Røislien, Jo; Hov, Maren Ranhoff & Larsen, Karianne (2026). Geospatial optimization of Air-Mobile Stroke Unit deployment in Norway: expanding the frontiers of neurocritical care. Frontiers in Neurology. 17. doi: 10.3389/fneur.2026.1740806. Full text in Research Archive
• Renberg, Mattias; Gustavsson, Jenny; Rehn, Marius & Günther, Mattias (2026). Hemodynamic rescue after blast injury: intravenous administration outperforms intramuscular vasopressin in a swine model. European Journal of Trauma and Emergency Surgery. ISSN 1863-9933. 52(1). doi: 10.1007/s00068-026-03155-y. Full text in Research Archive
• Amer, Marwa; Møller, Morten Hylander; Granholm, Anders; Alotaibi, Haifa F.; AlMuhaidib, Shadan & Duhailib, Zainab Al [Show all 23 contributors for this article] (2025). A systematic methodological evaluation of sepsis guidelines: Protocol for quality assessment and consistency of recommendations. Acta Anaesthesiologica Scandinavica. ISSN 0001-5172. 69(6). doi: 10.1111/aas.70036. Full text in Research Archive Show summary

  Background Sepsis is a leading cause of mortality worldwide, characterized by a dysregulated host response to infection. Despite the development of multiple clinical practice guidelines (CPGs) to standardize sepsis management, substantial variability exists in methodological quality and key clinical recommendations. This inconsistency complicates guideline implementation and potentially affects patient outcomes. The proposed systematic methodological review aims to evaluate the quality and consistency of sepsis guidelines to identify areas for improvement and provide actionable insights for guideline developers. Methods This protocol outlines a systematic methodological review of sepsis CPGs published over the last two decades (2004–2025). A comprehensive search strategy will be conducted across PubMed, EMBASE, the Cochrane Library, and the official websites of professional societies to identify relevant guidelines. The inclusion criteria are CPGs targeting adult sepsis management published by recognized medical or governmental organizations with detailed methodological descriptions. We will use the Appraisal of Guidelines for Research and Evaluation II instrument to assess methodological quality across six domains: scope and purpose, stakeholder involvement, rigor of development, clarity of presentation, applicability, and editorial independence. Data extraction will focus on key clinical recommendations, including fluid resuscitation, antimicrobial therapy, vasopressor and inotrope use, corticosteroids, source control, blood glucose management, hemodynamic management, and mechanical ventilation management. The consistency of the recommendations will be analyzed, and trends in guideline quality over time will be evaluated. Artificial intelligence (AI) tools will be evaluated for data extraction processes in systematic reviews to determine their capacity for efficiency and accuracy in extracting data compared to human-driven methods. Conclusion By systematically appraising the quality and consistency of sepsis guidelines, this review aims to address the existing gaps and discrepancies in guideline development and application. These findings will provide valuable insights into the evolution of sepsis guideline quality, highlight areas for improvement, and support the development of more robust evidence-based recommendations. These results will inform clinicians and guideline developers, ultimately enhancing the standardization and effectiveness of sepsis management worldwide. Integrating AI into the review process represents a novel methodological advancement that streamlines data extraction and analysis.

• Bekkevold, Marit; Solvik-Olsen, TONE; Lang, Astri Maria; Heyerdahl, Fridtjof; Hagemo, Jostein Skjalg & Rehn, Marius (2025). Data variables reported during neonatal transport: a systematic literature review. Journal of Perinatology. ISSN 0743-8346. 46(1), p. 6–11. doi: 10.1038/s41372-025-02483-y. Full text in Research Archive Show summary

  Neonatal transports are essential for providing access to advanced intensive care treatment for sick and premature neonates. There is a lack of consensus of which core physiological variables, clinical parameters and quality metrics to report for clinical guidance during transport and clinical governance of transport systems. We performed a systematic literature review to identify which data variables are reported during neonatal transports and assess whether these variables are uniform and transferable across studies. In the final data extraction and quality appraisal, 108 studies were included. The studies were heterogenous, presented a large variation of registered variables and frequently lacked uniform definitions. Reaching consensus on a set of defined variables for registration and implementation internationally will enhance the opportunity to improve the safety, effectiveness and quality of care for these vulnerable neonates.

• Solvik-Olsen, TONE; Bekkevold, Marit; Heyerdahl, Fridtjof; Lang, Astri Maria; Hagemo, Jostein Skjalg & Rehn, Marius (2025). Environmental factors and clinical markers of stress during neonatal transport: A systematic literature review. BMJ Paediatrics Open. 9(1). doi: 10.1136/bmjpo-2025-003568. Full text in Research Archive Show summary

  Background Neonatal transport is an essential component of modern neonatal intensive care globally, providing access to advanced treatment while exposing vulnerable neonates to environmental conditions that may increase the risk of physiological instability. Objective To systematically review studies measuring environmental exposures, specifically vibration, sound and temperature fluctuations during neonatal transport and to evaluate their impact on clinical parameters in neonates. Methods A systematic literature review identified studies reporting environmental factors or clinical data during transport via ground, rotor or fixed-wing air ambulances. The medical databases searched included MEDLINE/PubMed, Embase, the Cochrane database of systematic reviews, Nursing Reference Center Plus, UpToDate and SveMed covering the period from November 2020 to January 2025. Results 15 observational studies, 13 prospective and 2 retrospective covering publications from 1992 to 2025 were included. The studies included data on vibration, sound, ambient temperature and a wide range of clinical parameters such as heart rate and heart rate variability, change in clinical behaviour scales and cortisol in saliva reflecting the neonatal condition. Only four articles reported the effect of environmental factors on neonatal physiology. Conclusions This review highlights the presence of environmental factors, particularly noise and vibration, during transport and raises concerns about their impact on neonates. Although diverse clinical parameters were documented, the small sample sizes and variability in measurement methods across studies limit the ability to draw definitive conclusions. These observations emphasise the need

• Hansen, Peter Martin; Nielsen, Martine Siw; Rehn, Marius; Lassen, Annmarie; Perner, Anders & Mikkelsen, Søren [Show all 7 contributors for this article] (2025). Association of ambulance and helicopter response times with patient survival: A systematic literature review and meta-analysis. PLOS ONE. 20(11). doi: 10.1371/journal.pone.0335665. Full text in Research Archive Show summary

  Background Only sparse scientific evidence supports the notion that the shortest possible response time relates to improved patient outcomes in acute conditions, other than out-of-hospital cardiac arrest and trauma. Confounders such as bidirectional causality and confounding by indication may influence patient-centered outcomes, which may prevent actionable conclusions from literature reviews. The purpose of the systematic literature review was to assess current evidence on association, if any, between ambulance and helicopter response times and survival in all patient categories treated by ambulance or helicopter services. Methods The systematic search was conducted in MEDLINE, Cochrane Library, EMBASE, CINAHL, Scopus, and Clinical Trial Registries. All study designs and settings identified as relevant to the topic were eligible. The investigators retrieved data from a predefined template and extracted data from a predefined template. Two reviewers worked independently, and conflicts were resolved by a third reviewer. The researchers used PRISMA guidelines for abstracting data and GRADE methodology for assessing data quality and validity. As per study protocol, the primary study outcome was patient survival, and the main measurement was response time for emergency medical services vehicles. Results The investigators included 115 studies that in total included 691,056 patients, comprising patients with out-of-hospital cardiac arrest, trauma, drownings, and including both adults and children in various settings. The overall median survival rate was 11.5% (IQR 5.2; 25.8). Response time varied between 1.10 and 48.62 minutes. The predefined domains and items of interest were accounted for in 46.7% of the included literature. In a meta-analysis of sub-groups, there was a positive correlation in selected populations. Certainty of evidence was very low as per GRADE methodology. Conclusions This systematic review and meta-analysis found lack of evidence to infer an association between the EMS response time and patient survival, with very low certainty of evidence. The investigators found substantive research and knowledge gaps. Therefore, no actionable conclusions can be made from this systematic review.

• Farbu, Bjørn Hoftun; Hagemo, Jostein Skjalg & Rehn, Marius (2025). Abdominal organ injury in cardiac arrest: Systematic literature review. PLOS ONE. 20(8). doi: 10.1371/journal.pone.0329164. Full text in Research Archive Show summary

  Background Both cardiopulmonary resuscitation (CPR) and ischaemia could lead to abdominal organ injury. However, the importance of abdominal injury in cardiac arrest remains uncertain. We aimed to systematically review indexed literature to describe incidence of abdominal injury after non-traumatic cardiac arrest and associations with outcome. Methods We searched MEDLINE/PubMed, Embase, The Cochrane Database of Systematic Reviews and Scopus up to 12th September 2024 for studies reporting differences in outcomes between patients with and without abdominal injury, and all studies reporting abdominal adverse events after cardiac arrest. Two independent reviewers screened articles for eligibility. One reviewer extracted data and assessed risk of bias using the Critical Appraisal Skills Programme checklist. Injuries were defined as traumatic or ischaemic, either in the studies or otherwise by the reviewers. Results were summarized and presented in tables and Forest plots. We followed the PRISMA guidelines, and registered the study in PROSPERO. Results We included 68 studies and 140 case reports. Most studies were single-centre. Quantitative synthesis of evidence was not feasible given high heterogeneity and risk of bias. Traumatic injuries affected mostly liver and spleen, with incidences from 0% to 15%, reaching 29% in one study of mechanical chest compressions. Life-threatening injuries were uncommon. The incidence of ischaemic injury was dependent on assessment method; 7% to 28% had liver injury, 0.7% to 2.5% was diagnosed with non-occlusive mesenteric ischaemia, 82% to 100% had intestinal injury measured by biomarkers. Ischaemic injuries were associated with mortality. Conclusion In this comprehensive review of abdominal injuries following cardiac arrest, CPR-related traumatic injuries were uncommon, but should be considered in patients with unexplained clinical deterioration. Ischaemic injury incidence ranged from 0.7% to 100%, and was consistently associated with mortality. Whether abdominal ischaemia independently contributes to poor outcomes remains unresolved and warrants further investigation.

• Simensen, Randi; Fjose, Lars Olav; Thorsen, Kjetil; Olsen, Inge Christoffer; Rehn, Marius & Hagemo, Jostein Skjalg [Show all 8 contributors for this article] (2025). Comparison of inhalational methoxyflurane, intranasal fentanyl, and intravenous morphine for treatment of prehospital acute pain in Norway (PreMeFen): a randomised, non-inferiority, three-arm, phase 3 trial. The Lancet. ISSN 0140-6736. p. 1–10. doi: 10.1016/s0140-6736(25)01575-2. Full text in Research Archive Show summary

  Background: Adequate pain control is essential; however, acute pain is often undertreated in prehospital care. This study aimed to evaluate three analgesic regimens for treating acute pain in an ambulance setting. Methods: PreMeFen is a randomised, open-label, non-inferiority, three-arm, phase 3 trial conducted in the working areas of the ground ambulance service of the Innlandet Hospital Trust, Norway. Patients aged 18-69 years and 70 years and older with traumatic or medical acute pain scoring 4 or higher on the Numeric Rating Scale (NRS) were randomly assigned (1:1:1) to receive in titration doses 3 mL inhalational methoxyflurane, 50 μg or 100 μg intranasal fentanyl, or 0·05 mg/kg or 0·1 mg/kg intravenous morphine, respectively, depending on the age group. The primary endpoint was change in pain NRS score from baseline to 10 min after treatment start and was analysed per protocol. The non-inferiority margin was 1·3. This trial is registered with ClinicalTrials.gov (NCT05137184) and is completed. Findings: Between Nov 12, 2021, and April 22, 2023, 632 patients were assessed for eligibility, and 338 were randomly assigned to methoxyflurane (n=112), fentanyl (n=115), or morphine (n=111). 281 patients were included in the per-protocol population. 145 (52%) of 281 patients were female and 136 (48%) were male. Median age was 61 years (IQR 47-75). The baseline NRS score was 7·6 (SD 1·8). Mean NRS score changes after 10 min were -3·31 (SD 2·67) for methoxyflurane, -1·98 (2·28) for fentanyl, and -2·74 (2·12) for morphine. Comparing changes in mean NRS score while adjusting for baseline showed that methoxyflurane was non-inferior to fentanyl (-1·33 [95% CI -2·01 to -0·64]) and morphine (-0·36 [-1·03 to 0·31]). Intranasal fentanyl was not non-inferior to morphine at 10 min (0·91 [0·27 to 1·55]). Adverse events occurred in 26 (24%) of 109 patients in the morphine group, 27 (24%) of 112 in the fentanyl group, and 24 (22%) of 111 in the methoxyflurane group. Two serious adverse events, respiratory depression (grade 2) and loss of consciousness (grade 3), occurred in the same patient in the methoxyflurane group. There were no treatment-related deaths. Interpretation: Inhalational methoxyflurane is non-inferior to intranasal fentanyl and intravenous morphine for acute pain management in the prehospital environment, assessed 10 min after administration. Inhalational methoxyflurane serves as a valuable non-intravenous alternative in the early phase of treatment and might bridge the gap to longer-acting analgesics.

• Kjær, Jeannett; Milling, Louise; Brøchner, Anne Craveiro; Lippert, Freddy; Blomberg, Stig Nikolaj & Christensen, Helle Collatz [Show all 187 contributors for this article] (2025). Prehospital cardiac arrest resuscitation practices differ around the globe. Resuscitation Plus. 25, p. 1–7. doi: 10.1016/j.resplu.2025.101017. Full text in Research Archive
• Hyldmo, Per Kristian; Rehn, Marius; Friesgaard, Kristian Dahl; Rognås, Leif; Raatiniemi, Lasse & Kurola, Jouni [Show all 11 contributors for this article] (2024). Inhaled analgesics for the treatment of prehospital acute pain— A systematic review. Acta Anaesthesiologica Scandinavica. ISSN 0001-5172. 68(10), p. 1306–1318. doi: 10.1111/aas.14527. Full text in Research Archive Show summary

  Background Many prehospital emergency patients receive suboptimal treatment for their moderate to severe pain. Various factors may contribute. We aim to systematically review literature pertaining to prehospital emergency adult patients with acute pain and the pain-reducing effects, adverse events (AEs), and safety issues associated with inhaled analgetic agents compared with other prehospital analgesic agents. Methods As part of an initiative from the Scandinavian Society of Anaesthesia and Intensive Care Medicine, we conducted a systematic review (PROSPERO CRD42018114399), applying the PRISMA guidelines, Grading of Recommendations Assessment, Development, and Evaluation (GRADE), and Cochrane methods, searching the Cochrane Library, Epistemonikos, Centre for Reviews and Dissemination, PubMed, and EMBASE databases (updated March 2024). Inclusion criteria were the use of inhaled analgesic agents in adult patients with acute pain in the prehospital emergency care setting. All steps were performed by minimum of two individual researchers. The primary outcome was pain reduction; secondary outcomes were speed of onset, duration of effect, and relevant AEs. Results We included seven studies (56,535 patients in total) that compared inhaled agents (methoxyflurane [MF] and nitrous oxide [N2O]) to other drugs or placebo. Study designs were randomized controlled trial (1; n = 60), randomized non-blinded study (1; n = 343), and randomized open-label study (1; n = 270). The remaining were prospective or retrospective observational studies. The evidence according to GRADE was of low or very low quality. No combined meta-analysis was possible. N2O may reduce pain compared to placebo, but not compared to intravenous (IV) paracetamol, and may be less effective compared to morphine and MF. MF may reduce pain compared to paracetamol, ketoprofen, tramadol, and fentanyl. Both agents may be associated with marked but primarily mild AEs. Conclusion We found low-quality evidence suggesting that both MF and N2O are safe and may have a role in the management of pain in the prehospital setting. There is low-quality evidence to support MF as a short-acting single analgesic or as a bridge to IV access and the administration of other analgesics. There may be occupational health issues regarding the prehospital use of N2O.

• Amer, Marwa; Møller, Morten Hylander; Alshahrani, Mohammed; Shehabi, Yahya; Arabi, Yaseen M. & Alshamsi, Fayez [Show all 23 contributors for this article] (2024). Ketamine Analgo-sedation for Mechanically Ventilated Critically Ill Adults: A Rapid Practice Guideline from the Saudi Critical Care Society and the Scandinavian Society of Anesthesiology and Intensive Care Medicine. Anesthesia and Analgesia. ISSN 0003-2999. doi: 10.1213/ANE.0000000000007173. Full text in Research Archive
• Rehn, Marius; Chew, Michelle S.; Kalliomaki, Maija; Olkkola, Klaus T.; Sigurðsson, Martin Ingi & Møller, Morten Hylander (2024). ESAIC focused guideline for the use of cardiac biomarkers in perioperative risk evaluation: Endorsement by the Scandinavian Society of Anaesthesiology and Intensive Care Medicine. Acta Anaesthesiologica Scandinavica. ISSN 0001-5172. doi: 10.1111/aas.14472. Full text in Research Archive
• Olsen, Ingrid Anette Hustad; Horn, Morten Andreas; Rehn, Marius; Taubøll, Erik & Hov, Maren Ranhoff (2024). Prehospital seizure management protocols need standardized guidelines. A descriptive study from Norway. Seizure. ISSN 1059-1311. 123, p. 92–96. doi: 10.1016/j.seizure.2024.10.002. Full text in Research Archive Show summary

  Background: Patients with convulsive seizures constitute a significant group in acute neurology. No common European clinical practice guidelines on prehospital seizure management exist, and today most patients are brought to hospital for seizure treatment, with great variation in which prehospital treatment is provided. Only 33 % of status epilepticus patients receive a benzodiazepine as first anti-seizure medication (ASM). The aim of this study is to assess the prehospital seizure control protocols in the Emergency Medical Services (EMS) in Norway, and compare these with current evidence for acute management. Method: We performed a descriptive analysis of the 18 regional EMS protocols in Norway and compared the findings with recent evidence on prehospital treatment. We analysed recommended drug and dosage, route of medication administration, number of additional rescue doses permitted, requirements for registration of type of seizures and seizure duration. Results: The protocols vary in terms of preferred medication, administration method, dosage and recommendations regarding first- and second-line therapies. 33 % of protocols explicitly define status epilepticus according to contemporary guidelines, and 16.7 % have an operational definition of when to administer benzodiazepines. All protocols showed variations in dosing and administration instructions and only 28 % had a clearly stated first line treatment. Conclusion: There are disparities in the prehospital seizure management protocols within the Norwegian healthcare system, a system comparable to other European countries. To improve seizure management there is a need for standardised guidelines for prehospital treatment.

• Carenzo, Luca; Calgaro, Giulio; Rehn, Marius; Perkins, Zane; Qasim, Zaffer A. & Gamberini, Lorenzo [Show all 7 contributors for this article] (2024). Contemporary management of traumatic cardiac arrest and peri-arrest states: a narrative review. Journal of Anesthesia, Analgesia and Critical Care. doi: 10.1186/s44158-024-00197-9. Full text in Research Archive Show summary

  Trauma is a leading cause of death and disability worldwide across all age groups, with traumatic cardiac arrest (TCA) presenting a significant economic and societal burden due to the loss of productive life years. Despite TCA’s high mortality rate, recent evidence indicates that survival with good and moderate neurological recovery is possible. Successful resuscitation in TCA depends on the immediate and simultaneous treatment of reversible causes according to pre-established algorithms. The HOTT protocol, addressing hypovolaemia, oxygenation (hypoxia), tension pneumothorax, and cardiac tamponade, forms the foundation of TCA management. Advanced interventions, such as resuscitative thoracotomy and resuscitative endovascular balloon occlusion of the aorta (REBOA), further enhance treatment. Contemporary approaches also consider metabolic factors (e.g. hyperkalaemia, calcium imbalances) and hemostatic resuscitation. This narrative review explores the advanced management of TCA and peri-arrest states, discussing the epidemiology and pathophysiology of peri-arrest and TCA. It integrates classic TCA management strategies with the latest evidence and practical applications.

• Bekkevold, Marit; Solvik-Olsen, Tone; Heyerdahl, Fridtjof; Lang, Astri Maria; Hagemo, Jostein Skjalg & Rehn, Marius (2024). Reporting interhospital neonatal intensive care transport: international five-step Delphi-based template. BMJ Paediatrics Open. 8(1), p. 1–7. doi: 10.1136/bmjpo-2023-002374. Full text in Research Archive Show summary

  Objective To develop a general and internationally applicable template of data variables for reporting interhospital neonatal intensive care transports. Design A five-step Delphi method. Setting A group of experts was guided through a formal consensus process using email. Subjects 12 experts in neonatal intensive care transports from Canada, Denmark, Norway, the UK and the USA. Four women and eight men. The experts were neonatologists, anaesthesiologists, intensive care nurse, anaesthetic nurse, medical leaders, researchers and a parent representative. Main outcome measures 37 data variables were included in the final template. Results Consensus was achieved on a template of 37 data variables with definitions. 30 variables to be registered for each transport and 7 for annual registration of the system of the transport service. 11 data variables under the category structure, 20 under process and 6 under outcome. Conclusions We developed a template with a set of data variables to be registered for neonatal intensive care transports. To register the same data will enable larger datasets and comparing services.

• Nordviste, Vegard; Rehn, Marius; Krüger, Andreas Jørstad & Brede, Jostein Rødseth (2024). Time difference between pad placement in single versus double external defibrillation: A live patient simulation model. Resuscitation Plus. 19. doi: 10.1016/j.resplu.2024.100741. Full text in Research Archive Show summary

  Background Out-of-hospital cardiac arrest (OHCA) cause significant patient morbidity and mortality. Double sequential external defibrillation (DSED) represents an alternative treatment for OHCA patients, but the use is currently reserved for patients in refractory ventricular fibrillation. However, OHCA patients may achieve return of spontaneous circulation earlier with the use of DSED as initial treatment. This study compares the necessary times needed to establish pad placement in DSED compared to normal pad placement in a live patient simulation model. Methods This study was an observational cohort study with ambulance personnel and live patient models. The procedure was performed on two patient categories, with BMI 20.9 (patient A) and BMI 32.8 (patient B). Two-member teams established two defibrillators ready for rhythm analysis. Time spent for standard and DSED procedure was registered in the same procedure. All team members performed the procedure on both patient categories. Results In total, 108 procedures were performed on both patient categories. Mean time to standard pad placement was 24.6 ± 3.3 s for patient A, and 27.4 ± 3.7 s for patients B. Mean time to DSED pad placement was 38.3 ± 7.0 s for patient A, and 41.3 ± 7.4 s for patient B. Mean difference in time needed for DSED versus standard pad placement was 13.7 ± 4.8 s for patient A, and 13.9 ± 4.6 s for patient B. There was no significant difference in time spent between the two patient categories (p = 0.725). Conclusion The necessary time to establish DSED versus standard defibrillation pad placement was short. This may support clinical studies on DSED as initial treatment for OHCA patients without risk of significant increase in time to first defibrillation.

• Amer, Marwa; Møller, Morten Hylander; Alshahrani, Mohammed; Shehabi, Yahya; Arabi, Yaseen M. & Alshamsi, Fayez [Show all 23 contributors for this article] (2024). Ketamine analgo-sedation for mechanically ventilated critically ill adults: A rapid practice guideline from the Saudi Critical Care Society and the Scandinavian Society of Anesthesiology and Intensive Care Medicine. Acta Anaesthesiologica Scandinavica. ISSN 0001-5172. 68, p. 1161–1178. doi: 10.1111/aas.14470. Full text in Research Archive
• Lie, Sole Lindvåg; Hisdal, Jonny; Rehn, Marius & Høiseth, Lars Øivind (2024). Effect of systemic vascular resistance on the agreement between stroke volume by noninvasive pulse wave analysis and Doppler ultrasound in healthy volunteers. PLOS ONE. 19(5). doi: 10.1371/journal.pone.0302159. Full text in Research Archive Show summary

  Background Stroke volume can be estimated beat-to-beat and non-invasively by pulse wave analysis (PWA). However, its reliability has been questioned during marked alterations in systemic vascular resistance (SVR). We studied the effect of SVR on the agreement between stroke volume by PWA and Doppler ultrasound during reductions in stroke volume in healthy volunteers. Methods In a previous study we simultaneously measured stroke volume by PWA (SVPWA) and suprasternal Doppler ultrasound (SVUS). We exposed 16 healthy volunteers to lower body negative pressure (LBNP) to reduce stroke volume in combination with isometric hand grip to elevate SVR. LBNP was increased by 20 mmHg every 6 minutes from 0 to 80 mmHg, or until hemodynamic decompensation. The agreement between SVPWA and SVUS was examined using Bland-Altman analysis with mixed regression. Within-subject limits of agreement (LOA) was calculated from the residual standard deviation. SVRUS was calculated from SVUS. We allowed for a sloped bias line by introducing the mean of the methods and SVRUS as explanatory variables to examine whether the agreement was dependent on the magnitude of stroke volume and SVRUS. Results Bias ± limits of agreement (LOA) was 27.0 ± 30.1 mL. The within-subject LOA was ±11.1 mL. The within-subject percentage error was 14.6%. The difference between methods decreased with higher means of the methods (-0.15 mL/mL, confidence interval (CI): -0.19 to -0.11, P<0.001). The difference between methods increased with higher SVRUS (0.60 mL/mmHg × min × L-1, 95% CI: 0.48 to 0.72, P<0.001). Conclusion PWA overestimated stroke volume compared to Doppler ultrasound during reductions in stroke volume and elevated SVR in healthy volunteers. The agreement between SVPWA and SVUS decreased during increases in SVR. This is relevant in settings where a high level of reliability is required.

• Brede, Jostein Rødseth; Skjærseth, Eivinn Årdal & Rehn, Marius (2024). Prehospital anaesthesiologists experience with cardiopulmonary resuscitation-induced consciousness in Norway – A national cross-sectional survey. Resuscitation Plus. 18. doi: 10.1016/j.resplu.2024.100591. Full text in Research Archive Show summary

  Background - During cardiopulmonary resuscitation (CPR) cerebral blood flow may be sufficient to restore some cerebral function, and CPR-induced consciousness (CPRIC) may occur. CPRIC includes signs of life such as gasping, breathing efforts, eye opening, movements of extremities or communication with the rescuers. There is a lack in evidence for prevalence, experience, and possible treatment strategies for CPRIC. This survey aimed to assess prehospital anaesthesiologists experience with CPRIC in Norway. Methods - A web-based cross-sectional survey. All physicians working at a Norwegian air ambulance, search-and-rescue base or physician-staffed rapid response car were invited to participate. Result - Out of 177 invited, 115 responded. All were anaesthesiologist, with mean 12.7 (SD 7.2) years of prehospital experience, and 25% had attended more than 200 out-of-hospital cardiac arrests (OHCA). CPRIC was known amongst most physicians prior to the survey and experienced by 91%. Mechanical compression device was used in 79% of cases. The CPRIC were CPR-interfering in 31% of cases. Next-of-kin reported the CPRIC as upsetting in 5% of cases. Medication and/or physical restraint were administered in 75% patients. For patients with CPRIC 50% answered that sedation was needed. If sedation should be provided, 62% answered that this should only be performed by a physician, while 25% answered that both ambulance crew and physicians could provide sedation. Fentanyl, ketamine, and midazolam were suggested as the most appropriate sedation agents. Conclusion - This nationwide survey indicates that CPRIC during OHCA are well known amongst prehospital anaesthesiologist in Norway. Most patients with CPRIC were treated with chest compression device. Most physicians recommend sedation of patients with CPRIC during resuscitation.

• Deodatus, J.A.; Kratz, M.A.; Steller, M.; Veeger, N.; Dercksen, B. & Lyon, R.M. [Show all 13 contributors for this article] (2024). Attributes of leadership skill development in high-performance pre-hospital medical teams: results of an international multi-service prospective study. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 32(1). doi: 10.1186/s13049-024-01221-1. Full text in Research Archive Show summary

  Backgrounds Team leadership skills of physicians working in high-performing medical teams are directly related to outcome. It is currently unclear how these skills can best be developed. Therefore, in this multi-national cross-sectional prospective study, we explored the development of these skills in relation to physician-, organization- and training characteristics of Helicopter Emergency Medicine Service (HEMS) physicians from services in Europe, the United States of America and Australia. Methods Physicians were asked to complete a survey regarding their HEMS service, training, and background as well as a full Leader Behavior Description Questionnaire (LBDQ). Primary outcomes were the 12 leadership subdomain scores as described in the LBDQ. Secondary outcome measures were the association of LBDQ subdomain scores with specific physician-, organization- or training characteristics and self-reported ways to improve leadership skills in HEMS physicians. Results In total, 120 HEMS physicians completed the questionnaire. Overall, leadership LBDQ subdomain scores were high (10 out of 12 subdomains exceeded 70% of the maximum score). Whereas physician characteristics such as experience or base-specialty were unrelated to leadership qualities, both organization- and training characteristics were important determinants of leadership skill development. Attention to leadership skills during service induction, ongoing leadership training, having standards in place to ensure (regular) scenario training and holding structured mission debriefs each correlated with multiple LBDQ subdomain scores. Conclusions Ongoing training of leadership skills should be stimulated and facilitated by organizations as it contributes to higher levels of proficiency, which may translate into a positive effect on patient outcomes. Trial registration Not applicable.

• Lie, Sole Lindvåg; Hisdal, Jonny; Rehn, Marius & Høiseth, Lars Øivind (2023). Hemodynamic effects of supplemental oxygen versus air in simulated blood loss in healthy volunteers: a randomized, controlled, double-blind, crossover trial. Intensive Care Medicine Experimental. 11(1). doi: 10.1186/s40635-023-00561-z. Full text in Research Archive Show summary

  Background Trauma patients frequently receive supplemental oxygen, but its hemodynamic effects in blood loss are poorly understood. We studied the effects of oxygen on the hemodynamic response and tolerance to simulated blood loss in healthy volunteers. Methods Fifteen healthy volunteers were exposed to simulated blood loss by lower body negative pressure (LBNP) on two separate visits at least 24 h apart. They were randomized to inhale 100% oxygen or medical air on visit 1, while inhaling the other on visit 2. To simulate progressive blood loss LBNP was increased every 3 min in levels of 10 mmHg from 0 to 80 mmHg or until hemodynamic decompensation. Oxygen and air were delivered on a reservoired face mask at 15 L/min. The effect of oxygen compared to air on the changes in cardiac output, stroke volume and middle cerebral artery blood velocity (MCAV) was examined with mixed regression to account for repeated measurements within subjects. The effect of oxygen compared to air on the tolerance to blood loss was measured as the time to hemodynamic decompensation in a shared frailty model. Cardiac output was the primary outcome variable. Results Oxygen had no statistically significant effect on the changes in cardiac output (0.031 L/min/LBNP level, 95% confidence interval (CI): − 0.015 to 0.077, P = 0.188), stroke volume (0.39 mL/LBNP level, 95% CI: − 0.39 to 1.2, P = 0.383), or MCAV (0.25 cm/s/LBNP level, 95% CI: − 0.11 to 0.61, P = 0.176). Four subjects exhibited hemodynamic decompensation when inhaling oxygen compared to 10 when inhaling air (proportional hazard ratio 0.24, 95% CI: 0.065 to 0.85, P = 0.027). Conclusions We found no effect of oxygen compared to air on the changes in cardiac output, stroke volume or MCAV during simulated blood loss in healthy volunteers. However, oxygen had a favorable effect on the tolerance to simulated blood loss with fewer hemodynamic decompensations. Our findings suggest that supplemental oxygen does not adversely affect the hemodynamic response to simulated blood loss. Trial registration This trial was registered in ClinicalTrials.gov (NCT05150418) December 9, 2021

• Chew, Michelle S.; Olkkola, Klaus T.; Kalliomäki, Maija-Liisa; Rehn, Marius; Sigurðsson, Martin Ingi & Møller, Morten Hylander (2023). ISTH guidelines for antithrombotic treatment in COVID-19: Endorsement by the Scandinavian Society of Anaesthesiology and Intensive Care Medicine. Acta Anaesthesiologica Scandinavica. ISSN 0001-5172. doi: 10.1111/aas.14259. Full text in Research Archive Show summary

  The Clinical Practice Committee of the Scandinavian Society of Anaesthesiology and Intensive Care Medicine endorses the ISTH guidelines for antithrombotic treatment in COVID-19. This evidence-based guideline serves as a useful decision aid for Nordic anaesthesiologists caring for patients with COVID-19.

• Brede, Jostein Rødseth & Rehn, Marius (2023). The end of balloons? Our take on the UK-REBOA trial. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. doi: 10.1186/s13049-023-01142-5. Full text in Research Archive Show summary

  Background Resuscitative endovascular balloon occlusion of the aorta (REBOA) is increasingly used. The recently published UK-REBOA trial aimed to investigate patients suffering haemorrhagic shock and randomized to standard care alone or REBOA as adjunct to standard care and concludes that REBOA may increase the mortality. Main body In this commentary we try to balance the discussion on use of REBOA and address limitations in the UK-REBOA trial that may have influenced the outcome of the study. Conclusion The situation is complex, and the patients are in extremis. In summary, we do not think this is the end of balloons.

• Hansen, Peter Martin; Mikkelsen, Søren; Alstrøm, Henrik; Damm-Hejmdal, Anders; Rehn, Marius & Berlac, Peter Anthony (2023). The Field’s mass shooting: emergency medical services response. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 31(1). doi: 10.1186/s13049-023-01140-7. Full text in Research Archive Show summary

  Background Major incidents (MI) happen infrequently in Scandinavia and mass shootings are even less frequently occurring. Case reports and research are called for, as literature is scarce. On 3rd July 2022, a mass shooting took place at the shopping mall Field’s in Copenhagen, Denmark. Three people were killed and seven injured by a gunman, firing a rifle inside the mall. A further 21 people suffered minor injuries during the evacuation of the mall. In this case report, we describe the emergency medical services (EMS) incident response and evaluate the EMS´ adherence to the MI management guidelines to identify possible areas of improvement. Case presentation Forty-eight EMS units including five Tactical Emergency Medical Service teams were dispatched to the incident. Four critically injured patients were taken to two trauma hospitals. The deceased patients were declared dead at the scene and remained there for the sake of the investigation. A total of 24 patients with less severe and minor injuries were treated at four different hospitals in connection with the attack. The ambulance resources were inherently limited in the initial phase of the MI, mandating improvisation in medical incident command. Though challenged, Command and Control, Safety, Communication, Assessment, Triage, Treatment, Transport (CSCATTT) principles were followed. Conclusions The EMS response generally adhered to national guidelines for MI. The activation of EMS and the hospital preparedness program was relevant. Important findings were communication shortcomings; inherent lack of readily available ambulance resources in the initial critical phase; uncertainty regarding the number of perpetrators; uncertainty regarding number of casualties and social media rumors that unnecessarily hampered and prolonged the response. The incident command had to use non-standard measures to mitigate potential challenges.

• Rehn, Marius; Heyerdahl, Fridtjof; Osbakk, Svein Are; Andresen, Åke Erling Lappen & Hagemo, Jostein Skjalg (2023). Challenges and Risks in Out-of-Hospital Transport of Patients During the Coronavirus Disease 2019 Pandemic. Air Medical Journal. ISSN 1067-991X. 42(3), p. 191–195. doi: 10.1016/j.amj.2023.02.002. Full text in Research Archive Show summary

  Objective: Norwegian critical care resources are regionalized making air ambulances transport of suspected or confirmed coronavirus disease 2019 (COVID-19)-positive patients a necessity. We prospectively observed pre- and interhospital transportation of patients with suspected or confirmed COVID-19 in our physician-manned emergency medical services. Methods: This was a prospective, observational quality assurance study of primary and secondary missions conducted by 2 Norwegian air ambulances during the COVID-19 pandemic. Results: Forty-one (24.1%) were primary missions, whereas 129 (75.9%) were interhospital transports. Most patients (158 [92.9%]) were transported with ground-based vehicles, and 12 (7.1%) were transported by rotor wing aircrafts. One hundred thirty-four of 170 patients (78.8%) were COVID-19 positive at the time of transportation. The median (interquartile range) fraction of inspired oxygen concentration was 0.60 (0.50-0.80), the positive end-expiratory pressure was 11 cm H2O (8-13.5 cm H2O), and the peak inspiratory pressure was 26 cm H2O (22-30 cm H2O). Some degree of elevated treatment challenge was reported in 157 (87.7%) transports, and in 139 (77.7%), the patient risk was considered elevated. The physician stated that some degree of elevated risk for the provider was elevated in 131 (73.2%) of the transports. Conclusion: The capacity of the physician-manned emergency medical services to safely transfer patients remains essential to maintain resilient critical care capacity, and the perceived elevated risks should be considered in capacity planning.

• Hansen, Peter Martin; Mikkelsen, Soren & Rehn, Marius (2023). Communication in Sudden-Onset Major Incidents: Patterns and Challenges - Scoping Review. Disaster Medicine and Public Health Preparedness. ISSN 1935-7893. 17(3). doi: 10.1017/dmp.2023.132. Full text in Research Archive Show summary

  Objective: To identify and describe patterns and challenges in communication in sudden-onset major incidents. Methods: Systematic scoping review according to Joanna Briggs Institute and PRISMA-ScR guidelines. Data sources included Cochrane Library, EMBASE, PubMed/MEDLINE, Scopus, SweMed+, Web of Science, and Google Scholar. Non-indexed literature was searched as well. The included literature went through data extraction and quality appraisal as per pre-registered protocol. Results: The scoping review comprised 32 papers from different sources. Communication breakdown was reported in 25 (78.1%) of the included papers. Inter-authority communication challenges were reported in 18 (56.3%) of the papers. System overload and incompatibility was described in 9 papers (28.1%). Study design was clearly described in 30 papers (93.8%). Conclusions: The pattern in major incident communication is reflected by frequent breakdowns with potential and actual consequences for patient survival and outcome. The challenges in communication are predominantly inter-authority communication, system overload and incompatibility, and insufficient pre-incident planning and guidelines.

• Rehn, Marius; Chew, Michelle; Kalliomäki, Maija-Liisa; Olkkola, Klaus T.; Sigurðsson, Martin Ingi & Møller, Morten Hylander (2023). Awake proning in patients with COVID-19-related hypoxemic acute respiratory failure: Endorsement by the Scandinavian Society of Anaesthesiology and Intensive Care Medicine. Acta Anaesthesiologica Scandinavica. ISSN 0001-5172. doi: 10.1111/aas.14367. Full text in Research Archive Show summary

  Abstract Background Awake proning in spontaneously breathing patients with hypoxemic acute respiratory failure was applied during the coronavirus disease 2019 (COVID‐19) pandemic to improve oxygenation while avoiding tracheal intubation. An updated systematic review and meta‐analysis on the topic was published. Methods The Clinical practice committee (CPC) of the Scandinavian Society of Anaesthesiology and Intensive Care Medicine (SSAI) assessed the clinical practice guideline “ Awake proning in patients with COVID‐19‐related hypoxemic acute respiratory failure: A rapid practice guideline ” for possible endorsement. The Appraisal of Guidelines for REsearch and Evaluation (AGREE) II tool was used. Results Four out of six SSAI CPC members completed the appraisal. The individual domain totals were: Scope and Purpose 90%; Stakeholder Involvement 89%; Rigour of Development 74%; Clarity of Presentation 85%; Applicability 75%; Editorial Independence 98%; Overall Assessment 79 %. Conclusion The SSAI CPC endorses the clinical practice guideline “ Awake proning in patients with COVID‐19‐related hypoxemic acute respiratory failure: A rapid practice guideline ”. This guideline serves as a useful decision aid for clinicians caring for critically ill patients with COVID‐19‐related acute hypoxemic respiratory failure and can be used to provide guidance on use of prone positioning in this group of patients.

• Møller, Morten Hylander; Sigurðsson, Martin Ingi; Olkkola, Klaus T.; Rehn, Marius; Yli-Hankala, Arvi & Chew, Michelle S. (2022). Transfusion strategies in bleeding critically ill adults: A clinical practice guideline from the European Society of Intensive Care Medicine: Endorsement by the Scandinavian Society of Anaesthesiology and Intensive Care Medicine. Acta Anaesthesiologica Scandinavica. ISSN 0001-5172. p. 1–2. doi: 10.1111/aas.14047. Full text in Research Archive
• Avest, Avest ter; Carenzo, L.; Lendrum, R.A.; Christian, M.D.; Lyon, R.M. & Coniglio, C. [Show all 9 contributors for this article] (2022). Advanced interventions in the pre-hospital resuscitation of patients with non-compressible haemorrhage after penetrating injuries. Critical Care. ISSN 1364-8535. 26(1). doi: 10.1186/s13054-022-04052-7. Full text in Research Archive Show summary

  Early haemorrhage control and minimizing the time to definitive care have long been the cornerstones of therapy for patients exsanguinating from non-compressible haemorrhage (NCH) after penetrating injuries, as only basic treatment could be provided on scene. However, more recently, advanced on-scene treatments such as the transfusion of blood products, resuscitative thoracotomy (RT) and resuscitative endovascular balloon occlusion of the aorta (REBOA) have become available in a small number of pre-hospital critical care teams. Although these advanced techniques are included in the current traumatic cardiac arrest algorithm of the European Resuscitation Council (ERC), published in 2021, clear guidance on the practical application of these techniques in the pre-hospital setting is scarce. This paper provides a scoping review on how these advanced techniques can be incorporated into practice for the resuscitation of patients exsanguinating from NCH after penetrating injuries, based on available literature and the collective experience of several helicopter emergency medical services (HEMS) across Europe who have introduced these advanced resuscitation interventions into routine practice.

• Møller, Morten Hylander; Sigurðsson, Martin Ingi; Olkkola, Klaus T.; Rehn, Marius; Yli-Hankala, Arvi & Chew, Michelle S. (2022). Regional anaesthesia in patients on antithrombotic drugs – a joint ESAIC/ESRA guideline: Endorsement by the Scandinavian Society of Anaesthesiology and Intensive Care Medicine. Acta Anaesthesiologica Scandinavica. ISSN 0001-5172. 66(7), p. 887–889. doi: 10.1111/aas.14093. Full text in Research Archive Show summary

  The Clinical Practice Committee of the Scandinavian Society of Anaesthesiology and Intensive Care Medicine endorses the clinical practice guideline Regional anaesthesia in patients on antithrombotic drugs – a joint ESAIC/ESRA guideline. This clinical practice guideline serves as a useful decision aid for Nordic anaesthesiologists providing regional anaesthesia to adult patients on antithrombotic drugs.

• Rehn, Marius; Chew, Michelle S.; Olkkola, Klaus T.; Sigurðsson, Martin Ingi; Yli-Hankala, Arvi & Møller, Morten Hylander (2022). Surviving sepsis campaign: International guidelines for management of sepsis and septic shock in adults 2021 - endorsement by the Scandinavian society of anaesthesiology and intensive care medicine. Acta Anaesthesiologica Scandinavica. ISSN 0001-5172. 66(5), p. 634–635. doi: 10.1111/aas.14045. Full text in Research Archive Show summary

  The Clinical Practice Committee of the Scandinavian Society of Anaesthesiology and Intensive Care Medicine endorses the clinical practice guideline Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. The guideline serves as a useful bedside decision aid for clinicians managing adults with suspected and confirmed septic shock and sepsis-associated organ dysfunction. BACKGROUND Sepsis and septic shock remain a leading global cause of mortality and morbidity.1-3 Anaesthesiologists and intensivists are regularly involved in the identification, resuscitation and management of adults with sepsis and septic shock. In November 2021, the Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021 was published.4 The Clinical Practice Committee (CPC) of the Scandinavian Society of Anaesthesiology and Intensive Care Medicine (SSAI) decided to appraise this guideline for possible endorsement to guide Scandinavian anaesthesiologists and intensivists in the identification, resuscitation, and management of adults with sepsis and septic shock. METHODS The SSAI CPC assessed the guideline using the Appraisal of Guidelines for REsearch and Evaluation (AGREE) II tool,5 as per the outlined process for endorsement of non-SSAI guidelines.6 RESULTS Five SSAI CPC members completed the appraisal. One member co-authored the guideline and was excluded from the evaluation, as per the SSAI endorsement process.6 The individual domain totals were: 1) scope and purpose 89%; 2) stakeholder involvement 92%; 3) rigor of development 81%; 4) clarity of presentation 89%; 5) applicability 73%; 6) editorial independence 85%; 7) overall assessment 87% (Figure 1).

• Friesgaard, Kristian Dahl; Vist, Gunn Elisabeth; Hyldmo, Per Kristian; Raatiniemi, Lasse; Kurola, Jouni & Larsen, Robert [Show all 11 contributors for this article] (2022). Opioids for Treatment of Pre-hospital Acute Pain: A Systematic Review. Pain and Therapy. ISSN 2193-8237. 11, p. 17–36. doi: 10.1007/s40122-021-00346-w. Full text in Research Archive Show summary

  ntroduction Acute pain is a frequent symptom among patients in the pre-hospital setting, and opioids are the most widely used class of drugs for the relief of pain in these patients. However, the evidence base for opioid use in this setting appears to be weak. The aim of this systematic review was to explore the efficacy and safety of opioid analgesics in the pre-hospital setting and to assess potential alternative therapies. Methods The PubMed, EMBASE, Cochrane Library, Centre for Reviews and Dissemination, Scopus, and Epistemonikos databases were searched for studies investigating adult patients with acute pain prior to their arrival at hospital. Outcomes on efficacy and safety were assessed. Risk of bias for each included study was assessed according to the Cochrane approach, and confidence in the evidence was assessed using the GRADE method. Results A total of 3453 papers were screened, of which the full text of 125 was assessed. Twelve studies were ultimately included in this systematic review. Meta-analysis was not undertaken due to substantial clinical heterogeneity among the included studies. Several studies had high risk of bias resulting in low or very low quality of evidence for most of the outcomes. No pre-hospital studies compared opioids with placebo, and no studies assessed the risk of opioid administration for subgroups of frail patients. The competency level of the attending healthcare provider did not seem to affect the efficacy or safety of opioids in two observational studies of very low quality. Intranasal opioids had a similar effect and safety profile as intravenous opioids. Moderate quality evidence supported a similar efficacy and safety of synthetic opioid compared to morphine. Conclusions Available evidence for pre-hospital opioid administration to relieve acute pain is scarce and the overall quality of evidence is low. Intravenous administration of synthetic, fast-acting opioids may be as effective and safe as intravenous administration of morphine. More controlled studies are needed on alternative routes for opioid administration and pre-hospital pain management for potentially more frail patient subgroups.

• Møller, Morten H.; Chew, Michelle S.; Olkkola, Klaus T.; Rehn, Marius; Yli-Hankala, Arvi & Sigurðsson, Martin I. (2022). Therapeutics and COVID-19—A living WHO guideline: Endorsement by the Scandinavian Society of Anaesthesiology and Intensive Care Medicine. Acta Anaesthesiologica Scandinavica. ISSN 0001-5172. 66(5), p. 636–637. doi: 10.1111/aas.14046. Full text in Research Archive
• Samdal, Martin; Thorsen, Kjetil; Græsli, Ola; Sandberg, Mårten & Rehn, Marius (2021). Dispatch accuracy of physician-staffed emergency medical services in trauma care in south-east Norway: a retrospective observational study. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 29(1). doi: 10.1186/s13049-021-00982-3. Full text in Research Archive Show summary

  Background Selection of incidents and accurate identification of patients that require assistance from physician-staffed emergency medical services (P-EMS) remain essential. We aimed to evaluate P-EMS availability, the underlying criteria for dispatch, and the corresponding dispatch accuracy of trauma care in south-east Norway in 2015, to identify areas for improvement. Methods Pre-hospital data from emergency medical coordination centres and P-EMS medical databases were linked with data from the Norwegian Trauma Registry (NTR). Based on a set of conditions (injury severity, interventions performed, level of consciousness, incident category), trauma incidents were defined as complex, warranting P-EMS assistance, or non-complex. Incident complexity and P-EMS involvement were the main determinants when assessing the triage accuracy. Undertriage was adjusted for P-EMS availability and response and transport times. Results Among 19,028 trauma incidents, P-EMS were involved in 2506 (13.2%). The range of overtriage was 74–80% and the range of undertriage was 20–32%. P-EMS readiness in the event of complex incidents ranged from 58 to 70%. The most frequent dispatch criterion was “Police/fire brigade request immediate response” recorded in 4321 (22.7%) of the incidents. Criteria from the groups “Accidents” and “Road traffic accidents” were recorded in 10,875 (57.2%) incidents, and criteria from the groups “Transport reservations” and “Unidentified problem” in 6025 (31,7%) incidents. Among 4916 patient pathways in the NTR, 681 (13.9%) could not be matched with pre-hospital data records. Conclusions Both P-EMS availability and dispatch accuracy remain suboptimal in trauma care in south-east Norway. Dispatch criteria are too vague to facilitate accurate P-EMS dispatch, and pre-hospital data is inconsistent and insufficient to provide basic data for scientific research. Future dispatch criteria should focus on the care aspect of P-EMS. Better tools for both dispatch and incident handling for the emergency medical coordination centres are essential. In general, coordination, standardisation, and integration of existing data systems should enhance the quality of trauma care and increase patient safety.

• Yli-Hankala, Arvi; Chew, Michelle S.; Olkkola, Klaus T.; Rehn, Marius; Sverrisson, Kristinn Ö. & Møller, Morten Hylander (2021). Clinical practice guideline on spinal stabilisation of adult trauma patients: Endorsement by the Scandinavian Society of Anaesthesiology and Intensive Care Medicine. Acta Anaesthesiologica Scandinavica. ISSN 0001-5172. p. 1–2. doi: 10.1111/aas.13933. Full text in Research Archive
• Crewdson, Kate; Heywoth, Ainsley; Rehn, Marius; Sadek, Samy & Lockey, David (2021). Apnoeic oxygenation for emergency anaesthesia of pre-hospital trauma patients. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 29(1), p. 1–7. doi: 10.1186/s13049-020-00817-7. Full text in Research Archive Show summary

  Background Efficient and timely airway management is universally recognised as a priority for major trauma patients, a proportion of whom require emergency intubation in the pre-hospital setting. Adverse events occur more commonly in emergency airway management, and hypoxia is relatively frequent. The aim of this study was to establish whether passive apnoeic oxygenation was effective in reducing the incidence of desaturation during pre-hospital emergency anaesthesia. Methods A prospective before-after study was performed to compare patients receiving standard care and those receiving additional oxygen via nasal prongs. The primary endpoint was median oxygen saturation in the peri-rapid sequence induction period, (2 minutes pre-intubation to 2 minutes post-intubation) for all patients. Secondary endpoints included the incidence of hypoxia in predetermined subgroups. Results Of 725 patients included; 188 patients received standard treatment and 537 received the intervention. The overall incidence of hypoxia (first recorded SpO2 < 90%) was 16.7%; 10.9% had SpO2 < 85%. 98/725 patients (13.5%) were hypoxic post-intubation (final SpO2 < 90% 10 minutes post-intubation). Median SpO2 was 100% vs. 99% for the standard vs. intervention group. There was a statistically significant benefit from apnoeic oxygenation in reducing the frequency of peri-intubation hypoxia (SpO2 < =90%) for patients with initial SpO2 > 95%, p = 0.0001. The other significant benefit was observed in the recovery phase for patients with severe hypoxia prior to intubation. Conclusion Apnoeic oxygenation did not influence peri-intubation oxygen saturations, but it did reduce the frequency and duration of hypoxia in the post-intubation period. Given that apnoeic oxygenation is a simple low-cost intervention with a low complication rate, and that hypoxia can be detrimental to outcome, application of nasal cannulas during the drug-induced phase of emergency intubation may benefit a subset of patients undergoing emergency anaesthesia.

• Hansen, Peter Martin; Jepsen, Søren Bruun; Mikkelsen, Søren & Rehn, Marius (2021). The Great Belt train accident: the emergency medical services response. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 29(1). doi: 10.1186/s13049-021-00954-7. Full text in Research Archive Show summary

  Background Major incidents (MI) are rare occurrences in Scandinavia. Literature depicting Scandinavian MI management is scarce and case reports and research is called for. In 2019, a trailer falling off a freight train struck a passing high-speed train on the Great Belt Bridge in Denmark, killing eight people instantly and injuring fifteen people. We aim to describe the emergency medical services (EMS) response to this MI and evaluate adherence to guidelines to identify areas of improvement for future MI management. Case presentation Nineteen EMS units were dispatched to the incident site. Ambulances transported fifteen patients to a trauma centre after evacuation. Deceased patients were pronounced life-extinct on-scene. Radio communication was partly compromised, since 38.9% of the radio shifts were not according to the planned radio grid and presented a potential threat to patient outcome and personnel safety. Access to the incident site was challenging and delayed due to traffic congestion and safety issues. Conclusion Despite harsh weather conditions and complex logistics, the availability of EMS units was sufficient and patient treatment and evacuation was uncomplicated. Triage was relevant, but at the physicians’ discretion. Important findings were communication challenges and the consequences of difficult access to the incident site. There is a need for an expansion of capacity in formal education in MI management in Denmark.

• Mæhlen, Jens Otto; Mikalsen, Roger; Heimdal, Hans Julius; Rehn, Marius; Hagemo, Jostein Skjalg & Ottestad, William Arne (2021). Pre-hospital critical care management of severe hypoxemia in victims of Covid-19: a case series. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 29, p. 1–5. doi: 10.1186/s13049-021-00831-3. Full text in Research Archive Show summary

  Objective Despite critical hypoxemia, Covid-19 patients may present without proportional signs of respiratory distress. We report three patients with critical respiratory failure due to Covid-19, in which all presented with severe hypoxemia refractory to supplemental oxygen therapy. We discuss possible strategies for ventilatory support in the emergency pre-hospital setting, and point out some pitfalls regarding the management of these patients. Guidelines for pre-hospital care of critically ill Covid-19 patients cannot be established based on the current evidence base, and we have to apply our understanding of respiratory physiology and mechanics in order to optimize respiratory support. Methods Three cases with similar clinical presentation were identified within the Norwegian national helicopter emergency medical service (HEMS) system. The HEMS units are manned by a consultant anaesthesiologist. Patient’s next of kin and the Regional committee for medical and health research ethics approved the publication of this report. Conclusion Patients with Covid-19 and severe hypoxemia may pose a considerable challenge for the pre-hospital emergency medical services. Intubation may be associated with a high risk of complications in these patients and should be carried out with diligence when considered necessary. The following interventions are worth considering in Covid-19 patients with refractory hypoxemia before proceeding to intubation. First, administering oxygen via a tight fitting BVM with an oxygen flow rate that exceeds the patient’s ventilatory minute volume. Second, applying continuous positive airway pressure, while simultaneously maintaining a high FiO2. Finally, assuming the patient is cooperative, repositioning to prone position.

• Rehn, Marius; Chew, Michelle S.; Olkkola, Klaus T.; Sigurðsson, Martin Ingi; Yli-Hankala, Arvi & Møller, Morten Hylander (2021). Clinical practice guideline on the management of septic shock and sepsis-associated organ dysfunction in children: Endorsement by the Scandinavian Society of Anaesthesiology and Intensive Care Medicine. Acta Anaesthesiologica Scandinavica. ISSN 0001-5172. p. 1–2. doi: 10.1111/aas.13958. Full text in Research Archive
• Brede, Jostein Rødseth; Skulberg, Arne Kristian; Rehn, Marius; Thorsen, Kjetil; Klepstad, Pål & Tylleskär, Ida [Show all 11 contributors for this article] (2021). REBOARREST, resuscitative endovascular balloon occlusion of the aorta in non-traumatic out-of-hospital cardiac arrest: a study protocol for a randomised, parallel group, clinical multicentre trial. Trials. 22(1), p. 1–9. doi: 10.1186/s13063-021-05477-1. Full text in Research Archive Show summary

  Background: Survival after out-of-hospital cardiac arrest (OHCA) is poor and dependent on high-quality cardiopulmonary resuscitation. Resuscitative endovascular balloon occlusion of the aorta (REBOA) may be advantageous in non-traumatic OHCA due to the potential benefit of redistributing the cardiac output to organs proximal to the aortic occlusion. This theory is supported by data from both preclinical studies and human case reports. Methods: This multicentre trial will enrol 200 adult patients, who will be randomised in a 1:1 ratio to either a control group that receives advanced cardiovascular life support (ACLS) or an intervention group that receives ACLS and REBOA. The primary endpoint will be the proportion of patients who achieve return of spontaneous circulation with a duration of at least 20 min. The secondary objectives of this trial are to measure the proportion of patients surviving to 30 days with good neurological status, to describe the haemodynamic physiology of aortic occlusion during ACLS, and to document adverse events. Discussion: Results from this study will assess the efficacy and safety of REBOA as an adjunctive treatment for nontraumatic OHCA. This novel use of REBOA may contribute to improve treatment for this patient cohort. Trial registration: The trial is approved by the Regional Committee for Medical and Health Research Ethics in Norway (reference 152504) and is registered at ClinicalTrials.gov (reference NCT04596514) and as Universal Trial Number WHO: U1111-1253-0322.

• Tønsager, Kristin; Rehn, Marius; Krüger, Andreas; Røislien, Jo & Ringdal, Kjetil G. (2020). Assignment of pre-event ASA physical status classification by pre-hospital physicians: A prospective inter-rater reliability study. BMC Anesthesiology. 20(1). doi: 10.1186/s12871-020-01083-x. Full text in Research Archive Show summary

  Background - Individualized treatment is a common principle in hospitals. Treatment decisions are made based on the patient’s condition, including comorbidities. This principle is equally relevant out-of-hospital. Furthermore, comorbidity is an important risk-adjustment factor when evaluating pre-hospital interventions and may aid therapeutic decisions and triage. The American Society of Anesthesiologists Physical Status (ASA-PS) classification system is included in templates for reporting data in physician-staffed pre-hospital emergency medical services (p-EMS) but whether an adequate full pre-event ASA-PS can be assessed by pre-hospital physicians remains unknown. We aimed to explore whether pre-hospital physicians can score an adequate pre-event ASA-PS with the information available on-scene. Methods - The study was an inter-rater reliability study consisting of two steps. Pre-event ASA-PS scores made by pre- and in-hospital physicians were compared. Pre-hospital physicians did not have access to patient records and scores were based on information obtainable on-scene. In-hospital physicians used the complete patient record (Step 1). To assess inter-rater reliability between pre- and in-hospital physicians when given equal amounts of information, pre-hospital physicians also assigned pre-event ASA-PS for 20 of the included patients by using the complete patient records (Step 2). Inter-rater reliability was analyzed using quadratic weighted Cohen’s kappa (κw). Results - For most scores (82%) inter-rater reliability between pre-and in-hospital physicians were moderate to substantial (κw 0,47-0,89). Inter-rater reliability was higher among the in-hospital physicians (κw 0,77 to 0.85). When all physicians had access to the same information, κw increased (κw 0,65 to 0,93). Conclusions - Pre-hospital physicians can score an adequate pre-event ASA-PS on-scene for most patients. To further increase inter-rater reliability, we recommend access to the full patient journal on-scene. We recommend application of the full ASA-PS classification system for reporting of comorbidity in p-EMS.

• Tønsager, Kristin; Krüger, Andreas; Ringdal, Kjetil G. & Rehn, Marius (2020). Template for documenting and reporting data in physician-staffed pre-hospital services: a consensus-based update. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 28. doi: 10.1186/s13049-020-0716-1. Full text in Research Archive Show summary

  Background: Physician-staffed emergency medical services (p-EMS) are resource demanding, and research is needed to evaluate any potential effects of p-EMS. Templates, designed through expert agreement, are valuable and feasible, but they need to be updated on a regular basis due to developments in available equipment and treatment options. In 2011, a consensus-based template documenting and reporting data in p-EMS was published. We aimed to revise and update the template for documenting and reporting in p-EMS. Methods: A Delphi method was applied to achieve a consensus from a panel of selected European experts. The experts were blinded to each other until a consensus was reached, and all responses were anonymized. The experts were asked to propose variables within five predefined sections. There was also an optional sixth section for variables that did not fit into the pre-defined sections. Experts were asked to review and rate all variables from 1 (totally disagree) to 5 (totally agree) based on relevance, and consensus was defined as variables rated ≥4 by more than 70% of the experts. Results: Eleven experts participated. The experts generated 194 unique variables in the first round. After five rounds, a consensus was reached. The updated dataset was an expanded version of the original dataset and the template was expanded from 45 to 73 main variables. The experts approved the final version of the template. Conclusions: Using a Delphi method, we have updated the template for documenting and reporting in p-EMS. We recommend implementing the dataset for standard reporting in p-EMS.

• Tønsager, Kristin; Krüger, Andreas; Ringdal, Kjetil G. & Rehn, Marius (2020). Data quality of Glasgow Coma Scale and Systolic Blood Pressure in scientific studies involving physician-staffed emergency medical services: Systematic review. Acta Anaesthesiologica Scandinavica. ISSN 0001-5172. 64(7), p. 888–909. doi: 10.1111/aas.13596. Full text in Research Archive Show summary

  BACKGROUND: Emergency physicians on-scene provide highly specialized care to severely sick or injured patients. High-quality research relies on the quality of data, but no commonly accepted definition of EMS data quality exits. Glasgow Coma Score (GCS) and Systolic Blood Pressure (SBP) are core physiological variables, but little is known about the quality of these data when reported in p-EMS research. This systematic review aims to describe the quality of pre-hospital reporting of GCS and SBP data in studies where emergency physicians are present on-scene. METHODS: A systematic literature search was performed using CINAHL, Cochrane, Embase, Medline, Norart, Scopus, SweMed + and Web of Science, in accordance with the PRISMA guidelines. Reported data on accuracy of reporting, completeness and capture were extracted to describe the quality of documentation of GCS and SBP. External and internal validity assessment was performed by extracting a set of predefined variables. RESULTS: We included 137 articles describing data collection for GCS, SBP or both. Most studies (81%) were conducted in Europe and 59% of studies reported trauma cases. Reporting of GCS and SBP data were not uniform and may be improved to enable comparisons. Of the predefined external and internal validity data items, 26%-45% of data were possible to extract from the included papers. CONCLUSIONS: Reporting of GCS and SBP is variable in scientific papers. We recommend standardized reporting to enable comparisons of p-EMS.

• Sandberg, Mårten; Hyldmo, Per Kristian; Kongstad, Poul; Friesgaard, Kristian D.; Raatiniemi, Lasse & Larsen, Robert [Show all 11 contributors for this article] (2020). Ketamine for the treatment of prehospital acute pain: a systematic review of benefit and harm. BMJ Open. 10(11). doi: 10.1136/bmjopen-2020-038134. Full text in Research Archive Show summary

  Background Few publications have addressed prehospital use of ketamine in analgesic doses. We aimed to assess the effect and safety profile of ketamine compared with other analgesic drugs (or no drug) in adult prehospital patients with acute pain. Methods A systematic review of clinical trials assessing prehospital administration of ketamine in analgesic doses compared with other analgesic drugs or no analgesic treatment in adults. We searched PubMed, EMBASE, Cochrane Library and Epistemonikos from inception until 15 February 2020, including relevant articles in English and Nordic languages. We used the Cochrane and Grading of Recommendations Assessment, Development and Evaluation methodologies and exclusively assessed patient-centred outcomes. Two independent authors screened trials for eligibility, extracted data and assessed risk of bias. Results We included eight studies (2760 patients). Ketamine was compared with various opioids given alone, and intranasal ketamine given with nitrous oxide was compared with nitrous oxide given alone. Four randomised controlled trials (RCTs) and one cluster randomised trial included 699 patients. One prospective cohort included 27 patients and two retrospective cohorts included 2034 patients. Five of the eight studies had high risks of bias. Pain score with ketamine is probably lower than after opioids as demonstrated in a cluster-RCT (308 patients) and a retrospective cohort (158 patients) study, Δvisual analogue scale −0.4 (−0.8 to 0.0) and Δnumeric pain rating scale −3.0 (−3.86 to −2.14), respectively. Ketamine probably leads to less nausea and vomiting (risk ratio (RR) 0.24 (0.11 to 0.52)) but more agitation (RR 7.81 (1.85 to 33)) than opioids. Conclusions This systematic literature review finds that ketamine probably reduces pain more than opioids and with less nausea and vomiting but higher risk of agitation. Risk of bias in included studies is high.

• Brede, Jostein Rødseth; Kramer-Johansen, Jo & Rehn, Marius (2020). A needs assessment of resuscitative endovascular balloon occlusion of the aorta (REBOA) in non-traumatic out-of-hospital cardiac arrest in Norway. BMC Emergency Medicine. 20(28). doi: 10.1186/s12873-020-00324-z. Full text in Research Archive Show summary

  Introduction: Out of hospital cardiac arrest (OHCA) carries an 86% mortality rate in Norway. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a potential adjunct in management of non-traumatic cardiac arrest and is feasible in pre-hospital setting without compromising standard cardiopulmonary resuscitation (CPR). However, number of patients potentially eligible for REBOA remain unknown. In preparation for a clinical trial to investigate any benefit of pre-hospital REBOA, we sought to assess the need for REBOA in Norway as an adjunct treatment in OHCA. Methods: Retrospective observational cohort study of data from the Norwegian Cardiac Arrest Registry in the 3- year period 2016–2018. We identified number of patients potentially eligible for pre-hospital REBOA during CPR, defined by suspected non-traumatic origin, age 18–75 years, witnessed arrest, ambulance response time less than 15 min, treated by ambulance personnel and resuscitation effort over 30 min. Results: In the 3-year period, ambulance personnel resuscitated 8339 cases. Of these, a group of 720 patients (8.6%) were eligible for REBOA. Only 18% in this group achieved return of spontaneous circulation and 7% survived for 30 days or more. Conclusion: This national registry data analysis constitutes a needs assessment of REBOA in OHCA. We found that each year approximately 240 patients, or nearly 9% of ambulance treated OHCA, in Norway is potentially eligible for pre-hospital REBOA as an adjunct treatment to standard resuscitation. This needs assessment suggests that there is sufficient patient population in Norway to study REBOA as an adjunct treatment in OHCA.

• Johnsen, Anne Siri; Samdal, Martin; Sollid, Stephen J. M. & Rehn, Marius (2020). Major incident management by helicopter emergency medical services in south-east Norway from 2000 to 2016: Retrospective cohort study. Acta Anaesthesiologica Scandinavica. ISSN 0001-5172. 64(7), p. 1014–1020. doi: 10.1111/aas.13583. Full text in Research Archive Show summary

  Background Helicopter emergency medical services (HEMS) and search and rescue helicopters (SAR) aim to bring specialized personnel to major incidents and transport patients to definite care, but their operational pattern remains poorly described. We aim to describe the use of HEMS and SAR in major incidents in Norway and investigate the feasibility of retrospectively collecting uniform data from incident reports. Methods We searched HEMS medical databases from three HEMS and one SAR base in south‐east Norway for the written reports of incidents from 2000 to 2016. After incidents were included through consensus in the author group, we collected data as described in majorincidentreporting.org and a previous cross‐sectional study and rated availability of the variables. Results From a total of 31 803 missions, we identified 50 (0.16%) major incidents with HEMS/SAR involvement where road traffic accidents were the most common type of incident (n = 28, 56%), and rural area was the most prevalent location (n = 35, 70%). Inter‐agency cooperation was common and HEMS contributed most often with treatment and transport. The majority of information was found in the free‐text area in the medical records hereby increasing the risk for rater variability. Conclusion Major incidents are rare in Norway. HEMS and SAR play an important role in incident logistics, cooperation with other agencies, treatment and transport of patients and should be included in major incident plans. Retrospective data collection is challenging as data variables are not systematically integrated into the database. Future research should focus on systematic data gathering and a system for sharing lessons learned.

• Raatiniemi, Lasse; Magnússon, Vidar; Hyldmo, Per Kristian; Friesgaard, Kristian D.; Kongstad, Poul & Kurola, Jouni [Show all 11 contributors for this article] (2020). Femoral nerve blocks for the treatment of acute pre-hospital pain: A systematic review with meta-analysis. Acta Anaesthesiologica Scandinavica. ISSN 0001-5172. 64(8), p. 1038–1047. doi: 10.1111/aas.13600. Full text in Research Archive Show summary

  Background Pain management is one of the most important interventions in the emergency medical services. The femoral nerve block (FNB) is, among other things, indicated for pre- and post-operative pain management for patients with femoral fractures but its role in the pre-hospital setting has not been determined. The aim of this review was to assess the effect and safety of the FNB in comparison to other forms of analgesia (or no treatment) for managing acute lower extremity pain in adult patients in the pre-hospital setting. Methods A systematic review (PROSPERO registration (CRD42018114399)) was conducted. The Cochrane and GRADE methods were used to assess outcomes. Two authors independently reviewed each study for eligibility, extracted the data and performed risk of bias assessments. Results Four studies with a total of 252 patients were included. Two RCTs (114 patients) showed that FNB may reduce pain more effectively than metamizole (mean difference 32 mm on a 100 mm VAS (95% CI 24 to 40)). One RCT (48 patients) compared the FNB with lidocaine and magnesium sulphate to FNB with lidocaine alone and was only included here for information regarding adverse effects. One case series included 90 patients. Few adverse events were reported in the included studies. The certainty of evidence was very low. We found no studies comparing FNB to inhaled analgesics, opioids or ketamine. Conclusions Evidence regarding the effectiveness and adverse effects of pre-hospital FNB is limited. Studies comparing pre-hospital FNB to inhaled analgesics, opioids or ketamine are lacking.

• Rehn, Marius; Chew, Michelle S.; Olkkola, Klaus T.; Sverrison, Kristinn Ö.; Yli-Hankala, Arvi & Møller, Morten Hylander (2019). Clinical practice guideline on atraumatic (pencil-point) vs conventional needles for lumbar puncture: Endorsement by the Scandinavian Society of Anaesthesiology and Intensive Care Medicine. Acta Anaesthesiologica Scandinavica. ISSN 0001-5172. 63, p. 438–439. doi: 10.1111/aas.13312. Full text in Research Archive
• Tønsager, Kristin; Rehn, Marius; Ringdal, Kjetil G.; Lossius, Hans Morten; Virkkunen, Ilkka & Østerås, Øyvind [Show all 8 contributors for this article] (2019). Collecting core data in physician-staffed pre-hospital helicopter emergency medical services using a consensus-based template: international multicentre feasibility study in Finland and Norway. BMC Health Services Research. 19. doi: 10.1186/s12913-019-3976-6. Full text in Research Archive Show summary

  Background - Comparison of services and identification of factors important for favourable patient outcomes in emergency medical services (EMS) is challenging due to different organization and quality of data. The purpose of the present study was to evaluate the feasibility of physician-staffed EMS (p-EMS) to collect patient and system level data by using a consensus-based template. Methods - The study was an international multicentre observational study. Data were collected according to a template for uniform reporting of data from p-EMS using two different data collection methods; a standard and a focused data collection method. For the standard data collection, data were extracted retrospectively for one year from all FinnHEMS bases and for the focused data collection, data were collected prospectively for six weeks from four selected Norwegian p-EMS bases. Completeness rates for the two data collection methods were then compared and factors affecting completeness rates and template feasibility were evaluated. Standard Chi-Square, Fisher’s Exact Test and Mann-Whitney U Test were used for group comparison of categorical and continuous data, respectively, and Kolomogorov-Smirnov test for comparison of distributional properties. Results - All missions with patient encounters were included, leaving 4437 Finnish and 128 Norwegian missions eligible for analysis. Variable completeness rates indicated that physiological variables were least documented. Information on pain and respiratory rate were the most frequently missing variables with a standard data collection method and systolic blood pressure was the most missing variable with a focused data collection method. Completeness rates were similar or higher when patients were considered severely ill or injured but were lower for missions with short patient encounter. When a focused data collection method was used, completeness rates were higher compared to a standard data collection method. Conclusions - We found that a focused data collection method increased data capture compared to a standard data collection method. The concept of using a template for documentation of p-EMS data is feasible in physician-staffed services in Finland and Norway. The greatest deficiencies in completeness rates were evident for physiological parameters. Short missions were associated with lower completeness rates whereas severe illness or injury did not result in reduced data capture.

• Chew, Michelle S.; Rehn, Marius; Olkkola, Klaus T.; Sverrisson, Kristinn Örn; Yli-Hankala, Arvi & Møller, Morten Hylander (2019). Clinical practice guideline on prevention of rhabdomyolysis induced acute kidney injury: Endorsement by the Scandinavian Society of Anaesthesiology and Intensive Care Medicine. Acta Anaesthesiologica Scandinavica. ISSN 0001-5172. p. 1–2. doi: 10.1111/aas.13458. Full text in Research Archive
• Reid, Bjørn Ole; Haugland, Helge Nystad; Rehn, Marius; Uleberg, Oddvar & Krüger, Andreas (2019). Search and Rescue and Remote Medical Evacuation in a Norwegian Setting: Comparison of Two Systems. Wilderness & environmental medicine (Print). ISSN 1080-6032. 30(2), p. 155–162. doi: 10.1016/j.wem.2019.02.003. Full text in Research Archive
• Samdal, Martin; Eiding, Helge; Markengbakken, Lars; Røislien, Jo; Rehn, Marius & Sandberg, Mårten (2019). Time Course of Hoist Operations by the Search and Rescue Helicopter Service in Southeast Norway. Wilderness & environmental medicine (Print). ISSN 1080-6032. 30(4), p. 351–361. doi: 10.1016/j.wem.2019.06.004. Full text in Research Archive Show summary

  Introduction Optimal dispatch of emergency medical services relies on accurate time estimates of the various prehospital stages. Hoist rescue work time intervals performed by the search and rescue (SAR) helicopter service in Norway have not been studied to date. We aimed to describe the epidemiologic, operational, and medical aspects of the SAR service in southeast Norway. To complement the prehospital timeline, we performed simulated hoist operations. Methods We reviewed time and patient descriptors and medical interventions in hoist operations performed at a SAR base over 5 y. In addition, a simulation study measuring hoist rescue time intervals was performed. Data are presented as mean±SD, except National Advisory Committee for Aeronautics (NACA) scores, which are presented as modes. Results There were 148 hoist operations performed during the study period, involving 180 patients. Time to take-off was 13±7 min. There were 88 patients (49%) who were injured; 53 (29%) had a medical condition, and 39 (22%) were evacuees. The mode of the NACA score was 3. Forty-five patients (25%) had an NACA score of 4 to 6. Medical interventions were performed on 77 patients (43%) in 73 operations (49%). Nine patients (5%) were endotracheally intubated, and 1 thoracostomy was performed. The simulated rescuer access time was 4±2 min, the simulated anesthesiologist access time was 6±2 min, and the simulated hoist extrication time was 13±2 min. Conclusions Hoist rescue was performed in 10% (n=148) of the SAR operations. New information about hoist extrication time intervals can improve rescue helicopter dispatch accuracy.

• Hagemo, Jostein Skjalg; Bredmose, Per Poelhøi; Stave, Halvard; Rehn, Marius & Buskop, Christian (2019). Response to: Best practice advice on pre-hospital emergency anaesthesia &amp; advanced airway management. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 27(1). doi: 10.1186/s13049-019-0613-7. Full text in Research Archive
• Rehn, Marius; Weaver, Anne; Brohi, Karim; Eshelby, Sarah; Green, Laura E. & Røislien, Jo [Show all 7 contributors for this article] (2018). Effect of Prehospital Red Blood Cell Transfusion on Mortality and Time of Death in Civilian Trauma Patients. Shock. ISSN 1073-2322. 51(3), p. 284–288. doi: 10.1097/SHK.0000000000001166. Full text in Research Archive
• Rehn, Marius; Chew, Michelle S.; Olkkola, Klaus T.; Sverrison, Kristinn Örn; Yli-Hankala, Arvi & Møller, Morten Hylander (2018). Endorsement of clinical practice guidelines by the Scandinavian Society of Anaesthesiology and Intensive Care Medicine. Acta Anaesthesiologica Scandinavica. ISSN 0001-5172. 63, p. 161–163. doi: 10.1111/aas.13306. Full text in Research Archive
• Crewdson, Kate; Rehn, Marius; Brohi, Karim & Lockey, David (2018). Pre-hospital emergency anaesthesia in awake hypotensive trauma patients: beneficial or detrimental? Acta Anaesthesiologica Scandinavica. ISSN 0001-5172. Full text in Research Archive
• Crewdson, Kate; Rehn, Marius & Lockey, David (2018). Airway management in pre-hospital critical care: A review of the evidence for a 'top five' research priority. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 26:89, p. 1–6. doi: 10.1186/s13049-018-0556-4. Full text in Research Archive
• Samdal, Martin; Haugland, Helge Nystad; Fjeldet, Cato; Rehn, Marius & Sandberg, Mårten (2018). Static rope evacuation by helicopter emergency medical services in rescue operations in Southeast Norway. Wilderness & environmental medicine (Print). ISSN 1080-6032. 29(3), p. 315–324. doi: 10.1016/j.wem.2018.03.010. Full text in Research Archive Show summary

  Introduction Physician-staffed helicopter emergency medical services (HEMS) in Norway are an adjunct to existing search and rescue services. Our aims were to study the epidemiological, operational, and medical aspects of HEMS daylight static rope operations performed in the southeastern part of the country and to examine several quality dimensions that are characteristic of this service. Methods We reviewed the static rope operations performed at 3 HEMS bases during a 3-y period and applied a set of quality indicators designed for physician-staffed emergency medical services to evaluate the quality of care. Data are presented as medians with quartiles, except National Advisory Committee for Aeronautics (NACA) scores, which are presented as mean (SD). Results Fifty-nine static rope operations were identified, involving 60 patients. Median (quartiles) age was 43 (27–55) y. Median (quartiles) take-off time was 9 (5–13) min. Trauma-related injuries were found in 48 patients. The main conditions were lower limb injuries, found in 32 patients. Ten patients experienced medical conditions. Mean (SD) NACA score was 3.3 (1.3). A potential or actual life-threatening diagnosis (NACA score: 4–6) was reported among 15 patients. The main interventions were intravenous lines (19 patients), analgesics (17), and oxygen treatment (14). Four patients were intubated, and 1 thoracostomy was performed. Conclusions Static rope operations are rarely performed. The quality indicators suggest that the service is safe, available, and equitable. Its main benefit seems to be evacuation and the maintenance of readiness before rapid transport of the physician to the scene or the patient to the hospital.

• Rehn, Marius; Davies, Gareth; Foster, Elizabeth & Lockey, David (2018). Prehospital Management of Pediatric Hanging. Pediatric emergency care. ISSN 0749-5161. 34(4), p. 263–266. doi: 10.1097/PEC.0000000000000860. Full text in Research Archive
• Reid, Bjørn Ole; Rehn, Marius; Uleberg, Oddvar; Næss-Pleym, Lars E. & Krüger, Andreas (2018). Inter-disciplinary cooperation in a physician-staffed emergency medical system. Acta Anaesthesiologica Scandinavica. ISSN 0001-5172. 62(7), p. 1007–1013. doi: 10.1111/aas.13112. Full text in Research Archive
• Haugland, Helge Nystad; Uleberg, Oddvar; Klepstad, Pål; Krüger, Andreas & Rehn, Marius (2018). Quality measurement in physician-staffed emergency medical services: a systematic literature review. International Journal for Quality in Health Care. ISSN 1353-4505. 31(1), p. 2–10. doi: 10.1093/intqhc/mzy106. Full text in Research Archive Show summary

  Purpose Quality measurement of physician-staffed emergency medical services (P-EMS) is necessary to improve service quality. Knowledge and consensus on this topic are scarce, making quality measurement of P-EMS a high-priority research area. The aim of this review was to identify, describe and evaluate studies of quality measurement in P-EMS. Data sources The databases of MEDLINE and Embase were searched initially, followed by a search for included article citations in Scopus. Study selection The study eligibility criteria were: (1) articles describing the use of one quality indicator (QI) or more in P-EMS, (2) original manuscripts, (3) articles published from 1 January 1968 until 5 October 2016. The literature search identified 4699 records. 4543 were excluded after reviewing title and abstract. An additional 129 were excluded based on a full-text review. The remaining 27 papers were included in the analysis. Methodological quality was assessed using an adapted critical appraisal tool. Data extraction The description of used QIs and methods of quality measurement was extracted. Variables describing the involved P-EMSs were extracted as well. Results of data synthesis In the included papers, a common understanding of which QIs to use in P-EMS did not exist. Fifteen papers used only a single QI. The most widely used QIs were ‘Adherence to medical protocols’, ‘Provision of advanced interventions’, ‘Response time’ and ‘Adverse events’. Conclusion The review demonstrated a lack of shared understanding of which QIs to use in P-EMS. Moreover, papers using only one QI dominated the literature, thus increasing the risk of a narrow perspective in quality measurement. Future quality measurement in P-EMS should rely on a set of consensus-based QIs, ensuring a comprehensive approach to quality measurement.

• Reid, Bjørn Ole; Rehn, Marius; Uleberg, Oddvar & Krüger, Andreas Jørstad (2018). Physician-provided prehospital critical care, effect on patient physiology dynamics and on-scene time. European journal of emergency medicine. ISSN 0969-9546. 25(2), p. 114–119. doi: 10.1097/MEJ.0000000000000432. Full text in Research Archive Show summary

  Introduction Improved physiologic status can be seen as a surrogate measure of improved outcome and a field-friendly prognostic model such as the Mainz Emergency Evaluation Score (MEES) could quantify the effect on physiological response. We aim to examine the dynamic physiological profile as measured by this score on patients managed by physician-manned helicopter emergency medical services and how this profile was related to on-scene time expenditure and critical care interventions. Materials and methods Data including patient characteristics, physiological data, and description of diagnostic and therapeutic interventions were prospectively collected over two 14-day periods, summer and winter, at six participating Norwegian bases. The MEES score was utilized to examine the difference between a score measured at first patient contact (MEES 1) and end-of-care (MEES 2), (MEES 2–MEES 1=ΔMEES). Results A total of 240 primary missions with patient-onscene form the basis of the study. In total, 43% were considered severely ill or injured, of whom 59% were medical patients. Twenty-nine percent were severely deranged physiologically. The most common advanced procedure performed was advanced airway management (15%), followed by defibrillation (8.8%). Using ΔMEES as an indicator, 1% deteriorated under care, whereas 66% remained unchanged and 33% showed an improvement in their physiological status. With increasing on-scene time, fewer patients deteriorated and a greater proportion of patients improved. Conclusion Restoring deranged physiology remains a mantra for all critical care practitioners. We have shown that this is also possible in the prehospital context, even when prolonging on-scene time, and after initiating advanced procedures.

• Hardy, Sophie; Fattah, Sabina; Wisborg, Torben; Raatiniemi, Lasse; Staff, Trine & Rehn, Marius (2018). Systematic reporting to improve the emergency medical response to major incidents: A pilot study. BMC Emergency Medicine. 18:4, p. 1–7. doi: 10.1186/s12873-018-0153-x. Full text in Research Archive Show summary

  <i>Background:</i> Major incidents affect us globally, and are occurring with increasing frequency. There is still no evidence-based standard regarding the best medical emergency response to major incidents. Currently, reports on major incidents are non-standardised and variable in quality. This pilot study examines the first systematic reports from a consensus-based, freely accessible database, aiming to identify how descriptive analysis of reports submitted to this database can be used to improve the major incident response. <br><br> <i>Methods:</i> Majorincidentreporting.net is a website collecting reports on major incidents using a standardised template. Data from these reports were analysed to compare the emergency response to each incident. <br><br> <i>Results:</i> Data from eight reports showed that effective triage by experienced individuals and the use of volunteers for transport were notable successes of the major incident response. Inadequate resources, lack of a common triage system, confusion over command and control and failure of communication were reported failures. The following trends were identified: Fires had the slowest times for several aspects of the response and the only three countries to have a single dialling number for all three emergency services had faster response times. Helicopter Emergency Medical services (HEMS) were used for transport and treatment in rural locations and for triage and treatment in urban locations. In two incidents, a major incident was declared before the arrival of the first Emergency Medical Services (EMS) personnel.<br><br> <i>Conclusion:</i> This study shows that we can obtain relevant data from major incidents by using systematic reporting. Though the sample size from this pilot study is not large enough to draw any specific conclusions it illustrates the potential for future analyses. Identified lessons could be used to improve the emergency medical response to major incidents.

• Crewdson, K.; Lockey, David; Røislien, Jo; Lossius, Hans Morten & Rehn, Marius (2017). The success of pre-hospital tracheal intubation by different pre-hospital providers: a systematic literature review and meta-analysis. Critical Care. ISSN 1364-8535. 21(31). doi: 10.1186/s13054-017-1603-7. Full text in Research Archive Show summary

  Background: Pre-hospital basic airway interventions can be ineffective at providing adequate oxygenation and ventilation in some severely ill or injured patients, and advanced airway interventions are then required. Controversy exists regarding the level of provider required to perform successful pre-hospital intubation. A previous meta-analysis reported pre-hospital intubation success rates of 0.849 for non-physicians versus 0.991 for physicians. The evidence base on the topic has expanded significantly in the last 10 years. This study systematically reviewed recent literature and presents comprehensive data on intubation success rates. Methods: A systematic search of MEDLINE and EMBASE was performed using PRISMA methodology to identify articles on pre-hospital tracheal intubation published between 2006 and 2016. Overall success rates were estimated using random effects meta-analysis. The relationship between intubation success rate and provider type was assessed in weighted linear regression analysis. Results: Of the 1838 identified studies, 38 met the study inclusion criteria. Intubation was performed by non-physicians in half of the studies and by physicians in the other half. The crude median (range) reported overall success rate was 0.969 (0.616–1.000). In random effects meta-analysis, the estimated overall intubation success rate was 0.953 (0.938–0.965). The crude median (range) reported intubation success rates for non-physicians were 0.917 (0.616–1.000) and, for physicians, were 0.988 (0.781–1.000) (p = 0.003). Discussion: The reported overall success rate of pre-hospital intubation has improved, yet there is still a significant difference between non-physician and physician providers. The finding that less-experienced personnel perform less well is not unexpected, but since there is considerable evidence that poorly performed intubation carries a significant risk of morbidity and mortality careful consideration should be given to the training and experience required to deliver this intervention safely.

• Rehn, Marius; Davies, Gareth; Smith, Paul & Lockey, David (2017). Emergency versus standard response: time efficacy of London's Air Ambulance rapid response vehicle. Emergency Medicine Journal. ISSN 1472-0205. 34(12), p. 806–809. doi: 10.1136/emermed-2017-206663. Full text in Research Archive
• Rehn, Marius; Weaver, A.E.; Eshelby, Sarah; Røislien, Jo & Lockey, David (2017). Pre-hospital transfusion of red blood cells in civilian trauma patients. Transfusion Medicine. ISSN 0958-7578. 28(4), p. 277–283. doi: 10.1111/tme.12483. Full text in Research Archive
• Sollid, Stephen J. M. & Rehn, Marius (2017). The role of the anaesthesiologist in air ambulance medicine. Current Opinion in Anaesthesiology. ISSN 0952-7907. 30(4), p. 513–517. doi: 10.1097/ACO.0000000000000480. Full text in Research Archive
• Johnsen, Anne Siri; Sollid, Stephen J. M.; Vigerust, Trond; Jystad, Morten & Rehn, Marius (2017). Helicopter emergency medical services in major incident management: A national Norwegian cross-sectional survey. PLOS ONE. 12:e0171436(2), p. 1–12. doi: 10.1371/journal.pone.0171436. Full text in Research Archive
• Haugland, Helge Nystad; Rehn, Marius; Klepstad, Pål & Krüger, Andreas Jørstad (2017). Developing quality indicators for physician-staffed emergency medical services: a consensus process. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 25(14), p. 1–8. doi: 10.1186/s13049-017-0362-4. Full text in Research Archive Show summary

  Background There is increasing interest for quality measurement in health care services; pre-hospital emergency medical services (EMS) included. However, attempts of measuring the quality of physician-staffed EMS (P-EMS) are scarce. The aim of this study was to develop a set of quality indicators for international P-EMS to allow quality improvement initiatives. Methods A four-step modified nominal group technique process (expert panel method) was used. Results The expert panel reached consensus on 26 quality indicators for P-EMS. Fifteen quality indicators measure quality of P-EMS responses (response-specific quality indicators), whereas eleven quality indicators measure quality of P-EMS system structures (system-specific quality indicators). Discussion When measuring quality, the six quality dimensions defined by The Institute of Medicine should be appraised. We argue that this multidimensional approach to quality measurement seems particularly reasonable for services with a highly heterogenic patient population and complex operational contexts, like P-EMS. The quality indicators in this study were developed to represent a broad and comprehensive approach to quality measurement of P-EMS. Conclusions The expert panel successfully developed a set of quality indicators for international P-EMS. The quality indicators should be prospectively tested for feasibility, validity and reliability in clinical datasets. The quality indicators should then allow for adjusted quality measurement across different P-EMS systems.

• Fattah, Sabina; Agledahl, Kari Milch; Rehn, Marius & Wisborg, Torben (2016). Experience With a Novel, Global, Open-Access Template for Major Incidents: Qualitative Feasibility Study. Disaster Medicine and Public Health Preparedness. ISSN 1935-7893. p. 1–4. doi: 10.1017/dmp.2016.156. Full text in Research Archive
• Rehn, Marius; Hyldmo, Per Kristian; Magnússon, Vidar; Kurola, Jouni; Kongstad, Poul & Rognås, Leif Kåre [Show all 8 contributors for this article] (2016). Scandinavian SSAI clinical practice guideline on pre-hospital airway management. Acta Anaesthesiologica Scandinavica. ISSN 0001-5172. 60(7), p. 852–864. doi: 10.1111/aas.12746. Full text in Research Archive Show summary

  Background: The Scandinavian society of anaesthesiology and inten- sive care medicine task force on pre-hospital airway management was asked to formulate recommendations following standards for trustworthy clinical practice guidelines. Methods: The literature was systematically reviewed and the grading of recommendations assessment, development and evaluation (GRADE) system was applied to move from evidence to recommendations. Results: We recommend that all emergency medical service (EMS) pro- viders consider to: apply basic airway manoeuvres and airway adjuncts (good practice recommendation); turn unconscious non-trauma patients into the recovery position when advanced airway management is unavail- able (good practice recommendation); turn unconscious trauma patients to the lateral trauma position while maintaining spinal alignment when advanced airway management is unavailable [strong recommendation, low quality of evidence (QoE)]. We suggest that intermediately trained provi- ders use a supraglottic airway device (SAD) or basic airway manoeuvres on patients in cardiac arrest (weak recommendation, low QoE). We recom- mend that advanced trained providers consider using an SAD in selected indications or as a rescue device after failed endotracheal intubation (ETI) (good practice recommendation). We recommend that ETI should only be performed by advanced trained providers (strong recommendation, low QoE). We suggest that videolaryngoscopy is considered for ETI when direct laryngoscopy fails or is expected to be difficult (weak recommenda- tion, low QoE). We suggest that advanced trained providers apply cricothy- roidotomy in ‘cannot intubate, cannot ventilate’ situations (weak recommendation, low QoE). Conclusion: This guideline for pre-hospital airway management includes a combination of techniques applied in a stepwise fashion appropriate to patient clinical status and provider training.

• Fattah, Sabina; Rehn, Marius & Wisborg, Torben (2016). Field Reports: Yes, They Will Add to the Prehospital and Disaster Knowledge Base. Prehospital and Disaster Medicine. ISSN 1049-023X. 31(4), p. 461–461. Full text in Research Archive
• Turner, Conor DA; Lockey, David & Rehn, Marius (2016). Pre-hospital management of mass casualty civilian shootings: A systematic literature review. Critical Care. ISSN 1364-8535. 20(1). doi: 10.1186/s13054-016-1543-7. Full text in Research Archive
• Johnsen, Anne Siri; Fattah, Sabina; Sollid, Stephen J. M. & Rehn, Marius (2016). Utilisation of helicopter emergency medical services in the early medical response to major incidents: A systematic literature review. BMJ Open. 6(2). doi: 10.1136/bmjopen-2015-010307. Full text in Research Archive Show summary

  Objective: This systematic review identifies, describes and appraises the literature describing the utilisation of helicopter emergency medical services (HEMS) in the early medical response to major incidents. <p> Setting: Early prehospital phase of a major incident. <p>Design: Systematic literature review performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, the Web of Science, PsycINFO, Scopus, Cinahl, Bibsys Ask, Norart, Svemed and UpToDate were searched using phrases that combined HEMS and ‘major incidents’ to identify when and how HEMS was utilised. The identified studies were subjected to data extraction and appraisal. <p>Results: The database search identified 4948 articles. Based on the title and abstract, the full text of 96 articles was obtained; of these, 37 articles were included in the review, and an additional five were identified by searching the reference lists of the 37 articles. HEMS was used to transport medical and rescue personnel to the incident and to transport patients to the hospital, especially when the infrastructure was damaged. Insufficient air traffic control, weather conditions, inadequate landing sites and failing communication were described as challenging in some incidents. <p> Conclusions: HEMS was used mainly for patient treatment and to transport patients, personnel and equipment in the early medical management of major incidents, but the optimal utilisation of this specialised resource remains unclear. This review identified operational areas with improvement potential. A lack of systematic indexing, heterogeneous data reporting and weak methodological design, complicated the identification and comparison of incidents, and more systematic reporting is needed.

• Fattah, Sabina; Johnsen, Anne Siri; Sollid, Stephen J. M.; Wisborg, Torben; Rehn, Marius & Sóti, Ákos [Show all 22 contributors for this article] (2016). Reporting Helicopter Emergency Medical Services in Major Incidents: A Delphi Study. Air Medical Journal. ISSN 1067-991X. 35(6), p. 348–351. doi: 10.1016/j.amj.2016.08.003. Full text in Research Archive Show summary

  Objective: Research on helicopter emergency medical services (HEMS) in major incidents is predominately based on case descriptions reported in a heterogeneous fashion. Uniform data reported with a consensus-based template could facilitate the collection, analysis, and exchange of experiences. This type of database presently exists for major incident reporting at www.majorincidentreporting.net. This study aimed to develop a HEMS-specific major incident template. Methods: This Delphi study included 17 prehospital critical care physicians with current or previous HEMS experience. All participants interacted through e-mail. We asked these experts to define data variables and rank which were most important to report during an immediate prehospital medical response to a major incident. Five rounds were conducted. Results: In the first round, the experts suggested 98 variables. After 5 rounds, 21 variables were determined by consensus. These variables were formatted in a template with 4 main categories: HEMS background information, the major incident characteristics relevant to HEMS, the HEMS response to the major incident, and the key lessons learned. Conclusion: Based on opinions from European experts, we established a consensus-based template for reporting on HEMS responses to major incidents. This template will facilitate uniformity in the collection, analysis, and exchange of experience.

• Rehn, Marius; Davies, Gareth; Smith, Paul & Lockey, David (2016). Structure of Rapid Response Car Operations in an Urban Trauma Service. Air Medical Journal. ISSN 1067-991X. 35(3), p. 143–147. doi: 10.1016/j.amj.2015.12.015. Full text in Research Archive
• Rehn, Marius (2015). A practical approach to resuscitative thoracotomy. Surgery (United Kingdom). ISSN 0263-9319. doi: 10.1016/j.mpsur.2015.07.010. Full text in Research Archive
• Fattah, Sabina; Rehn, Marius & Wisborg, Torben (2015). Implementing a template for major incident reporting: Experiences from the first year. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 23:55(55). doi: 10.1186/s13049-015-0132-0. Full text in Research Archive Show summary

  Major incidents are resource-demanding situations that require urgent and effective medical management. The possibility to extract learning from them is therefore important. Comparative analysis of information based on uniform data collection from previous incidents may facilitate learning. The Major Incident Reporting Collaborators have developed a template for reporting of the medical pre-hospital response to major incidents. The template is accompanied by an open access webpage (www.majorincidentreporting.org) for online reporting and access to published reports. This commentary presents the experiences from the first year of implementing the template including a presentation of the five published reports.

• Kristiansen, Thomas; Lossius, Hans Morten; Rehn, Marius; Kristensen, Petter; Gravseth, Hans Magne Ulrik & Røislien, Jo [Show all 7 contributors for this article] (2014). Epidemiology of trauma: A population-based study of geographical risk factors for injury deaths in the working-age population of Norway. Injury. ISSN 0020-1383. 45(1), p. 23–30. doi: 10.1016/j.injury.2013.07.007. Full text in Research Archive Show summary

  Introduction Trauma is a major global cause of morbidity and mortality. Population-based studies identifying high-risk populations and regions may facilitate primary prevention and the development of optimal trauma systems. This study describes the epidemiology of adult trauma deaths in Norway and identifies high-risk areas by assessing different geographical measures of rurality. Methods All trauma-related deaths in Norway from 1998 to 2007 among individuals aged 16–66 years were identified by accessing national registries. Mortality data were analysed by linkage to population and geographical data at municipal, county and national levels. Three measures of rurality (centrality, population density and settlement density) were compared based on their association with trauma mortality rates. Results The study included 8466 deaths, of which 78% were males. The national annual trauma mortality rate was 28.7 per 100,000. Population density was the best predictor of high-risk areas, and there was a consistent inverse relationship between mortality rates and population density. The most rural areas had 52% higher trauma mortality rates compared to the most urban areas. This difference was largely due to deaths following transport-related injury. Seventy-eight per cent of all deaths occurred in the prehospital phase. Rural areas and death following self-harm had higher proportion of prehospital deaths. Conclusion Rural areas, as defined by population density, are at a higher risk of deaths following traumatic injuries and have higher proportions of prehospital deaths and deaths following transport-related injuries. The heterogeneous characteristics of trauma populations with respect to geography and mode of injury should be recognised in the planning of preventive strategies and in the organisation of trauma care.

• Fattah, Sabina; Johnsen, Anne Siri; Andersen, Jan Einar; Vigerust, Trond; Olsen, Terje & Rehn, Marius (2014). Rapid extrication of entrapped victims in motor vehicle wreckage using a Norwegian chain method - cross-sectional and feasibility study. BMC Emergency Medicine. 14(1). doi: 10.1186/1471-227X-14-14. Full text in Research Archive Show summary

  Background Road traffic injury (RTI) is a global problem causing some 1,2 million deaths annually and another 20–50 million people sustain non-fatal injuries. Pre-hospital entrapment is a risk factor for complications and delays transport to the hospital. The Rapid Extrication (RE) method combines winching and cutting of both front poles and utilising two larger vehicles to pull car wreckage apart to extricate patients. A previous study indicates that RE is an efficient alternative to previously existing methods. Methods All Fire Departments in Norway were questioned on: background, frequency of training, use and implementation of the method, protocol and equipment. Times used for extrication from motor vehicle wreckage were measured at the National Championship in RE. Questionnaires presented to participants asked about frequency of training, inter-disciplinary cooperation and self-perceived safety for both providers and patients on a 1–7 Likert scale (1 - worst and 7 - best). Results Participating Fire Departments use RE in 95% of cases on passenger cars and 77% of cases on larger vehicles. Teams participating in the National Championship scored self-perceived security of crew as median 7 and IQR (6, 7), patient safety 7 (6, 7), communication between personnel 7 (6, 7), teamwork 7 (6, 7), and how well the technique functioned 7 (6, 7). All teams had extricated and transported the patient into the ambulance within 20 minutes. Conclusion Interdisciplinary and regular training of RE can lead to safe extrication of a critically injured patient in less than 20 minutes and may be life saving.

• Thompson, Julian; Rehn, Marius; Lossius, Hans Morten & Lockey, David (2014). Risks to emergency medical responders at terrorist incidents: A narrative review of the medical literature. Critical Care. ISSN 1364-8535. 18(5:521). doi: 10.1186/s13054-014-0521-1. Full text in Research Archive Show summary

  As the threat of international terrorism rises, there is an increasing requirement to provide evidence-based information and training for the emergency personnel who will respond to terrorist incidents. Current major incident training advises that emergency responders prioritize their own personal safety above that of the ‘scene and survivors’. However, there is limited information available on the nature of these threats and how they may be accurately evaluated. This study reviews the published medical literature to identify the hazards experienced by emergency responders who have attended previous terrorist incidents. A PubMed literature search identified 10,894 articles on the subject of ‘terrorism’, and there was a dramatic increase in publications after the 9/11 attacks in 2001. There is heterogeneity in the focus and quality of this literature, and 307 articles addressing the subject of scene safety were assessed for information regarding the threats encountered at terrorist incidents. These articles demonstrate that emergency responders have been exposed to both direct terrorist threats and environmental scene hazards, including airborne particles, structural collapse, fire, and psychological stress. The emphasis of training and preparedness for terrorist incidents has been primarily on the direct threats, but the published literature suggests that the dominant causes of mortality and morbidity in responders after such incidents are the indirect environmental hazards. If the medical response to terrorist incidents is to be based on evidence rather than anecdote, analysis of the current literature should be incorporated into major incident training, and consistent collection of key data from future incidents is required.

• Fattah, Sabina; Rehn, Marius; Lockey, David; Thompson, Julian; Lossius, Hans Morten & Wisborg, Torben (2014). A consensus based template for reporting of pre-hospital major incident medical management. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 22:5. doi: 10.1186/1757-7241-22-5. Full text in Research Archive Show summary

  Background: Structured reporting of major incidents has been advocated to improve the care provided at future incidents. A systematic review identified ten existing templates for reporting major incident medical management, but these templates are not in widespread use. We aimed to address this challenge by designing an open access template for uniform reporting of data from pre-hospital major incident medical management that will be tested for feasibility. Methods: An expert group of thirteen European major incident practitioners, planners or academics participated in a four stage modified nominal group technique consensus process to design a novel reporting template. Initially, each expert proposed 30 variables. Secondly, these proposals were combined and each expert prioritized 45 variables from the total of 270. Thirdly, the expert group met in Norway to develop the template. Lastly, revisions to the final template were agreed via e-mail. Results: The consensus process resulted in a template consisting of 48 variables divided into six categories;pre-incident data, Emergency Medical Service (EMS) background, incident characteristics, EMS response, patient characteristics and key lessons. Conclusions: The expert group reached consensus on a set of key variables to report the medical management of pre-hospital major incidents and developed a novel reporting template. The template will be freely available for downloading and reporting on www.majorincidentreporting.org. This is the first global open access database for pre-hospital major incident reporting. The use of a uniform dataset will allow comparative analysis and has potential to identify areas of improvement for future responses.

• Ringdal, Kjetil G.; Skaga, Nils Oddvar; Hestnes, Morten; Steen, Petter Andreas; Røislien, Jo & Rehn, Marius [Show all 9 contributors for this article] (2013). Abbreviated Injury Scale: Not a reliable basis for summation of injury severity in trauma facilities? Injury. ISSN 0020-1383. 44(5), p. 691–699. doi: 10.1016/j.injury.2012.06.032. Full text in Research Archive
• Johnsen, Anne Siri; Fattah, Sabina; Sollid, Stephen & Rehn, Marius (2013). Impact of helicopter emergency medical services in major incidents: systematic literature review. BMJ Open. 3. doi: 10.1136/bmjopen-2013-003335. Full text in Research Archive Show summary

  Introduction: Helicopter emergency medical services (HEMS) aim to bring highly specialised crews to the major incident for triage, treatment and transport. When the site is difficult to access, HEMS may be the only mode of transportation of both personnel and patients. This systematic review will identify, describe and appraise literature regarding the role of HEMS in medical response to major incidents. We aim to improve knowledge on HEMS role in a major incident and provide a basis for future research. Methods and analysis: A systematic literature review will be conducted with search phrases that combine HEMS and major incidents to identify when and how HEMS have been used. Included literature will be subject to quality appraisal and data extraction. Ethics: No ethical approval is sought because this is a literature review. It will be submitted to a peer-reviewed journal and the PRISMA guidelines will be followed.

• Fattah, Sabina; Rehn, Marius; Reierth, Eirik & Wisborg, Torben (2013). Systematic literature review of templates for reporting prehospital major incident medical management. BMJ Open. 3(8), p. 1–8. doi: 10.1136/bmjopen-2013-002658. Full text in Research Archive Show summary

  To identify and describe the content of templates for reporting prehospital major incident medical management. Systematic literature review according to PRISMA guidelines. PubMed/MEDLINE, EMBASE, CINAHL, Scopus and Web of Knowledge. Grey literature was also searched. Eligibility criteria for selected studies: Templates published after 1 January 1990 and up to 19 March 2012. Non-English language literature, except Scandinavian; literature without an available abstract; and literature reporting only psychological aspects were excluded. The main database search identified 8497 articles, among which 8389 were excluded based on title and abstract. An additional 96 were excluded based on the full-text. The remaining 12 articles were included in the analysis. A total of 107 articles were identified in the grey literature and excluded. The reference lists for the included articles identified five additional articles. A relevant article published after completing the search was also included. In the 18 articles included in the study, 10 different templates or sets of data are described: 2 methodologies for assessing major incident responses, 3 templates intended for reporting from exercises, 2 guidelines for reporting in medical journals, 2 analyses of previous disasters and 1 Utstein-style template. More than one template exists for generating reports. The limitations of the existing templates involve internal and external validity, and none of them have been tested for feasibility in real-life incidents.

• Sollid, Stephen; Rimstad, Rune; Rehn, Marius; Nakstad, Anders Rostrup; Tomlinson, Ann-Elin & Strand, Terje [Show all 9 contributors for this article] (2012). Oslo government district bombing and Utøya island shooting July 22, 2011 : the immediate prehospital emergency medical service response. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 20, p. 12–12. doi: 10.1186/1757-7241-20-3. Full text in Research Archive Show summary

  Background: On July 22, 2011, a single perpetrator killed 77 people in a car bomb attack and a shooting spree incident in Norway. This article describes the emergency medical service (EMS) response elicited by the two incidents. Methods: A retrospective and observational study was conducted based on data from the EMS systems involved and the public domain. The study was approved by the Data Protection Official and was defined as a quality improvement project. Results: We describe the timeline and logistics of the EMS response, focusing on alarm, dispatch, initial response, triage and evacuation. The scenes in the Oslo government district and at Utøya island are described separately. Conclusions: Many EMS units were activated and effectively used despite the occurrence of two geographically separate incidents within a short time frame. Important lessons were learned regarding triage and evacuation, patient flow and communication, the use of and need for emergency equipment and the coordination of helicopter EMS.

• Fattah, Sabina; Rehn, Marius; Reierth, eirik & Wisborg, Torben (2012). Templates for reporting pre-hospital major incident medical management: systematic literature review. BMJ Open. 2(3). doi: 10.1136/bmjopen-2012-001082. Full text in Research Archive Show summary

  Introduction In 2010, a total of 385 natural disasters killed more than 297 000 people worldwide and affected over 217 million others. More standardised reporting of major incident management have been advocated in the previous years. Prevention, mitigation, preparedness and major incident response may be improved through collection and analysis of high-quality standardised data on medical management of major incidents. Standardised data may elevate the level of scientific evidence within disaster medicine research. Methods and analysis A systematic literature review will be conducted to identify templates for reporting pre-hospital major incident medical management. The first set of entry terms aims to describe major incidents published during the last 20 years. The second set aims to focus the number of search results from the first set to those publications that describe templates based on data collections from these major incidents. Predefined free search phases will be combined with the first two sets.

• Rehn, Marius; Lossius, Hans Morten; Tjosevik, Kjell E; Vetrhus, Morten; Østebø, Olav & Eken, Torsten (2012). Efficacy of a two-tiered trauma team activation protocol in a Norwegian trauma centre. British Journal of Surgery. ISSN 0007-1323. 99(2), p. 199–208. doi: 10.1002/bjs.7794. Full text in Research Archive
• Kristiansen, Thomas; Rehn, Marius; Gravseth, Hans Magne; Lossius, Hans Morten & Kristensen, Petter (2012). Paediatric trauma mortality in Norway: population-based study of injury characteristics and urban-rural differences. Injury. ISSN 0020-1383. 43, p. 1865–1872. doi: 10.1016/j.injury.2011.08.011. Full text in Research Archive Show summary

  Introduction: Paediatric injury is a major global public health challenge. Epidemiological research is required for effective primary injury prevention and to develop trauma systems for optimal management of childhood injuries. This study aimed to describe the characteristics and geographical distribution of paediatric trauma deaths and to assess the relationship between rural locations and mortality rates. Materials and methods: By accessing national registries, all trauma related deaths of persons aged 0–15 years in Norway from 1998 to 2007 were included. Paediatric trauma mortality rates and injury characteristic were analysed in relation to three different measures of municipal rurality: centrality, population density and settlement density. Results: There were 462 trauma related deaths during the study period and the national annual paediatric mortality rate was 4.81/100 000. Rural areas had higher mortality rates, and this difference was best predicted by municipal centrality. Rural trauma was characterised by traffic accidents and deaths that occurred prior to reaching hospital. The rural and northernmost county, Finnmark, had a mortality rate three times the national average. Conclusion: Mortality rates after childhood injury are high in rural areas. Substantiated measures of rurality are required for optimal allocation of primary and secondary preventive measures.

• Kristensen, Petter; Kristiansen, Thomas; Rehn, Marius; Gravseth, Hans Magne Ulrik & Bjerkedal, Tor (2012). Social inequalities in road traffic deaths at age 16-20 years among all 611 654 Norwegians born between 1967 and 1976: a multilevel analysis. Injury Prevention. ISSN 1353-8047. 18(1), p. 3–9. doi: 10.1136/ip.2011.031682. Full text in Research Archive Show summary

  Background: Road traffic injury is a major cause of death among youths. Aims: To estimate mortality differences in family socioeconomic position (SEP) and municipal disadvantage level. Methods: Data on all Norwegians born in 1967–76, gathered from national registries, were linked by a unique national identification number. The 611 654 participants were followed-up for 5 years from age 16 years. Parental education level, father's income level, and proportion of high-income earners in the municipality served as SEP indicators. Associations between SEP and road traffic deaths were analysed by multilevel Poisson regression. Results: Road traffic deaths (n=676, rate 22.2 per 100 000 person-years) constituted a major cause of death, of which 91.9% were motor vehicle occupants. SEP distributions differed according to gender and type of motor vehicle crash (collision, non-collision). There was an inverse relationship between municipal proportions of high-income earners and mortality (population attributable fraction (PAF) 0.43, 95% CI 0.30 to 0.53) in all categories of gender-specific crash types. Family SEP gradients were not found except for male non-collision deaths, where increasing mortality was found in association with decreasing parental education level (PAF 0.94, 95% CI 0.59 to 0.99) and increasing paternal income (PAF 0.25, 95% CI 0.06 to 0.40). Conclusion: The different SEP patterns for road traffic deaths across gender and motor vehicle crash type illustrate that heterogeneity of social inequalities in health can be found even within narrow age bands and for similar causes of death.

• Kristiansen, Thomas; Søreide, Kjetil; Ringdal, Kjetil G.; Rehn, Marius; Krüger, Andreas J. & Reite, Andreas [Show all 9 contributors for this article] (2012). Trauma systems and early management of severe injuries in Scandinavia: review and current status. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 04(17). doi: 10.1186/1757-7241-17-S3-O29. Full text in Research Archive
• Fattah, Sabina; Krüger, Andreas J.; Andersen, Jan Einar; vigerust, trond & Rehn, Marius (2012). Major incident preparedness and on-site work among Norwegian rescue personnel - a cross-sectional study. International Journal of Emergency Medicine. ISSN 1865-1372. 5(1), p. 40–40. doi: 10.1186/1865-1380-5-40. Full text in Research Archive Show summary

  A major incident has occurred when the number of live casualties, severity, type of incident or location requires extraordinary resources. Major incident management is interdisciplinary and involves triage, treatment and transport of patients. We aimed to investigate experiences within major incident preparedness and management among Norwegian rescue workers. A questionnaire was answered by 918 rescue workers across Norway. Questions rated from 1 (doesn’t work) to 7 (works excellently) are presented as median and range. Health-care personnel constituted 34.1% of the participants, firefighters 54.1% and police 11.8%. Training for major incident response scored 5 (1, 7) among health-care workers and 4 (1, 7) among firefighters and police. Preparedness for major incident response scored 5 (1, 7) for all professions. Interdisciplinary cooperation scored 5 (3, 7) among health-care workers and police and 5 (1, 7) among firefighters. Among health-care workers, 77.5% answered that a system for major-incident triage exists; 56.3% had triage equipment available. The majority – 45.1% of health-care workers, 44.7% of firefighters and 60.4% of police – did not know how long it would take to get emergency stretchers to the scene. Rescue personnel find major incident preparedness and on-scene multidisciplinary cooperation to function well. Some shortcomings are reported with regard to systems for major incident triage, tagging equipment for triage and knowledge about access to emergency stretchers.

• Rehn, Marius; Perel, Pablo; Blackhall, Karen & Lossius, Hans Morten (2011). Prognostic models for the early care of trauma patients: a systematic review. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 19. doi: 10.1186/1757-7241-19-17. Full text in Research Archive Show summary

  Background: Early identification of major trauma may contribute to timely emergency care and rapid transport to an appropriate health-care facility. Several prognostic trauma models have been developed to improve early clinical decision-making. Methods: We systematically reviewed models for the early care of trauma patients that included 2 or more predictors obtained from the evaluation of an adult trauma victim, investigated their quality and described their characteristics. Results: We screened 4 939 records for eligibility and included 5 studies that derivate 5 prognostic models and 9 studies that validate one or more of these models in external populations. All prognostic models intended to change clinical practice, but none were tested in a randomised clinical trial. The variables and outcomes were valid, but only one model was derived in a low-income population. Systolic blood pressure and level of consciousness were applied as predictors in all models. Conclusions: The general impression is that the models perform well in predicting survival. However, there are many areas for improvement, including model development, handling of missing data, analysis of continuous measures, impact and practicality analysis.

• Lossius, Hans Morten; Sollid, Stephen; Rehn, Marius & Lockey, David (2011). Revisiting the value of pre-hospital tracheal intubation: an all time systematic literature review extracting the Utstein airway core variables. Critical Care. ISSN 1364-8535. 15(1). doi: 10.1186/cc9973. Full text in Research Archive Show summary

  Introduction: Although tracheal intubation (TI) in the pre-hospital setting is regularly carried out by emergency medical service (EMS) providers throughout the world, its value is widely debated. Heterogeneity in procedures, providers, patients, systems and stated outcomes, and inconsistency in data reporting make scientific reports difficult to interpret and compare, and the majority are of limited quality. To hunt down what is really known about the value of pre-hospital TI, we determined the rate of reported Utstein airway variables (28 core variables and 12 fixed-system variables) found in current scientific publications on pre-hospital TI. Methods: We performed an all time systematic search according to the PRISMA guidelines of Medline and EMBASE to identify original research pertaining to pre-hospital TI in adult patients. Results: From 1,076 identified records, 73 original papers were selected. Information was extracted according to an Utstein template for data reporting from in-the-field advanced airway management. Fifty-nine studies were from North American EMS systems. Of these, 46 (78%) described services in which non-physicians conducted TI. In 12 of the 13 non-North American EMS systems, physicians performed the pre-hospital TI. Overall, two were randomised controlled trials (RCTs), and 65 were observational studies. None of the studies presented the complete set of recommended Utstein airway variables. The median number of core variables reported was 10 (max 21, min 2, IQR 8-12), and the median number of fixed system variables was 5 (max 11, min 0, IQR 4-8). Among the most frequently reported variables were “patient category” and “service mission type”, reported in 86% and 71% of the studies, respectively. Among the least-reported variables were “co-morbidity” and “type of available ventilator”, both reported in 2% and 1% of the studies, respectively. Conclusions: Core data required for proper interpretation of results were frequently not recorded and reported in studies investigating TI in adults. This makes it difficult to compare scientific reports, assess their validity, and extrapolate to other EMS systems. Pre-hospital TI is a complex intervention, and terminology and study design must be improved to substantiate future evidence based clinical practice.

• Kristiansen, Thomas; Søreide, Kjetil; Ringdal, Kjetil G.; Rehn, Marius; Krüger, Andreas J. & Reite, Andreas [Show all 9 contributors for this article] (2010). Trauma systems and early management of severe injuries in Scandinavia: Review of the current state. Injury. ISSN 0020-1383. 41(5), p. 444–452. doi: 10.1016/j.injury.2009.05.027. Full text in Research Archive
• Rehn, Marius & Kristiansen, Thomas (2010). Triage and interhospital transfer: influencing trauma mortality? Acta Anaesthesiologica Scandinavica. ISSN 0001-5172. Full text in Research Archive
• Rehn, Marius; Eken, Torsten; Krüger, Andreas J.; Steen, Petter Andreas; Skaga, Nils Oddvar & Lossius, Hans Morten (2009). Precision of field triage in patients brought to a trauma centre after introducing trauma team activation guidelines. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 17. doi: 10.1186/1757-7241-17-1. Full text in Research Archive Show summary

  Background Field triage is important for regional trauma systems providing high sensitivity to avoid that severely injured are deprived access to trauma team resuscitation (undertriage), yet high specificity to avoid resource over-utilization (overtriage). Previous informal trauma team activation (TTA) at Ulleval University Hospital (UUH) caused imprecise triage. We have analyzed triage precision after introduction of TTA guidelines. Methods Retrospective analysis of 7 years (2001–07) of prospectively collected trauma registry data for all patients with TTA or severe injury, defined as at least one of the following: Injury Severity Score (ISS) > 15, proximal penetrating injury, admitted ICU > 2 days, transferred intubated to another hospital within 2 days, dead from trauma within 30 days. Interhospital transfers to UUH and patients admitted by non-healthcare personnel were excluded. Overtriage is the fraction of TTA where patients are not severely injured (1-positive predictive value); undertriage is the fraction of severely injured admitted without TTA (1-sensitivity). Results Of the 4 659 patients included in the study, 2 221 (48%) were severely injured. TTA occurred 4 440 times, only 2 002 of which for severely injured (overtriage 55%). Overall undertriage was 10%. Mechanism of injury was TTA criterion in 1 508 cases (34%), of which only 392 were severely injured (overtriage 74%). Paramedic-manned prehospital services provided 66% overtriage and 17% undertriage, anaesthetist-manned services 35% overtriage and 2% undertriage. Falls, high age and admittance by paramedics were significantly associated with undertriage. A Triage-Revised Trauma Score (RTS) < 12 in the emergency department reduced the risk for undertriage compared to RTS = 12 (normal value). Field RTS was documented by anaesthetists in 64% of the patients compared to 33% among paramedics. Patients subject to undertriage had an ISS-adjusted Odds Ratio for 30-day mortality of 2.34 (95% CI 1.6–3.4, p < 0.001) compared to those correctly triaged to TTA. Conclusion Triage precision had not improved after TTA guideline introduction. Anaesthetists perform precise trauma triage, whereas paramedics have potential for improvement. Skewed mission profiles makes comparison of differences in triage precision difficult, but criteria or the use of them may contribute. Massive undertriage among paramedics is of grave concern as patients exposed to undertriage had increased risk of dying.

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• Simensen, Randi; Rehn, Marius; Hagemo, Jostein Skjalg; Fjose, Lars Olav & Heyerdahl, Fridtjof (2026). Methoxyflurane: analgesic benefit and environmental impact – Authors' reply. The Lancet. ISSN 0140-6736. 407, p. 1427–1428. doi: 10.1016/s0140-6736(26)00495-2. Full text in Research Archive
• Torbjørnsen, Sara Stadskleiv; Lie, Sole Lindvåg; Rehn, Marius; Hisdal, Jonny & Høiseth, Lars Øivind (2025). Protocol for a randomized crossover study of thigh cuff inflation in experimental hemorrhage: Assessing its potential as a model for zone 3 REBOA. doi: 10.1371/journal.pone.0327404. Full text in Research Archive Show summary

  Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a method to provide temporary control of noncompressible torso hemorrhage in trauma patients. Previous research on REBOA has mainly focused on animals and patients. This study aims to explore whether thigh cuff inflation combined with simulated hemorrhage can serve as an experimental human model for zone 3 REBOA. Lower body negative pressure is a model of hypovolemia. A zone 3 REBOA occludes aorta at its bifurcation, essentially excluding the pelvis and lower extremities from the circulation. Bilateral proximal thigh cuffs will occlude blood vessels to and from the lower extremities. Twenty healthy volunteers will be exposed to bilateral proximal thigh cuff inflation to suprasystolic pressures to simulate the hemodynamic effects of REBOA during experimental hemorrhage using lower body negative pressure (LBNP). Each participant will complete two experimental conditions in a randomized order within one study visit. In the one condition, subjects will undergo only 60 mmHg LBNP for six minutes. In the alternate condition, 60 mmHg LBNP will be applied for six minutes, adding thigh cuff inflation during the final three minutes. Continuous, non-invasive monitoring of systemic hemodynamic parameters—including arterial blood pressure, stroke volume, and heart rate—will be conducted. Cerebral hemodynamics will be assessed by measuring middle cerebral artery blood velocity and cerebral oxygenation. Pain related to thigh cuff inflation will be assessed using a verbal numerical rating scale. The impact of thigh cuff inflation on systemic and cerebral hemodynamics will be evaluated using mixed-effects regression modeling. This study aims to examine the systemic and cerebral hemodynamic effects of combined thigh cuff inflation and lower body negative pressure in healthy volunteers. Based on the feasibility and findings, the potential of this combination as a model for zone 3 REBOA in simulated hemorrhage will be discussed.

• Hooper, Matthew & Rehn, Marius (2025). Beyond life extension– is it time for ‘Emergency Last Aid’ training? Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 33(1). doi: 10.1186/s13049-025-01330-5. Full text in Research Archive
• Rognås, Leif; Rehn, Marius & Nørby, Karina Damsgaard (2025). Post-mission debriefs in helicopter emergency medicine services- introducing "The compassionate debrief". Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 33(1), p. 10–10. doi: 10.1186/s13049-025-01326-1. Full text in Research Archive
• Hansen, Peter Martin; Rehn, Marius; Jakobsen, Rasmus Peter; Byrdorf, Jesper; Lundorff, Simon Hestbech & Mikkelsen, Søren (2025). Concrete silo collapse: emergency medical services response to a mass casualty incident. doi: 10.1186/s13049-025-01376-5. Full text in Research Archive Show summary

  Background Major incidents evolving from occupational accidents are very infrequent in Scandinavia and therefore, case reports are called for. On 26 November, 2024, a fatal occupational accident took place during the construction of a concrete silo in the small rural town of Flemløse (population 574), Denmark. Three people died and six were injured as the result of a collapsing concrete roof during construction. We aim to describe the incident response by the emergency medical services (EMS), to identify areas of improvement, and to evaluate the adherence to current national major incident guidelines and communication grids. Case presentation The initial call to the emergency medical dispatch center described an accident comprising fifteen injured persons, all of whom were migrant workers. Seventeen EMS units including two helicopter EMS units were dispatched to scene. Three critically injured patients were admitted to a nearby trauma center, whereas three lightly injured were taken to a regional trauma hospital. The initial reports overestimated the number of possible casualties and therefore, the available resources were ample. The very construction of the silo resulted in challenging conditions for evacuation of the injured patients. Chemical, biological, radiological, nuclear, and explosive (CBRNE) aspects of the incident added to the inherent complexity in major incident management. Although potentially detrimental to the patients, the prolonged extrication of the patients enabled the prehospital services to procure a timely organization of the incident site according to guidelines and an organized transport prioritization of the victims. The communication within EMS and between authorities was generally as per national guideline. Conclusions The EMS response to this major incident generally adhered to the national guidelines and, furthermore, the communication within and between authorities was established according to guidelines. Important findings included the use of local resources by the incident command and improvised means for the evacuation of victims from a highly hostile environment. The triage of patients adhered to local and national major incident guidelines. Migrant workers have increased risk for occupational accidents.

• Strobel, Johannes; Rognås, Leif; Steen, Evi; Miranda, Dinis Reis; Schwietring, Jens & Reifferscheid, Florian [Show all 8 contributors for this article] (2025). Same standards - different outcomes? Why clinical governance is essential to safe and consistent high-quality patient care: A call for a european governance alliance in HEMS. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 33(1). doi: 10.1186/s13049-025-01421-3. Full text in Research Archive
• Hooper, Matthew & Rehn, Marius (2025). Response to Bollig and Zelco. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 33(1). doi: 10.1186/s13049-025-01394-3. Full text in Research Archive Show summary

  In this reply we discuss the comments raised by Bollig and Zelco on our Editorial on Emergency Last Aid (ELA). We focus on that ELA is a clinician-focused educational initiative specifically tailored for those working in high-acuity, high-consequence settings such as pre-hospital, emergency, and critical care environments. The course is designed specifically for clinicians operating in environments where leadership, decision-making, and compassionate communication often occur under intense pressure, frequently with limited time and support.

• Kvernberg, Joachim; Henriksen, Finn Lund; Lauridsen, Kasper Glerup; Rehn, Marius & Hansen, Peter Martin (2025). Oxygen Saturation in Relation to Flying Altitude. A Scoping Review Protocol. doi: 10.1111/aas.70041. Full text in Research Archive
• Nordviste, Vegard; Rehn, Marius; Krüger, Andreas Jørstad & Brede, Jostein Rødseth (2024). Time difference between pad placement in double versus single external defibrillation: a live patient simulation model. Full text in Research Archive
• Simensen, Randi; Fjose, Lars Olav; Rehn, Marius; Hagemo, Jostein Skjalg; Thorsen, Kjetil & Heyerdahl, Fridtjof (2023). Comparison of three regimens with inhalational methoxyflurane versus intranasal fentanyl versus intravenous morphine in pre-hospital acute pain management: study protocol for a randomized controlled trial (PreMeFen). Trials. 24(1). doi: 10.1186/s13063-023-07590-9. Full text in Research Archive Show summary

  Background Pre-hospital pain management has traditionally been performed with intravenous (IV) morphine, but oligoanalgesia remain a recognized problem. Pain reduction is essential for patient satisfaction and is regarded as a measure of successful treatment. We aim to establish whether non-invasive methods such as inhalation of methoxyflurane is non-inferior to intranasal fentanyl or non-inferior to the well-known IV morphine in the pre-hospital treatment of acute pain. Method/design The PreMeFen study is a phase three, three-armed, randomized, controlled, non-inferiority trial to compare three regimens of analgesics: inhalation of methoxyflurane and intranasal (IN) fentanyl versus IV morphine. It is an open-label trial with a 1:1:1 randomization to the three treatment groups. The primary endpoint is the change in pain numeric rating scale (NRS) (0–10) from baseline to 10 min after start of investigational medicinal product administration (IMP). The non-inferiority margin was set to 1.3, and a sample size of 270 patients per protocol (90 in each treatment arm) will detect this difference with 90% power. Discussion We chose a study design with comparison of analgesic regimens rather than fixed doses because of the substantial differences in drug characteristics and for the results to be relevant to inform policymakers in the pre-hospital setting. We recognize that easier administration of analgesics will lead to better pain management for many patients if the regimens are as good as the existing, and hence, we chose a non-inferiority design. The primary endpoint, the change in pain (NRS) after 10 min, is set to address the immediate need of pain reduction for patients with acute prehospital pain. On a later stage, more analgesic methods are often available. Summary PreMeFen is a non-inferiority randomized controlled trial comparing three analgesic regimens aiming to establish whether inhalation of methoxyflurane or intranasal fentanyl is as good as IV morphine for fast reduction of acute pain in the prehospital setting.

• Sigurðsson, Martin Ingi; Chew, Michelle; Olkkola, Klaus T.; Rehn, Marius; Kalliomäki, Maija-Liisa & Møller, Morten Hylander (2023). Saudi Critical Care Society clinical practice guidelines on the prevention of venous thromboembolism in adults with trauma: Endorsement by the Scandinavian Society of Anaesthesiology and Intensive Care Medicine. Acta Anaesthesiologica Scandinavica. ISSN 0001-5172. doi: 10.1111/aas.14292. Full text in Research Archive
• Hansen, Peter Martin; Nielsen, Martine Siw; Rehn, Marius; Lassen, Annmarie Touborg; Mikkelsen, Søren & Perner, Anders [Show all 7 contributors for this article] (2023). Ambulance and helicopter response time. Association with patient outcome and illness severity: Protocol of a systematic literature review and meta-analysis. Acta Anaesthesiologica Scandinavica. ISSN 0001-5172. doi: 10.1111/aas.14339. Full text in Research Archive
• Brede, Jostein Rødseth; Søvik, Edmund & Rehn, Marius (2022). Resuscitative endovascular balloon occlusion of the aorta: the postpartum haemorrhage perspective. Critical Care. ISSN 1364-8535. 26. doi: 10.1186/s13054-022-03942-0. Full text in Research Archive
• Hagemo, Jostein Skjalg; Skulberg, Arne Kristian; Rehn, Marius; Valberg, Morten; Pesonen, Maiju & Heimdal, Hans Julius [Show all 7 contributors for this article] (2022). Inhaled nitric oxide as temporary respiratory stabilization in patients with COVID-19 related respiratory failure (INOCOV): Study protocol for a randomized controlled trial. PLOS ONE. 17(5). doi: 10.1371/journal.pone.0268822. Full text in Research Archive Show summary

  Background In March 2020, WHO announced the COVID-19 a pandemic and a major global public health emergency. Mortality from COVID-19 is rapidly increasing globally, with acute respiratory failure as the predominant cause of death. Many patients experience severe hypoxia and life-threatening respiratory failure often requiring mechanical ventilation. To increase safety margins during emergency anaesthesia and rapid sequence intubation (RSI), patients are preoxygenated with a closed facemask with high-flow oxygen and positive end-expiratory pressure (PEEP). Due to the high shunt fraction of deoxygenated blood through the lungs frequently described in COVID-19 however, these measures may be insufficient to avoid harmful hypoxemia. Preoxygenation with inhaled nitric oxide (iNO) potentially reduces the shunt fraction and may thus allow for the necessary margins of safety during RSI. Methods and design The INOCOV protocol describes a phase II pharmacological trial of inhaled nitric oxide (iNO) as an adjunct to standard of care with medical oxygen in initial airway and ventilation management of patients with known or suspected COVID-19 in acute respiratory failure. The trial is parallel two-arm, randomized, controlled, blinded trial. The primary outcome measure is the change in oxygen saturation (SpO2), and the null hypothesis is that there is no difference in the change in SpO2 following initiation of iNO. Trial registration EudraCT number 2020-001656-18; WHO UTN: U1111-1250-1698. Protocol version: 2.0 (June 25th, 2021).

• Lie, Sole Lindvåg; Hisdal, Jonny; Rehn, Marius & Høiseth, Lars Øivind (2022). Effects of supplemental oxygen on systemic and cerebral hemodynamics in experimental hypovolemia: Protocol for a randomized, double blinded crossover study. PLOS ONE. 17(6). doi: 10.1371/journal.pone.0270598. Full text in Research Archive Show summary

  Supplemental oxygen is widely administered in trauma patients, often leading to hyperoxia. However, the clinical evidence for providing supplemental oxygen in all trauma patients is scarce, and hyperoxia has been found to increase mortality in some patient populations. Hypovolemia is a common finding in trauma patients, which affects many hemodynamic parameters, but little is known about how supplemental oxygen affects systemic and cerebral hemodynamics during hypovolemia. We therefore plan to conduct an experimental, randomized, double blinded crossover study to investigate the effect of 100% oxygen compared to room air delivered by a face mask with reservoir on systemic and cerebral hemodynamics during simulated hypovolemia in the lower body negative pressure model in 15 healthy volunteers. We will measure cardiac output, stroke volume, blood pressure, middle cerebral artery velocity and tolerance to hypovolemia continuously in all subjects at two visits to investigate whether oxygen affects the cardiovascular response to simulated hypovolemia. The effect of oxygen on the outcome variables will be analyzed with mixed linear regression. Trial registration: The study is registered in the European Union Drug Regulating Authorities Clinical Trials Database (EudraCT, registration number 2021-003238-35).

• Sverrisson, Kristinn Örn; Chew, Michelle S.; Olkkola, Klaus T.; Rehn, Marius; Yli-Hankala, Arvi & Møller, Morten Hylander (2020). Clinical practice guideline on gastrointestinal bleeding prophylaxis for critically ill patients: Endorsement by the Scandinavian Society of Anaesthesiology and Intensive Care Medicine. Acta Anaesthesiologica Scandinavica. ISSN 0001-5172. doi: 10.1111/aas.13773. Full text in Research Archive
• Rehn, Marius; Bache, Kristi Cecilie Grønvold; Lossius, Hans Morten & Lockey, David (2020). Top five research priorities in physician-provided pre-hospital critical care - appropriate staffing, training and the effect on outcomes. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. doi: 10.1186/s13049-020-00724-x. Full text in Research Archive
• Rehn, Marius & Lockey, David (2020). Early management of multi-trauma. In Gough, Christopher; Barnett, J & Cook, Tim (Ed.), Challenging concepts in critical care : Cases with expert commentary. Oxford University Press. ISSN 9780198814924. p. 53–65. doi: 10.1093/med/9780198814924.003.0004. Full text in Research Archive
• Bache, Kristi Cecilie Grønvold & Rehn, Marius (2019). The boundaries of our imagination are not restricted by limits, but by lack of knowledge. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 27. doi: 10.1186/s13049-019-0677-4. Full text in Research Archive
• Seligmann, William; Dodds, N; Bourn, S; Ray, A; Paulich, S & Rehn, Marius [Show all 7 contributors for this article] (2018). A systematic review of blood and CSF biomarkers as early prognosticators in severe traumatic brain injury. Full text in Research Archive
• Crewdson, Kate; Rehn, Marius; Brohi, Karim & Lockey, David (2018). Response to Burns et al. Acta Anaesthesiologica Scandinavica. ISSN 0001-5172. Full text in Research Archive
• Bache, Kristi Cecilie Grønvold; Rehn, Marius & Thompson, Julian (2018). Seven years since defining the top five research priorities in physician-provided pre-hospital critical care - what did it lead to and where are we now? Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 26(101). doi: 10.1186/s13049-018-0562-6. Full text in Research Archive
• Crewdson, Kate; Rehn, Marius; Brohi, Karim & Lockey, David (2018). Response letter to Voelckel et al. Acta Anaesthesiologica Scandinavica. ISSN 0001-5172. Full text in Research Archive
• Thompson, Charles Julian; Rehn, Marius & Sollid, Stephen J. M. (2018). EHAC medical working group best practice advice on the role of air rescue and pre hospital critical care at major incidents. 26:65, p. 1–5. doi: 10.1186/s13049-018-0522-1. Full text in Research Archive
• Hardy, Sophie; Fattah, Sabina; Wisborg, Torben; Raatiniemi, Lasse; Staff, Trine & Rehn, Marius (2018). Correction: Systematic reporting to improve the emergency medical response to major incidents: A pilot study. BMC Emergency Medicine. 18(6). doi: 10.1186/s12873-018-0157-6. Full text in Research Archive
• Fattah, Sabina; Rehn, Marius & Wisborg, Torben (2018). Slik kan man lære av katastrofer. Dagens næringsliv. ISSN 0803-9372. Full text in Research Archive
• Reid, Bjørn Ole; Haugland, Helge Nystad; Rehn, Marius; Uleberg, Oddvar & Krüger, Andreas (2018). Search and rescue compared to remote Medical Evacuation in a Norwegian setting. Full text in Research Archive
• Nava, Sam; Thompson, Julian & Rehn, Marius (2018). ECMO in major trauma: a systematic literature review. Full text in Research Archive
• Viinamäki, J; Fattah, Sabina; Wisborg, Torben; Rehn, Marius; Engblom, J & Raatiniemi, Lasse (2018). Inter-rater reliability of a global major incident reporting template – a pilot study. Laurea Journal. Full text in Research Archive
• Rehn, Marius; Weaver, AE; Eshelby, Sarah; Røislien, Jo & Lockey, David (2018). Pre-hospital transfusion of red blood cells: the role of balanced transfusion protocols and survival bias. Transfusion Medicine. ISSN 0958-7578. doi: 10.1111/tme.12565. Full text in Research Archive
• Rehn, Marius; Hyldmo, Per Kristian; Magnússon, Vidar; Kurola, Jouni O.; Kongstad, Poul C. & Rognås, Leif Kåre [Show all 8 contributors for this article] (2017). Reply from the authors: SSAI guideline on pre-hospital airway management: keep it safe and simple. Acta Anaesthesiologica Scandinavica. ISSN 0001-5172. 61(1), p. 127–128. doi: 10.1111/aas.12817. Full text in Research Archive
• Hardy, S.; Fattah, Sabina; Raatiniemi, Lasse; Staff, T.; Wisborg, T & Rehn, Marius (2017). How can systematic reporting improve the emergency medical response to major incidents? A pilot study. Full text in Research Archive
• Reid, Bjørn Ole; Rehn, Marius; Uleberg, Oddvar; Næss-Pleym, Lars E. & Krüger, Andreas (2017). Tverretatlig samhandling i legebemannet luftambulanse tjeneste. NAForum. ISSN 0802-5088. 30(3), p. 44–44. Full text in Research Archive
• Viinamäki, J; Fattah, Sabina; Jokela, J; Wisborg, T; Rehn, Marius & Engblom, J (2017). An inter-rater variability study of a global major incident reporting template: A pilot study. Full text in Research Archive
• Samdal, Martin; Haugland, Helge; Fjeldet, Cato; Rehn, Marius & Sandberg, Mårten (2017). Underhengende evakuering med ambulansehelikopter i forbindelse med redningstekniske aksjoner i Helse Sørøst. Full text in Research Archive
• Reid, Bjørn Ole; Rehn, Marius; Uleberg, Oddvar; Næss-Pleym, Lars E. & Krüger, Andreas (2017). Tverretatlig samhandling i legebemannet luftambulanse tjeneste. Full text in Research Archive
• Haugland, Helge Nystad; Uleberg, Oddvar; Klepstad, Pål; Krüger, Andreas & Rehn, Marius (2017). Kvalitetsmåling i legebemannede utrykningstjenester: en systematisk litteraturgjennomgang. Full text in Research Archive
• Haugland, Helge Nystad; Uleberg, Oddvar; Klepstad, Pål; Krüger, Andreas & Rehn, Marius (2017). Kvalitetsmåling i legebemannede utrykningstjenester: en systematisk litteraturgjennomgang. NAForum. ISSN 0802-5088. 30(3), p. 45–45. Full text in Research Archive
• Turner, Conor D.A.; Lockey, David & Rehn, Marius (2017). Erratum: Pre-hospital management of mass casualty civilian shootings: A systematic literature review[literature review. Crit Care,20 (2016)(362)] DOI:10.1186/s13054-016-1543-7. Critical Care. ISSN 1364-8535. 21:94, p. 1–1. doi: 10.1186/s13054-017-1663-8. Full text in Research Archive
• Rehn, Marius (2015). Prehospital håndtering av pediatriske hengninger. Full text in Research Archive
• Rehn, Marius (2015). Reporting of major incident medical management. Full text in Research Archive
• Rehn, Marius (2015). Implementering og anvendbarhet av en global rapporteringsmal for pre-hospital medisinsk håndtering av større hendelser. Full text in Research Archive
• Rehn, Marius (2015). Londons ́s Air Ambulance: 15 year experience with paediatric hanging. Full text in Research Archive
• Reid, Bjørn Ole; Rehn, Marius; Uleberg, Oddvar & Krüger, Andreas (2015). Should we “stay-and-play? A study of patient physiology in Norwegian Helicopter Emergency Services. Full text in Research Archive
• Rehn, Marius (2015). Should we “stay-and-play? A study of patient physiology in Norwegian Helicopter Emergency Services. Full text in Research Archive
• Rehn, Marius (2015). Mechanism of injury as a predictor of severity of injury in road traffic collisions: a literature review. Full text in Research Archive
• Tønsager, Kristin & Rehn, Marius (2015). Pre-hospital management of mass casualty civilian shootings. Full text in Research Archive
• Fattah, Sabina; Rehn, Marius; Lockey, David; Thompson, Julian; Lossius, Hans Morten & Wisborg, Torben (2014). Erratum to A consensus based template for reporting of pre-hospital major incident medical management [Scand J Trauma Resusc Emerg Med 22 (2013) 5]. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 22(1), p. 1–1. doi: 10.1186/s13049-014-0042-6. Full text in Research Archive
• Rehn, Marius & Krüger, Andreas (2014). Quality improvement in pre-hospital critical care : increased value through research and publication. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 22:34. doi: 10.1186/1757-7241-22-34. Full text in Research Archive Show summary

  Pre-hospital critical care is considered to be a complex intervention with a weak evidence base. In quality improvement literature, the value equation has been used to depict the inevitable relationship between resources expenditure and quality. Increased value of pre-hospital critical care involves moving a system from quality assurance to quality improvement. Agreed quality indicators can be integrated in existing quality improvement and complex intervention methodology. A QI system for pre-hospital critical care includes leadership involvement, multi-disciplinary buy-in, data collection infrastructure and long-term commitment. Further, integrating process control with governance systems allows evidence-based change of practice and publishing of results.

• Rehn, Marius & Sollid, Stephen (2013). Retningslinjer for masseskadetriage er etablert. Tidsskrift for Den norske legeforening (Tidsskriftet). ISSN 0029-2001. 133(19), p. 2029–2029. Full text in Research Archive
• Kristiansen, Thomas; Kristensen, Petter; Gravseth, Hans Magne Ulrik; Rehn, Marius; Røislien, Jo & Søreide, Kjetil [Show all 7 contributors for this article] (2013). Epidemiology of trauma: a population-based study of fatal injury and geographical challenges in Norwegian trauma care. Full text in Research Archive
• Fattah, Sabina; Rehn, Marius; Lockey, David; Thompson, J; Lossius, Hans Morten & Wisborg, Torben (2013). A consensus based template for reporting pre-hospital major incident medical management. Acta Anaesthesiologica Scandinavica. ISSN 0001-5172. 57, p. 22–22. Full text in Research Archive
• Rehn, Marius (2013). Improving adjustments for older age in pre-hospital assessment and care. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 21. doi: 10.1186/1757-7241-21-4. Full text in Research Archive
• Kristiansen, Thomas; Rehn, Marius; Gravseth, Hans Magne Ulrik; Lossius, HM & Kristensen, Petter (2011). Paediatric trauma mortality in Norway. Full text in Research Archive
• Kristiansen, Thomas; Rehn, Marius; Braarud, Anne-Cathrine; Holtan, Anders; Skaga, Nls Oddvar & Strand, Terje [Show all 9 contributors for this article] (2010). NYE TRIAGEKRITERIER: OSLO–AKERSHUS TRIAGE STUDIE (OATS). Full text in Research Archive
• Lossius, Hans Morten; Kristiansen, Thomas; Ringdal, Kjetil G. & Rehn, Marius (2010). Inter-hospital transfer: the crux of the trauma system, a curse for trauma registries. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 18. doi: 10.1186/1757-7241-18-15. Full text in Research Archive Show summary

  The inter-hospital transfer of patients is crucial to a well functioning trauma system, and the transfer process may serve as a quality indicator for regional trauma care. However, the assessment of the transfer process requires high-quality data from various sources. Prospective studies and studies based on single-centre trauma registries may fail to capture an appropriate width and depth of data. Thus the creation of inclusive regional and national trauma registries that receive information from all of the services within a trauma system is a prerequisite for high quality inter-hospital transfer studies in the future.

• Rehn, Marius; Vigerust, T; Kruger, A & Andersen, John E. (2010). Paediatric vital sign tape on stretchers: a field-friendly triage tool? Emergency Medicine Journal. ISSN 1472-0205. 27(5), p. 412–412. doi: 10.1136/emj.2009.087585. Full text in Research Archive
• Kristensen, Petter; Kristiansen, Thomas; Rehn, Marius; Gravseth, Hans Magne Ulrik & Bjerkedal, Tor (2010). Fatal road traffic injuries at age 16-20 years among 611654 persons born in Norway 1967-1976: multilevel cohort study. Injury Prevention. ISSN 1353-8047. 16, p. A156–A156. doi: 10.1136/ip.2010.029215.559. Full text in Research Archive
• Kristiansen, Thomas; Rehn, Marius; Gravseth, Hans Magne Ulrik; Lossius, HM & Kristensen, Petter (2010). Patterns of paediatric trauma deaths: 10-year population–based register study. Full text in Research Archive
• Kristensen, Petter; Kristiansen, Thomas; Rehn, Marius; Gravseth, Hans Magne Ulrik & Bjerkedal, Tor (2010). Fatal road traffic injuries at age 16-20 years among 611654 persons born in Norway 1967-1976: multilevel cohort study. Full text in Research Archive
• Krüger, Andreas & Rehn, Marius (2010). Early prophylactic hypothermia in severe traumatic brain injury-Challenging a pre-hospital paradigm? Injury. ISSN 0020-1383. 41(7), p. 1062–1062. doi: 10.1016/j.injury.2009.09.034. Full text in Research Archive
• Krüger, Andreas & Rehn, Marius (2010). Early prophylactic hypothermia in severe traumatic brain injury-Challenging a pre-hospital paradigm? Injury. ISSN 0020-1383. 41(9), p. 975–975. doi: 10.1016/j.injury.2009.09.034. Full text in Research Archive
• Rehn, Marius; Kristiansen, Thomas; Braarud, Anne-Cathrine; Holtan, Anders; Skaga, Nls Oddvar & Strand, Terje [Show all 9 contributors for this article] (2010). Nye triagekriterier: Oslo–Akershus Triage Studie (OATS). Full text in Research Archive
• Rehn, Marius & Krüger, Andreas J. (2010). Det prehospitale paradoks. Full text in Research Archive
• Rehn, Marius & Lossius, Hans Morten (2010). Katastrofetriage. Behov for en nasjonal standard. Full text in Research Archive
• Rehn, Marius; Eken, Torsten; Kruger, Andreas; Steen, Petter Andreas & Lossius, Hans Morten (2009). Re: Field triage in trauma - do the data justify the conclusions? Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 17, p. 25–25. Full text in Research Archive
• Rehn, Marius; Eken, Torsten; Kruger, Andreas; Skaga, Nils Oddvar; Steen, Petter Andreas & Lossius, Hans Morten (2008). Imprecise field triage of trauma victims. Full text in Research Archive
• Rehn, Marius; Eken, Torsten; Kruger, Andreas; Skaga, Nils Oddvar; Steen, Petter Andreas & Lossius, Hans Morten (2008). Upresis felttriage av alvorlig skadde. Full text in Research Archive
• Tønsager, Kristin; Krüger, Andreas; Ringdal, Kjetil G. & Rehn, Marius (2021). Defining core data for continuous benchmarking in pre-hospital critical care. Universitetet i Stavanger. ISSN 9788276449808. Full text in Research Archive Show summary

  The aim of medical research is to improve patient care through evidence-based practice. Currently, the evidence base in physician-staffed emergency medical services (p-EMS) is weak and we remain uncertain for which patients p-EMS assistance is essential to and for which patients p-EMS is not needed. To increase the evidence-base of p-EMS and to evaluate its potential effects, high quality data is pivotal. Currently, data is not reported uniformly, thereby complicating research. Furthermore, we should make better use of routinely collected data as these are readily available, thereby facilitating research. The aim of this thesis was to increase the quality of routinely reported data in p-EMS by focusing on accuracy and completeness. We did this through the following objectives: 1. Explore the feasibility of collecting template data according to a predefined template 2. Explore whether pre-hospital physicians can score a reliable pre-event American Society of Anesthesiologists Physical Scale (ASA-PS) on-scene 3. Describe the quality of reported Glasgow Coma Score (GCS) and Systolic Blood Pressure (SBP) data in studies depicting p-EMS 4. Revise and update a template for reporting in p-EMS We conducted four studies; one feasibility study, one prospective observational study, one systematic literature review and one qualitative consensus project. Accuracy and completeness are two important attributes describing quality in medical research. Without accurate data, research will be inaccurate and erroneous conclusions can be drawn. Furthermore, high completeness rates are always preferable to incomplete data. Based on the four studies we can conclude that the use of a template is feasible in p-EMS, that the quality of reported GCS and SBP is variable and that a reliable pre-event ASA-PS can be scored on-scene. We also created an updated template for reporting in p-EMS. The findings are important because highlighting the varying quality of reporting in p-EMS may increase awareness which may further increase both accuracy and completeness. Furthermore, we argue for incorporation of a full pre-event ASA-PS when reporting from p-EMS, thereby enabling us to take comorbidity into account in p-EMS research. By reporting according to the updated template, we may, in the future, enable comparisons and further development of p-EMS.

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