ORIGINAL RESEARCH Open Access
Physician-s a ed helicop e eme gency
medical se ice has a bene icial impac on
he incidence o p ehospi al hypoxia and
secu ed ai ways on pa ien s wi h se e e
auma ic b ain inju y
Toni Pakkanen
1,2*
, An i Kämä äinen
3
, Heini Huh ala
4
, Tom Sil as
5
, Jouni Nu mi
6
, Ilkka Vi kkunen
1
and
A i Yli-Hankala
2,7
Abs ac
Backg ound: A e auma ic b ain inju y (TBI), hypo ension, hypoxia and hype capnia ha e been shown o esul in
seconda y b ain inju y ha can lead o inc eased mo ali y and disabili y. E ec i e p ehospi al assessmen and
ea men by eme gency medical se ice (EMS) is conside ed essen ial o a ou able ou come. The aim o his
s udy was o e alua e he e ec o a physician-s a ed helicop e eme gency medical se ice (HEMS) in he
ea men o TBI pa ien s.
Me hods: This was a e ospec i e coho s udy. P ehospi al da a om wo pe iods we e collec ed: be o e (EMS
g oup) and a e (HEMS g oup) he implemen a ion o a physician-s a ed HEMS. Unconscious p ehospi al pa ien s
due o se e e TBI we e included in he s udy. Unconsciousness was de ined as a Glasgow coma scale (GCS)
sco e ≤8 and was documen ed ei he on-scene, du ing anspo a ion o by an on-call neu osu geon on hospi al
admission. Modi ied Glasgow Ou come Sco e (GOS) was used o assessmen o six-mon h neu ological ou come
and good neu ological ou come was de ined as GOS 4–5.
Resul s: Da a om 181 pa ien s in he EMS g oup and 85 pa ien s in he HEMS g oup we e a ailable o
neu ological ou come analyses. The baseline cha ac e is ics and he i s eco ded i al signs o he wo coho s
we e simila . Good neu ological ou come was mo e equen in he HEMS g oup; 42% o he HEMS managed
pa ien s and 28% (p= 0.022) o he EMS managed pa ien s had a good neu ological eco e y. The ai way was mo e
equen ly secu ed in he HEMS g oup (p< 0.001). On a i al a he eme gency depa men , he pa ien s in he
HEMS g oup we e less o en hypoxic (p= 0.024). In uni a ia e analysis HEMS pe iod, lowe age and secu ed ai way
we e associa ed wi h good neu ological ou come.
Conclusion: The in oduc ion o a physician-s a ed HEMS uni esul ed in dec eased incidence o p ehospi al
hypoxia and inc eased he numbe o secu ed ai ways. This may ha e con ibu ed o he obse ed imp o ed
neu ological ou come du ing he HEMS pe iod.
T ial egis a ion: ClinicalT ials.go IDNCT02659046. Regis e ed Janua y 15 h, 2016.
Keywo ds: P ehospi al eme gency ca e (MeSH), Eme gency medical se ices (MeSH), C i ical ca e (MeSH), T auma ic
b ain inju y (MeSH), Ai way managemen (MeSH), Endo acheal in uba ion (MeSH), Pa ien ou come assessmen
(MeSH), Glasgow ou come scale (MeSH)
* Co espondence: [email p o ec ed]
1
FinnHEMS L d, Resea ch and De elopmen Uni , Van aa, Finland
2
Depa men o Anaes hesia, Tampe e Uni e si y Hospi al, Tampe e, Finland
Full lis o au ho in o ma ion is a ailable a he end o he a icle
© The Au ho (s). 2017 Open Access This a icle is dis ibu ed unde he e ms o he C ea i e Commons A ibu ion 4.0
In e na ional License (h p://c ea i ecommons.o g/licenses/by/4.0/), which pe mi s un es ic ed use, dis ibu ion, and
ep oduc ion in any medium, p o ided you gi e app op ia e c edi o he o iginal au ho (s) and he sou ce, p o ide a link o
he C ea i e Commons license, and indica e i changes we e made. The C ea i e Commons Public Domain Dedica ion wai e
(h p://c ea i ecommons.o g/publicdomain/ze o/1.0/) applies o he da a made a ailable in his a icle, unless o he wise s a ed.
Pakkanen e al. Scandina ian Jou nal o T auma, Resusci a ion and Eme gency Medicine
(2017) 25:94
DOI 10.1186/s13049-017-0438-1
In oduc ion
A e auma ic b ain inju y (TBI), hypo ension, hypoxia
and hype capnia ha e been shown o esul in seconda y
b ain inju y ha can lead o inc eased mo ali y and dis-
abili y [1]. As he p ognosis o pa ien s wi h se e e TBI
and a low Glasgow Coma Scale (GCS) sco e depends on
ea ly suppo o i al unc ions [2, 3], e ec i e p ehospi-
al assessmen and ea men is conside ed essen ial o
a ou able ou come [4]. In pa icula , p ehospi al p e-
en ion o hypoxia by adequa e ai way and espi a o y
managemen including a secu ed ai way, no mo en ila-
ion and p e en ion o aspi a ion is s ongly associa ed
wi h imp o ed ou come [5–8].
Depending on he s uc u e o he eme gency medical
se ice (EMS) sys em he le el o a ailable ea men
a ies, and his may ha e an impac on he pa ien ’s ou -
come. A sys ema ic e iew om 2009 e ealed only a
ew con olled s udies examining he e ec o ad anced
in e en ions by a p ehospi al EMS physician on ou -
come. Inc eased su i al was ound in majo auma pa-
ien s and in pa ien s wi h ca diac a es [9].
Al hough a Helicop e Eme gency Medical Se ice
(HEMS) is a pa o he p ehospi al auma sys em in
many coun ies, HEMS and he possible impac i has
on ou come in auma ically inju ed pa ien s emains a
subjec o deba e. S udies ha e been pe o med wi h he
aim o e alua e he e ec o HEMS on ou come in
auma pa ien s, wi h con adic o y esul s [10–15]. Di -
e ences in HEMS eam composi ion, dispa ch p o ocols,
EMS o ganisa ion, hospi al ea men and me hodology
and ou come measu es make compa isons be ween
s udies di icul .
The aim o his s udy was o e alua e he e ec o a
physician-s a ed HEMS in he ea men o TBI pa-
ien s. The hypo hesis was ha implemen a ion o a
physician-s a ed HEMS would ha e a posi i e e ec on
ou come.
Ma e ial and me hods
The Pi kanmaa dis ic has he second la ges popula ion
in Finland, wi h app oxima ely a hal million inhabi an s
li ing in he ci y o Tampe e and in he su ounding mu-
nicipali ies. All TBI pa ien s in he s udy egion a e admi -
ed o Tampe e Uni e si y Hospi al, which is he e e al
cen e in he a ea, and p o ides immedia e neu osu gical
ca e acco ding o na ional guidelines ( he i s edi ion
published in 2003, wi h an upda e in 2008) [16].
Pe iod 1 (2005–2010): Pa amedic EMS (EMS g oup)
The EMS was he esponsibili y o and o ganised by
each o he municipali ies in he egion. The sys em was
wo- ie ed, wi h eme gency medical echnician basic li e
suppo and pa amedic ad anced li e suppo uni s.
The e we e no dedica ed on-call EMS medical di ec o s,
and no physician-s a ed EMS uni s a ailable on-scene.
P ehospi al c ews consul ed on-call hospi al and local
p ima y ca e physicians o ea men guidelines when
deemed necessa y. Pa ien s wi h a dec eased le el o
consciousness we e ou inely adminis e ed oxygen ac-
co ding o na ional guidelines and en ila ion was
assis ed wi h bag- al e mask i equi ed. Endo acheal
in uba ion was p ima ily pe o med in ca diac a es pa-
ien s and in equen ly in pa ien s wi h a dec eased le el
o consciousness. Hypno ics o neu omuscula blocking
agen s we e no a ailable in he p ehospi al se ing and
endo acheal in uba ion was pe o med using seda i es
and opioids only, a he disc e ion o he pa amedic on
he scene.
Pe iod 2 (2012–2015): Physician-s a ed HEMS
(HEMS g oup)
A physician-s a ed HEMS was in oduced in o he EMS
in he au umn o 2011, co e ing all municipali ies in he
s udy a ea. The HEMS is dispa ched on p ima y missions
oge he wi h basic o ad anced li e suppo EMS uni s o
pa ien s wi h po en ial majo auma o o he c i ical
medical condi ion. The ole o he helicop e is p ima ily
o anspo he physician o he scene, while pa ien
anspo is mainly ca ied ou by EMS g ound ehicles
wi h he physician esco ing he pa ien o he eme gency
depa men (ED) when necessa y. The physicians a e
anaes hesiologis s expe ienced in p ehospi al c i ical
eme gency medicine and conduc ad anced ai way man-
agemen acco ding o he HEMS uni TBI s anda d ope -
a ion p ocedu e (SOP). Gene al anaes hesia complying
wi h he p inciples o neu oanaes hesia, including hyp-
no ics, opioids and neu omuscula blocking agen s, is ou-
inely used o apid sequence in uba ion (RSI).
Capnog aphy-assis ed con olled en ila ion, in asi e
haemodynamic moni o ing wi h a e ial blood gas sam-
pling and, i necessa y, no ad enaline-in usion and hype -
onic saline a e also ou inely employed acco ding o he
uni ’s TBI SOP and na ional guidelines [16].
S udy design
This e ospec i e coho s udy compa es he ou come o
pa ien s wi h se e e TBI. P ehospi al da a om wo pe-
iods we e collec ed: be o e (EMS g oup) and a e
(HEMS g oup) he implemen a ion o he HEMS. Da a o
he EMS g oup ha e been p esen ed in a p e ious s udy
[10] compa ing he ou come o TBI pa ien s in wo di e -
en ly s uc u ed EMS sys ems and we e used as a his o -
ical con ol coho in he cu en s udy. As he physician-
s a ed HEMS was in oduced in he au umn o 2011, ha
yea was excluded om da a collec ing.
Unconscious p ehospi al pa ien s due o se e e TBI
we e included in he s udy. Unconsciousness was de-
ined as a Glasgow coma scale (GCS) sco e ≤8 [17] and
Pakkanen e al. Scandina ian Jou nal o T auma, Resusci a ion and Eme gency Medicine (2017) 25:94 Page 2 o 7
was documen ed ei he on-scene, du ing anspo a ion
o by an on-call neu osu geon on hospi al admission.
The ICD-10 hospi al discha ge diagnoses o auma ic
b ain inju y and/o skull ac u e (S06.2-S06.6, S06.8,
S02.1) we e used o iden i y he pa ien s, and hei pa-
ien eco ds we e c oss- e e enced wi h EMS and
HEMS un-shee s. Pa ien s wi h concomi an mul iple
inju ies wi h he need o o he han neu osu gical in e -
en ions we e excluded, as we e pa ien s ans e ed
om o he hospi als.
Da a collec ed included age, gende , mechanism o in-
ju y, GCS sco e and i al signs on-scene and on a i al
a he ED, ai way managemen , esponse and o al mis-
sion imes. Hypoxia was de ined as an SpO
2
below 90%
and hypo ension was de ined as a sys olic blood p essu e
(SBP) below 90 mmHg. These de ini ions a e consis en
wi h he la es edi ion o he B ain T auma Founda ion’s
guidelines o p ehospi al managemen o auma ic
b ain inju y [1]. Fo assessmen o neu ological ou come,
a modi ied six-mon h Glasgow Ou come Sco e (GOS)
was used [18, 19]. A GOS o 1 deno ed dea h wi hin six
mon hs, GOS 2–3 poo neu ological ou come (need o
assis ance in ac i i ies o daily li ing) and GOS 4–5good
neu ological eco e y (independen li e). Ou come
e alua ion was pe o med, o ime o dea h was ob-
ained, by he co esponding au ho , based on hospi al
pa ien eco ds six mon hs a e he inciden . I he ou -
come e alua ion was unclea , he esea ch eam mem-
be s e iewed he case and a join decision was made.
S a is ical analyses
Resul s a e exp essed as medians wi h anges o pe cen -
ages. The g oups we e compa ed using he chi-squa e o
Fishe ’s exac es o ca ego ical a iables. Six-mon h
su i al is p esen ed wi h Kaplan-Meie cu es. Com-
pa ison be ween EMS and HEMS was made wi h he
log- ank es .
Bina y logis ic eg ession analysis was used o p edic
good ou come. Va iables o he uni a ia e analysis wi h
p< 0.05 we e added o he mul i a iable analysis. S a is-
ical signi icance was conside ed a a p- alue less han
0.05. The da a we e analysed using IBM SPSS S a is ics
o Windows Ve sion 21.0. A monk, NY: IBM Co p. e-
leased 2012.
Resul s
Du ing he s udy pe iod (Pe iods 1 + 2) da a om 181
pa ien s in he EMS g oup and 85 pa ien s in he HEMS
g oup we e a ailable o neu ological ou come analyses
(Fig. 1). The baseline cha ac e is ics and he i s e-
co ded i al signs o he wo coho s we e simila and
a e p esen ed in Table 1.
Fig. 1 Flow-cha
Pakkanen e al. Scandina ian Jou nal o T auma, Resusci a ion and Eme gency Medicine (2017) 25:94 Page 3 o 7
Good neu ological ou come was mo e equen in he
HEMS g oup; 42% o he HEMS managed pa ien s and
28% (p= 0.022) o he EMS managed pa ien s had a
good neu ological eco e y (GOS 4–5), li ing an inde-
penden li e six mon hs a e he inciden . The e was a
end o highe su i al (53% s. 43%, Log Rank
p= 0.066) in he HEMS g oup du ing he 6-mon h
ollow-up pe iod, p esen ed as Kaplan-Meie cu es in
Fig. 2. A p ehospi al decision no o ea was done by
he a ending HEMS physician on wo pa ien s. A sub-
g oup Kaplan-Meie analysis wi h hese wo pa ien s e-
mo ed om he HEMS g oup esul ed in highe su i al
(p= 0.045).
The logis ic eg ession analysis is p esen ed in Table 2.
The ai way was secu ed mo e equen ly in he HEMS
g oup (p< 0.001). Due o long dis ances, 10 pa ien s
we e ai anspo ed o he ED in he HEMS g oup,
while pa ien anspo was mainly ca ied ou by EMS
g ound ehicles wi h he physician esco ing he pa ien .
On a i al a he ED, pa ien s in he HEMS g oup we e
less o en hypoxic (p= 0.024). In uni a ia e analysis
HEMS-pe iod, lowe age and secu ed ai way we e
Table 1 Baseline cha ac e is ics
Pe iod 1: EMS Pe iod 2: HEMS
n= 181 n= 85 p- alue
Age, yea s (Median, Q
1
-Q
3
)54 33–69 53 23–74 0.479
Gende , male (n, %) 127 70 58 68 0.820
Mechanism o inju y (n, %) 0.288
Fall om g ound le el 79 43 32 38
T a ic acciden 41 23 29 34
Fall om a heigh (> 2 m) 25 14 9 11
Violence 14 8 6 7
O he 4 2 4 5
Unknown 18 10 5 6
P ima y GCS (Median, Q
1
-Q
3
)5 3–75 3–7 0.956
P ima y i al pa ame e s (n/ o al, %)
Hypoxia 32/170 19 18/84 21 0.369
Hypo ension 7/174 4 4/84 5 0.514
Ai way secu ed (n, %) 29 16 81 95 < 0.001
P ehospi al decision no o ea ––22
Vi al pa ame e s on a i al a he ED (n/ o al, %)
Hypoxia 18/173 10 2/84 2 0.024
Hypo ension 7/179 4 4/85 5 0.750
Mission ela ed imes, minu es (Median, Range)
F om dispa ch o a i al on-scene
1s EMS Uni on-scene 8 0–37 12 4–41 0.006
HEMS ––23 6–85
To al mission ime 54 18–180 82 30–201 < 0.001
Fig. 2 Six-mon h su i al acco ding o EMS sys em (Log
Rank p= 0.066)
Pakkanen e al. Scandina ian Jou nal o T auma, Resusci a ion and Eme gency Medicine (2017) 25:94 Page 4 o 7
associa ed wi h good neu ological ou come. In mul i a i-
able analysis lowe age emained as a signi ican ac o
o good ou come.
Discussion
The in oduc ion o a physician-s a ed HEMS uni sig-
ni ican ly dec eased he p opo ion o hypoxic TBI pa-
ien s and inc eased he numbe o pa ien s wi h
secu ed ai ways on hospi al admission. This may ha e
con ibu ed o he obse ed imp o ed neu ological ou -
come du ing he HEMS pe iod.
This suppo s ou p e ious indings when e alua ing
mo ali y and neu ological ou come o TBI pa ien s in
wo egions wi h di e en ly s uc u ed EMS sys ems [10].
The baseline cha ac e is ics o he wo coho s we e
simila , wi h no di e ences be ween he g oups ega d-
ing gende , mechanism o inju y o ini ial GCS. Only he
mission- ela ed ime ames di e ed, since he esponse
ime and delay o hospi al admission we e longe in he
HEMS g oup. In he HEMS g oup 10 pa ien s we e ai
anspo ed o he ED, bu as he o al mission imes in
he HEMS g oup we e longe , his esul in ou opinion
excludes he impac o he ai anspo i sel .
The p inciples o p ehospi al ai way managemen o
TBI pa ien s a e desc ibed in in e na ional guidelines: an
ai way should be es ablished in pa ien s who ha e se e e
TBI (GCS ≤8), who a e unable o main ain an adequa e
ai way o who a e hypoxaemic despi e supplemen al
oxygen [1]. The op imal way o secu e he ai way s ill e-
mains con o e sial [20, 21]. Wi h endo acheal in ub-
a ion, i RSI is pe o med poo ly, hypoxia and hypo ension
ha e been shown o ha e a nega i e e ec on ou come o
TBI pa ien s [21–23]. In he p esen s udy, i ually all
pa ien s we e in uba ed in he p ehospi al se ing in he
physician-s a ed HEMS g oup, whe eas only a ew
pa ien s we e in uba ed in he pa amedic EMS g oup. In
uni a ia e analysis o he HEMS-pe iod, secu ing he
ai way was associa ed wi h good neu ological ou come.
Anaes he ics we e used by he HEMS physicians, while
he pa amedics we e limi ed o he use o seda i es and
opioids. This may ha e in luenced on he obse ed di e -
ence in he a e o ai way managemen p ocedu es du ing
he wo pe iods.
Table 2 Uni a ia e and mul i a iable logis ic eg ession o six-mon h good ou come p edic o s
Uni a ia e Mul i a iable
OR 95% CI p- alue OR 95% CI p- alue
Pe iod
HEMS 1.87 1.09–3.21 0.022 2.46 0.89–6.84 0.083
EMS 1
Age 0.95 0.93–0.96 < 0.001 0.95 0.93–0.96 < 0.001
Sex
Male 1.78 0.99–3.19 0.055 No en e ed
Female 1
GCS 1.07 0.97–1.18 0.183 No en e ed
Hypoxia
On-scene 1 No en e ed
No p esen 1.65 0.81–3.37 0.165
Hypo ension
On-scene 1 No en e ed
No p esen 2.26 0.48–10.72 0.303
Ai way
Secu ed 1.89 1.12–3.19 0.017 0.71 0.27–1.88 0.486
No secu ed 1
Hypoxia
A ER 1 No en e ed
No p esen 2.12 0.69–6.54 0.193
Hypo ension
A ER 1 No en e ed
No p esen 2.28 0.48–10.78 0.299
Pakkanen e al. Scandina ian Jou nal o T auma, Resusci a ion and Eme gency Medicine (2017) 25:94 Page 5 o 7

In p e ious s udies bo h hypoxaemia and hypo ension
ha e been shown o ha e a nega i e impac on TBI ou -
come [2, 5]. We ound no di e ence in he on-scene oc-
cu ence o dis u bances o hese i al signs be ween he
s udy g oups. The p opo ion o hypo ensi e pa ien s on
a i al o he ED was simila in bo h g oups. Howe e ,
hypoxia was mo e common in he pa ien s managed by
he pa amedic EMS. The likely explana ion o his ind-
ing is he highe equency o p ehospi al endo acheal
in uba ion, con olled en ila ion and mo e p ecise and
in asi e moni o ing o he i al signs in he HEMS
g oup.
Age has been demons a ed o be an impo an p e-
dic o o ou come a e head inju y. Olde age has been
shown o be an independen isk ac o o highe mo -
ali y and poo unc ional ou come in TBI [24, 25]. In
his s udy, in uni- and mul i a ia e analysis o he
HEMS-pe iod lowe age was associa ed wi h good
neu ological ou come.
S udy limi a ions
This was a e ospec i e obse a ional s udy and he ol-
lowing limi a ions should be conside ed when in e p e -
ing he esul s. The p ehospi al da a we e o iginally sel -
epo ed, could no be independen ly e i ied, and could
he e o e ha e been biased. Con inuous da a on i al
signs co e ing he whole p ehospi al phase we e no
a ailable; he e o e, sho -li ed hypoxia o hypo ension
du ing he p ehospi al pe iod canno wi h ce ain y be
excluded du ing ei he pe iod. Due o he low a e o
endo acheal in uba ion in he pa amedic EMS g oup,
pa ame e s ega ding en ila ion could no be compa ed.
The i s CT scans we e no e alua ed using he Ma -
shall classi ica ion. Neu osu gical and in ensi e ca e
ha e ad anced du ing he s udy pe iod, which may also
ha e a ec ed he esul s and may o some ex en ac-
coun o he imp o ed ou come. Ou come e alua ion
was based on pa ien eco d assessmen wi hou clinical
examina ion o he help o a ques ionnai e. I is possible
ha he dea hs occu ing in he la e s ages o he ollow-
up pe iod we e un ela ed o he p ehospi al index e en ,
wi h seconda y diseases o inju y being he cause.
Conclusions
The in oduc ion o a physician-s a ed HEMS uni e-
sul ed in a bene icial impac on pa ien ca e e lec ed by
a dec eased incidence o p ehospi al hypoxia and an in-
c eased numbe o pa ien s wi h secu ed ai ways. This
may ha e con ibu ed o he obse ed imp o ed neu o-
logical ou come du ing he HEMS pe iod. Fu he p o-
spec i e mul icen e s udies wi h de ailed da a a e
needed o con i m he hypo hesis ha a physician-
s a ed HEMS has a posi i e impac on he ou come o
TBI pa ien s.
Abb e ia ions
ED: Eme gency Depa men ; EMS: Eme gency Medical Se ices; GCS: Glasgow
Coma Scale; GOS: Glasgow Ou come Sco e; HEMS: Helicop e Eme gency
Medical Se ice; RSI: Rapid Sequence In uba ion; TBI: T auma ic B ain Inju y
Acknowledgemen s
This s udy is dedica ed o he memo y o Janne Vi a, M.D.
A ailabili y o da a and suppo ing ma e ials
Please con ac au ho o da a eques s.
Funding
This s udy was suppo ed by a s udy g an om FinnHEMS l d, Resea ch and
De elopmen Uni .
Decla a ions
The s udy was conduc ed in he he Pi kanmaa Hospi al Dis ic , Finland.
Au ho s’con ibu ions
TP: he concep and design o he s udy, acquisi ion and e alua ion o he
da a and co esponding au ho . AK: he concep and design o he s udy,
e alua ion o he da a and he manusc ip . HH: s a is ical analyses. TS:
e alua ion o he da a and he manusc ip . JN: e alua ion o he da a and
he manusc ip . IV: e alua ion o he da a and he manusc ip . AYH:
e alua ion o he da a and he manusc ip . All au ho s ead and app o ed
he inal manusc ip .
E hics app o al and consen o pa icipa e
The s udy p o ocol was app o ed by he Regional E hics Commi ee o he
Pi kanmaa Hospi al Dis ic ( e e ence numbe R15158), pe mission o conduc
he s udy was ob ained om he Resea ch Di ec o o Tampe e Uni e si y
Hospi al and egis e ed in ClinicalT ials.go (Iden i ie NCT02659046, egis e ed
Janua y 15 h 2016).
Consen o publica ion
No applicable.
Compe ing in e es s
The au ho s decla e ha hey ha e no compe ing in e es s.
Publishe ’sNo e
Sp inge Na u e emains neu al wi h ega d o ju isdic ional claims in
published maps and ins i u ional a ilia ions.
Au ho de ails
1
FinnHEMS L d, Resea ch and De elopmen Uni , Van aa, Finland.
2
Depa men o Anaes hesia, Tampe e Uni e si y Hospi al, Tampe e, Finland.
3
Tays Eme gency Medical Se ice, FinnHEMS 30, Tampe e Uni e si y Hospi al,
Tampe e, Finland.
4
Facul y o Social Sciences, Uni e si y o Tampe e,
Tampe e, Finland.
5
Depa men o Anaes hesia and In ensi e Ca e, Helsinki
Uni e si y Hospi al, Uni e si y o Helsinki, Helsinki, Finland.
6
Depa men o
Eme gency Medicine and Se ices, Helsinki Uni e si y Hospi al and
Eme gency Medicine, Uni e si y o Helsinki, Helsinki, Finland.
7
Facul y o
Medicine and Li e Sciences, Uni e si y o Tampe e, Tampe e, Finland.
Recei ed: 27 Ma ch 2017 Accep ed: 6 Sep embe 2017
Re e ences
1. Badja ia N, Ca ney N, C occo TJ, Falla ME, Hennes HM, Jagoda AS, e al.
Guidelines o p ehospi al managemen o auma ic b ain inju y 2nd
edi ion. P ehosp Eme g Ca e. 2008;12(Suppl 1):S1–52.
2. Chesnu RM, Ma shall LF, Klaube MR, Blun BA, Baldwin N, Eisenbe g HM,
e al. The ole o seconda y b ain inju y in de e mining ou come om
se e e head inju y. J T auma. 1993;34(2):216–22.
3. S ocche i N, Fu lan A, Vol a F. Hypoxemia and a e ial hypo ension a he
acciden scene in head inju y. J T auma. 1996;40(5):764–7.
4. Boe C, F anschman G, Loe SA. P ehospi al managemen o se e e
auma ic b ain inju y: concep s and ongoing con o e sies. Cu Opin
Anaes hesiol. 2012;25(5):556–62.
Pakkanen e al. Scandina ian Jou nal o T auma, Resusci a ion and Eme gency Medicine (2017) 25:94 Page 6 o 7
5. Wang HE, Pei zman AB, Cassidy LD, Adelson PD, Yealy DM. Ou -o -hospi al
endo acheal in uba ion and ou come a e auma ic b ain inju y. Ann
Eme g Med. 2004;44(5):439–50.
6. Mu ay JA, Deme iades D, Be ne TV, S a on SJ, C ye HG, Bonga d F, e al.
P ehospi al in uba ion in pa ien s wi h se e e head inju y. J T auma. 2000;
49(6):1065–70.
7. Da is DP. P ehospi al in uba ion o b ain-inju ed pa ien s. Cu Opin C i
Ca e. 2008;14(2):142–8.
8. Da is DP. Ea ly en ila ion in auma ic b ain inju y. Resusci a ion. 2008;76(3):
333–40.
9. Bo ke MT, Bakke SA, Ch is ensen EF. A sys ema ic e iew o con olled
s udies: do physicians inc ease su i al wi h p ehospi al ea men ? Scand J
T auma Resusc Eme g Med. 2009;17:12.
10. Pakkanen T, Vi kkunen I, Kama ainen A, Huh ala H, Sil as T, Vi a J, e al.
P e-hospi al se e e auma ic b ain inju y - compa ison o ou come in
pa amedic e sus physician s a ed eme gency medical se ices. Scand J
T auma Resusc Eme g Med. 2016;24:62.
11. Ringbu g AN, Thomas SH, S eye be g EW, an Lieshou EM, Pa ka P,
Schippe IB. Li es sa ed by helicop e eme gency medical se ices: an
o e iew o li e a u e. Ai Med J. 2009;28(6):298–302.
12. F ankema SP, Ringbu g AN, S eye be g EW, Edwa ds MJ, Schippe IB, an
Vug AB. Bene icial e ec o helicop e eme gency medical se ices on
su i al o se e ely inju ed pa ien s. B J Su g. 2004;91(11):1520–6.
13. Ga ne A, Rash o d S, Lee A, Ba olacci R. Addi ion o physicians o
pa amedic helicop e se ices dec eases blun auma mo ali y. Aus N Z J
Su g. 1999;69(10):697–701.
14. Ii ola TT, Laaksonen MI, Vahlbe g TJ, Pal e HK. E ec o physician-s a ed
helicop e eme gency medical se ice on blun auma pa ien su i al and
p ehospi al ca e. Eu J Eme g Med. 2006;13(6):335–9.
15. Nicholl JP, B azie JE, Snooks HA. E ec s o London helicop e eme gency
medical se ice on su i al a e auma. BMJ. 1995;311(6999):217–22.
16. T auma ic B ain Inju y (online). Cu en Ca e Guidelines.Wo king g oup se
up by he Finnish Medical Socie y Duodecim. Helsinki: The Finnish Medical
Socie y Duodecim. h p://www.kaypahoi o. i/. Accessed 7 Jan 2017.
17. Teasdale G, Jenne B. Assessmen o coma and impai ed consciousness.
A p ac ical scale. Lance . 1974;2(7872):81–4.
18. Jenne B, Bond M. Assessmen o ou come a e se e e b ain damage.
Lance . 1975;1(7905):480–4.
19. Jenne B, Snoek J, Bond MR, B ooks N. Disabili y a e se e e head inju y:
obse a ions on he use o he Glasgow ou come scale. J Neu ol Neu osu g
Psychia y. 1981;44(4):285–93.
20. Be na d SA, Nguyen V, Came on P, Masci K, Fi zge ald M, Coope DJ, e al.
P ehospi al apid sequence in uba ion imp o es unc ional ou come o
pa ien s wi h se e e auma ic b ain inju y: a andomized con olled ial.
Ann Su g. 2010;252(6):959–65.
21. Da is DP, Dun o d JV, Pos e JC, Ochs M, Holb ook T, Fo lage D, e al. The
impac o hypoxia and hype en ila ion on ou come a e pa amedic apid
sequence in uba ion o se e ely head-inju ed pa ien s. J T auma. 2004;57(1):
1–8. discussion −10
22. Hal meie T, Benjamin E, Siboni S, e al. P ehospi al in uba ion o isola ed
se e e blun auma ic b ain inju y: wo se ou comes and highe mo ali y.
Eu J T auma Eme g Su g. 2016. h ps://doi.o g/10.1007/s00068-016-0718-x.
23. Bosse s SM, Schwa e LA, Loe SA, Twisk JW, Boe C, Schobe P. Expe ience
in P ehospi al endo acheal in uba ion signi ican ly in luences mo ali y o
pa ien s wi h se e e auma ic b ain inju y: a sys ema ic e iew and me a-
analysis. PLoS One. 2015;10(10):e0141034.
24. Susman M, DiRusso SM, Sulli an T, Risucci D, Nealon P, Cu S, e al.
T auma ic b ain inju y in he elde ly: inc eased mo ali y and wo se
unc ional ou come a discha ge despi e lowe inju y se e i y. J T auma.
2002;53(2):219–23. discussion 23-4
25. Mosen hal AC, La e y RF, Addis M, Kaul S, Ross S, Ma bu ge R, e al.
Isola ed auma ic b ain inju y: age is an independen p edic o o mo ali y
and ea ly ou come. J T auma. 2002;52(5):907–11.
• We accep p e-submission inqui ies
• Ou selec o ool helps you o ind he mos ele an jou nal
• We p o ide ound he clock cus ome suppo
• Con enien online submission
• Tho ough pee e iew
• Inclusion in PubMed and all majo indexing se ices
• Maximum isibili y o you esea ch
Submi you manusc ip a
www.biomedcen al.com/submi
Submi you nex manusc ip o BioMed Cen al
and we will help you a e e y s ep:
Pakkanen e al. Scandina ian Jou nal o T auma, Resusci a ion and Eme gency Medicine (2017) 25:94 Page 7 o 7