Pre-hospital treatment of severe traumatic brain injury in Stockholm – some critical comments. Leif Rognas, Pre-hospitale Critical Care Services, The Central Denmark Region 1 June 2014 Dear Editor, We read with great interest the paper written by Falk et al entitled ”Has increased nursing competence in the ambulance service impacted on pre-hospital assessment and interventions in severe traumatic brain-injured patients” and published in SJTREM in March 2014. Congratulations to the authors for trying to answer an important question. We do feel however, that several important aspects of the paper deserve further attention: First, we wonder why the authors chose to focus on traumatic brain injury (TBI) patients with a Glasgow Coma Scale (GCS) score below 8 when international guidelines [1, 2] use a GCS score below 9 as the cut-off for severe TBI. It would have been desirable if the authors had described the emergency medical system (EMS) in question in more detail; especially regarding pre-hospital airway management (other than stating that “the nurses have knowledge and skills for advanced life support”). What are the competence level and treatment capabilities of a standard EMS crew? Do they use supraglottic airway devices? Do they perform pre-hospital endotracheal intubations? If so, do they perform rapid sequence intubation (RSI)? Alternatively, was the intubations performed by the pre-hospital critical care physician? This information would have eased the interpretation and discussion of some of the authors’ key findings. We are alarmed by the fact that 61 % of the patients with severe TBI were treated with pre-hospital sedation despite pre-hospital endotracheal intubation being carried out in only 18 – 19 % of these patients. In our opinion, administering sedation to these patients without securing a patent airway may severely increase the risk of airway compromise, hypoxemia, hypoventilation (and resulting hypercapnia) and aspiration of gastric content to the lungs. All these complications increase the risk of secondary brain damage and adverse outcome [1, 2]. The authors do not discuss these findings and their potential fatal consequences. We are also concerned by the low fraction of patients with severe TBI transported directly to a level 1 trauma centre. This may be because of local protocol or the supposed lack of advanced airway management capabilities among standard EMS crews or it may have other explanations. The authors do not address these findings in the paper. New Scandinavian guidelines for pre-hospital management of traumatic brain injury were published in the study period . The authors cite these guidelines but do not discuss why they have not implemented the new guidelines in their practise. The main research question asked by the authors is whether nursing competence in the ambulance service improve pre-hospital treatment. In that respect, it would have been interesting if the authors had provided physiological data (i.e. ETCO2, PaCO2, PaO2 and MABP) measured immediately upon arrival to the trauma centre. These data may further have indicated whether nurses in the pre-hospital setting improve quality of care and prevent secondary insults. Finally, we are worried by the authors’ statement that the treatment of “a patient with a severe TBI may actually not be a challenge for the ambulance personnel as assessing patient needs, immediate care and treatment are continuously trained for”. It has been repeatedly shown, most recently in our own anaesthesiologist-staffed pre-hospital critical care system , that treating these patients according to guidelines and preventing secondary brain damage may be challenging even for experienced pre-hospital critical care physicians. Based on the results presented by Falk et al we suspect that these challenges are even bigger in the Swedish EMS they investigated. We hope the authors will elaborate on the questions above. Authors: Leif Rognås MD, PhD Lead Clinician, Pre-hospital Critical Care Services, Central Denmark Region Consultant anaesthesiologist, Section for neuroanaesthesia, Department of Anaesthesia, Aarhus University Hospital, Denmark Stig Eric Dyrskog MD, PhD Pre-hospital Critical Care Physician, Pre-hospital Critical Care Services, Central Denmark Region Consultant anaesthesiologist, Section for neuroanaesthesia, Department of Anaesthesia, Aarhus University Hospital, Denmark Niels Juul MD Pre-hospital Critical Care Physician, Pre-hospital Critical Care Services, Central Denmark Region Consultant anaesthesiologist, Section for neuroanaesthesia, Department of Anaesthesia, Aarhus University Hospital, Denmark Mads Rasmussen MD, PhD Pre-hospital Critical Care Physician, Pre-hospital Critical Care Services, Central Denmark Region Consultant anaesthesiologist, Section for neuroanaesthesia, Department of Anaesthesia, Aarhus University Hospital, Denmark Corresponding author: Leif Rognås Pre-hospital Critical Care Service Oluf Palmes Allé 32 8200 Aarhus N Denmark firstname.lastname@example.org References: 1. Badjatia N, Carney N, Crocco TJ, Fallat ME, Hennes HM, Jagoda AS, Jernigan S, Letarte PB, Lerner EB, Moriarty TM et al: Guidelines for prehospital management of traumatic brain injury 2nd edition. Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors 2008, 12 Suppl 1:S1-52. 2. Juul N, Sollid S, Sundstrom T, Kock-Jensen C, Eskesen V, Bellander BM, Wester K, Romner B: [Scandinavian guidelines on the pre-hospital management of traumatic brain injury]. Ugeskrift for laeger 2008, 170(26-32):2337-2341. 3. Rognås L, Hansen TM, Kirkegaard H, Tønnesen E: Anaesthesiologist-provided prehospital airway management in patients with traumatic brain injury: an observational study. European journal of emergency medicine : official journal of the European Society for Emergency Medicine 2013. Competing interests The authors declare that they have no competing interests.