Meeting abstracts of the Toronto Resuscitation Conference

LO1 Multiple out-of-hospital cardiac arrest patient events: A case series from a national cardiac arrest dataset

Jennifer Bacon

Alberta Health Services Emergency Medical Services, Alberta, Canada

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2025, 33(3):LO1

Managing multiple out-of-hospital cardiac arrests (MOHCA) in a single event provides a unique challenge. These events are poorly described in the research literature, and current triaging systems do not provide guidance when multiple patients on-scene are in cardiac arrest except in specific situations such as avalanches and electrocution. Objective: Describe MOHCA events from a national out-of-hospital cardiac arrest (OHCA) dataset (Canadian Resuscitation Outcomes Consortium—CanROC).

MOHCA events from six Canadian sites between 2018–2022 were identified by a unique event number, time (within five minutes), and location GPS data (within two kilometers). After case ascertainment, calls were reviewed to ensure they were MOCHA events by confirming at least two patients. Descriptive analyses are provided.

A total of 87,763 OHCA events yielded 61 MOHCA events and a total of 127 patients. There were two patients in 56 (91.8%) events, and three patients in five (8.2%) events. In 34(55.7%) events all patients were “obviously dead”, and in 27(44.3%) resuscitation by a professional was attempted on at least one patient. Six events occurred in 2018, 10 events in 2019, 17 events in 2020, 16 events in 2021, and 12 events in 2022. 27 events were witnessed and eight had bystander CPR on one or more patients, but none of the events had an AED applied. Event etiology included drug toxicity (n = 21), trauma (n = 11), smoke inhalation (n = 7), no obvious cause (n = 4), drowning (n = 3), hanging (n = 1), and chemical poisoning (n = 1). The mean(SD) age of patients was 44.6(18.4) years with five patients (3.9%) under 18 years, and 41 (32.3%) patients female. Initial heart rhythm of treated patients included 29 (55.8%) asystole, 12 (23.1%) pulseless electrical activity, 9 (17.3%) “non-shockable”, one (1.9%) v-fibrillation, and one (1.9%) “shockable”. Of the 52 treated patients, 14 (26.9%) achieved field return of spontaneous circulation (ROSC) and 30 (57.7%) were transported to hospital.

Approximately one in every 1,400 cardiac arrest events were a MOHCA, the majority are due to drug toxicity, one-fourth of treated patients achieved field ROSC, and over half were transported. Future research will explore paramedic experience with these low-frequency high-acuity events and develop general triaging guidelines.

LO2 Characteristics and predictors of opioid-associated out-of-hospital cardiac arrest: A retrospective analysis in southern Ontario

Hania Siddiqui

Institute for Medical Sciences, University of Toronto, Canada

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2025, 33(3):LO2

Opioids are associated with 10–20% of the 350,000 annual out-of-hospital cardiac arrests (OHCA) in North America and are increasingly being identified as a cause of OHCA. The increasing prevalence of opioid-associated cardiac arrest (OA-OHCA) is alarming, and there is a need to better understand the characteristics of this patient population.

We performed a retrospective study of adult OHCA patients attended to by three paramedic services in Southern Ontario from 2020–2022. Paramedic data was matched with reports from the Office of the Chief Coroner of Ontario to determine the etiology of the arrest. Etiology was categorized as non-overdose or overdose, with overdose-related arrests broken into OA-OHCA vs non-opioid-related arrests. Descriptive statistics were used to summarize characteristics by etiology. Univariate logistic regression was conducted to identify variables associated with OA-OHCA.

Paramedic services attended to and treated approximately 5412 OHCA cases from 2020–2022. Of these, 1302 cases had no apparent cause of arrest. Coroner reports revealed that 199 (15%) of the 1302 arrests were overdose-related cases, 153 OA-OHCA, and 46 non-opioid-related arrests. The average age of OHCA patients with no apparent cause was 63 (SD = 18); 66 (SD = 17) for non overdose-related arrests and 43 (SD = 13) for overdose-related arrests. For the overdose-related arrests, the average age was 41 for OA-OHCAs and 47 for non-opioid-related arrests. 86% of the OA-OHCAs and 70% of the non-opioid related arrests were male. Variables significantly associated with OA-OHCA (p-value < 0.05) based on univariate analyses included age (OR = 0.92, 95% CI 0.91—0.93), male sex (OR = 3.04, 95% CI 1.96—4.93), bystander naloxone (OR = 40.82, 95% CI 17.66—111.08), ROSC (OR = 2.00 95% CI 1.19—3.25), and unwitnessed arrest status (OR = 4.16, 95% CI 2.44—7.64).

OA-OHCA are common causes of cardiac arrest without a known etiology. Age and sex differences exist between overdose and non-overdose cardiac arrests, with further variations between opioid- and non-opioid-related arrests within the overdose group. Our findings highlight that OA-OHCAs may represent a distinct patient population with unique characteristics compared to non-overdose arrests. Further work to better identify these patients in the field could lead to tailored treatment and improved outcomes for this patient population.

LO3 Association between socioeconomic status and EMS management of out-of-hospital cardiac arrest in France: Do you need to be wealthy to survive? A multicenter retrospective cohort study

Simon Cahen, Etienne Audureau, Lecarpentier Eric, Abdeslame Bouzit, Auguste Fourneau, Julien Vaux, Matthieu Heidet

Hôpital Universitaire Henri Mondor AP-HP, France

Correspondence: Simon Cahen

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2025, 33(3):LO3

The prognosis after out-of-hospital cardiac arrest (OHCA) remains poor (< 5% survival in France). A low socioeconomic status is associated with reduced access to healthcare. However, its relationship with the level of prehospital management remains uncertain. This study aimed to identify and characterize the profiles of patients managed for OHCA by an emergency medical service (EMS) at the national level and to assess variations in management practices according to socioeconomic status.

Data were obtained from the national RéAC registry, including 102,843 adult patients who suffered a non-traumatic OHCA. Patients were classified into two groups based on their socioeconomic status using the European Deprivation Index. Unsupervised clustering methods were used to identify patient profiles.

Management and prognosis varied according to socioeconomic status and geographical context. Socioeconomically disadvantaged young patients, often from urban areas, received intensive resuscitation but had low survival rates. Disadvantaged elderly patients, often from rural areas, received more limited care and had a poor prognosis. Socioeconomically advantaged young patients, often male and from rural areas, had a more favorable prognosis with comprehensive resuscitation.

Socioeconomic status significantly influences EMS management and the prognosis of patients with cardiac arrest.

LO4 Identifying risk factors for early fibrinogen replacement in bleeding trauma patients: A single-center, retrospective cohort study

Fayad Al-Haimus¹, Ehsan Ghamarian², Rosane Nisenbaum², Amanda McFarlan², Melissa McGowan², Katerina Pavenski^1,2, Andrew Beckett^1,2, Brodie Nolan^1,2

¹University of Toronto, Canada; ²St. Michael’s Hospital, Unity Health Toronto, Canada

Correspondence: Fayad Al-Haimus

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2025, 33(3):LO4

Trauma remains one of the major causes of death and hemorrhage is a leading preventable cause of mortality in injured patients. In a bleeding trauma patient, fibrinogen level drops significantly and early on in resuscitation. Fibrinogen is critical for hemostasis and its early replacement may improve survival. The primary objective was to identify characteristics associated with a low fibrinogen level in bleeding injured patients as understanding them may identify patients who would benefit from early fibrinogen replacement.

This is a retrospective cohort study of trauma patients presenting to a single Level 1 trauma center between 2016 to 2021 and aged > 18 years. We excluded patients who died before laboratory sampling. The primary outcome was an initial fibrinogen level below 1.5g/L indicating the need for fibrinogen supplementation. A multivariable logistic regression model explored the association between base excess, injury type, blood components received, time from injury, and systolic blood pressure with an initial fibrinogen level of < 1 0.5g/L.

A total of 4936 patients met inclusion criteria, of which 155 (3%) patients had initial fibrinogen level of < 1.5g/L.

The adjusted odds of having fibrinogen level < 1 0.5g/L increased for every unit of blood component transfused (OR = 1.16, 95%CI = [1.09, 1.24]), when systolic blood pressures were less than 90 and 90–119 respectively (OR = 2.52, 95%CI = [1.04, 5.84], (OR = 1.91, 95%CI = [1.03, 3.56]), and with each hour following injury (OR = 1.03, 95%CI = [0.99, 1.07]). The odds of having fibrinogen level < 1 0.5g/L decreased with increasing base excess (OR = 0.84, 95%CI = [0.81, 0.87]) and with penetrating injuries (OR = 0.43, 95%CI = [0.21 to 0.83]).

Initial hypofibrinogenemia was associated with increased blood transfusion requirements, low base excess, and delayed presentation after the injury. Since obtaining a fibrinogen level takes time and early replacement may improve hemostasis, empiric fibrinogen replacement may be considered in patients with these characteristics.

LO6 Acute traumatic coagulopathy and hypofibrinogenemia in trauma patients who receive prehospital transfusion: A retrospective cohort study

Evan Hanna^1,2, Michael Peddle¹, Yulia Lin^3,4, Melissa McGowan⁵, Mahvareh Ahghari¹, Noah Zweig³, Nura Khattab⁴, Aditi Khandelwal^3,4,5,6, Brodie Nolan^1,4,5, Johannes von Vopelius-Feldt^1,4,5

¹Ornge Air Ambulance, Canada; ²Charles Stuart University, Australia; ³Sunnybrook Health Sciences Centre, Toronto, Canada; ⁴University of Toronto, Canada; ⁵St Michael’s Hospital, Unity Health Toronto, Toronto Canada; ⁶Canadian Blood Services, Canada

Correspondence: Evan Hanna

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2025, 33(3):LO6

Acute traumatic coagulopathy and hypofibrinogenemia are common in severely injured trauma patients, occur early after injury, and are associated with significant increases in mortality. Ornge air ambulance, based in Ontario, Canada, provides prehospital blood transfusion through its Blood on Board program, consisting of 2 units of O-negative packed red blood cells (pRBCs) in a temperature-controlled and monitored cooler. This study will assess the incidence of acute traumatic coagulopathy and hypofibrinogenemia in trauma patients transported by Ornge who receive prehospital transfusion.

This retrospective cohort study will review trauma patients transported by Ornge to one of two lead trauma hospitals in Toronto, Ontario, who received at least one unit of pRBCs from the Blood on Board program, between September 2021 and July 2024. Data from prehospital electronic medical records will be linked to hospital data from trauma registries. Primary outcomes will include the incidence of acute traumatic coagulopathy, defined as an INR > 1.5, and hypofibrinogenemia, defined as a fibrinogen < 1.5 g/L, on admission to the lead trauma hospital. Secondary outcomes will include the rates of massive transfusion and operative intervention within 4 h of admission, and factors associated with coagulopathy.

Results of this study are pending data extraction and analysis as of March 3, 2025.

By identifying the presence of acute traumatic coagulopathy and/or hypofibrinogenemia in this patient population, the outcomes of this study may inform decision-making surrounding the addition of freeze-dried plasma, prothrombin complex concentrate and/or fibrinogen concentrate into Ornge’s Blood on Board program.

LO7 Review of alternative areas of chest compression during cardiopulmonary resuscitation

Rohit Mohindra

North York General Hospital, Toronto, Canada

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2025, 33(3):LO7

Out-of-Hospital Cardiac Arrest (OHCA) is a significant public health issue. High-quality chest compressions during cardiopulmonary resuscitation (CPR) are essential for survival. Current CPR guidelines recommend compressions over the lower half of the sternum, but studies suggest that compressions targeting the left ventricle may offer superior hemodynamic benefits. This systematic review evaluated the impact of alternative chest compression sites on clinical outcomes, such as return of spontaneous circulation (ROSC) and survival.

This review was registered on PROSPERO database (No: CRD42023387508) and followed PRISMA guidelines. We searched Medline, EMBASE, CINAHL, and Cochrane Register of Controlled Trials (CENTRAL). We included adult patients with non-traumatic cardiac arrest where chest compressions were performed using an alternative area compared to the standard AHA guideline suggested location. The risk of bias was assessed using the ROBINS-I tool and the Newcastle–Ottawa Scale.

A total of 3,583 articles were identified during the search process. After screening studies by title and abstract, 12 were selected for full-text review, with four studies meeting the inclusion criteria for final analysis. These studies comprised three observational studies and one case series. The risk of bias across the studies was assessed as moderate to serious. Due to heterogeneity in study designs and outcome measures, a meta-analysis was not conducted.

The review found no substantial differences in ROSC, survival to hospital discharge, or neurological outcomes when comparing alternative chest compression techniques to the standard approach. While some studies reported improved hemodynamics, such as higher EtCO2 levels, when compressions targeted the left ventricle, these enhancements did not significantly affect clinical outcomes.

Our review indicates that chest compressions at alternate locations during CPR did not lead to better long-term outcomes, such as survival to discharge or neurological status. These findings advocate for more individualized compression strategies, especially through imaging techniques like FOCUS or TEE. Larger randomized trials, especially focusing on long-term outcomes are needed to validate these approaches.

LO8 Severe accidental hypothermia: The development of an urban inner-city emergency department pathway

Evelyn Dell^1,2, Sam Vaillancourt^1,2, Farah Warsi¹, Garrick Mok^1,2

¹St. Michael’s Hospital, Unity Health Toronto; ²Faculty of Medicine, University of Toronto

Correspondence: Evelyn Dell

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2025, 33(3):LO8

Toronto Emergency Departments (ED) regularly encounter cases of severe accidental hypothermia. These resource intensive resuscitations involve a nuanced approach regarding ACLS alterations, re-warming techniques, prognostication, and potential deployment of Extracorporeal membrane oxygenation (ECMO). This quality improvement (QI) project sought to standarize the care for cases of severe accidental hypothermia at two inner-city EDs via the creation of a Hypothermia Pathway, with a specific focus on ECMO deployment.

We aimed to create a pathway that leads to a 100% increase in provider access to a streamlined management process for severe accidental hypothermia by March 1 st, 2025.

In March 2024, a case of severe hypothermia was reviewed. After a stakeholder analysis, a multidisciplinary team was created. A root cause analysis via an Ishikawa diagram and process mapping was undertaken. Key themes included: need for a streamlined pathway, education for clinical providers, and improved interdepartmental communication. A Model for Improvement approach was applied through Plan-Do-Study-Act (PDSA) cycles involving in-situ simulation, real case review, case debriefing, and frontline staff feedback. The previous process was modified, leading to the implemented pathway. After pathway launch, cases of severe hypothermia were reviewed to assess value, adherence, and perceptions.

We created a pathway to manage severe hypothermia. The pathway includes a flow-chart alongside a set of cue cards. The poster prompts management in three key realms: modified ACLS, re-warming techniques, and prognostication/ECMO. The cue cards provide supplemental details as needed. To date, 100% (4/4) cases utilized the pathway. Iterative feedback from providers is ongoing.

This QI project produced an evidence-based clinical tool to help improve ED care for patients with severe accidental hypothermia. Future work includes exploring additional gaps in management, replication of the similar pathway at other centers, and a city-wide ECMO pathway.

LO9 The feasibility of monitoring trauma patients with a wireless, wearable doppler ultrasound

Lowyl Notario¹, Sarah Atwi², Luis Teodoro Da Luz¹, Rachael Irvine¹, Diane Farah², Delaney Johnston², Jon-Emile S. Kenny^2,3, Joseph K. Eibl^2,4, Dylan Pannell¹

¹Sunnybrook Health Sciences Centre, Toronto, Canada; ²Flosonics Medical, Sudbury, Canada; ³Clinical Research, Health Sciences North Research Institute Walford Site, Greater Sudbury, Canada; ⁴Biomolecular Science, Laurentian University, Greater Sudbury, Canada

Correspondence: Lowyl Notario

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2025, 33(3):LO9

Blood loss following traumatic injury leads to a decline in stroke volume (SV) and cardiac output (CO). Clinical signs of hypoperfusion are delayed by compensatory mechanisms like increased heart rate and systemic vascular resistance. Early detection of reduced SV or CO may enable faster resuscitative interventions. Corrected carotid artery flow time (ccFT) has been proposed as a surrogate for SV during blood volume loss.

We conducted a feasibility study using a wireless, wearable Doppler ultrasound to measure ccFT in traumatically injured patients at a level 1 trauma center. A convenience sample of 34 patients were enrolled. Patients were dichotomized into those requiring and not requiring blood transfusion. Device performance was assessed by the ability to capture at least 15 consecutive cardiac cycles in the minute prior to blood pressure monitor cycling.

Successful placement of the wearable Doppler was achieved in 91% of patients, and clinically relevant Doppler signals was captured in 93%. Aligning with hemodynamic compromise observed in prior studies, blood transfusion patients exhibited lower ccFT values.

This study demonstrates the feasibility of deploying wearable Doppler ultrasound in trauma settings. While findings suggest that ccFT could serve as an early marker of hemodynamic compromise, further large-scale, multi-center studies are needed to validate its predictive value and clinical utility in guiding trauma resuscitation.

P1 Initial experiences with the out-of-hospital transfusion of emergency supply blood products between 2019 and 2024 in British Columbia, Canada

Adam Greene¹, Andrew Shih², Stephen Wheeler³, Shelley Feenstra⁴, Rob Schlamp¹, Kalani Polson¹, Jade Munro¹, David Obert⁵, Rob Gooch³, Erik Vu¹, Jan Trojanowski⁶

¹BCEHS Air Ambulance and Critical Care Operations, Canada; ²University of British Columbia, Canada; ³BCEHS, Vancouver Canada; ⁴Vancouver Coastal Health, Vancouver, Canada; ⁵BCEHS Emergency Dispatch; ⁶BCEHS EPOS and Clinical Hub, Canada

Correspondence: Adam Greene

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2025, 33(3):P1

For critically ill and injured patients, timely access to blood products is emerging as best practice for select trauma and medical patients. In the Canadian Province of British Columbia, blood products carried by British Columbia Emergency Health Services (BCEHS) critical care transport (CCT) teams are often the first to be administered to critically ill and injured patients outside of major metropolitan areas.

We aim to describe our initial experiences with out-of-hospital transfusion between 2019 and 2024.

A service evaluation was conducted utilizing a retrospective review of out-of-hospital and in-hospital patient care records, laboratory data, imaging, and interventional radiology and operative reports for all patients receiving an out-of-hospital blood transfusion from February 2019 to December 2024.

During the study period, 172 patients received an out-of-hospital transfusion of emergency blood products. All out-of-hospital transfusions were audited for quality improvement and quality assurance purposes. The median age of patients receiving a transfusion was 46.94 years, 69.81% were male, and 76.74% patients sustained blunt trauma. Out-of-hospital transfusion was associated with a significant increase in systolic blood pressure (76.39 mmHg to 102.00 mmHg, p < 0.001) and mean arterial pressure (57.78 mmHg to 77.00 mmHg, p < 0.001), a decrease in mean shock index (1.52 to 1.01, p < 0.001), and a 65-min reduction in the time to first transfusion, all with minimal waste (RBC 0.90% and 13.61% FFP) and complete traceability. There were no reported patient-related adverse events.

The results of this service evaluation demonstrate the successful introduction of an out-of-hospital blood program in British Columbia, Canada, including the achievement of acceptable product utilization rates, no patient-related adverse events, and complete product traceability. Further prospective research is needed to assess the impacts of these interventions on patient-oriented outcomes in these patient populations.

P2 Initial experiences with real-time critical care paramedic support in the patient transport coordination centre between 2016 and 2024 in British Columbia, Canada

Adam Greene, Kalani Polson, Kevin Lambert, Rob Schlamp, Erik Vu

BCEHS Air Ambulance and Critical Care Operations, Canada

Correspondence: Adam Greene

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2025, 33(3):P2

British Columbia is Canada’s westernmost province, with approximately 5.26 million people, spread over nearly 1 million square kilometres of access- and weather- challenged geography. Healthcare in British Columbia is highly regionalized, with secondary, tertiary- and quaternary-level care concentrated into regional hubs. As a result, a robust interfacility transport program is essential to support the equity of care and overcome the tyranny of distance. Established in 2016, the critical care paramedic advisor (CCPA) program places an experienced critical care paramedic into the patient transport coordination centre (PTCC) to provide real-time logistical and operational decision-making support during the interfacility transfer planning process and to provide clinical decision-making support to paramedics of all license levels.

We aim to describe our initial experiences with real-time critical care paramedic support in the PTCC between 2016 and 2024 in British Columbia, Canada.

A service evaluation was conducted utilizing a retrospective review of dispatch records (time stamps, and CAD notes) and specific bespoke shift activity forms for all events the CCPA program interacted with from March 2016 to December 2024.

Over the past six years, the CCPA program has interacted with over 55,000 individual events. In 2024, the CCPA program triaged approximately 4,600 interfacility transport conferences, evaluated over 3,300 prehospital (trauma, stroke, and remote) requests for service, and provided logistical, operational and/or clinical decision-making support to another 2,650 events.

The results of this service evaluation demonstrate the successful introduction of real-time critical care paramedic support into the PTCC. Further prospective research is needed to assess the impact of such an intervention on patient-oriented outcomes.

P3 Blood consumption in patients with gunshot wounds: A Canadian single-centre experience

Ali Tabatabaey^1,2, Melissa McGowan², Brodie Nolan^1,2, Katerina Pavenski^1,2

¹University of Toronto, Canada; ²St. Michael’s Hospital, Unity Health Toronto, Canada

Correspondence: Ali Tabatabaey

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2025, 33(3):P3

Gun violence in Canada has risen steadily in recent years. Patients with gunshot wounds (GSW) often demand complex multidisciplinary care, and frequently require transfusions. Utilization of blood products in this patient population was not previously described in Canada. This study describes the transfusion requirements of GSW patients treated at a single level-one urban trauma centre located in the fourth most populous North American city.

This is a retrospective chart review at a level-one trauma centre in Toronto, Canada. A hospital trauma registry of all trauma team activations was utilized to identify patients presenting with injuries from GSWs between January 1, 2017, and December 31, 2021. Patients under 16, those refusing transfusions, and patients with Absent Vital Signs for whom resuscitation was not initiated were excluded. We tallied type and amount of blood products transfused during the admission. Transfusion of Packed Red Blood Cells (PRBC), Fresh Frozen Plasma (FFP), and Platelets are described individually alongside total all-product transfusions.

Of 5452 Trauma team activations, 5% were GSWs (n = 275). These patients were mostly male (n = 251, 91.3%) with a median age of 26 (IQR 12) years. Median injury severity score was 9 (17) with 26.6% of patients having ISS of 1. Assault was the most common cause of GSW (97.1%). Massive Hemorrhage Protocols were activated in 49 patients (17.9%). In total, 77 patients received 1134 units of blood products while 198 patients did not require any transfusions. 716 units of red blood cells (RBC), 344 units of plasma, and 74 platelet pools were transfused to 75, 42, and 22 patients respectively. Average all-product requirement was 4.05 units for all GSW patients and 14.47 units for those requiring transfusions. The distribution of transfusion requirements was markedly skewed: 6.5% of patients consumed 70.5% of RBC transfusions, 3.3% of patients received 72.7% of plasma, and 1.1% of patients used 59.5% of platelet pools.

In this five-year review, GSW patients account for a small minority of trauma patients. However, our findings support previous reports that these patients require a significant number of blood products, with a few patients consuming majority of units. Increasing GSW incidences is bound to strain the blood supply, whereas preventing a single event may save hundreds of units.

P4 A comparative analysis of the STAT taxonomy and T-NOTECHS for assessing trauma team non-technical skills: A secondary analysis using trauma video review

Anisa Nazir¹, Eliane Shore², Charles Keown-Stoneman², Ryan Dumas³, Caitlin Fitzgerald⁴, Melissa McGowan², Teodor Grantcharov⁵, Brodie Nolan²

¹Institute of Medical Sciences, University of Toronto, Canada; ²St Michaels’ Hospital, Unity Health Toronto, Canada; ³Baylor College of Medicine, Department of Surgery, Houston, TX, United States; ⁴Brody School of Medicine, East Carolina University, Greenville, NC, United States; ⁵Department of Surgery, Clinical Excellence Research Center, Stanford University, California, United States

Correspondence: Anisa Nazir

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2025, 33(3):P4

Non-technical skills (NTS), such as leadership, communication and interaction, situational awareness, cooperation and resource management (CRM), and assessment and decision-making, are critical to optimizing team performance and reducing adverse events (AEs) during trauma resuscitations. This study examines the relationship between NTS, assessed using the Trauma – NOn-TECHnical Skills (T-NOTECHS) tool, and AEs, classified using the STAT taxonomy.

This secondary analysis included 30 adult trauma team activations at Parkland Hospital, Dallas, Texas, with inclusion criteria of patients aged > 16 years and trauma video recordings available from the Trauma Video Review Repository between January 1, 2019, and January 15, 2022. T-NOTECHS evaluated NTS across five domains using a 5-point Likert scale (1 = poor, 5 = excellent). AEs were identified and categorized using the STAT taxonomy. Descriptive statistics summarized T-NOTECHS scores, AEs, and demographic factors. Poisson regression were used to analyze associations between T-NOTECHS scores, AEs, and demographic variables, while Spearman’s correlation was conducted as an exploratory analysis to evaluate general trends.

T-NOTECHS scores ranged from 17 to 25, with a median of 22, indicating strong team performance. AEs ranged from 4 to 29 per case, with a median of 9.5. Spearman correlation revealed a strong negative association between T-NOTECHS scores and AEs (r = −0.62, p each one-point increase in T-NOTECHS was associated with a 13% reduction in the expected AE rate (IRR = 0.87, 95% CI: 0.83–0.92, p < 0.001). Age was significantly associated with AEs (IRR = 1.013, p < 0.001), indicating a 1.3% increase in AE rate per year of patient age, while sex and ISS were not significant predictors. Additionally, age, sex, and ISS had no significant association with T-NOTECHS scores, suggesting that team performance remains independent of patient demographics and injury severity.

Higher non-technical performance, as measured by T-NOTECHS, is strongly associated with fewer adverse events in trauma resuscitations. These findings underscore the importance of structured training and assessment of NTS to enhance patient safety and team dynamics. Future studies should validate these results in larger datasets and explore interventions to improve non-technical skills in trauma care further.

P6 Perceptions and experiences of trauma staff on identifying adverse events and error reporting systems in Canadian multi-centre institutions

Anisa Nazir¹, Eliane Shore², Charles Keown-Stoneman², Melissa McGowan², Teodor Grantcharov³, Brodie Nolan²

¹Institute of Medical Sciences, University of Toronto, Canada; ²St Michaels’ Hospital, Unity Health Toronto, Canada; ³Department of Surgery, Clinical Excellence Research Center, Stanford University, California, United States

Correspondence: Anisa Nazir

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2025, 33(3):P6

Adverse event (AE) identification and reporting in trauma care are essential for improving patient safety and quality of care. However, trauma care presents unique challenges in AE identification due to the high-acuity environment, complex team dynamics, and time-sensitive decision-making. Despite the availability of reporting systems, underreporting and inconsistent documentation remain persistent issues. Understanding how trauma staff perceive and engage with AE reporting is crucial for optimizing these systems, addressing barriers, and enhancing institutional learning.

This qualitative study employs a constructivist grounded theory approach to explore AE reporting experiences. Semi-structured interviews were conducted with 14 trauma professionals, including physicians, nurses, and administrators from diverse trauma centres across Canada. Participants, primarily male (71.4%), held various roles, with trauma directors comprising 28.6%. Common educational backgrounds included MD, EM (21.4%) and MD, MSc General Surgery (21.4%). Interviews focused on AE identification processes, reporting challenges, and institutional frameworks. Data were transcribed, coded, and analyzed using constant comparative analysis to identify emergent themes. Rigor was maintained through iterative coding, peer debriefing, and reflexivity.

Participants recognized AE reporting’s role in patient safety but cited concerns over system limitations and underreporting. Cognitive biases, institutional priorities, and inconsistent thresholds affected AE recognition. Defining AE severity and balancing patient care with AE reduction were key challenges. Structured feedback, peer review, and trauma video review were seen as potential improvements. Leadership engagement varied, with cultural resistance in some centres. Real-time AE identification was difficult due to retrospective data limitations. Interprofessional collaboration was both a facilitator and barrier. AI-assisted reporting and structured communication were proposed solutions. Resource constraints, lack of education, and tracking gaps were persistent obstacles.

This study highlights systemic barriers to AE reporting and opportunities for improvement. Addressing reporting inconsistencies, enhancing collaboration, and leveraging technology could strengthen AE identification and reporting, improving trauma care quality and patient safety.

P7 Prehospital resuscitative endovascular balloon occlusion of the aorta (REBOA) in patients with major trauma and cardiac arrest: A systematic review of the literature

Devlyn Sun¹, Matthew Olejarz¹, Pierre-Marc Dion², Melissa McGowan³, Carolyn Zeigler³, Johannes von Vopelius-Feldt^3,4

¹McMaster University, Hamilton, Canada; ²Royal Canadian Medical Service, Canadian Armed Forces, Ottawa, Canada; ³St. Michael’s Hospital, Unity Health Toronto; ⁴Ornge Air Ambulance, Canada

Correspondence: Devlyn Sun

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2025, 33(3):P7

Resuscitative endovascular balloon occlusion of the aorta (REBOA) effectively provides temporary hemorrhage control and optimizes perfusion to vital organs. Despite success in civilian and combat pre-hospital settings, there is no consensus on its application. Research has shown mixed effects on mid- to long-term survival, and the inherently high mortality risk among patients receiving REBOA complicates literature interpretation. This systematic review consolidates evidence on REBOA use in the pre-hospital and transport medicine setting.

A literature search was conducted using Ovid MEDLINE, EMBASE, CENTRAL, LILACS, CINAHL, Scopus, conference abstract listings, and clinical trial registries. Original studies on human subjects were included. Two independent reviewers extracted patient and intervention details, outcomes, and study quality. Risk of bias was assessed using the GRADE tool. Primary outcomes were overall survival and feasibility, while secondary outcomes included complications and other relevant safety outcomes. Due to anticipated heterogeneity, a narrative synthesis was conducted, grouping studies by outcomes and methods to evaluate key themes and limitations.

The search yielded 1,066 articles, 31 registered trials, and 151 conference abstracts, of which 15 case studies and three prospective observational studies met the inclusion criteria. The included studies were of low quality due to inherent limitations. Pre-hospital REBOA was successfully deployed in 82% of civilian trauma cases, 92% of civilian non-traumatic cardiac arrest cases, and 97% of combat trauma cases. All studies reported significant elevation of blood pressure following REBOA, although survival rates and complications varied largely. Survival to discharge was reported in 25% and 71% of civilian and military patients, respectively. These rates were largely influenced by patient selection criteria and the nature of injuries. Placement using external landmarks is safe and effective. This method was used in most combat cases (33/37) but rarely in civilian cases (1/61) and achieved successful aortic occlusion in 97% (33/34) of patients.

The current evidence is limited by the small number of cases in existing studies and the lack of control groups in most available case series of REBOA in the pre-hospital and transport medicine setting. Larger, higher-quality research is required to strengthen the evidence for REBOA in this context.

P8 Prehospital resuscitative balloon occlusion of the aorta (REBOA) in Ontario: Evaluating needs

Fabio Botelho^1,2, Brodie Nolan^2,3, Andrew Beckett^1,2,4, Mahvareh Ahghari³, Melissa McGowan², Johannes von Vopelius-Feldt^2,3

¹Department of Surgery, University of Toronto, Canada; ²St Michael’s Hospital, Unity Health Toronto, Canada; ³Ornge Air Ambulance, Canada; ⁴Royal Canadian Medical Service, Canadian Armed Forces, Ottawa, Canada.

Correspondence: Fabio Botelho

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2025, 33(3):P8

Prehospital Resuscitative Balloon Occlusion of the Aorta (REBOA) is a potentially life-saving intervention for trauma patients in hemorrhagic shock. Its success depends on appropriate patient selection and logistics optimizing time from balloon inflation to damage control surgery. Evidence for prehospital REBOA, especially in the Canadian setting with paramedic-delivered care and long transport times, remains limited. This study evaluates the needs of prehospital REBOA by analyzing trauma cases meeting criteria for its deployment.

We conducted a retrospective chart review of adult trauma patients transported by Ornge, Ontario’s sole prehospital critical care provider. Adult trauma cases from 2019–2024 with at least three consecutive systolic blood pressure (SBP) readings below 90 mmHg were included. Transport times exceeding 10 min were also analyzed as a key logistical consideration.

Over five years, 747 adult trauma patients presented with SBP < 90 mmHg on at least three consecutive measurements. Of these, 622 patients experienced transport times exceeding 10 min. Among cases with SBP 70–50 mmHg, 229 patients met these criteria, including 145 with prolonged transport times. For patients with SBP < 50 mmHg, 60 cases were identified, with 32 having transport times > 10 min.

A significant number of trauma patients could potentially have benefitted from REBOA, particularly in the context of prolonged transport times. These findings support the development of a pilot project to evaluate prehospital REBOA’s implementation in Canada.

P9 Machine learning for the prediction of massive hemorrhage in trauma: A systematic review, meta-analysis, and APPRAISE-AI study

Gemma Postill¹, Anglin Dent¹, Richard Cheng², Anton Nikouline³, Teruko Kishibe⁴, Melissa McGowan⁴, Jethro Kwong¹, Brodie Nolan^1,4

¹Faculty of Medicine, University of Toronto, Canada; ²Queen’s University, Kingston, Canada; ³University of Alberta, Edmonton, Canada; ⁴St. Michael’s Hospital, Unity Health Toronto, Canada.

Correspondence: Gemma Postill

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2025, 33(3):P9

Timely provision of appropriate blood supplies is an essential aspect of care for patients with traumatic injuries. In the literature, machine learning (ML) algorithms have demonstrated potential for automated prediction of Massive Hemorrhage Protocols (MHP). However, the model quality and performance of such algorithms have yet to be evaluated comprehensively.

We conducted a systematic review and meta-analysis of studies published between January 1, 2004 to July 15, 2024 reporting the performance of ML models predicting MHP need among patients with traumatic injuries. In duplicate, title and abstracts and then full texts were screened. Data were extracted from included texts. A meta-analysis using a random-effects model was completed to compare performance metrics. A bivariate mixed-effects model and summary receiver operating characteristics curve was completed to assess the sensitivity and specificity for each ML model type. Quality was assessed using APPRAISE-AI.

Following review of 4542 abstracts, 18 studies were included with 36 unique ML algorithms generated. Meta-analysis revealed ML models to outperform the clinical reference model (Assessment of Blood Consumption [ABC] score) in area under the receiver-operating-characteristic curve (AUROC), sensitivity, and specificity. Random forest algorithms had the highest pooled AUROC (0.89 [95% CI: 0.80–0.97]), while XGBoost and neural networks had the highest sensitivity (0.86 [95% CI: 0.82–0.90] and 0.86 [95% CI: 0.82–0.90], respectively) and specificity (0.82 [95% CI: 0.81–0.81] and 0.80 [95% CI: 0.72–0.87], respectively). Models were mostly considered “moderate quality” according to APPRAISE-AI.

ML models outperformed traditional clinical prediction tools for MHP prediction. Overall, the reporting quality and reproducibility of ML models was low. Future ML algorithm types should improve reporting, specifically of model training data, data preprocessing, and subgroup performance, to facilitate comparison of model development procedures and increase confidence in newly developed models for MHP prediction.

P10 Use of naloxone by EMS for opioid-associated out-of-hospital cardiac arrest and associated patient-centered outcomes: A systematic review

Hania Siddiqui

Institute of Medical Sciences, University of Toronto

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2025, 33(3):P10

As opioid-related fatalities continue to climb, it is imperative to advance our understanding of the management of life-threatening opioid emergencies, including cardiac arrest. Emergency Medical Services (EMS) administered naloxone reverses critical respiratory depression within minutes, however, the role of naloxone in cases of opioid-associated cardiac arrest (OA-OHCA) is unknown. Current guidelines state that there is insufficient evidence to make recommendations for the use of naloxone in cardiac arrest management. This systematic review sought to examine patient outcomes following EMS-administered naloxone in OA-OHCA cases.

Following PRISMA guidelines, a systematic search was conducted in OVID Medline, Embase, and Cochrane from database inception to December 2024. Original, peer-reviewed studies examining patients with OA-OHCA who were given naloxone by EMS were included. Two independent reviewers screened titles/abstracts and full-texts in Covidence based on predetermined inclusion criteria. Relevant data points were extracted, and a risk of bias assessment was conducted for included studies. No meta-analysis was performed due to heterogeneity across the included studies.

The literature search yielded 4814 articles, of which 8 studies met eligibility and were included. Seven of the included studies were retrospective cohort studies conducted in the United States. The eighth included study was a prospective cohort study conducted in Denmark. The total sample size for drug-related OHCA patients was 1293 (range 16–471) from all the included studies. The risk of bias was assessed to be low to moderate in seven studies and serious in one study. A minority of patients achieved return of spontaneous circulation (ROSC), with ROSC ranging from 4.3% to 50%. Survival to hospital admission ranged from 11.1% to 55%, while survival to hospital discharge ranged from 0% to 20.4%.

There are a limited number of studies assessing the use of naloxone in OA-OHCA patients. Further research, including randomized controlled trials, are needed to evaluate naloxone and to guide treatment in this patient population.

P11 Association between EMS response times, socioeconomic status, and outcomes of out-of-hospital cardiac arrest in rural and urban areas in France: territorial inequalities in access to urgent care. A national, retrospective cohort study.

Hillary Minka¹, Etienne Audureau², Oceane Minka², Valentine Canon³, Sami Souihi⁴, Herve Hubert³, Eric Revue¹, Patrick Plaisance¹, Anthony Chauvin¹, Matthieu Heidet.¹

¹Hôpital Lariboisière, Assistance publique – Hôpitaux de Paris, Paris, France; ²Emergency department, Sorbonne Université, Hôpital Bichat, Assistance publique – Hôpitaux de Paris, Paris, France; ³Université de Lille, CHU Lille, Lille, France; ⁴Université Paris-Est Créteil (UPEC), LISSI Lab EA 3956, Vitry-sur-Seine, France

Correspondence: Hillary Minka

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2025, 33(3):P11

Emergency medical services’ response times (EMS-RT) are associated with outcomes of out-of-hospital cardiac arrest (OHCA). Their determinants include geographic and socioeconomic variables. However, interactions between these two dimensions remain poorly explored. The objective of this work was to describe and analyze the associations between EMS-RT, scene-level socioeconomic status, type of territory, and outcomes of OHCA.

Retrospective, multicenter, nation-wide cohort study, carried out from the national registry of cardiac arrests in France (RéAC), on adult, non-traumatic, non-EMS witnessed, OHCA patients included between 2011 and 2019. Scene-level census tracts attributes were used to assess the type of territory (urban vs. rural) and area-level socioeconomic status (using the European Deprivation Index [EDI; continuous, and divided into quintiles, Q5 = most deprived]). Using a categorical term of interaction between the type of territory and socioeconomic status, we evaluated access outcomes of dispatch-to-arrival at scene (EMS-RT) and patient clinical outcomes (return of spontaneous circulation [ROSC], survival, and neurological status at day 30). Associations between EMS-RT, socioeconomic status, type of territory and clinical outcomes were modeled using multilevel mixed-effects regression models.

A total of 81,033 patients were included, mostly in urban areas (55,755; 86%) of low socioeconomic status (23,777 in Q5; 35%). Median EMS-RT was 19 min (interquartile range, 14–27). After multivariate analysis, for each minute increase in EMS-RT in rural areas of high socioeconomic status (RURAL-Q1), EMS-RT increased by a factor of 1.11 (95% CI 1.078 to 1.15; p < 0.0001) in OHCAs in rural areas of low socioeconomic status (RURAL-Q5) and decreased by a factor of 0.90 (95% CI 0.89 to 0.92; p < 0.0001) and by a factor of 0.87 (95% CI 0.86 to 0.88; p < 0.0001) in OHCAs in urban of high (URBAN-Q1) and low (URBAN-Q5) socioeconomic status, respectively. Increased EMS-RT were negatively associated with ROSC (aOR = 0.62, 95% CI 0.58 to 0.67; p < 0 0.001), and survival at day 30 (aOR = 0.53, 95% CI 0.46 to 0.61; p < 0 0.001).

EMS-RT were longer in rural areas of low socioeconomic status than in urban areas in OHCA patients. Prolonged EMS-RT were significantly associated with poor clinical outcomes, emphasizing important nation-wide inequities in access to urgent prehospital care.

P12 Accuracy of the 2021 American College of Surgeons guidelines for the field triage of injured patients in predicting need for trauma center care

Ian Beamish¹, David Friedman², Rosane Nisenbaum², Ian Drennan^1,2, Melissa McGowan², Brodie Nolan^1,2

¹Faculty of Medicine, University of Toronto; ²St Michael’s Hospital, Unity Health Toronto

Correspondence: Ian Beamish

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2025, 33(3):P12

The Guidelines for the Field Triage of Injured Patients (Field Triage Guidelines, FTG), established by the American College of Surgeons, were updated in 2021 to improve the reliability of prehospital trauma triage. The objective of this study was to assess the accuracy of the 2021 FTG criteria in their ability to identify patients requiring dedicated trauma center care from a cohort of patients transported to a level 1 trauma center.

This was a retrospective cohort study of FTG criteria met for trauma team activations from January 2020 to December 2021. Hospital-based and injury severity score (ISS)-based trauma center need were defined and sensitivity and specificity of the FTG calculated for both. Area under the receiver operator curves (AUROC) were used to assess accuracy. Multivariable logistic regression was used to evaluate the association of each criteria with trauma center need (TCN).

A total of 1427 patients were included and 90.3% met at least one FTG criteria. Overall, patients meeting hospital-based TCN was 33.8% compared to 28.4%, which met ISS-based TCN. FTG criteria demonstrated a sensitivity of 97.3% and specificity of 13.3% with respect to hospital-based TCN with an AUROC of 0.80. Mental status and vital signs were the most sensitive criteria and showed the highest association with either definition of trauma center need.

The updated 2021 FTG demonstrate good accuracy and the high sensitivity of the new guidelines may help to reduce under triage rates to the international goal of < 5%. However, extremely low specificity may increase over triage rates.

P13 PRESTO: Prehospital REgistry for STEMI treatment and Outcomes

Jason Buick¹, Peter Austin^2,3,4, Sheldon Cheskes^1,2, Dennis Ko^2,3,4, Clare Atzema^2,3,4

¹University of Toronto; ²Sunnybrook Health Sciences Centre, Toronto, Canada; ³Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; ⁴ICES, Toronto, Canada

Correspondence: Jason Buick

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2025, 33(3):P13

Timely recognition and management of ST-elevation myocardial infarction (STEMI) in the prehospital setting is critical for improving outcomes. Early electrocardiogram (ECG) acquisition, prehospital catheterization lab activation, and timely reperfusion therapy reduce treatment delays. However, variations in prehospital STEMI care exist, and data collection remains limited. Currently, no prehospital STEMI care database exists in Canada. To address this gap, we developed a database to collect and analyze prehospital STEMI patient data, with the aim of identifying trends, gaps, and opportunities for quality improvement.

A database was developed using manual data extraction from paramedic documentation, including electronic patient care records (ePCR) and biometric data. Adult STEMI patients from four large urban paramedic services in Ontario who are taken directly to a PCI center will be included. Patients in cardiac arrest with subsequent return of spontaneous circulation (ROSC) will be included. Interfacility transfers and pediatric patients will be excluded. We will capture ~ 1,800 STEMI patients per year. We will collect demographics, ECG findings, transport times, treatments, and prehospital outcomes. Quality assurance measures ensure data accuracy. The database includes fields for potential future linkage with in-hospital data. The study was approved by the Research Ethics Board at Sunnybrook Health Sciences Centre (REB #5802).

This prehospital STEMI database will help identify gaps in care, and in turn inform system-wide quality improvement initiatives, including paramedic training and protocol refinements. Future research will explore patient outcomes, treatment variability, predictors of adverse events, and adherence to STEMI guidelines. The database offers opportunities to explore factors influencing delays in STEMI recognition, the impact of prehospital interventions on patient deterioration, and the role of paramedic decision-making in triage. It can also be used to assess disparities in access to timely STEMI care, and novel prehospital strategies, contributing to improved emergency care across multiple domains. Additionally, this approach may support prehospital research in other time-sensitive conditions such as stroke and trauma.

P14 Bridging the gap: Optimizing prehospital STEMI care in Canada

Jason Buick¹, Peter Austin^2,3,4, Sheldon Cheskes^1,2, Dennis Ko^2,3,4, Clare Atzema^2,3,4

¹University of Toronto; ²Sunnybrook Health Sciences Centre, Toronto, Canada; ³Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; ⁴ICES, Toronto, Canada

Correspondence: Jason Buick

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2025, 33(3):P14

Acute myocardial infarction is a leading cause of morbidity and mortality in Canada. Paramedics play a key role in rapid identification and initiation of reperfusion therapy, which improves outcomes. However, many patients do not receive timely care due to barriers in STEMI management. This project aims to categorize current practices, examine regional variation in prehospital STEMI care, and identify areas for improvement.

A cross-sectional online survey of stakeholders across Canada was conducted. Participants included professionals from both prehospital and in-hospital STEMI care. The survey was developed using prior literature and Canadian Cardiovascular Society guidelines, and was pilot-tested prior to distribution. Descriptive statistics, including counts, frequencies, and medians with interquartile ranges, were used for analysis. The study was approved by the Research Ethics Board at Sunnybrook Health Sciences Centre (REB #5525).

Of 182 invitees, 108 (59% response rate) completed the survey. Overall, 86% of participants reported having a STEMI bypass program/system, with 5.5% indicating a program was in development. Among those with a STEMI program, prehospital treatment protocols varied widely, with 84% having multiple prehospital reperfusion therapies; only 16% provided prehospital thrombolysis. All ambulances had 12-lead ECG capability, and 97% of prehospital providers could acquire and/or interpret ECGs. Significant regional variations existed in the process of cardiac catheterization team activation following STEMI diagnosis. Common barriers reported included ECG transmission issues, catheterization lab staffing, infrastructure limitations, PCI timing/availability, paramedic training, prehospital ECG accuracy, and hospital-specific protocol differences. Over two-thirds of participants reported a quality assurance program, but only 44% received individualized patient outcome data, and 42% contributed data to a STEMI registry.

Prehospital STEMI care evolved over the past 20 years, yet opportunities remain to optimize patient outcomes, including further standardization, enhanced training, and improved coordination. Addressing identified barriers could further streamline STEMI care in Canada. Strengthening quality assurance programs, increasing feedback, and promoting data contributions to STEMI registries would facilitate evidence-based evaluation of future interventions.

P16 A scoping review of sepsis management in prehospital and emergency department settings: Barriers, facilitators and strategies to improve care

Jennifer Greene

Dalhousie University, Halifax, Canada

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2025, 33(3):P16

Despite high-quality guidelines, barriers to timely evidence-based sepsis care persist, worsening morbidity and mortality. This scoping review describes barriers and facilitators to providing sepsis care in the prehospital and emergency department (ED) settings and strategies that support better sepsis care.

Employing the Briggs scoping review method and PRISMA-ScR reporting standards, we systematically searched MEDLINE, Embase, CINAHL, and Scopus for studies on the quality of sepsis care in prehospital and ED settings. Study selection was performed in duplicate and data extraction and quality assessment, using the PEP Program Levels of Evidence scale, was performed by one reviewer and verified by a second.

After screening 7840 titles, 363 articles were included. Most (59.5%; n = 216) studies were from the United States. ED (81.8%; n = 297), prehospital (11.8%; n = 43) or both (n = 23; 6.3%) settings were studied. Nurses (33.9% n = 222), physicians (33.8% n = 221) and paramedics (9.3% n = 61) were the most studied personnel. Most studies (62.3% n = 226) were of moderate quality however 18 studies (5.0%; 7 RCTs and 11 SRs) were high quality. Half of studies reported on adult populations (50.7%; n = 184), though pediatrics and older adults were represented at 11.6% and 1.4% of the literature respectively. Antibiotic delivery was the most reported on interventional aspect of care (14.0%; n = 51).

Improvement strategies included educational interventions (16.8%; n = 66), sepsis bundles (14.0%; n = 55), and using novel screening methods (11.5%; n = 45). Most strategies improved care (81.8%; n = 193). Barriers to care were difficult recognition, (23.3%n = 120), low awareness of guidelines (17.3%; n = 89) and inadequate staffing (9.3%; n = 48). Facilitators for implementing strategies were education (29.5%; n = 145), communication (12.2%; n = 60) and visual tools/checklists (10.2%; n = 50).

This is the largest review of strategies to improve sepsis outcomes in the prehospital and ED settings. There is an abundance of moderate quality literature that can guide improved awareness, early recognition and systems-based care.

P17 Paramedic sepsis identification and impact on time to antibiotic treatment: A retrospective chart review

Jennifer Greene

Dalhousie University, Halifax, Canada

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2025, 33(3):P17

Sepsis syndrome is associated with high mortality. Early recognition coupled with prompt delivery of antibiotics can increase survivability. Our objectives were to describe the impact of paramedic sepsis recognition on time to antibiotic administration and to determine the accuracy of paramedic sepsis recognition compared to Emergency Department (ED) physician diagnosis.

We conducted a retrospective chart review of patients with transported by paramedics to the Queen Elizabeth II ED between Jan 1 st, 2019 and Dec 31 st, 2019 who were diagnosed in the ED or by paramedics with sepsis. The primary outcome was time to antibiotic. Critical time intervals between these groups were compared. We calculated the sensitivity and positive predictive value of the paramedic recognition.

A total of 214 cases were identified, 49% (n = 104) were female and had a mean age of 70 years (SD: 15 years). The mean overall time from triage to antibiotic treatment was 3 h 2 min (SD: 2 h 27 min, IQR 2 h 16 min) with 11.2% receiving the antibiotics within 1-h of ED triage. When paramedics had suspected sepsis there was a 48-min reduction in mean time to antibiotic (mean 2 h 14 min, SD 2 h 4 min, IQR 1 h 31 min). Moreover, 31.6% of the EMS suspected group received antibiotics in the 1-h recommendation compared to 6.33% in the non-suspected by EMS group. The mean time from first vitals to antibiotic was 3 h 45 min (SD 2 h 29 min, IQR 2HR 30 min). 126 (59.1%) cases were suspected sepsis by paramedics and 105 (49.3%) were diagnosed by the ED, and 6 (2.8%) were missing the ED diagnosis. The sensitivity and positive predictive value for paramedic suspicion are 18.1% and 15.7% respectively.

Paramedics have poor ability to recognize sepsis in the field. However, their recognition may play a role in timely treatment. The guideline recommended treatment timelines are poorly adhered to in the ED.

P18 Effectiveness of prehospital critical care scene response for major trauma: A systematic review

Jeremy Penn¹, Ryan McAleer², Carolyn Ziegler³, Sheldon Cheskes^1,3, Brodie Nolan^1,2,3,4, Johannes von Vopelius-Feldt^1,2,3,4

¹Faculty of Medicine, University of Toronto; ²Ornge Air Ambulance, Canada; ³Li Ka Shing Knowledge Institute, Unity Health Toronto; ⁴St Michael’s Hospital, Unity Health Toronto

Correspondence: Jeremy Penn

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2025, 33(3):P18

Major trauma is a leading cause of morbidity and mortality worldwide. It is unclear if the addition of a critical care response unit (CCRU) with capabilities comparable to hospital emergency departments might improve outcomes following major trauma, when added to Basic or Advanced Life Support (BLS/ALS) prehospital care. This systematic review describes the evidence for a CCRU scene response model for major trauma.

We searched Medline (Ovid), Embase (Ovid), Cochrane Central Register of Controlled Trials (Ovid), CINAHL (EBSCOhost), Science Citation Index Expanded (Web of Science), Conference Proceedings Citation Index – Science (Web of Science), LILACS (Latin American and Caribbean Health Sciences Literature) for relevant publications from 2003 to 2024. We included any study that compared CCRU and BLS/ALS care at scene of major trauma, reported patient-focused outcomes, and utilized statistical methods to reduce bias and confounding. Risk of bias was assessed by two independent reviewers, using the ROBINS-I tool. Based on our a priori knowledge of the literature, a narrative analysis was chosen. The review was prospectively registered (Prospero ID CRD42023490668).

The search yielded 5,243 unique records, of which 26 retrospective cohort studies and one randomized controlled trial met inclusion criteria. Sample sizes ranged from 308 to 153,729 patients. Eighteen of the 27 included studies showed associations between CCRUs and improved survival following trauma, which appear to be more consistently found in more critically injured and adult patients, as well as those suffering traumatic cardiac arrest. The remaining nine studies showed no significant difference in outcomes between CCRU and BLS/ALS care. Most studies demonstrated critical or severe risks of bias.

Some negative studies were likely underpowered, and selection bias may have influenced results. Despite these limitations, existing evidence suggests that early advanced prehospital interventions may improve outcomes, aligning with the principles of early in-hospital trauma care.

Current evidence examining CCRU scene response for major trauma suggests potential benefits in severely injury patients but is limited by overall low quality. Further high-quality research is required to confirm benefits from CCRU scene response for major trauma.

P19 A survey of pediatric educational needs among Canadian paramedics

Jonathan Lee, Ian Drennan

Ornge Air Ambulance, Canada

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2025, 33(3):P19

Pediatric patients are high stress, low frequency events for paramedics. Research informing ongoing training needs of Canadian paramedics is lacking. The objective of this study was to identify the educational needs of Canadian paramedics related to pediatric care to guide curriculum development for both initial and continuing education.

A convenience sample of paramedics from the Regional Paramedic Program for Eastern Ontario completed an online survey during continuing education training to determine paramedic comfort in caring for pediatric patients as well as training barriers and preferences. We used descriptive statistics to present our results, as well as examining participant responses by years of service. This study was approved by the research ethics board of Georgian College.

A total of 1398 paramedics were surveyed of which 785 (56.1%) provided consent and completed the survey. 58.7% of respondents were male, 62.8% were PCP (33.3% ACP). Average years of service was 8 years. Paramedics most often reported being uncomfortable/very uncomfortable with the following clinical skills: IV access (41%), endotracheal intubation (25%) and IO access (20%). Comfort with these skills appeared to improve over years at level of certification. Paramedics were most uncomfortable/very uncomfortable with the following patient presentations: newborn resuscitation (47%), cardiac arrest/arrhythmia (43%) and giving bad news (38%). 52% of paramedics received no pediatric training within the previous two years, however, 80% wanted more pediatric training. With respect to future training: high fidelity simulation was the most preferred learning method (41%) and self-paced learning the most preferred length of training (27%).

Paramedics report discomfort with low frequency skills and presentations in pediatrics and overwhelming express the desire for more training. Comfort with certain skills changes with years at level of certification, the potential for targeted training based on years of experience should be explored.

P20 Venous arterial doppler enhanced resuscitation (VADER) index: Real-time detection of cryptic hemorrhage and resuscitation

Joseph Eibl

Flosonics Medical, Sudbury, ON, Canada

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2025, 33(3):P20

Venous Arterial Doppler Enhanced Resuscitation Index is obtained via a noninvasive, wearable wireless Doppler ultrasound patch that continuously assesses blood flow metrics in the jugular vein and carotid artery as a surrogate for central venous pressure and stroke volume, respectively. Unlike traditional methods, VADER enables beat-to-beat monitoring of venous and arterial Doppler waveforms, offering real-time insight into evolving hemodynamic changes including falling stroke volume and diminishing venous return in the face of stable blood pressure. Here we explore the feasibility of VADER in the trauma setting.

A feasibility study at a Level 1 trauma center enrolled 34 patients with traumatic injuries. The primary outcome was successful signal acquisition the trauma bay. The venous arterial Doppler patch was assessed for placement feasibility and its ability to capture at least 15 consecutive cardiac cycles. Venous/Arterial blood flow metrics were assessed in all participants as well as standard vital monitors used in the trauma bay.

Successful placement was achieved in 91% of patients. Patients requiring transfusion exhibited lower carotid flow time and minimal venous flow aligning with prior studies on hemodynamic compromise. High signal acquisition rates suggest feasibility for the trauma bay and hold promise for the pre-hospital setting where traditional monitoring is limited.

These findings support VADER’s potential to detect cryptic hemorrhage early, optimizing resuscitation strategies before hemodynamic collapse occurs.

P21 Viscoelastic testing at Canadian trauma centres: A cross-sectional survey of current practices, barriers, and facilitators

Kara Tastad¹, Melissa McGowan², Andrew Beckett^1,2,3, Michelle Sholzberg^1,2,3, Brodie Nolan^1,2,3

¹Faculty of Medicine, University of Toronto; ²St Michael’s Hospital, Unity Health Toronto; ³Li Ka Shing Knowledge Institute, Unity Health Toronto

Correspondence: Kara Tastad

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2025, 33(3):P21

Hemorrhage is a leading cause of death from trauma, often exacerbated by trauma induced coagulopathy (TIC). Detecting TIC early while using targeted blood component resuscitation is critical. Viscoelastic hemostatic assays (VHAs) quickly identify TIC, but their adoption in Canada is poorly described. Our study aims to describe VHA programs in Canadian level 1 and 2 trauma centres and identify perceived barriers and facilitators to implementation.

An interprofessional team of trauma and hematology clinicians developed an electronic survey, which included a blend of multiple choice, Likert, and open-text questions, which was piloted for usability before distribution. Trauma and/or hematology/transfusion medicine leads at level 1 and 2 adult trauma centers across Canada were invited to participate. The survey was administered via JotForm and responses were analyzed using descriptive statistics.

There were 31 centres invited. In total, 20 centres responded, representing 6 provinces (British Columbia, Alberta, Saskatchewan, Ontario, Nova Scotia, and Newfoundland and Labrador). Majority of sites agreed that there is evidence in current literature to support the use of VHAs to assess TIC (84%). Majority (65%) of centres did not have access to VHAs. Of these respondents, 94% said their institution would benefit from a VHA program. Most common identified barriers to implementation were cost/lack of funding, lack of knowledge on how to interpret results, and lack of institutional support. Centres with VHA programs used them exclusively in the operating room, primarily for cardiac surgery.

Despite widely accepted knowledge regarding the benefits of VHA for care in trauma centres, preliminary results demonstrate significant barriers to implementation. High cost, lack of institutional support, and knowledge of how to interpret results were the most common perceived barriers. Targeted knowledge translation facilitating VHA interpretation and development of national standards regarding VHA use in trauma may help facilitate its future use.

P23 The ‘Breast’ approach: Improving the cardiopulmonary resuscitation (CPR) narrative by disrupting the status quo

Kerry Fraser, Kristen Sampson, Gabriela Gonzalez Villacorta, Julia Lee, Nicole Fricker, Sue Zelko, Mark Joithe, Camille Gallant, Caseita Dewar-Morgan, Lindsay Beavers

Simulation Program, Unity Health Toronto

Correspondence: Kerry Fraser

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2025, 33(3):P23

Systems of oppression, e.g. racism, colonialism, sexism, etc., are historic and ongoing social structures that result in unearned advantage for some and disadvantage for others. In simulation, sexism and racism manifest through the availability of simulation equipment and operational and curriculum decisions regarding representation. The Unity Health Toronto’s Simulation Program (UHTSP) is not immune to inadvertently reinforcing systems of oppression in our work. UHTSP had exclusively white and male representing cardiopulmonary resuscitation (CPR) trainers until very recently. This representation is problematic as studies reveal that females are less likely to receive bystander CPR attempts and have poorer outcomes vs. males. Attempts and outcomes are worse for racialized vs white females. Despite breast tissue being identified as a perceived barrier to providing quality CPR, male representing manikins make up 95% of the available CPR trainers and 30% of trainers are offered exclusively in a white skin tone. Therefore, we wanted to understand how adding breast prostheses to UHTSP’s CPR manikins impacts learners’ perspectives.

In September 2022, half of UHTSP’s existing CPR manikins were supplemented with breast prostheses, with equal representation of available skin tones (light and dark).

Data collection periods were Jan 2021 – Aug 2022 (pre) and Sept 2022-Dec 2024 (post). The open text portion of UHTSP’s standardized post-session survey was analyzed, searching for key words related to sex, gender & race: woman(en), female, breast(s), gender, race, diversity/diverse and represent(ation).

3014 surveys were reviewed. Pre-breast implementation (n = 1559), no words related to sex, gender or race were identified. Post-breast implementation (n = 1455), the key word search yielded 67 discreet mentions: woman(en) (1), female (28), breast(s) (26), gender (2), race (0), diverse/diversity (2) and represent(ation) (3). All comments reflected positive feedback regarding the use of breast tissue and indications of evolving practice.

Sexism and racism exist in simulation education. However, it is often invisible despite the serious healthcare impacts. Adding breast prostheses to CPR manikins increased the number of participants who noted sex and gender differences, an essential step towards recognizing sexism. Notably, there were no comments related to race. Ongoing work by the UHTSP will be needed to continue to disrupt racism and sexism.

P24 Prehospital application of pelvic binders for suspected pelvic ring injuries: A retrospective cohort at St. Michael’s Hospital, Toronto

Lindsay MacLean¹, David Friedman², Anisa Nazir³, Ian Drennan⁴, Melissa McGowan², Brodie Nolan^1,2,4

¹Faculty of Medicine, University of Toronto; ²St. Michael’s Hospital, Unity Health Toronto; ³Institute of Medical Sciences, University of Toronto; ⁴Li Ka Shing Knowledge Institute, Unity Health Toronto

Correspondence: Lindsay MacLean

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2025, 33(3):P24

Pelvic fractures occur in 8% of major traumas and have significant life-threatening consequences, the application of pelvic binders in the prehospital setting can improve outcomes. The primary objective of this study was to determine how many patients had prehospital pelvic binders applied in patients with image confirm fractures. Additionally trauma characteristics were explored to identify associations with unstable pelvic fractures.

This was a retrospective cohort study from a single trauma centre between January 2017 and December 2022. Patients were included if > 16 years of age, transported directly from scene, and had a confirmed pelvic fracture on imaging. A manual review of electronic medical records and ambulance call records were performed by two reviewers to rate imaging findings and patient assessments. Cohen’s Kappa assessed interrater reliability on classification of unstable pelvic fractures on imaging. Continuous variables summarized as means and standard deviations or medians and interquartile ranges. Categorical variables presented as counts and percentages. Unadjusted logistic regression explored the association between unstable pelvic fracture and vital signs, physical exam findings, and mechanism of injury and presented as odds ratios(OR) and 95% confidence intervals(CI). P-values < 0 0.05 were considered significant.

429 patients met initial criteria; 95 were excluded for no records and 15 for no imaging, resulting in a final cohort of 319 patients. The mean age was 45 ± 19.9, 59.6% were male, and 92.1% blunt trauma. There were 83 unstable fractures. Interrater reliability for pelvic instability was high (Kappa 0.94). Prehospital pelvic binders were applied to 30 patients overall and 14/83(17%) with unstable pelvic fractures. Logistic regression showed no association with mechanism of injury and physical exam. There was a non-linear relationship between both heart rate (HR) and systolic blood pressure (SBP) with unstable pelvic fractures. Patients with HR between 65-110bpm had lower odds of instability compared to HR > 110bpm (OR 0.40, 95% CI 0.21–0.79 p 110mmHg (OR 5.79, 95% CI: 2.04–17.04 p < 0 0.01).

Overall, less than 10% of patients had a pelvic binder applied and only 20% in unstable pelvic fractures. Vitals signs of HR and SBP correlated with instability, could be helpful for increasing identification.

P25 Implementation of nurse-led assess-at-the-door (AATD) trauma team activation for patients not clearly meetingfield trauma triage guidelines

Lowyl Notario, Karla Kennedy, Aamirah Ashraf, Winny Li, Leah Kainer, Miranda Lamb, Justin Hall, Luis Teodoro Da Luz

Sunnybrook Health Sciences Centre, Toronto, Canada

Correspondence: Lowyl Notario

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2025, 33(3):P25

Field trauma triage (FTT) guidelines have provided prehospital professionals criteria to consider diverting to a lead trauma hospital (LTH). However, some ambiguous patient presentations may not clearly meet FTT guidelines and thus warrant a full trauma team activation (TTA). Locally, an emergency physician was often called to perform a physician-led assess-at-the-door (PL-AATD) to decide on full TTA vs usual care in the ED. PL-AATD assessment had been protocolized to follow local TT activation criteria which differed from field trauma triage criteria. While PL-AATD had no bearing on quality of care or disposition from the ED the process added up to 27 min to total triage time, placing unnecessary burden on physician resources and delays to definitive care. An exclusively nurse-led AATD (NL-AATD) process was hypothesized to take a shorter amount of time without negatively impacting quality of care.

Using a 3-month prospective cohort convenience sample, patients that presented to a LTH that did not clearly meet FTT guidelines, yet required consideration for TTA were assessed by a triage nurse. Triage nurses were trained to use an established protocol for TTA using just-in-time training. Consultation with the trauma team leader (TTL) on-call was permitted. The intervention group was retrospectively compared to a PL-AATD cohort from the prior year during the same time of year. Triage records were screened according to presenting complaints and narrative description using keywords to determine if an AATD was initiated. Primary outcomes included overall task time compared to all comers to triage, decision to activate trauma team, and disposition after triage. Secondary outcomes included frequency of TTL consultation for NL-AATD.

298 NL-AATD were collected over the 3-month period. Decision to activate the TT was 40% using the PL-AATD compared to 18% with NL-AATD. 80% of all NL- AATD were discharged from the ED. TTLs were consulted 40% of the time. 6% of NL-AATD that did not result in TTA were ultimately admitted to hospital. In patients that did not have an activation but required admission, the TTL was consulted 30% of the time. 5% of NL-AATD that resulted in TTA were discharged home. In patients that had a TTA but were discharged home, the TTL was consulted 40% of the time. PL-AATD task time took a median difference of 00min:52s and average 1min:20s longer compared to all-comers to triage in the same time period. NL-AATD task time took a median difference of 2min:38s and average 2min:37s longer compared to all-comers to triage in the same time period.

NL-AATD took longer compared to PL-AATD, but resulted in fewer TTA without compromising care. Triage nurses can appropriately apply TTA criteria to appropriately allocate resources.

P26 A paler shade of black: Triaging and managing multiple out of hospital cardiac arrests

Marc Boutet, Jennifer Bacon, Matthew Schulz, Ian Blanchard, Nicola Cavanagh-Whitfield

Alberta Health Services Emergency Medical Services

Correspondence: Marc Boutet

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2025, 33(3):P26

Although paramedics frequently respond to cardiac arrests, there is little guidance when multiple out-of-hospital cardiac arrest (MOHCA) patients present at the same scene. With the exception of specific circumstances such as in avalanches and electrocution, mass casualty incident (MCI) triage protocols classify patients in cardiac arrest as “Black” and bypass them to focus on patients with a pulse. A national case series suggests one in every 1,400 cardiac arrest calls may be a MOHCA event.

This qualitative study recruited paramedics who have attended a MOHCA event for one-on-one semi-structured interviews. The objective was to identify current practices and challenges and to inform a conceptual framework. Content analysis techniques were used to identify emergent concepts, then thematic analysis refined the concepts into themes and sub-themes. Finally, a broad conceptual framework for approaching MOHCA events was developed.

Nine paramedics from six EMS agencies in three provinces participated in one-hour interviews. Three main themes and 10 sub-themes were identified. Theme one described the increased complexity of managing a MOHCA event and includes sub-themes such as coordination of resources across the scene, the impact on the quality of resuscitation because of the additional burden of incident command and temporary resource constraints, imperfect dispatch information not allowing for adequate preparation prior to arrival, and communication across all levels of response including those on-scene and those in the process of responding. The second described triaging MOHCA patients to determine who receives resources and in what order, with sub themes describing the use of clinical (e.g., initial ECG rhythm, body temperature), operational (e.g., restricted access, patient location), and emotional (e.g., child vs. adult) considerations. The third described operations and resourcing, with sub-themes relating to people and equipment resourcing (e.g., recruiting law enforcement officers and bystanders, etc.), scene command, and the physical environment (e.g., scene hazards, physical obstructions, etc.).

A framework of challenges and strategies in responding to MOHCA events from the paramedic perspective includes three themes: complexity, triage, and operations and resourcing. This work can offer a foundation to guide expert consensus in augmenting existing MCI procedures.

P27 Pediatric post cardiac arrest care in the pre-hospital setting

Maxime Kranenburg, Janice Tijssen

London Health Sciences Centre (LHSC)—Children Hospital, London, ON, Canada

Correspondence: Maxime Kranenburg

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2025, 33(3):P27

Survival and neurological outcomes after pediatric out-of-hospital cardiac arrest (POHCA) remain poor. While post-cardiac arrest care (PCAC) has been associated with improved outcomes, no studies have addressed PCAC of pediatric patients in the pre-hospital setting. This study describes pediatric PCAC in the prehospital setting.

A retrospective multicenter study was conducted in South-West Ontario between January 2012 and May 2024, including POHCA patients with return of spontaneous circulation (ROSC) prior to hospital arrival. Ambulance Call Records and prehospital defibrillator data were analyzed to assess post-cardiac arrest monitoring and the occurrence of specific post-cardiac arrest conditions in the prehospital setting. The primary outcome was re-arrest, i.e. recurrence of cardiac arrest after initial ROSC while still under paramedic care.

This study included twenty patients, assessing 11 monitoring modalities and 12 post cardiac arrest conditions. A mean of 8.3 (1.6 SD) monitoring targets were achieved per patient, but only 5% received all monitoring. Monitoring included oxygen saturation (SpO2; 70%), end-titled capnography (EtCO2; 80%), non-invasive blood pressure (NIBP; 75%) and heart rhythm (95%). Glucose and temperature were measured in (1.9 SD) conditions occurred per patient, most commonly hypoxia (55%), hypercarbia (55%) and hypotension (45%). Four patients (20%) experienced a re-arrest. The re-arrest group received fewer monitoring modalities (mean: 6.25, SD: 0.50) compared to those who did not re-arrest (mean: 8.75, SD: 1.34) (p = 0.002). Blood pressure monitoring was also associated with re-arrest (p = 0.032) and was performed in only 25% (1/4) of the re-arrest cases compared to 87.5% (14/16) of those who did not re-arrest.

This study revealed that post cardiac arrest monitoring in pediatric patients is performed inconsistently in the prehospital setting. When monitoring is performed, post cardiac arrest conditions are frequently detected. Additionally, monitoring was associated with the occurrence of re-arrest. This pediatric study is the first to suggest a critical role for post cardiac arrest monitoring in the pre-hospital setting.

P28 Ignored and forgotten: Could current missing data practices be limiting the usefulness of transfusion prediction scores?

Melissa O’Neill¹, Sheldon Cheskes², Ian Drennan², Charles Keown-Stoneman², Steve Lin^2,3, Brodie Nolan^2,3

¹Institute of Medical Sciences, University of Toronto; ²Li Ka Shing Knowledge Institute, Unity Health Toronto; ³St Michael’s Hospital, Unity Health Toronto

Correspondence: Melissa O’Neill

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2025, 33(3):P28

Early blood transfusion is critical for reducing hemorrhage-related mortality in trauma patients. Several prediction scores have been developed to improve identification of injured patients requiring transfusions, however, their validity is highly dependent on the completeness of trauma registry data. This study aimed to examine the statistical methods used to address trauma registry missingness among research assessing the performance of the ABC score and Shock Index for predicting transfusion need.

We conducted a literature review of primary studies included in a previously published scoping review of predictors of transfusion in trauma. Registry-based retrospective cohort studies that quantitatively analyzed the performance of the ABC Score or Shock Index were included. Guided by recommendations for the conduct and reporting of analysis affected by missing data, we evaluated the extent of each manuscript’s reporting of missingness, and discussion of the methods used to manage missing data.

Overall, 18 studies published between 2008–2020 were included. Most studies used data from single-centre trauma registries (n = 15; 83%) and were conducted in the United States (n = 12; 67%). Ten studies (56%) assessed the ABC Score, seven assessed the Shock Index (39%), and one (6%) assessed the performance of both scores for predicting transfusion need. Among these, 39% (n = 7) made no mention of missing data, 34% (n = 6) identified that patients with missing data were excluded but did not quantify any missingness, and only one (n = 6%) quantified missingness for all variables. Almost all studies (n = 17; 94%) failed to compare patient characteristics in cohorts with and without missing data. Methods used to address missing data were complete case analysis (n = 9; 50%), pairwise deletion (n = 1; 6%) and single imputation (n = 1; 6%). Methods were unknown for studies that made no mention data completeness (n = 7; 39%). None (n = 0; 0%) of the included studies employed multiple imputation.

Among trauma registry-based assessments of the ABC score and Shock Index, most studies contained minimal—if any—discussion of missing data. Of the methods used to address missing data, nearly all studies employed complete case analysis, a method known to bias results in clinical research. To ensure prediction scores are sufficiently validated before clinical use, missingness must be appropriately addressed to prevent patients with missing data from being inappropriately excluded from study populations.

P29 Development and feasibility of a national prehospital transfusion registry: Insights from the Blood on Board program at Ornge

Noah Zweig¹, Nura Khattab², Mahvareh Ahghari³, Luis Da Luz^1,2, Melissa McGowan⁴, Harley Meirovich¹, Michael Peddle³, Aditi Khandelwal^1,2,4,5, Yulia Lin^1,2, Brodie Nolan^2,3,4,6

¹Sunnybrook Health Sciences Centre, Toronto, ON, Canada; ²Faculty of Medicine, University of Toronto; ³Ornge Air Ambulance, Canada; ⁴St Michael’s Hospital, Unity Health Toronto; ⁵Canadian Blood Services; ⁶Li Ka Shing Knowledge Institute, Unity Health Toronto

Correspondence: Noah Zweig

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2025, 33(3):P29

Out-of-hospital blood transfusion (OHBT) is an emerging practice for the management of hemorrhagic shock following trauma, but its outcomes remain unclear. The Canadian Prehospital and Transport Transfusion (CAN-PATT) network aims to standardize OHBT practices and link out-of-hospital care with in-hospital outcomes through a national registry. This pilot study assessed the feasibility of linking these records for patients who received OHBT via a provincial air ambulance service.

This retrospective cohort study included patients who received at least one unit of OHBT through an air ambulance Blood on Board program between September 2021 and July 2024 and were transported to one of two adult level 1 trauma centers. Prehospital data from the air ambulance database were linked to hospital data from the trauma registries. Hospital charts were manually reviewed for the missing variables. The primary outcome of the study was the percentage of prehospital and in-hospital records that could be successfully linked. Secondary outcomes included the percentage of variables collected by the registry vs chart review, injury patterns, and in-hospital mortality. Continuous variables were summarized as means/SDs or medians/IQRs, and categorical variables as counts and frequencies.

There were 93 patients that received an OHBT during the study period; 90 were transported to one of the level 1 trauma centres and 3 died in transport. Of those 90 patients, 83 (92%) were successfully linked (Site 1: 36/39; Site 2: 47/51) between the air ambulance database and hospital trauma registries. The remaining patients were unlinked due to unmatched identifiers like age and time of arrival. The air ambulance database provided 100% (97/97) of required out-of-hospital variables; the hospital registries collected 45% (13/29) (site 1) and 52% (15/29) (site 2) of required in-hospital variables. Among the 83 linked patients, median (IQR) age was 41.5 years (29–60), 73% male, 89% blunt trauma, and 22% in-hospital mortality.

This study demonstrates the feasibility of linking prehospital and in-hospital records for OHBT recipients, achieving a 92% linkage rate. Challenges in linking records and in-hospital data collection highlight obstacles for an efficient registry. Future work should explore incorporating missing variables into hospital registries to support the establishment of a national OHBT registry to enhance prehospital trauma care.

P30 Where every minute counts: Collecting, reflecting and improving massive hemorrhage protocol practices at St Michael’s Hospital

Matthew Olejarz¹, Amy Moorehead², Katerina Pavenski^2,3, Russel Omboa², Maria Lee Disano², Verity Tulloch², Melissa McGowan², Andrew Petrosoniak^2,3

¹McMaster University; ²St Michael’s Hospital, Unity Health Toronto; ³Faculty of Medicine, University of Toronto

Correspondence: Matthew Olejarz

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2025, 33(3):P30

Major hemorrhage is a challenging clinical problem that may occur with traumatic injury, gastrointestinal bleeding, major surgery or post-partum hemorrhage. When a patient is bleeding, having a standardized massive hemorrhage protocol (MHP) enables a rapid, coordinated and efficient approach to life-saving blood products. Ontario’s first recommendations for MHP published in 2019 included 8 quality metrics to be tracked at the hospital level and provincially. The reporting of quality metrics promotes improvement and facilitates transparency both within the hospital and across the system. Thus, we describe our experience in participating, tracking and utilizing feedback to improve MHP utilization.

MHP activations from January 1, 2019 to June 15, 2024 were identified. Data was extracted from patient charts and transfusion records, then entered into the Provincial Quality Metrics Portal. An autogenerated local and quarterly provincial report was generated from the data for peer benchmarking.

650 cases identified. Location of MHP activation: trauma (246, 39%), intensive care unit (183, 28%), emergency department (115, 18%), and operating room (72, 11%) with 87 plasma (FFP) units wasted. For applicable cases, 73.5% of patients received tranexamic acid within one hour. In addition, 59.4% of evaluated cases called for an appropriate MHP activation. Challenges with collection relate to time intensiveness of abstraction and traceability, need for dedicated personnel and usability of reports.

We describe the quality of MHP at a Level 1 trauma hospital benchmarked against 8 provincial quality metrics. We identified challenges in the data collection process, however, given MHP is used for critically ill patients, efficient and accurate data collection is an institutional priority. With this information, we aim to understand the specific challenges during MHP activation, and understand the steps towards improving quality of care. Our data provides further insights into the necessary resources required to support this process and stewarding our most precious resources – blood products.

P31 Prehospital whole blood transfusion for hemorrhagic shock: A systematic review

Pierre-Marc Dion^1,2, Adam Greene³, Andy Pan^1,4, Ian Drennan⁴, Johannes von Vopelius-Feldt^4,5, Risa Shorr¹, Brodie Nolan^4,5

¹Faculty of Medicine, University of Ottawa; ²Royal Canadian Medical Service, Canadian Armed Forces, Ottawa, Canada; ³BCEHS Air Ambulance and Critical Care Operations, Canada; ⁴Ornge Air Ambulance, Canada; ⁵Li Ka Shing Knowledge Institute, Unity Health Toronto

Correspondence: Pierre-Marc Dion

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2025, 33(3):P31

Hemorrhagic shock is a leading cause of preventable death in trauma and critically ill patients. Whole blood (WB) transfusion has re-emerged in prehospital resuscitation due to its ability to provide red blood cells, plasma, and platelets in a single unit. However, its efficacy and safety remain uncertain. This systematic review evaluates the impact of prehospital WB transfusion on mortality, transfusion requirements, and safety in patients with hemorrhagic shock.

The systematic review was conducted following PRISMA guidelines. MEDLINE, EMBASE, Cochrane, and Web of Science were searched from inception to present. Studies evaluating prehospital WB transfusion in adult patients (≥ 16 years) with hemorrhagic shock were included. The primary outcome was 24-h mortality. Secondary outcomes included early (1-h, 3- to 6-h, and 28- to 30-day) mortality, transfusion requirements, and adverse events. Risk of bias was assessed using Cochrane RoB 2 and ROBINS-I tools, and results were narratively synthesized due to heterogeneity.

The search yielded 3,845 studies, with 71 full texts reviewed and 6 studies included. Three studies with comparators (n = 2,186) reported mortality and transfusion outcomes, while three non-comparator studies (n = 86) assessed feasibility and safety. Study designs included retrospective cohort studies (n = 2), a multi-center retrospective analysis (n = 1), a prospective randomized pilot trial (n = 1), a retrospective observational study (n = 1), and a military case series (n = 1). Among comparator studies, WB transfusion was associated with lower 6-h mortality (7% vs. 12%, p = 0.04) but no significant difference in 28-day mortality (25.0% vs. 26.1%, p = 0.85). Massive transfusion activation was lower (22.6% vs. 32.4%, p = 0.01), and median transfused units were lower (4, IQR 2–9.5). Feasibility studies reported a median WB administration time of 35 min, and survival rates ranged from 78 to 87%. Transfusion-related adverse events were rare, with no significant increase in transfusion reactions, venous thromboembolism, or acute kidney injury. The overall risk of bias was moderate, and the quality of evidence remains low to moderate due to study design limitations.

Prehospital WB transfusion is feasible and may reduce transfusion requirements and early mortality. However, study heterogeneity and a lack of high-quality evidence limit definitive conclusions. Large-scale randomized trials are essential to determine its true impact on survival and safety.

P33 A survey of staff perceptions on the development and utilization of a machine learning-based blood transfusion support tool in the trauma bay

Richard Cheng¹, Vinyas Harish², Melissa McGowan³, Adam Szulewski¹, Michelle Sholzberg^2,3,4, Muhammad Mamdani^3,4, Brodie Nolan^2,3,4

¹Faculty of Medicine, Queens University; ²Faculty of Medicine, University of Toronto; ³St Michael’s Hospital, Unity Health Toronto; ⁴Li Ka Shing Knowledge Institute, Unity Health Toronto

Correspondence: Richard Cheng

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2025, 33(3):P33

Hemorrhage accounts for nearly half of deaths in the first 24 h following traumatic injury. Massive hemorrhage protocols (MHPs) aim to administer blood products early to reduce mortality. Machine learning (ML) may help predict the need for MHP using early clinical markers and reduce the cognitive burden on trauma teams. Here, we assess trauma staff perceptions of an ML-based transfusion support tool to aid its development and integration into real-world workflows.

We conducted a cross-sectional survey among trauma staff at St. Michael’s Hospital, a level 1 trauma centre in Toronto, Canada to evaluate their perception of ML tools to predict MHP. Our survey was designed to align with best practices from the Consolidated Framework for Implementation Research and Kelley et al.’s checklist to explore beliefs, barriers, and facilitators to ML adoption in trauma care. Our survey was distributed to interdisciplinary trauma team members including physicians, nurses, and other allied health staff. Descriptive statistics were used to summarize responses.

Among 25 respondents, 68% were familiar with ML concepts and 64% were optimistic about their implementation in trauma workflows. Our proposed tool for predicting MHP received positive feedback for predicting critical events, including the need for massive transfusion (Likert score 3.8/5) and ICU admission (score 3.75). Respondents believed that the most potentially useful data sources included EMR lab data as well as continuous vital signs (both 4.16). However, 40% of respondents were also concerned about privacy and medicolegal implications.

Interdisciplinary trauma team members at a level 1 trauma centre viewed an ML tool to predict MHP favourably. While they raised concerns about privacy and medicolegal risk, they believed such a tool had value in improving decision-making among critically ill patients. Our findings emphasize the importance of continued frontline engagement in the development and deployment of ML tools for trauma care.

P34 Feasibility of using autopsy data to examine prehospital care for traumatic cardiac arrest: a pilot study

Sasha Jones¹, Anthony Persaud¹, Ian Drennan^2,3,4, Sheldon Cheskes^2,3,4, Johannes von Vopelius-Feldt^2,3

¹St Michael’s Hospital, Unity Health Toronto; ²Faculty of Medicine, University of Toronto; ³Li Ka Shing Knowledge Institute, Unity Health Toronto; ⁴Sunnybrook Center for Prehospital Medicine, Toronto, ON, Canada

Correspondence: Sasha Jones

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2025, 33(3):P34

Over 70% of deaths from trauma occur in the prehospital environment. In Canada and the U.S., the level of care for these patients is mostly limited to basic or advanced life support (BLS/ALS). Recent research has raised concerns that a small but important number of patients might have a chance of survival if they received critical care interventions such as thoracostomy, thoracotomy, blood transfusion, REBOA, at scene We undertook a pilot study to assess the feasibility of using coroners’ records to test this hypothesis.

We undertook a retrospective chart review of prehospital trauma deaths in a mixed urban/suburban region of Ontario, Canada. Basic demographics such as injury date, time, estimated age, sex and mechanism of injury from Emergency Medical Services (EMS) records were used to identify records at the Office of the Chief Coroner of Ontario. Demographics, timelines, prehospital interventions and injury details were extracted from the coroner’s records. The primary outcome was the number of cases identified within the coroner’s archives, secondary outcome were the level of autopsy details and the ability to estimate the need for critical care interventions.

A total of 580 potential cases were identified from EMS records, leading to identification of 367 cases of prehospital traumatic cardiac arrest with corresponding coroner’s records. Of these156 cases had no resuscitation commenced by paramedics on scene and were therefore excluded as cases of obvious death. For the remaining 211 cases, the median age range was 30–40 with a gender distribution of 76% male, and penetrating mechanism of trauma in 28% of cases. Level of autopsy performed were assessed: full internal autopsy (49%), computed tomography with external autopsy (40%) and external examination only (10%). Based on a preliminary single expert review, 120 cases (57%) had at least one indication for a critical care intervention not delivered within the current prehospital level of care. There was insufficient data to answer this question in 25 cases (12%).

Our pilot study demonstrates that data extraction from coroner reports to examine prehospital deaths is feasible and can inform treatment recommendations for prehospital trauma care. Multi-disciplinary review of trauma deaths is required to establish if cases might have been amenable to advanced prehospital interventions.

P35 Factors of variability in the management of out-of-hospital cardiac arrest according to age in France: Is it really necessary to resuscitate elderly patients? A multicenter retrospective cohort study.

Simon Cahen, Etienne Audureau, Lecarpentier Eric, Steven Bennington, Francois Revaux, Matthieu Heidet

Hôpital Universitaire Henri Mondor AP-HP, France

Correspondence: Simon Cahen

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2025, 33(3):P35

The incidence of out-of-hospital cardiac arrest (OHCA) increases with age, while survival rates decrease. Although prehospital management requires an individualized approach, data on the influence of age in resuscitation decisions remain limited. The primary objective of this study was to identify and characterize patient profiles managed for OHCA by an emergency medical service (EMS) at the national level and to assess variability in management according to age. Secondary objectives included analyzing the prognostic associations of these profiles.

Using data from the RéAC registry, we included adult patients who suffered a non-traumatic OHCA in France between July 1, 2011, and April 2, 2024. Patient profiles were identified using unsupervised clustering (Self-Organizing Maps, SOMs).

Among 124,619 patients, six distinct groups were identified, showing age-related differences. Younger patients received more intensive interventions and had better 30-day survival rates. Older patients generally received more limited interventions, but among them, some were treated more aggressively, leading to better prognoses.

The intensity of EMS management and survival outcomes for OHCA patients vary with age. In younger patients, intensive interventions improve survival. In older patients, a more nuanced approach appears necessary.

P38 Development and validation of a machine learning model to predict massive hemorrhage in the trauma bay

Vinyas Harish¹, Gemma Postill¹, Fayad Al-Haimus¹, Muhammad Mamdani^2,3, Derek Beaton², Melissa McGowan², Andrew Beckett^2,3, Michelle Sholzberg^2,3, Brodie Nolan^2,3

¹Faculty of Medicine, University of Toronto; ²St Michael’s Hospital, Unity Health Toronto; ³Li Ka Shing Knowledge Institute, Unity Health Toronto

Correspondence: Vinyas Harish

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2025, 33(3):P38

Providing critically injured patients with blood products is an essential aspect of trauma resuscitation. Massive hemorrhage protocols (MHPs) exist to streamline the approach and delivery of measures necessary to stabilize patients until they can undergo definitive source control. Minimizing time to MHP activation is critical for improving patient outcomes; however, clinical gestalt and existing predictive scores fail to capture the dynamic and complex process of trauma-induced coagulopathy adequately. We aimed to develop and internally validate a machine learning (ML) model to predict massive hemorrhage in the trauma bay using early clinical and laboratory biomarkers at a level-one trauma centre in Toronto, Canada.

We conducted a retrospective cohort study of all trauma patients who presented to St. Michael’s Hospital between January 1 st, 2017 and December 31 st, 2021. Massive hemorrhage in the trauma bay was defined as requiring three or more blood component transfusions. Four ML models (logistic regression, generalized additive model, support vector machine and gradient-boosted decision trees) were trained and validated on 3325 patients and tested on 1425 patients. There were 25 features used to train the models including demographics, injury details, triage vitals, and laboratory and point-of-care coagulation testing biomarkers. The primary model evaluation metric was discrimination as measured by the area under the receiver operating characteristic curve (AUROC). We followed the TRIPOD + AI statement in conducting and reporting the study.

Of the 4750 patients, 239 (5%) experienced the outcome of massive hemorrhage. The best-performing ML model, gradient-boosted decision trees, achieved a test AUROC of 0.97, and at a 90% threshold achieved a sensitivity of 0.80 and a positive predictive value of 0.47. Of the 25 included features, the most important features for predicting massive hemorrhage included the systolic blood pressure on arrival, base excess, and measured fibrinogen.

Using a combination of early, readily available clinical and laboratory biomarkers, machine learning models can predict massive hemorrhage with high discrimination at acceptable sensitivity and positive predictive values. Future work, including silent trials, should investigate the utility of algorithmically activated massive hemorrhage protocols for improving outcomes in critically ill trauma patients.