Targeted temperature management: State of the Art

One of the indicated elements of post-resuscitation care is therapeutic hypothermia or temperature treatment management. the survivability of out-of-hospital cardiac arrest (OHCA) till admission to hospital is only 23%. Efficient thermoregulatory mechanisms are the basis for maintaining optimal body temperature. Therapeutic hypothermia shows normalizing effect on metabolic processes disturbed in ischaemic conditions, including improving metabolism and maintaining glucose balance in the brain, lowering the concentration of lactates, limiting the secretion of free radicals in damaged neurons, lowering the production of pro-inflammatory cytokines, stabilizes the blood-brain barrier and reduces endothelial dysfunction preventing ischaemic damage to tissues and organs. Hypothermia has a wide multidirectional effect on the human body, which can be useful in patients. Most available scientific studies show the efficacy and benefits of hypothermia in patients with out-of-hospital sudden cardiac arrest, including especially with ventricular fibrillation. The delay in the initiation of therapeutic hypothermia and reaching target temperature significantly increased the odds of a poor neurological outcome. Current American Heart Association (AHA) and European Resuscitation Council (ERC) resuscitation guidelines recommend that targeted temperature management should be implemented in all adult coma patients with return of spontaneous circulation (ROCS) after sudden cardiac arrest. The target temperature should be between 32°C and 36°C and then maintained for at least 24 hours. In patients with coma after TTM, fever should be actively prevented. For patients with out-of-hospital cardiac arrest, it is not recommended to routinely cool patients in prehospital conditions with a rapid intravenous infusion of cold fluids after ROSC

Application of interventional ultrasound in emergency medicine conditions

ULTRASONOGRAPHY is a modern diagnostic tool both in intensive care and emergency medicine. Small, portable and simple ultrasound devices have been introduced due to technological advances. The image quality, size, and weight of portable ultrasound devices are improving. Prehospital point-of-care ultrasonog- raphy may have an impact on the decision making in prioritizing initial treatment. First aid at the scene of the accident and transporting the patient to the hospital is a key element, which in the case of appropriate diagnostics allows you to fight life-threatening injuries. The intention of using ultrasound protocols is to shorten and simplify the ultrasound examination allowing to eliminate or find complications of an injury as soon as possible. The protocols used include elements of ultrasonography and echocardiography of the lung tissue, abdominal cavity, pelvis, large vessels or the eyeball. The intention of the authors of the article was to present to the reader the basic ultrasound protocols applicable to patients in emergency situations.

Ultrasound assessment of the optic nerve sheath as an indirect method of diagnosis of increased intracranial pressure

Ultrasonography is a diagnostic technique that has been used clinically for 30 years. Due to the increased availability of ultrasound machines as well as the reduction of their size and making them more mobile, ultrasound has found its place in early diagnosis in emergency medicine settings. One of the important, however, an underestimated ultrasound examination is the measurement of the thickness of the optic nerve sheath. The optic nerve is the second cranial nerve, meaning the same sheath surrounds it as the brain. At the moment of intracranial pressure increase, cerebrospinal fluid flows into the subarachnoid space causing an increase in intracranial pressure and thus increasing the diameter of the optic nerve sheath. therefore, ONSD imaging is a quick non-invasive test aimed at detecting and monitoring changes in intracranial pres- sure. Optic nerve sheath ultrasound is a simple, safe and inexpensive bedside diagnostic test. Ophthalmic ultrasound usually uses the frequency between 5 and 10.5 MHz to evaluate the eye and the orbit.  

Novel airway device Vie Scope in several pediatric airway scenario: A randomized simulation pilot trial

CONTEXT: Endotracheal intubation of pediatric patients is challenging, especially in the pre-hospital emergency setting and if performed by less experienced providers. Securing an airway should be achieved with a single intubation attempt, as each intubation attempt contributes to morbidity and mortality. A new airway device, the VieScope, was recently introduced into clinical market, but efficacy to reduced intubation attempts remains unclear thus far. OBJECTIVE: We aimed to compare endotracheal intubation by paramedics using the Vie Scope in different pediatric airway simulation conditions. METHODS: We conducted a randomized, cross-over simulation study. Following a theoretical and practical training session, paramedics performed endotracheal intubation in 3 different pediatric emergency scenarios: normal airway; tongue edema; cardiopulmonary resuscitation using the VieScope. Overall intubation success rate was the primary outcome. Secondary outcomes included number of intubation attempts, time to intubation, Cormack-Lehane grade, POGO score, and ease of use (using 1-100 scale). RESULTS: Fifty-five paramedics with at least 2 years of clinical experience and without any previous experience with the VieScope participated in this study. The overall intubation success rate was 100% in all 3 scenarios. The median intubation time was 27 (24-34) versus 27 (25-37) versus 29 (25-40) s for scenarios A, B, and C, respectively. In scenario A, all paramedics performed successful intubation with 1 single intubation attempt, whereas 2% of the paramedics had to perform 2 intubation attempts in scenario B and 9% in scenario C. CONCLUSIONS: Results of this simulation study indicate preliminary evidence, that the VieScope enables adequate endotracheal intubation in the pediatric setting. Further clinical studies are needed to confirm these results

New Flexible Tip Bougie catheter for difficult airway intubation. A randomized, crossover pilot study

INTRODUCTION: The ability to protect the airway is one of the basic skills that medical staff should have, especially those working within the Emergency Medical Service or Emergency Department. Endotracheal intubation under medical emergency conditions based on direct laryngoscopy is not effective enough; this effect is additionally reduced in the case of the difficult airway resulting from reduced visibility of the entrance to the glottis due to tongue or epiglottis oedema, trauma, etc. The aim of the study was to compare the intubation time and its effectiveness using two different stylets for difficult airway intubation. MATERIAL AND METHODS: The study involved 37 nurses who participated in training on advanced life support procedures. The experiment was designed as a randomized, cross-over simulation study. During the training, participants were instructed to perform endotracheal intubation using the tested intubation methods and had 20 minutes of practical training during which they were able to intubate with the tested stylets under normal airway. In the study, participants performed endotracheal intubation using a laryngoscope with a Macintosh blade and a difficult airway Bougie stylet (ONTEX, Chennai, India), or the Flexible Tip Bougie (MDSS GmbH, Hannover, Germany), which was designed to allow to guide the distal end of the anteriorly and posteriorly to facilitate entry into the larynx. RESULTS: The effectiveness of the first intubation attempt using a standard Bougie stylet was 37.8%, and that of the new Bougie stylet was 51.4% (p = 0.037). The mean intubation time was 55 s (IQR; 34–65) vs. 37 s (IQR; 25–41) (respectively, p = 0.021). The median ease of intubation was 7 (IQR; 5–9) points for a standard Bougie stylet and 5 (2.5–7) 2 points for a new Bougie stylet (p = 0.018). CONCLUSIONS: In a simulation study, the use of Flextip Bougie by nurses compared to a standard Bougie stylet was associated with higher efficacy and shorter intubation times in difficult airway

Efficacy of double-lumen intubation performed by paramedics on patients with lung damage. Experimental, pilot simulation trial

INTRODUCTION: The airway management and the implementation of optimal oxygen therapy in trauma patients, especially unconscious ones, is a key element of prehospital management. However, in cases of trauma lung or bronchial rupture, both lungs ventilation may not be advisable. In such cases, intubation with a double-lumen endotracheal tube may be helpful, allowing to provide one-lung ventilation. The aim of the experimental study was to assess the impact of short training in intubation using double-lumen tubes on the effectiveness of intubation performance and one-lung ventilation by paramedics in a simulated trauma patient setting. MATERIAL AND METHODS: This was a prospective, observational, randomized experimental trial. The study involved 30 paramedics. The participants had to perform tracheal intubation using Double Lumen Tube VivaSight-DL (VS-DL; ETView Ltd.; Misgav, Israel) under normal airway conditions. The effectiveness of the first intubation attempt, the time of intubation and the Cormack-Lehane scale were evaluated. RESULTS: The effectiveness of the first attempt at intubation with a double-lumen tube was 90% and the total effectiveness of intubation was 100%. The median time of the procedure was 63 (IQR; 38–72.5) seconds. CONCLUSIONS: In the simulation study, the paramedics were able to intubate using a double tube after a short training

Effect of 5 different cervical collars on optic nerve sheath diameter: A randomized crossover trial

BACKGROUND: There is considerable evidence that prolonged use of cervical collars potentially cause detrimental effects including increase in optic nerve sheath diameter (ONSD) among healthy volunteers. Different types of cervical collars immobilize cervical spine variably well and may presumably differently influence the venous compression and hence the intracranial pressure. We therefore aimed to evaluate the influence of cervical spine immobilization with 5 different types of cervical collars on ONSD measured noninvasively by ultrasound on healthy volunteers. METHODS: We conducted a randomized crossover trial including 60 adult healthy volunteers. Control assessment of the optic nerve sheath thickness was performed in both sagittal and transverse planes. Patient was placed supine on a transport stretcher, cervical collar was placed, and ONSD measurement was performed after 5 and 20 minutes. During the next days, the procedure was repeated with random allocation of participants and random cervical collar. RESULTS: Sixty healthy volunteers were included in our study. ONSD left diameter [mm] for the baseline was 3.8 [interquartile range (IQR): 3.65-3.93)] mm. Using AMBU after 5 min, ONSD was changed up to 4.505 (IQR 4.285-4.61; P \u3c .001) mm. The largest change at 5 minutes and 20 minutes was using Philly 4.73 (IQR: 4.49-4.895; P \u3c .001) and 4.925 (IQR: 4.65-5.06; P \u3c .001), respectively. Necklite reported the lower change in ONSD: 3.92 (IQR: 3.795-4; P = 1.0) mm in 5 minutes and 3.995 (IQR: 3.875 - 4.1; P = 1.0) mm in 20 minutes. ONSD right diameter [mm] for the baseline was 3.8 (IQR 3.675-3.9) mm. Using AMBU after 5 minutes, ONSD was changed up to 4.5 (IQR 4.21-4.6) mm. The largest change at 5 minutes and 20 minutes was using Philly 4.705 (IQR 4.455-4.9) and 4.93 (IQR 4.645-5.075), respectively. Necklite reported the lower change in ONSD -33.9 (IQR 3.795-3.99) mm in 5 minutes and 3.995 (IQR 3.86-4.09) mm in 20 minutes. CONCLUSION: We report significant increase of ONSD from the baseline after cervical collar placement among healthy volunteers at 5 minutes and 20 minutes interval. In addition, no significant difference was noted between ONSD measurements at 5 and 20 minutes. Clinicians should take proactive steps to assess the actual need of cervical collar case by case basis. Nonetheless, when needed, Necklite moldable neck brace seems to be a reasonable option

The COVID-19 pandemic — a view of the current state of the problem

The current pandemic has raised great global public health concern. The disease name was subsequently recommended as COVID-19 by the World Health Organisation (WHO) [1,2]. Meanwhile, 2019-nCoV was renamed SARS-CoV-2 by the International Committee on Taxonomy of Viruses. SARS CoV-2 is considered highly contagious. As of April 1, 2020, more than 883,255 confirmed cases, including more than 44,156 deaths, have been reported worldwide, affecting almost the whole world

Knowlege and attitudes toward intraosseous access among emergency medical service practitioners in Poland

INTRODUCTION: The administration of fluids, drugs and blood products is frequently indicated in patients suffering from serious injury or illness in the out-of-hospital emergency setting. Placement of a peripheral venous catheter may be challenging and several insertion attempts may delay intravenous therapy. Intraosseous access serves as a valuable alternative. However, this technique is rarely performed and knowledge of its use may not remain satisfactory in out-of-hospital Emergency Medical Service (EMS) personnel. METHODS: A written invitation to participate in this questionnaire study was sent to all EMS providers in Poland. Participants were asked to answer an online questionnaire consisting of 10 questions about their knowledge, ex­perience, and training of intraosseous devices. All answers were collected and processed anonymously. RESULTS: 438 out of 550 Polish EMS providers with a median experience of 5 years completed the questionnaire. Although 88% confirmed that there is an intraosseous access device available in their ambulance, only 47% had previously performed the procedure. Moreover, 48% reported subjective psychological barriers to obtaining an intraosseous access and 37% reported that intraosseous access should not be performed on paediatric patients. DISCUSSION: Intraosseous devices are widely available in many ambulances. Experience and knowledge regarding intraosseous access remains unsatisfactory among Polish EMS providers. Critical review of training and education curricula is therefore indicated

Comparison of blind intubation via supraglottic airway devices versus standard intubation during different airway emergency scenarios in inexperienced hand Randomized, crossover manikin trial

Background: Securing the airway and enabling adequate oxygenation and ventilation is essential during cardiopulmonary resuscitation (CPR). The aim of the study was to evaluate the success rate of blind intubation via the I-Gel and the Air-Q compared with direct laryngoscopy guided endotracheal intubation by inexperienced physician and to measure time to successful intubation. Methods: The study was designed as a randomized, cross-over simulation study. A total of 134 physicians, from specialties other than Anesthesia or Emergency Medicine, who considered themselves skilled in endotracheal intubation but who have never used any kind of supraglottic airway device performed blind intubation via the I-Gel and Air-Q and direct laryngoscopy guided endotracheal intubation in 3 randomized scenarios: normal airway without chest compression during intubation attempt; normal airway with continuous chest compression during intubation attempt; difficult airway with continuous chest compression. Results: Scenario A: Success rate with initial intubation attempt was 72% for endotracheal intubation, 75% in Air-Q, and 81% in I-Gel. Time to endotracheal intubation and ease of intubation was comparable with all 3 airway devices used. Scenario B: Success rate with the initial intubation attempt was 42% for endotracheal intubation, compared with 75% in Air-Q and 80% in I-Gel. Time for endotracheal intubation was significantly prolonged in endotracheal intubation (42seconds, 35-49), compared with Air-Q (21seconds, 18-32) and I-Gel (19seconds, 17-27). Scenario C: The success rate with the initial intubation attempt was 23% in endotracheal intubation, compared with 65% in Air-Q and 74% in I-Gel. Time to intubation was comparable with both supraglottic airway devices (20 vs 22seconds) but was significantly shorter compared with endotracheal intubation (50seconds, P <.001). Conclusions: Less to moderately experienced providers are able to perform endotracheal intubation in easy airways but fail during ongoing chest compressions and simulated difficult airway. Consequently, less to moderately experienced providers should refrain from endotracheal intubation during ongoing chest compressions during CPR and in expected difficult airways. Supraglottic airway devices are reliable alternatives and blind intubation through these devices is a valuable airway management strategy