Ambulance deceleration causes increased intra cranial pressure in supine position:a prospective observational proof of principle study

BACKGROUND: Ambulance drivers in the Netherlands are trained to drive as fluent as possible when transporting a head injured patient to the hospital. Acceleration and deceleration have the potential to create pressure changes in the head that may worsen outcome. Although the idea of fluid shift during braking causing intra cranial pressure (ICP) to rise is widely accepted, it lacks any scientific evidence. In this study we evaluated the effects of driving and deceleration during ambulance transportation on the intra cranial pressure in supine position and 30(°) upright position. METHODS: Participants were placed on the ambulance gurney in supine position. During driving and braking the optical nerve sheath diameter (ONSD) was measured with ultrasound. Because cerebro spinal fluid percolates in the optical nerve sheath when ICP rises, the diameter of this sheath will distend if ICP rises during braking of the ambulance. The same measurements were taken with the headrest in 30(°) upright position. RESULTS: Mean ONSD in 20 subjects in supine position increased from 4.80 (IQR 4.80–5.00) mm during normal transportation to 6.00 (IQR 5.75–6.40) mm (p < 0.001) during braking. ONSD’s increased in all subjects in supine position. After raising the headrest of the gurney 30(°) mean ONSD increased from 4.80 (IQR 4.67–5.02) mm during normal transportation to 4.90 (IQR 4.80–5.02) mm (p = 0.022) during braking. In 15 subjects (75%) there was no change in ONSD at all. CONCLUSIONS: ONSD and thereby ICP increases during deceleration of a transporting vehicle in participants in supine position. Raising the headrest of the gurney to 30 degrees reduces the effect of breaking on ICP

Deferred consent in emergency trauma research:A qualitative study assessing the healthcare professional's opinions

Introduction: Severely injured patients are often incapacitated to provide informed consent for clinical studies. Deferred consent could facilitate unbiased enrollment in studies involving these patients. Little is known about how healthcare professionals (HCPs) perceive deferred consent and how this impacts patient enrollment. The aim of this study was to identify factors that could influence HCPs decision-making during recruitment of patients for interventional studies in (pre)hospital emergency trauma research. Methods: This was a qualitative study in which physicians and nurses working in prehospital or in-hospital care were interviewed using a semi-structured interview guide. Interviews were audio-recorded, transcribed, and analyzed according to thematic analysis as described by Braun and Clarke. Results: Ten semi-structured interviews were conducted with six physicians and four nurses. Eight themes were identified as being relevant consent related factors influencing HCPs’ decision-making during patient recruitment in studies using deferred consent: (1) HCPs’ lack of knowledge; (2) Patients’ and proxies’ inability to be informed; (3) Practical (im)possibilities for informed consent; (4) Nature of intervention; (5) HCPs’ personal beliefs; (6) Importance of emergency care research; (7) HCPs’ trust in legal base; and (8) Communication and collaboration. Conclusions: Eight consent-related factors influencing HCPs’ decision making were identified. Insufficient knowledge about consent procedures among HCPs leads to significant negative attitudes towards deferred consent.</p

Emergency reflex action drill for traumatic cardiac arrest in a simulated pre-hospital setting; a one-group pre-post intervention study

Background: Emergency Reflex Action Drills (ERADs) are meant to decrease stress-associated cognitive demand in high urgency situations. The aim of this study was to develop and test an ERAD for witnessed traumatic cardiac arrest (TCA), an event in which potentially reversible causes need to be systematically addressed and treated in a short period of time. We hypothesize that this ERAD (the TCA-Drill) helps ground Emergency Medical Services (EMS) nurses in overcoming performance decline during this specific high-pressure situation. Methods: This was a prospective, experimental one-group pre-post intervention study. Ground EMS nurses participated in a session of four simulated scenarios, with an in-between educational session to teach the TCA-Drill. Scenarios were video recorded, after which adherence and time differences were analyzed. Self-confidence on clinical practice was measured before and after the scenarios. Results: Twelve ground EMS nurses participated in this study. Overall median time to address reversible causes of TCA decreased significantly using the TCA-Drill (132 vs. 110 s; p = 0.030) compared with the conventional ALS strategy. More specifically, participants adhering to the TCA-Drill showed a significantly lower time needed for hemorrhage control (58 vs. 37 s; p = 0.012). Eight of 12 (67 %) ground EMS nurses performed the ERAD without protocol deviations. Reported self-confidence significantly increased on 11 of the 13 surveyed items. Conclusions: The use of an ERAD for TCA (the TCA-Drill) significantly reduces the time to address reversible causes for TCA without delaying chest compressions in a simulated environment and can be easily taught to ground EMS nurses and increases self-confidence. Implications for clinical practice: The use of an ERAD for TCA (the TCA-Drill can significantly reduce the time to address reversible causes for TCA without delaying chest compression. This drill can be easily taught to ground EMS nurses and increases their self-confidence in addressing TCA-patients.</p

Emergency reflex action drill for traumatic cardiac arrest in a simulated pre-hospital setting; a one-group pre-post intervention study

Background: Emergency Reflex Action Drills (ERADs) are meant to decrease stress-associated cognitive demand in high urgency situations. The aim of this study was to develop and test an ERAD for witnessed traumatic cardiac arrest (TCA), an event in which potentially reversible causes need to be systematically addressed and treated in a short period of time. We hypothesize that this ERAD (the TCA-Drill) helps ground Emergency Medical Services (EMS) nurses in overcoming performance decline during this specific high-pressure situation. Methods: This was a prospective, experimental one-group pre-post intervention study. Ground EMS nurses participated in a session of four simulated scenarios, with an in-between educational session to teach the TCA-Drill. Scenarios were video recorded, after which adherence and time differences were analyzed. Self-confidence on clinical practice was measured before and after the scenarios. Results: Twelve ground EMS nurses participated in this study. Overall median time to address reversible causes of TCA decreased significantly using the TCA-Drill (132 vs. 110 s; p = 0.030) compared with the conventional ALS strategy. More specifically, participants adhering to the TCA-Drill showed a significantly lower time needed for hemorrhage control (58 vs. 37 s; p = 0.012). Eight of 12 (67 %) ground EMS nurses performed the ERAD without protocol deviations. Reported self-confidence significantly increased on 11 of the 13 surveyed items. Conclusions: The use of an ERAD for TCA (the TCA-Drill) significantly reduces the time to address reversible causes for TCA without delaying chest compressions in a simulated environment and can be easily taught to ground EMS nurses and increases self-confidence. Implications for clinical practice: The use of an ERAD for TCA (the TCA-Drill can significantly reduce the time to address reversible causes for TCA without delaying chest compression. This drill can be easily taught to ground EMS nurses and increases their self-confidence in addressing TCA-patients.</p

Emergency reflex action drill for traumatic cardiac arrest in a simulated pre-hospital setting; a one-group pre-post intervention study

Background: Emergency Reflex Action Drills (ERADs) are meant to decrease stress-associated cognitive demand in high urgency situations. The aim of this study was to develop and test an ERAD for witnessed traumatic cardiac arrest (TCA), an event in which potentially reversible causes need to be systematically addressed and treated in a short period of time. We hypothesize that this ERAD (the TCA-Drill) helps ground Emergency Medical Services (EMS) nurses in overcoming performance decline during this specific high-pressure situation. Methods: This was a prospective, experimental one-group pre-post intervention study. Ground EMS nurses participated in a session of four simulated scenarios, with an in-between educational session to teach the TCA-Drill. Scenarios were video recorded, after which adherence and time differences were analyzed. Self-confidence on clinical practice was measured before and after the scenarios. Results: Twelve ground EMS nurses participated in this study. Overall median time to address reversible causes of TCA decreased significantly using the TCA-Drill (132 vs. 110 s; p = 0.030) compared with the conventional ALS strategy. More specifically, participants adhering to the TCA-Drill showed a significantly lower time needed for hemorrhage control (58 vs. 37 s; p = 0.012). Eight of 12 (67 %) ground EMS nurses performed the ERAD without protocol deviations. Reported self-confidence significantly increased on 11 of the 13 surveyed items. Conclusions: The use of an ERAD for TCA (the TCA-Drill) significantly reduces the time to address reversible causes for TCA without delaying chest compressions in a simulated environment and can be easily taught to ground EMS nurses and increases self-confidence. Implications for clinical practice: The use of an ERAD for TCA (the TCA-Drill can significantly reduce the time to address reversible causes for TCA without delaying chest compression. This drill can be easily taught to ground EMS nurses and increases their self-confidence in addressing TCA-patients

Fire by spontaneous combustion of oxygen cylinders

The use of medicinal oxygen can be dangerous. The spontaneous combustion of an oxygen cylinder was the cause of a fire in an operating theatre and an emergency medical service. The fire developed after turning on the gas main while the flow supply valve was already open. Not opening the pressure reduction valve while the oxygen flow supply valve is open can prevent this type of fire. Information from the contractor shows that the probability of such an incident is 1 in a million.</p

Optic Nerve Sheath Viscoelastic Properties: Re-Examination of Biomechanical Behavior and Clinical Implications

Background: Meta-analyses show a variable relationship between optic nerve sheath diameter (ONSD) and the presence of raised intracranial pressure (ICP). Because optic nerve sheath (ONS) tissue can be deformed, it is possible that ONSD reflects not only the current ICP but also prior deforming biomechanical exposures. In this post hoc analysis of two published data sets, we characterize ONS Young’s modulus (E, mechanical stress per unit of strain) and calculate threshold pressure for plastic deformation. Methods: The authors of two previously published articles contributed primary data for these unique post hoc analyses. Human cadaveric ex vivo measurements of ONSD (n = 10) and luminal distending pressure (range 5 to 65 mm Hg) were used to calculate E and the threshold pressure for plastic deformation. Clinical in vivo measurements of ONSD and ICP during endotracheal tube suction from patients with traumatic brain injury (n = 15) were used to validate the ex vivo cadaveric findings. Results: Ex vivo ONS estimate of E was 140 ± 1.3 mm Hg (mean ± standard error), with evidence of plastic deformation occurring with distending pressure at 45 mm Hg. Similar E (71 ± 10 mm Hg) was estimated in vivo with an average ICP of 34 ± 2 mm Hg. Conclusions: Ex vivo, ONS plastic deformation occurs at levels of pressure commonly seen in patients with raised ICP, leading to distortion of the ICP–ONSD relationship. This evidence of plastic deformation may illustrate why meta-analyses fail to identify a single threshold in ONSD associated with the presence of raised ICP. Future studies characterizing time-dependent viscous characteristics of the ONS will help determine the time course of ONS tissue biomechanical behavior

Increase in intracranial pressure by application of a rigid cervical collar: a pilot study in healthy volunteers

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