Comprehensive assessment of a nationwide simulation-based course for artificial life support

BACKGROUND: Successful implementation of medical technologies applied in life-threatening conditions, including extracorporeal membrane oxygenation (ECMO) requires appropriate preparation and training of medical personnel. The pandemic has accelerated the creation of new ECMO centers and has highlighted continuous training in adapting to new pandemic standards. To reach high standards of patients\u27 care, we created the first of its kind, National Education Centre for Artificial Life Support (NEC-ALS) in 40 million inhabitants\u27 country in the Central and Eastern Europe (CEE). The role of the Center is to test and promote the novel or commonly used procedures as well as to develop staff skills on management of patients needing ECMO. METHOD: In 2020, nine approved and endorsed by ELSO courses of Artificial Life Support with ECMO were organized. Physicians participated in the three-day high-fidelity simulation-based training that was adapted to abide by the social distancing norms of the COVID-19 pandemic. Knowledge as well as crucial cognitive, behavioral and technical aspects (on a 5-point Likert scale) of management on ECMO were assessed before and after course completion. Moreover, the results of training in mechanical chest compression were also evaluated. RESULTS: There were 115 participants (60% men) predominantly in the age of 30-40 years. Majority of them (63%) were anesthesiologists or intensivists with more than 5-year clinical experience, but 54% had no previous ECMO experience. There was significant improvement after the course in all cognitive, behavioral, and technical self-assessments. Among aspects of management with ECMO that all increased significantly following the course, the most pronounced was related to the technical one (from approximately 1.0 to more 4.0 points). Knowledge scores significantly increased post-course from 11.4 ± SD to 13 ± SD (out of 15 points). The quality of manual chest compression relatively poor before course improved significantly after training. CONCLUSIONS: Our course confirmed that simulation as an educational approach is invaluable not only in training and testing of novel or commonly used procedures, skills upgrading, but also in practicing very rare cases. The implementation of the education program during COVID-19 pandemic may be helpful in founding specialized Advanced Life Support centers and teams including mobile ones. The dedicated R&D Innovation Ecosystem established in the ECMO for Greater Poland program, with developed National Education Center can play a crucial role in the knowledge and know-how transfer but future research is needed

Supraglottic devices — future or everyday life?

The most common cause of upper respiratory tract obstruction in an unconscious or unresponsive patient is the loss of muscle tone in the upper airway. Consequently, this leads to a reduction in the tone of the epiglottis, collapse of the tongue and closure of the airway at the level of the pharynx, preventing respiration. Diagnosing airway obstruction is associated with the implementation of urgent procedures aimed at restor­ing and maintaining patency. Among the techniques of restoring airway patency anatomically, we prefer extending the head and pushing the posterior mandible forward. Airway ventilation is not always possible through the use of non-surgical methods. Ventilating patients with obstructed airways using a self-inflating bag can prove to be very difficult. In such situations, it is necessary to use airway adjuncts. The purpose, regardless of the circumstances, is to remove anatomical barriers, prevent gastric aspiration and to facilitate proper lung ventilation. Endotracheal intubation is the gold standard for instrumentally maintaining a secure airway. The procedure, however, is reserved for experienced personnel because of how difficult it is to perform and the many complications that arise with it. In situations where difficulty is encountered, an alternative device to secure airway patency is needed

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

Pre-hospital management of penetrating pelvic injuries — a case study

INTRODUCTION: Penetrating pelvic injuries and the complications caused by them are a global problem in the provision of services by emergency medical teams. They often pose a significant challenge for medical personnel, particularly in patient evacuation and stabilization during transport. CASE REPORT: The emergency medical service (EMS) was dispatched to a traffic accident — the report contained information about one conscious victim with a foreign body within the patient's body. At the accident scene, a delivery truck crashed into the tow bar of a trailer standing on the road, and one person was seriously injured due to the impact. The preliminary assessment confirmed a foreign body penetrating the right thigh, deformation and enlargement of the thigh contour, pain in the thigh, pelvis, and tenderness in the thoracic-lumbar spine with the end part of the tow bar hook palpable under the skin. The victim was suspected of having a femur fracture, pelvic injuries, and damage to internal organs. On neurological examination, sensation and motor functions were preserved in all limbs. The evacuation procedure was established after the Fire Department (FD) rescuers arrived. The injured person was removed from the vehicle on an orthopedic board with the help of eight rescuers. The victim was placed on his left side with the right side elevated, with continuous manual stabilization supported by a blanket, pillows, and orthopedic boar straps. CONCLUSIONS: Each traumatic injury event requires selecting and using the appropriate equipment. A good compromise between speed and precision of actions should not significantly contribute to the worsening of the injury. An increase in a rescuer's substantive knowledge on how to proceed in the case of this type of trauma and injuries, as well as close cooperation with the fire department, will undoubtedly result in more appropriate actions

Re-hybrid thoracic stent graft implantation with total aortic arch debranching in urgent procedure: case report

INTRODUCTION: Implementation of emergency endovascular aortic repair provides an opportunity to treat complicated acute aortic syndromes involving descending aorta. CASE REPORT: A 40-year-old man with a history of aortic coarctation surgical repair as a child and an anastomosis aneurysm repair with a double endovascular stent graft implantation with hemi-arch transposition was urgently admitted with intensifying shortness of breath and hoarseness. A computed tomography study confirmed a blood leak into an aneurysm sac in proximal landing zones of implanted stent grafts (Type I endoleak). Therefore, he qualified for hybrid surgery. First, the ascending aorta brachiocephalic trunk was anastomosed with a 12 mm vascular prosthesis from an upper mini-sternotomy. In the next step, normothermic extracorporeal circulation was necessary to prevent cerebral circulation. Finally, a GORE stent graft (Gore Medical, Flagstaff, AZ, USA) was implanted with a proximal landing zone directly behind the anastomosis site of the vascular prosthesis and ascending aorta. The hospital course was uncomplicated, and the patient was discharged home 5 days after the procedure. CONCLUSIONS: Complicated aortic pathologies requiring emergent interventions can be treated by a hybrid approach utilizing multistep surgical and endovascular techniques achieving optimal results

Paramedic students need more training in left ventricular assist device — a pilot simulation study

INTRODUCTION: Mechanical Circulation Systems are a promising therapy for patients with end-stage of heart failure. Left ventricular assist device (LVAD) enforces using of concomitant anticoagulant therapy. This may lead to severe complications. LVAD patients are more and more frequent users of the emergency department. There are several differences in cardiovascular function in these patients, as well as on examination. Its interpretation may be challenging and result in potentially fatal conclusions. The aim of this research was to assess the skills of paramedic students in assessing patients with LVAD MATERIAL AND METHODS: The study was designed as a simulation study. The aim of this scenario was to provide a full primary survey of an unconscious, spontaneously breathing person with an LVAD pump implanted. Ten groups of paramedic students from Polish medical universities took part in this study. RESULTS: Four teams started chest compressions unnecessarily. Of them, only one had contacted LVAD local coordinator and discontinued after short instructions. Four teams completed the driveline and device check and six checked only the line without moving the controller. No major errors were noted in the field of airway assessment and management as well as assessment of consciousness, breathing, and circulation. CONCLUSIONS: More attention should be paid to educating paramedic students in LVAD therapy. Educators should focus mainly on differences in cardiovascular function and pay attention to complete perfusion assessment. Medical simulation seems to be a good tool for assessing difficult clinical cases rarely encountered in practice