Airway management in simulated restricted access to a patient - can manikin-based studies provide relevant data?

<p>Abstract</p> <p>Background</p> <p>Alternatives to endotracheal intubation (ETI) are required when access to the cranial end of the patient is restricted. In this study, the success rate and time duration of standard intubation techniques were compared with two different supraglottic devices. Two different manikins were used for the study, and the training effect was studied when the same manikin was repeatedly used.</p> <p>Methods</p> <p>Twenty anaesthesiologists from the Air Ambulance Department used iGEL^™, laryngeal tube LTSII^™and Macintosh laryngoscopes in two scenarios with either unrestricted (scenario A) or restricted (scenario B) access to the cranial end of the manikin. Different manikins were used for ETI and placement of the supraglottic devices. The technique selected by the physicians, the success rates and the times to completion were the primary outcomes measured. A secondary outcome of the study was an evaluation of the learning effect of using the same manikin or device several times.</p> <p>Results</p> <p>In scenario A, all anaesthesiologists secured an airway using each device within the maximum time limit of 60 seconds. In scenario B, all physicians secured the airway on the first attempt with the supraglottic devices and 16 (80%) successfully performed an ETI with either the Macintosh laryngoscope (n = 13, 65%) or with digital technique (n = 3, 15%). It took significantly longer to perform ETI (mean time 28.0 sec +/- 13.0) than to secure an airway with the supraglottic devices (iGel™: mean 12.3 sec +/- 3.6, LTSII™: mean 10.6 sec +/- 3.2). When comparing the mean time required for the two scenarios for each supraglottic device, there was a reduction in time for scenario B (significant for LTSII^™: 12.1 versus 10.6 seconds, p = 0.014). This may be due to a training effect using same manikin and device several times.</p> <p>Conclusions</p> <p>The amount of time used to secure an airway with supraglottic devices was low for both scenarios, while classic ETI was time consuming and had a low success rate in the simulated restricted access condition. This study also demonstrates that there is a substantial training effect when simulating airway management with airway manikins. This effect must be considered when performing future studies.</p

Dispatch accuracy of physician-staffed emergency medical services in trauma care in south-east Norway: a retrospective observational study

Background Selection of incidents and accurate identification of patients that require assistance from physician-staffed emergency medical services (P-EMS) remain essential. We aimed to evaluate P-EMS availability, the underlying criteria for dispatch, and the corresponding dispatch accuracy of trauma care in south-east Norway in 2015, to identify areas for improvement. Methods Pre-hospital data from emergency medical coordination centres and P-EMS medical databases were linked with data from the Norwegian Trauma Registry (NTR). Based on a set of conditions (injury severity, interventions performed, level of consciousness, incident category), trauma incidents were defined as complex, warranting P-EMS assistance, or non-complex. Incident complexity and P-EMS involvement were the main determinants when assessing the triage accuracy. Undertriage was adjusted for P-EMS availability and response and transport times. Results Among 19,028 trauma incidents, P-EMS were involved in 2506 (13.2%). The range of overtriage was 74–80% and the range of undertriage was 20–32%. P-EMS readiness in the event of complex incidents ranged from 58 to 70%. The most frequent dispatch criterion was “Police/fire brigade request immediate response” recorded in 4321 (22.7%) of the incidents. Criteria from the groups “Accidents” and “Road traffic accidents” were recorded in 10,875 (57.2%) incidents, and criteria from the groups “Transport reservations” and “Unidentified problem” in 6025 (31,7%) incidents. Among 4916 patient pathways in the NTR, 681 (13.9%) could not be matched with pre-hospital data records. Conclusions Both P-EMS availability and dispatch accuracy remain suboptimal in trauma care in south-east Norway. Dispatch criteria are too vague to facilitate accurate P-EMS dispatch, and pre-hospital data is inconsistent and insufficient to provide basic data for scientific research. Future dispatch criteria should focus on the care aspect of P-EMS. Better tools for both dispatch and incident handling for the emergency medical coordination centres are essential. In general, coordination, standardisation, and integration of existing data systems should enhance the quality of trauma care and increase patient safety.publishedVersio

In silico approach to predict pancreatic β-cells classically secreted proteins

Pancreatic β-cells, residents of the islets of Langerhans, are the unique insulin-producers in the body. Their physiology is a topic of intensive studies aiming to understand the biology of insulin production and its role in diabetes pathology. However, investigations about these cells' subset of secreted proteins, the secretome, are surprisingly scarce and a list describing islet/β-cell secretome upon glucose-stimulation is not yet available. In silico predictions of secretomes are an interesting approach that can be employed to forecast proteins likely to be secreted. In this context, using the rationale behind classical secretion of proteins through the secretory pathway, a Python tool capable of predicting classically secreted proteins was developed. This tool was applied to different available proteomic data (human and rodent islets, isolated β-cells, β-cell secretory granules, and β-cells supernatant), filtering them in order to selectively list only classically secreted proteins. The method presented here can retrieve, organize, search and filter proteomic lists using UniProtKB as a central database. It provides analysis by overlaying different sets of information, filtering out potential contaminants and clustering the identified proteins into functional groups. A range of 70-92% of the original proteomes analyzed was reduced generating predicted secretomes. Islet and β-cell signal peptide-containing proteins, and endoplasmic reticulum-resident proteins were identified and quantified. From the predicted secretomes, exemplary conservational patterns were inferred, as well as the signaling pathways enriched within them. Such a technique proves to be an effective approach to reduce the horizon of plausible targets for drug development or biomarkers identification

Standardised data reporting from pre-hospital advanced airway management - a nominal group technique update of the Utstein-style airway template

Background Pre-hospital advanced airway management with oxygenation and ventilation may be vital for managing critically ill or injured patients. To improve pre-hospital critical care and develop evidence-based guidelines, research on standardised high-quality data is important. We aimed to identify which airway data were most important to report today and to revise and update a previously reported Utstein-style airway management dataset. Methods We recruited sixteen international experts in pre-hospital airway management from Australia, United States of America, and Europe. We used a five-step modified nominal group technique to revise the dataset, and clinical study results from the original template were used to guide the process. Results The experts agreed on a key dataset of thirty-two operational variables with six additional system variables, organised in time, patient, airway management and system sections. Of the original variables, one remained unchanged, while nineteen were modified in name, category, definition or value. Sixteen new variables were added. The updated dataset covers risk factors for difficult intubation, checklist and standard operating procedure use, pre-oxygenation strategies, the use of drugs in airway management, airway currency training, developments in airway devices, airway management strategies, and patient safety issues not previously described. Conclusions Using a modified nominal group technique with international airway management experts, we have updated the Utstein-style dataset to report standardised data from pre-hospital advanced airway management. The dataset enables future airway management research to produce comparable high-quality data across emergency medical systems. We believe this approach will promote research and improve treatment strategies and outcomes for patients receiving pre-hospital advanced airway management.publishedVersio

Opioids for Treatment of Pre-hospital Acute Pain: A Systematic Review

Introduction Acute pain is a frequent symptom among patients in the pre-hospital setting, and opioids are the most widely used class of drugs for the relief of pain in these patients. However, the evidence base for opioid use in this setting appears to be weak. The aim of this systematic review was to explore the efficacy and safety of opioid analgesics in the pre-hospital setting and to assess potential alternative therapies. Methods The PubMed, EMBASE, Cochrane Library, Centre for Reviews and Dissemination, Scopus, and Epistemonikos databases were searched for studies investigating adult patients with acute pain prior to their arrival at hospital. Outcomes on efficacy and safety were assessed. Risk of bias for each included study was assessed according to the Cochrane approach, and confidence in the evidence was assessed using the GRADE method. Results A total of 3453 papers were screened, of which the full text of 125 was assessed. Twelve studies were ultimately included in this systematic review. Meta-analysis was not undertaken due to substantial clinical heterogeneity among the included studies. Several studies had high risk of bias resulting in low or very low quality of evidence for most of the outcomes. No pre-hospital studies compared opioids with placebo, and no studies assessed the risk of opioid administration for subgroups of frail patients. The competency level of the attending healthcare provider did not seem to affect the efficacy or safety of opioids in two observational studies of very low quality. Intranasal opioids had a similar effect and safety profile as intravenous opioids. Moderate quality evidence supported a similar efficacy and safety of synthetic opioid compared to morphine. Conclusions Available evidence for pre-hospital opioid administration to relieve acute pain is scarce and the overall quality of evidence is low. Intravenous administration of synthetic, fast-acting opioids may be as effective and safe as intravenous administration of morphine. More controlled studies are needed on alternative routes for opioid administration and pre-hospital pain management for potentially more frail patient subgroups.publishedVersio

Oslo government district bombing and Utøya island shooting July 22, 2011: The immediate prehospital emergency medical service response

<p>Abstract</p> <p>Background</p> <p>On July 22, 2011, a single perpetrator killed 77 people in a car bomb attack and a shooting spree incident in Norway. This article describes the emergency medical service (EMS) response elicited by the two incidents.</p> <p>Methods</p> <p>A retrospective and observational study was conducted based on data from the EMS systems involved and the public domain. The study was approved by the Data Protection Official and was defined as a quality improvement project.</p> <p>Results</p> <p>We describe the timeline and logistics of the EMS response, focusing on alarm, dispatch, initial response, triage and evacuation. The scenes in the Oslo government district and at Utøya island are described separately.</p> <p>Conclusions</p> <p>Many EMS units were activated and effectively used despite the occurrence of two geographically separate incidents within a short time frame. Important lessons were learned regarding triage and evacuation, patient flow and communication, the use of and need for emergency equipment and the coordination of helicopter EMS.</p

Femoral nerve blocks for the treatment of acute pre-hospital pain: A systematic review with meta-analysis

Background Pain management is one of the most important interventions in the emergency medical services. The femoral nerve block (FNB) is, among other things, indicated for pre- and post-operative pain management for patients with femoral fractures but its role in the pre-hospital setting has not been determined. The aim of this review was to assess the effect and safety of the FNB in comparison to other forms of analgesia (or no treatment) for managing acute lower extremity pain in adult patients in the pre-hospital setting. Methods A systematic review (PROSPERO registration (CRD42018114399)) was conducted. The Cochrane and GRADE methods were used to assess outcomes. Two authors independently reviewed each study for eligibility, extracted the data and performed risk of bias assessments. Results Four studies with a total of 252 patients were included. Two RCTs (114 patients) showed that FNB may reduce pain more effectively than metamizole (mean difference 32 mm on a 100 mm VAS (95% CI 24 to 40)). One RCT (48 patients) compared the FNB with lidocaine and magnesium sulphate to FNB with lidocaine alone and was only included here for information regarding adverse effects. One case series included 90 patients. Few adverse events were reported in the included studies. The certainty of evidence was very low. We found no studies comparing FNB to inhaled analgesics, opioids or ketamine. Conclusions Evidence regarding the effectiveness and adverse effects of pre-hospital FNB is limited. Studies comparing pre-hospital FNB to inhaled analgesics, opioids or ketamine are lacking.acceptedVersio

Hypoxia and hypotension in patients intubated by physician staffed helicopter emergency medical services - a prospective observational multi-centre study

Background The effective treatment of airway compromise in trauma and non-trauma patients is important. Hypoxia and hypotension are predictors of negative patient outcomes and increased mortality, and may be important quality indicators of care provided by emergency medical services. Excluding cardiac arrests, critical trauma and non-trauma patients remain the two major groups to which helicopter emergency medical services (HEMS) are dispatched. Several studies describe the impact of pre-hospital hypoxia or hypotension on trauma patients, but few studies compare this in trauma and non-trauma patients. The primary aim was to describe the incidence of pre-hospital hypoxia and hypotension in the two groups receiving pre-hospital tracheal intubation (TI) by physician-staffed HEMS. Methods Data were collected prospectively over a 12-month period, using a uniform Utstein-style airway template. Twenty-one physician-staffed HEMS in Europe and Australia participated. We compared peripheral oxygen saturation and systolic blood pressure before and after definitive airway management. Data were analysed using Cochran–Mantel–Haenszel methods and mixed-effects models. Results Eight hundred forty three trauma patients and 422 non-trauma patients receiving pre-hospital TI were included. Non-trauma patients had significantly lower predicted mean pre-intervention SpO2 compared to trauma patients. Post-intervention and admission SpO2 for the two groups were comparable. However, 3% in both groups were still hypoxic at admission. For hypotension, the differences between the groups were less prominent. However, 9% of trauma and 10% of non-trauma patients were still hypotensive at admission. There was no difference in short-term survival between trauma (97%) and non-trauma patients (95%). Decreased level of consciousness was the most frequent indication for TI, and was associated with increased survival to hospital (cOR 2.8; 95% CI: 1.4–5.4). Conclusions Our results showed that non-trauma patients had a higher incidence of hypoxia before TI than trauma patients, but few were hypoxic at admission. The difference for hypotension was less prominent, but one in ten patients were still hypotensive at admission. Further investigations are needed to identify reversible causes that may be corrected to improve haemodynamics in the pre-hospital setting. We found high survival rates to hospital in both groups, suggesting that physician-staffed HEMS provide high-quality emergency airway management in trauma and non-trauma patients.publishedVersio