Procedural Sedation Intubation in a Paramedic-Staffed Helicopter Emergency Medical System in Northern Finland

Publisher Copyright: © 2021 The AuthorsObjective: Airway management to ensure sufficient gas exchange is of major importance in emergency care. Prehospital endotracheal intubation (ETI) by paramedics is a widely debated method to ensure a patent airway. ETI is performed with procedural sedation in comatose patients because of the regulation. The use of medications increases the rate of successful airway management compared with nonmedication ETI and may also improve outcomes in patients with traumatic brain injury. In the absence of an operative emergency physician and with long distances, paramedic-induced airway management may increase the survival of patients in selected scenarios. A paramedic-staffed helicopter emergency medical system in Northern Finland operates in a rural area without an emergency physician and paralytic medications and treats critically ill patients using basic or advanced life support ground units. The aim of this study was to evaluate the success rates of ETI performed by a small, appropriately trained, and experienced group of 8 nurse paramedics in an out-of-hospital setting. Methods: The inclusion criterion for the study was an attempted intubation in patients with medical or traumatic indication for airway management by nurse paramedic. Results: Fifty-one patients were treated with ETI. The first-pass success rate was 72.5%, the second-pass success rate was 94.1%, and the overall success rate was 100% within 4 attempts. The median on-scene time was 54 minutes, and there were no signs of aspiration during laryngoscopy or after successful ETI. The primary mortality rate was 11.7%. Conclusion: The use of a rigid standard operating procedure for paramedic rapid sequence induction, paralytics, a video laryngoscope, and a gum elastic bougie might positively affect the ETI first-pass success rate. A follow-up study after these future modifications is needed. This small study suggests that intubation might be 1 option for airway management by an experienced nonanesthesiologist in Lapland.Peer reviewe

Procedural Sedation Intubation in a Paramedic-Staffed Helicopter Emergency Medical System in Northern Finland

Publisher Copyright: © 2021 The AuthorsObjective: Airway management to ensure sufficient gas exchange is of major importance in emergency care. Prehospital endotracheal intubation (ETI) by paramedics is a widely debated method to ensure a patent airway. ETI is performed with procedural sedation in comatose patients because of the regulation. The use of medications increases the rate of successful airway management compared with nonmedication ETI and may also improve outcomes in patients with traumatic brain injury. In the absence of an operative emergency physician and with long distances, paramedic-induced airway management may increase the survival of patients in selected scenarios. A paramedic-staffed helicopter emergency medical system in Northern Finland operates in a rural area without an emergency physician and paralytic medications and treats critically ill patients using basic or advanced life support ground units. The aim of this study was to evaluate the success rates of ETI performed by a small, appropriately trained, and experienced group of 8 nurse paramedics in an out-of-hospital setting. Methods: The inclusion criterion for the study was an attempted intubation in patients with medical or traumatic indication for airway management by nurse paramedic. Results: Fifty-one patients were treated with ETI. The first-pass success rate was 72.5%, the second-pass success rate was 94.1%, and the overall success rate was 100% within 4 attempts. The median on-scene time was 54 minutes, and there were no signs of aspiration during laryngoscopy or after successful ETI. The primary mortality rate was 11.7%. Conclusion: The use of a rigid standard operating procedure for paramedic rapid sequence induction, paralytics, a video laryngoscope, and a gum elastic bougie might positively affect the ETI first-pass success rate. A follow-up study after these future modifications is needed. This small study suggests that intubation might be 1 option for airway management by an experienced nonanesthesiologist in Lapland.Peer reviewe

Incidence and predictive factors of spinal cord stimulation treatment after lumbar spine surgery

Introduction: Spinal cord stimulation (SCS) is recommended for the treatment of postsurgical chronic back and leg pain refractory to other treatments. We wanted to estimate the incidence and predictive factors of SCS treatment in our lumbar surgery cohort. Patients and methods: Three questionnaires (a self-made questionnaire, the Oswestry Low Back Pain Disability Questionnaire, and the Beck Depression Inventory) were sent to patients aged 18-65 years with no contraindications for the use of SCS, and who had undergone non-traumatic lumbar spine surgery in the Oulu University Hospital between June 2005 and May 2008. Patients who had a daily pain intensity of >= 5/10 with predominant radicular component were interviewed by telephone. Results: After exclusions, 814 patients remained in this cohort. Of those, 21 patients had received SCS by the end of June 2015. Fifteen (71%) of these received benefit and continued with the treatment. Complications were rare. The number of patients who replied to the postal survey were 537 (66%). Eleven of them had undergone SCS treatment after their reply. Features predicting SCS implantation were daily or continuous pain, higher intensities of pain with predominant radicular pain, more severe pain-related functional disability, a higher prevalence of depressive symptoms, and reduced benefit from pain medication. The mean waiting time was 65 months (26-93 months). One hundred patients were interviewed by telephone. Fourteen seemed to be potential SCS candidates. From the eleven patients who underwent SCS after responding to the survey, two were classified as potential candidates in the phone interview, while nine were other patients. Twelve patients are still waiting for treatment to commence. Conclusion: In our region, the SCS treatment is used only for very serious pain conditions. Waiting time is too long and it may be the reason why this treatment option is not offered to all candidates.Peer reviewe

Feasibility of LMA Supreme for airway management in unconscious patients by ALS paramedics

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Depressive symptoms are associated with poor outcome for lumbar spine surgery

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Using Hilbert-Huang Transform to Assess EEG Slow Wave Activity During Anesthesia in Post-Cardiac Arrest Patients

Proceeding volume: 38Hypoxic ischemic encephalopathy (HIE) is a severe consequence of cardiac arrest (CA) representing a substantial diagnostic challenge. We have recently designed a novel method for the assessment of HIE after CA. The method is based on estimating the severity of the brain injury by analyzing changes in the electroencephalogram (EEG) slow wave activity while the patient is exposed to an anesthetic drug propofol in a controlled manner. In this paper, Hilbert-Huang Transform (HHT) was used to analyze EEG slow wave activity during anesthesia in ten post-CA patients. The recordings were made in the intensive care unit 36-48 hours after the CA in an experiment, during which the propofol infusion rate was incrementally decreased to determine the drug-induced changes in the EEG at different anesthetic levels. HHT was shown to successfully capture the changes in the slow wave activity to the behavior of intrinsic mode functions (IMFs). While, in patients with good neurological outcome defined after a six-month control period, propofol induced a significant increase in the amplitude of IMFs representing the slow wave activity, the patients with poor neurological outcome were unable to produce such a response. Consequently, the proposed method offer substantial prognostic potential by providing a novel approach for early estimation of HIE after CA.Peer reviewe

A characteristic time sequence of epileptic activity in EEG during dynamic penicillin-induced focal epilepsy—A preliminary study

AbstractPenicillin-induced focal epilepsy is a well-known model in experimental epilepsy. However, the dynamic evolution of waveforms, DC-level changes, spectral content and coherence are rarely reported. Stimulated by earlier fMRI findings, we also seek for the early signs preceding spiking activity from frequency domain of EEG signal. In this study, EEG data is taken from previous EEG/fMRI series (six pigs, 20–24kg) of an experimental focal epilepsy model, which includes dynamic induction of epileptic activity with penicillin (6000IU) injection into the somatosensory cortex during deep isoflurane anaesthesia. No ictal discharges were recorded with this dose. Spike waveforms, DC-level, time–frequency content and coherence of EEG were analysed. Development of penicillin induced focal epileptic activity was not preceded with specific spectral changes. The beginning of interictal spiking was related to power increase in the frequencies below 6Hz or 20Hz, and continued to a widespread spectral increase. DC-level and coherence changes were clear in one animal. Morphological evolution of epileptic activity was a collection of the low-amplitude monophasic, bipolar, triple or double spike-wave forms, with an increase in amplitude, up to large monophasic spiking. In conclusion, in the time sequence of induced epileptic activity, immediate shifts in DC-level EEG are plausible, followed by the spike activity-related widespread increase in spectral content. Morphological evolution does not appear to follow a clear continuum; rather, intermingled and variable spike or multispike waveforms generally lead to stabilised activity of high-amplitude monophasic spikes

Real-time monitoring of human blood-brain barrier disruption

Chemotherapy aided by opening of the blood-brain barrier with intra-arterial infusion of hyperosmolar mannitol improves the outcome in primary central nervous system lymphoma. Proper opening of the blood-brain barrier is crucial for the treatment, yet there are no means available for its real-time monitoring. The intact blood-brain barrier maintains a mV-level electrical potential difference between blood and brain tissue, giving rise to a measurable electrical signal at the scalp. Therefore, we used direct-current electroencephalography ( DC-EEG) to characterize the spatiotemporal behavior of scalp-recorded slow electrical signals during blood-brain barrier opening. Nine anesthetized patients receiving chemotherapy were monitored continuously during 47 blood-brain barrier openings induced by carotid or vertebral artery mannitol infusion. Left or right carotid artery mannitol infusion generated a strongly lateralized DC-EEG response that began with a 2 min negative shift of up to 2000 mu V followed by a positive shift lasting up to 20 min above the infused carotid artery territory, whereas contralateral responses were of opposite polarity. Vertebral artery mannitol infusion gave rise to a minimally lateralized and more uniformly distributed slow negative response with a posterior-frontal gradient. Simultaneously performed near-infrared spectroscopy detected a multiphasic response beginning with mannitol-bolus induced dilution of blood and ending in a prolonged increase in the oxy/deoxyhemoglobin ratio. The pronounced DC-EEG shifts are readily accounted for by opening and sealing of the blood-brain barrier. These data show that DC-EEG is a promising real-time monitoring tool for bloodbrain barrier disruption augmented drug delivery.Peer reviewe

Yhtenäiset vaatimukset lääketieteen ja hammaslääketieteen tohtorintutkinnolle Suomessa

Vertaisarvioitu. English summary.Peer reviewe