Erweiterte Reanimationsmaßnahmen für Erwachsene („adult advanced life support“)

Testing mechanical chest compression devices of different design for their suitability for prehospital patient transport - a simulator-based study

Background

Mechanical chest compression (mCPR) offers advantages during transport under cardiopulmonary resuscitation. Little is known how devices of different design perform en-route. Aim of the study was to measure performance of mCPR devices of different construction-design during ground-based pre-hospital transport.

Methods

We tested animax mono (AM), autopulse (AP), corpuls cpr (CC) and LUCAS2 (L2). The route had 6 stages (transport on soft stretcher or gurney involving a stairwell, trips with turntable ladder, rescue basket and ambulance including loading/unloading). Stationary mCPR with the respective device served as control. A four-person team carried an intubated and bag-ventilated mannequin under mCPR to assess device-stability (displacement, pressure point correctness), compliance with 2015 ERC guideline criteria for high-quality chest compressions (frequency, proportion of recommended pressure depth and compression-ventilation ratio) and user satisfaction (by standardized questionnaire).

Results

All devices performed comparable to stationary use. Displacement rates ranged from 83% (AM) to 11% (L2). Two incorrect pressure points occurred over 15,962 compressions (0.013%). Guideline-compliant pressure depth was > 90% in all devices. Electrically powered devices showed constant frequencies while muscle-powered AM showed more variability (median 100/min, interquartile range 9). Although physical effort of AM use was comparable (median 4.0 vs. 4.5 on visual scale up to 10), participants preferred electrical devices.

Conclusion

All devices showed good to very good performance although device-stability, guideline compliance and user satisfaction varied by design. Our results underline the importance to check stability and connection to patient under transport.

[Effect of different training methods on the use of the i-gel laryngeal mask by lay persons on a manikin]

BACKGROUND

Several studies have described the successful application of extraglottic airways by lay people to a phantom.

OBJECTIVES

This study examined the influence of the training method on the success of the application.

METHODS

A total of 150 visitors of a shopping mall were asked to place an i‑gel laryngeal mask (Intersurgical GmbH, Sankt Augustin, Germany) on a manikin. The short instruction was randomized and performed either as a practical demonstration or through the self-study of an illustrated manual.

RESULTS

Application success in the first attempt was 95.8 % for the practical demonstration group and 78.5 % for the written instruction group (p = 0.001). Placement times were also significantly different (median 11.5 s vs. 22.5 s, p < 0.001).

CONCLUSIONS

Learning success can be achieved with both training methods. Initially, a hands-on training should be carried out with a practical demonstration.

The Effect of Prehospital Epinephrine in Out-of-Hospital Cardiac Arrest: A Systematic Review and Meta-Analysis

INTRODUCTION

Epinephrine has been recommended for out-of-hospital cardiac arrest (OHCA) resuscitation for nearly one century, but its efficacy and safety remain unclear in the literature. The primary aim of this review was to determine whether epinephrine increases the return of spontaneous circulation in OHCA patients.

METHODS

A systematic review and meta-analysis were conducted using the following databases: MEDLINE, EMBASE, and CENTRAL, from their inception until October 2018. All the randomized controlled trials (RCTs) were included. Observational studies, case reports, case series, and non-systematic reviews were excluded.

RESULTS

Two trials including 8,548 patients were eligible for inclusion in the data synthesis. In patients who received epinephrine during OHCA, the incidence of return of spontaneous circulation was increased, with an odds ratio (95%CI) of 4.25 (3.79-4.75), P <.001, high-quality of evidence. The number of patients transported to hospital was increased in patients who had prehospital epinephrine, with an odds ratio (95%CI) of 2.31 (2.11-2.53), P <.001, high-quality of evidence. The prehospital use of epinephrine was associated with an increased survival to hospital discharge, the odds ratio (95%CI) being 1.43 (1.10-1.87), P = .008, moderate-quality of evidence. No significant effect was noted on the favorable neurologic state of patient at hospital discharge, with an odds ratio (95%CI) of 1.21 (0.90-1.64), P = .21, moderate-quality of evidence.

CONCLUSIONS

This meta-analysis suggests that the prehospital use of epinephrine increases return of spontaneous circulation, transport of patients to hospital, and survival to hospital discharge for OHCA. However, no significant effects on favorable neurologic function at hospital discharge were demonstrated. The general quality of evidence ranged from moderate to high.

[Statement of the Austrian Society for Anesthesiology, Resuscitation and Intensive Care Medicine (ÖGARI) on the use of laryngeal tubes by ambulancemen and paramedics]

Due to an increasing number of severe complications reported during the prehospital application of laryngeal tubes, the Austrian Society for Anesthesiology, Resuscitation and Intensive Care Medicine (ÖGARI) is prompted to formulate a respective statement. With regard to the current training situation and the applicable laws, ÖGARI recommends to convert the "Emergency Competence for Endotracheal Intubation (NKI)" for emergency paramedics into an "Emergency Competence for Extraglottic Airway Management, (NK-EGA)". Training should include at least 40 h of theoretical instruction, hands-on training on the manikin to secure mastery of the methodology and at least 20 successful applications under clinically elective conditions in adult patients under direct medical supervision. Here, depending on local conditions, both laryngeal mask and laryngeal tube can be used. In the prehospital environment, the device must be used which has been trained as mentioned above. Only 2nd generation EGA should be used. After successful EGA placement timely cuff pressure monitoring and gastric suction should be performed. The use of an EGA by ambulance-men cannot be recommended; these have to be limited to bag-mask ventilation.

[Implementation of Medical Emergency Teams to Improve Perioperative Patient Safety. Who? When? How?]

In contrast to prehospital emergency medicine, there are no comparable established structures or statutory requirements for structural and procedural organisation, or qualification of personnel and equipment for in-hospital emergency care in Germany. However, in perioperative patients, unexpected complications are fairly common on regular wards. Often, even hours before a possible critical event, warning signs of deterioration are present, which too often go unnoticed. Subsequently, potentially avoidable serious complications or cardiac arrest may occur. The establishment of so-called medical emergency teams (MET) serves to improve the emergency care organisation of the hospital and helps to avoid in-hospital cardiac arrest. The MET is alerted at an early stage of deterioration and uses a preventive therapy approach for pathophysiological deviations of the vital signs. This preventative approach can help to avoid in-hospital cardiac arrest and unplanned admission to an intensive care unit and thus contribute to increase perioperative patient safety.

[Unconsciousness and clouded awareness]

Stupor and coma are clinical states in which patients have impaired responsiveness or are unresponsive to external stimulation and are either difficult to arouse or are unarousable. The term stupor refer to states between alertness and coma. An alteration in arousal represents an acute life-threatening emergency, requiring prompt intervention for preservation of life and brain function.

[Cognitive errors in diagnostic decision making]

Approximately 10-15% of our diagnostic decisions are faulty and may lead to unfavorable and dangerous outcomes, which could be avoided. These diagnostic errors are mainly caused by cognitive biases in the diagnostic reasoning process.Our medical diagnostic decision-making is based on intuitive "System 1" and analytical "System 2" diagnostic decision-making and can be deviated by unconscious cognitive biases.These deviations can be positively influenced on a systemic and an individual level. For the individual, metacognition (internal withdrawal from the decision-making process) and debiasing strategies, such as verification, falsification and rule out worst-case scenarios, can lead to improved diagnostic decisions making.