Inability to get up after falling, subsequent time on floor, and summoning help: prospective cohort study in people over 90

OBJECTIVES

To describe the incidence and extent of lying on the floor for a long time after being unable to get up from a fall among people aged over 90; to explore their use of call alarm systems in these circumstances.

DESIGN

1 year follow-up of participants in a prospective cohort study of ageing, using fall calendars, phone calls, and visits.

SETTING

Participants' usual place of residence (own homes or care homes), mostly in Cambridge.

PARTICIPANTS

90 women and 20 men aged over 90 (n=110), surviving participants of the Cambridge City over-75s Cohort, a population based sample.

MAIN OUTCOME MEASURES

Inability to get up without help, lying on floor for a long time after falling, associated factors; availability and use of call alarm systems; participants' views on using call alarms to summon help if needed after falling.

RESULTS

In one year's intensive follow-up, 54% (144/265) of fall reports described the participant as being found on the floor and 82% (217/265) of falls occurred when the person was alone. Of the 60% who fell, 80% (53/66) were unable to get up after at least one fall and 30% (20/66) had lain on the floor for an hour or more. Difficulty in getting up was consistently associated with age, reported mobility, and severe cognitive impairment. Cognition was the only characteristic that predicted lying on the floor for a long time. Lying on the floor for a long time was strongly associated with serious injuries, admission to hospital, and subsequent moves into long term care. Call alarms were widely available but were not used in most cases of falls that led to lying on the floor for a long time. Comments from older people and carers showed the complexity of issues around the use of call alarms, including perceptions of irrelevance, concerns about independence, and practical difficulties.

CONCLUSIONS

Lying on the floor for a long time after falling is more common among the "oldest old" than previously thought and is associated with serious consequences. Factors indicating higher risk and comments from participants suggest practical implications. People need training in strategies to get up from the floor. Work is needed on access and activation issues for design of call alarms and information for their effective use. Care providers need better understanding of the perceptions of older people to provide acceptable support services.

The PTL, Combitube, laryngeal mask, and oral airway: a randomized prehospital comparative study of ventilatory device effectiveness and cost-effectiveness in 470 cases of cardiorespiratory arrest

PURPOSE

A prehospital study was conducted to assess and compare three alternative airway devices and the oral airway for use by non-Advanced Life Support emergency medical assistants (EMAs).

METHOD

A modified randomized crossover design was used. The Pharyngeal Tracheal Lumen Airway (PTL), the laryngeal mask (LM), and the esophageal tracheal Combitube (Combi) were compared objectively for success of insertion, ventilation, and arterial blood gas and spirometry measurements performed upon hospital arrival. Subjective assessment was carried out by EMAs and receiving physicians at the time of device use, and an eight-question comparative evaluation of all devices was completed by EMAs at study conclusion. A comparative cost analysis was performed. Operating room training was compared with mannequin training for the LM. Autopsy findings and survival to hospital discharge were analyzed. The study took place in four non-ALS communities over four and a half years, and involved 470 patients in cardiac and/or respiratory arrest. EMAs had automatic external defibrillator training but no endotracheal intubation skills.

RESULTS

Successful insertion and ventilation: Combi, 86%; PTL, 82%; LM, 73% (p = 0.048). No significant difference was found for objective measurements of ventilatory effectiveness (ABGs and spirometry). Significant comparative differences in subjective evaluation were found.

CONCLUSIONS

The PTL, LM, and Combi appear to offer substantial advances over the OA/BVM system. Although the most costly, the Combitube was associated with the least problems with ventilation and was the most preferred by a majority of EMAs.

Self-expanding metallic stent as a bridge to surgery versus emergency surgery for obstructive colorectal cancer: a meta-analysis

BACKGROUND

The use of a colonic stent as a bridge to surgery aims to provide patients with elective one-stage surgical resection while reducing stoma creation and postoperative complications. This study used meta-analytic techniques to compare the outcomes of stent use as a bridge to surgery and emergency surgery in the management of obstructive colorectal cancer.

METHODS

A literature search of Medline, Embase, Cochrane controlled trials registry, and the Chinese Biomedical Literature Database was performed on all studies comparing stent as a bridge to surgery and emergency surgery for obstructive colorectal cancer. A meta-analysis of the included studies was carried out to identify the differences in outcomes between the two procedures.

RESULTS

Eight studies matched the criteria for inclusion and reported on the outcomes of 601 patients, of whom 232 (38.6%) underwent stent insertion and 369 (61.4%) underwent emergency surgery. Fewer patients in the stent group needed intensive care (risk ratio [RR], 0.42; 95% confidence interval [CI], 0.19-0.93; p = 0.03) and stoma creation (RR, 0.70; 95% CI, 0.50-0.99; p = 0.04). The primary anastomosis rate in the stent group was higher (RR, 1.62; 95% CI, 1.21-2.16; p = 0.001). Overall complications (RR, 0.42; 95% CI, 0.24-0.71; p = 0.001), including anastomotic leakage (RR, 0.31; 95% CI, 0.14-0.69; p = 0.004), were reduced by stent insertion. Stent placement before elective surgery did not adversely affect mortality and long-term survival.

CONCLUSIONS

The use of a stent as a bridge to surgery for obstructive left-sided colorectal cancer could increase the chance of primary anastomosis and reduce the need for stoma creation and postprocedural complications. Stent insertion before subsequent surgery has no effect on perioperative mortality and long-term survival.

Medical issues associated with commercial flights

Almost 2 billion people travel aboard commercial airlines every year. Health-care providers and travellers need to be aware of the potential health risks associated with air travel. Environmental and physiological changes that occur during routine commercial flights lead to mild hypoxia and gas expansion, which can exacerbate chronic medical conditions or incite acute in-flight medical events. The association between venous thromboembolism and long-haul flights, cosmic-radiation exposure, jet lag, and cabin-air quality are growing health-care issues associated with air travel. In-flight medical events are increasingly frequent because a growing number of individuals with pre-existing medical conditions travel by air. Resources including basic and advanced medical kits, automated external defibrillators, and telemedical ground support are available onboard to assist flight crew and volunteering physicians in the management of in-flight medical emergencies.

Comparison of long-term outcomes of colonic stent as "bridge to surgery" and emergency surgery for malignant large-bowel obstruction: a meta-analysis

BACKGROUND

The short-term safety and efficacy of insertion of a self-expandable metallic colonic stent followed by elective surgery, bridge to surgery (BTS), for malignant large-bowel obstruction (MLBO) have been well described. However, long-term oncological outcomes are still debated. Hence, this study is conducted to evaluate long-term outcomes of colonic stent insertion followed by surgery for MLBO.

METHODS

A comprehensive electronic literature search through May 2014 was performed to identify studies comparing long-term outcomes between BTS and emergency surgery for MLBO. The main outcome measures were overall survival (OS), disease-free survival (DFS), and recurrence. A meta-analysis was performed using random-effects models to calculate risk ratios (RRs) with 95 % confidence intervals (95 % CIs).

RESULTS

There were 11 studies that matched the criteria for inclusion, yielding a total of 1136 patients, of whom 432 (38.0 %) underwent BTS and 704 (62.0 %) underwent emergency surgery. In OS analyses of all patients and patients who underwent curative resection, BTS was similar to emergency surgery [(RR = 0.95; 95 % CI 0.75-1.21; P = 0.66) (RR = 0.96; 95 % CI 0.67-1.37; P = 0.82), respectively]. DFS (RR = 1.06; 95 % CI 0.91-1.24; P = 0.43) and recurrence (RR = 1.13; 95 % CI 0.82-1.54; P = 0.46) did not differ significantly between the BTS and emergency surgery groups.

CONCLUSIONS

Results of this meta-analysis on long-term as well as well-described short-term outcomes suggest that BTS could be a promising alternative strategy for MLBO patients.

Intraosseous is faster and easier than umbilical venous catheterization in newborn emergency vascular access models

The purpose of this study is to compare the speed and ease of establishing newborn emergency vascular access using intraosseous (IO) versus umbilical venous catheterization (UVC). The study is an experimental design. A total of 42 medical students, without prior IO and UVC experience, were recruited as study subjects. All subjects performed the UVC procedure and were randomized (by a coin flip) to perform the IO procedure in one of two models: (1) turkey bone or (2) plastic infant leg. Each subject performed an initial trial for both the IO and UVC procedures without practice ("Inexperienced attempt") and a second trial in both procedures after practice ("Experienced attempt"), such that in total, each subject completed four attempts (two IO and two UVC). IO and UVC placement times were measured, and placement difficulty scores for IO and UVC were measured using a 10 cm visual analog scale (VAS). The averaged elapsed time to successful access was significantly shorter for the IO procedure on both the initial "inexperienced" attempt (52 versus 134 seconds, P < .001) as well as the "experienced" attempt (45 versus 95 seconds, P = .011). Procedure difficulty scores were lower in the IO procedure for both "inexperienced" and "experienced" attempts (3.5 versus 5.5, P = .001 and 2.6 versus 4.7, P < .001) as measured on a 10 cm VAS. Although UVC may be preferred by neonatologists, this model suggests that IO results in easier and more rapid vascular access in those who do not frequently perform newborn resuscitation. As such, the benefit of teaching UVC in pediatric resuscitation courses should be reconsidered. The recommended method of emergency newborn vascular access should be reconsidered pending further studies on this subject.

Issues related to the use of tourniquets on the battlefield

On the battlefield, a properly applied tourniquet can be an extremely effective means of controlling severe extremity wound hemorrhage. However, a great deal of confusion exists among soldiers, medics, and military medical officers on a number of tourniquet-related issues. What is an appropriate combat tourniquet? When is it appropriate to use a tourniquet? When and by whom should a tourniquet be removed? Under what conditions should a tourniquet not be released or removed? What are the most effective ways to increase limb salvage while using a tourniquet? These and other issues were addressed by a panel of experts at the 2003 Advanced Technology Applications for Combat Casualty Care Conference, August 21 and 23, 2003, St. Pete Beach, Florida. Here we review those issues and present a summary of the panel's recommendations.

Failed rapid sequence intubation in trauma patients: esophageal tracheal combitube is a useful adjunct

OBJECTIVE

To characterize the use of the esophageal tracheal combitube (ETC) in trauma patients who fail orotracheal rapid sequence intubation (RSI).

DESIGN

Prospective protocol design and retrospective chart review.

MATERIALS AND METHODS

Flight nurses were trained in the use of the ETC by mannequin simulation, videotape review, and didactic sessions. ETC insertion was attempted after failure of two or more attempts at orotracheal RSI. Over a 12-month period, 12 patients had ETC insertion, and 10 cases qualified for review. Injuries, number of failed orotracheal RSI attempts, definitive airway, initial arterial blood gas results, and outcome were recorded.

RESULTS

ETC insertion was successful in all 10 patients in whom it was attempted. Definitive airway control was achieved by conversion to orotracheal intubation in seven patients, emergency department cricothyroidotomy in one patient, and operative room tracheostomy in two patients. No patient died because of failure to control the airway. Seven patients requiring ETC had mandible fractures.

CONCLUSION

ETC insertion is an effective method of airway control in trauma patients who fail orotracheal RSI. It may be particularly useful in the patient with maxillofacial trauma and offers a practical alternative to surgical cricothyroidotomy in difficult airway situations.

Advanced ultrasonic diagnosis of extremity trauma: the FASTER examination

BACKGROUND

Ultrasound is of proven accuracy in abdominal and thoracic trauma and may be useful for diagnosing extremity injury in situations where radiography is not available such as military and space applications. We prospectively evaluated the utility of extremity ultrasound performed by trained, nonphysician personnel in patients with extremity trauma to simulate remote aerospace or military applications.

METHODS

Patients with extremity trauma were identified by history, physical examination, and radiographic studies. Ultrasound examination was performed bilaterally by nonphysician personnel, blinded to radiographic results, with a portable ultrasound device using a 10- to 5-MHz linear probe. Images were videorecorded for later analysis against radiography by Fisher's exact test.

RESULTS

There were 158 examinations performed in 95 patients. The average time of examination was 4 minutes. Ultrasound accurately diagnosed extremity injury in 94% of patients with no false-positive examinations; accuracy was greater in midshaft locations and least in the metacarpal/metatarsals. Soft tissue/tendon injury was readily visualized.

CONCLUSION

Extremity ultrasound can be performed quickly and accurately by nonphysician personnel with excellent accuracy. Pulmonary ultrasound appears promising; blinded verification of the utility of ultrasound in patients with extremity injury should be performed to determine whether extremity and respiratory evaluation should be added to the FAST examination (the FASTER examination) and to verify the technique in remote locations such as military and aerospace applications.

Potential impact of public access defibrillators on survival after out of hospital cardiopulmonary arrest: retrospective cohort study

OBJECTIVE

To estimate the potential impact of public access defibrillators on overall survival after out of hospital cardiac arrest.

DESIGN

Retrospective cohort study using data from an electronic register. A statistical model was used to estimate the effect on survival of placing public access defibrillators at suitable or possibly suitable sites.

SETTING

Scottish Ambulance Service.

SUBJECTS

Records of all out of hospital cardiac arrests due to heart disease in Scotland in 1991-8.

MAIN OUTCOME MEASURES

Observed and predicted survival to discharge from hospital.

RESULTS

Of 15 189 arrests, 12 004 (79.0%) occurred in sites not suitable for the location of public access defibrillators, 453 (3.0%) in sites where they may be suitable, and 2732 (18.0%) in suitable sites. Defibrillation was given in 67.9% of arrests that occurred in possibly suitable sites for locating defibrillators and in 72.9% of arrests that occurred in suitable sites. Compared with an actual overall survival of 744 (5.0%), the predicted survival with public access defibrillators ranged from 942 (6.3%) to 959 (6.5%), depending on the assumptions made regarding defibrillator coverage.

CONCLUSIONS

The predicted increase in survival from targeted provision of public access defibrillators is less than the increase achievable through expansion of first responder defibrillation to non-ambulance personnel, such as police or firefighters, or of bystander cardiopulmonary resuscitation. Additional resources for wide scale coverage of public access defibrillators are probably not justified by the marginal improvement in survival.

Needle thoracostomy in the prehospital setting

OBJECTIVES

To determine the effect of needle thoracostomy (NT) in the prehospital setting, its frequency of use, and its complication rate.

METHODS

This was a prospective case series from January 1, 1995, to December 31, 1996. Inclusion criteria were all patients who met trauma center criteria, were transported by paramedics to Los Angeles County/University of Southern California Medical Center (a large, urban, level I trauma center), and had placement of a prehospital NT.

RESULTS

Out of 6,241 major trauma patients transported by paramedics over the study period, 108 (1.7%) underwent 114 NTs. Sixty-four patients (59%) sustained gunshot wounds, 32 (30%) sustained stab wounds, eight (7%) were involved in motor vehicle accidents, and the remainder had other types of blunt trauma. The mean injury severity score (ISS) was 22.3, and the overall mortality rate was 28%. Of the patients who received NTs, five (5%) showed objective improvement in field vital signs and seven (7%) had subjective improvement of their dyspnea. Two NTs were found to have not penetrated into the thorax with the catheter tip in the soft tissue. Two patients (2%) received NTs despite the absence of any chest injuries found upon operative intervention, resulting in two iatrogenic pneumothoraxes. No other complications, including vascular injury or infection, were found in any of the patients.

CONCLUSION

Prehospital NT is a procedure infrequently performed by paramedics, even in a busy urban area. While there is a risk of the procedure's being done without proper indication, NT may improve outcomes in a small subset of chest-injured patients.

Preparation for emergencies in the offices of pediatricians and pediatric primary care providers

High-quality pediatric emergency care can be provided only through the collaborative efforts of many health care professionals and child advocates working together throughout a continuum of care that extends from prevention and the medical home to prehospital care, to emergency department stabilization, to critical care and rehabilitation, and finally to a return to care in the medical home. At times, the office of the pediatric primary care provider will serve as the entry site into the emergency care system, which comprises out-of-hospital emergency medical services personnel, emergency department nurses and physicians, and other emergency and critical care providers. Recognizing the important role of pediatric primary care providers in the emergency care system for children and understanding the capabilities and limitations of that system are essential if pediatric primary care providers are to offer the best chance at intact survival for every child who is brought to the office with an emergency. Optimizing pediatric primary care provider office readiness for emergencies requires consideration of the unique aspects of each office practice, the types of patients and emergencies that might be seen, the resources on site, and the resources of the larger emergency care system of which the pediatric primary care provider's office is a part. Parent education regarding prevention, recognition, and response to emergencies, patient triage, early recognition and stabilization of pediatric emergencies in the office, and timely transfer to an appropriate facility for definitive care are important responsibilities of every pediatric primary care provider. In addition, pediatric primary care providers can collaborate with out-of-hospital and hospital-based providers and advocate for the best-quality emergency care for their patients.

The Combitube as a salvage airway device for paramedic rapid sequence intubation

STUDY OBJECTIVE

The safety of out-of-hospital rapid sequence intubation depends on a reliable strategy when orotracheal intubation is unsuccessful. Here we describe our experience with the Combitube (esophageal-tracheal twin-lumen airway device) as a salvage airway device for paramedic rapid sequence intubation.

METHODS

The San Diego Paramedic Rapid Sequence Intubation Trial was performed to assess the effect of paramedic rapid sequence intubation on outcome in severely head-injured patients. Adults with severe head trauma (Glasgow Coma Scale score 3 to 8) who were unable to be intubated without medications were enrolled. Midazolam and succinylcholine were administered, and paramedics were allowed a maximum of 3 attempts at orotracheal intubation. If the attempts were unsuccessful, Combitube insertion was mandated. After confirmation of tube position, rocuronium was given and standard ventilation protocols were used. The primary outcome measure for this analysis was the success rate for Combitube insertion after unsuccessful orotracheal intubation. In addition, Combitube insertion and orotracheal intubation patients were compared with regard to demographic, clinical, and outcome data.

RESULTS

A total of 426 patients were enrolled in the trial, with 420 meeting inclusion criteria for this analysis. Orotracheal intubation was successful in 355 (84.5%) of 420; Combitube insertion was successful in 58 (95.1%) of 61 attempts, with no reported complications. Patients undergoing Combitube insertion had higher Face Abbreviated Injury Scale scores and were more likely to have oropharyngeal blood or vomitus. Arrival Pco(2) values were higher, and arrival Po(2) values were lower but still supranormal in patients undergoing Combitube insertion. There were no mortality differences between patients undergoing Combitube insertion and those undergoing orotracheal intubation.

CONCLUSION

The Combitube can be an effective salvage airway device for paramedic rapid sequence intubation in an urban/suburban, high-volume emergency medical services system with paramedics who are experienced in Combitube placement and with stringent protocols for its use. The device should be tested in other sizes and types of systems and under less medical scrutiny than was used in this study.

Cost-effectiveness of automated external defibrillator deployment in selected public locations

OBJECTIVE

The American Heart Association (AHA) recommends an automated external defibrillator (AED) be considered for a specific location if there is at least a 20% annual probability the device will be used. We sought to evaluate the cost-effectiveness of the AHA recommendation and of AED deployment in selected public locations with known cardiac arrest rates.

DESIGN

Markov Decision Model employing a societal perspective.

SETTING

Selected public locations in the United States.

PATIENTS

A simulated cohort of the American public.

INTERVENTION

Strategy 1: individuals experiencing cardiac arrest were treated by emergency medical services equipped with AEDs (EMS-D). Strategy 2: individuals were treated with AEDs deployed as part of a public access defibrillation program. Strategies differed only in the initial availability of an AED and its impact on cardiac arrest survival.

RESULTS

Under the base-case assumption that a deployed AED will be used on 1 cardiac arrest every 5 years (20% annual probability of AED use), the cost per quality-adjusted life year (QALY) gained is $30,000 for AED deployment compared with EMS-D care. AED deployment costs less than $50,000 per QALY gained provided that the annual probability of AED use is 12% or greater. Monte Carlo simulation conducted while holding the annual probability of AED use at 20% demonstrated that 87% of the trials had a cost-effectiveness ratio of less than $50,000 per QALY.

CONCLUSIONS

AED deployment is likely to be cost-effective across a range of public locations. The current AHA guidelines are overly restrictive. Limited expansion of these programs can be justified on clinical and economic grounds.

A preliminary evaluation of emergency ultrasound in the setting of an emergency medicine training program

In this article we seek to evaluate the diagnostic accuracy of emergency physicians performing emergency ultrasonography in the setting of an emergency medicine training program. A prospective observational study was performed at an inner city Level I trauma center with an emergency medicine residency training program. From July 1994 to December 1996 a convenience sample of ultrasound exams was recorded. The diagnostic quality ("acceptable or technically limited") was determined by a board-certified cardiologist or radiologist with fellowship training in ultrasonography. The emergency department interpretations were then compared to those of the blinded cardiologist or radiologist. Four hundred and fifty-six ultrasound examinations were videotaped and entered into the study; 408 (89%) of the studies performed were determined to be "acceptable." The diagnostic accuracy (sensitivity, specificity, positive and negative predictive values) of these studies were as follows: cardiac, to rule out effusion (n = 67; 0.83, 0.98, 0.88, 0.98); transabdominal, to rule out abdominal aortic aneurysms (AAA), cholelithiasis, or free peritoneal fluid (n = 263; 0.91, 0.89, 0.88, 0.92); renal, to rule out hydronephrosis (n = 45; 0.94, 0.96, 0.94, 0.96); pelvic, to rule in intrauterine pregnancy (n = 33; 1.0, 0.90, 0.96, 1.0). The 48 "technically limited studies" included: 39 transabdominal (33 gallbladder, 1 abdominal aortic aneurysm, 5 free peritoneal fluid), 6 cardiac, 2 renal, and 1 pelvic ultrasound. This study suggests that emergency physicians with a minimal amount of training display acceptable technical skill and interpretive acumen in their approach to emergency ultrasonography.

Emergency preparation in schools: a snapshot of a rural state

OBJECTIVE

To study emergency preparedness in public schools in a rural state.

METHOD

Questionnaires were mailed to school nurses registered with the State Department of Education. Data collected included school nurse and staff training, school location, emergency equipment available, and Emergency Medical Service (EMS) access.

RESULTS

Seventy-two percent of the surveys were returned after one or two mailings. They report little emergency training for both school nurses and school staff. Emergency equipment available varies widely: oxygen 20%, artificial airways 30%, cervical collars 22%, splints 69%. Equipment was more likely to be available in communities with populations of less than 200,000. Sixty-seven percent of schools activate EMS for a student and 37% for an adult annually. Eighty-four percent of schools have a less than 10-minute EMS response time.

CONCLUSIONS

EMS activation to schools is a common occurrence. Schools are ill prepared to care for this acuity of student or staff as assessed by equipment and emergency training. Schools in smaller communities, however, are better prepared for emergencies.

Auxiliary technologies related to transport and communication for obstetric emergencies

OBJECTIVES

To review the evidence on appropriate transport and communications technologies for obstetrical referrals in developing countries.

METHODS

Review of articles published in peer-reviewed journals and gray literature, supplemented by email and telephone consultations with key informants and field programmers.

RESULTS

A wide range of transportation options have been attempted. Initial approaches--such as those relying on ambulances owned and operated by health systems--have evolved into recommendations that emphasize community-based solutions. There are fewer options within the realm of communications technologies, and the recommendations are more consistent. Public health researchers are only beginning to evaluate the cost and effectiveness of different options.

CONCLUSIONS

One of the greatest barriers to effective use of transport and communications for obstetric emergencies is the short time interval necessary for action, which limits options for obstetric referrals more than for other medical referrals. Although evidence is still scarce, experience suggests that motorized transport is likely to be the most acceptable and effective transportation option. More sophisticated communications technologies such as cell phones are both practical and effective, and are increasingly becoming the technologies of choice for low-resource settings.

Prospective assessment of integrating the existing emergency medical system with automated external defibrillators fully operated by volunteers and laypersons for out-of-hospital cardiac arrest: the Brescia Early Defibrillation Study (BEDS)

AIMS

There are few data on the outcomes of cardiac arrest (CA) victims when the defibrillation capability of broad rural and urban territories is fully operated by volunteers and laypersons.

METHODS AND RESULTS

In this study, we investigated whether a programme based on diffuse deployment of automated external defibrillators (AEDs) operated by 2186 trained volunteers and laypersons across the County of Brescia, Italy (area: 4826 km(2); population: 1 112 628), would safely and effectively impact the current survival among victims of out-of-hospital CA. Forty-nine AEDs were added to the former emergency medical system that uses manual EDs in the emergency department of 10 county hospitals and in five medically equipped ambulances. The primary endpoint was survival free of neurological impairment at 1-year follow-up. Data were analysed in 692 victims before and in 702 victims after the deployment of the AEDs. Survival increased from 0.9% (95% CI 0.4-1.8%) in the historical cohort to 3.0% (95% CI 1.7-4.3%) (P=0.0015), despite similar intervals from dispatch to arrival at the site of collapse [median (quartile range): 7 (4) min vs. 6 (6) min]. Increase of survival was noted both in the urban [from 1.4% (95% CI 0.4-3.4 %) to 4.0% (95% CI 2.0-6.9 %), P=0.024] and in the rural territory [from 0.5% (95% CI 0.1-1.6%) to 2.5% (95% CI 1.3-4.2%), P=0.013]. The additional costs per quality-adjusted life year saved amounted to euro39 388 (95% CI euro16 731-49 329) during the start-up phase of the study and to euro23 661 (95% CI euro10 327-35 528) at steady state.

CONCLUSION

Diffuse implementation of AEDs fully operated by trained volunteers and laypersons within a broad and unselected environment proved safe and was associated with a significantly higher long-term survival of CA victims.

Noninvasive continuous positive airway pressure ventilation using a new helmet interface: a case-control prospective pilot study

OBJECTIVE

To evaluate the clinical efficacy of noninvasive continuous positive airway pressure ventilation (CPAP) using a new interface, constituted by a cephalic plastic helmet, in comparison with a standard facial mask.

DESIGN AND SETTING

A prospective pilot study with matched-control group, in the emergency department of a teaching hospital.

PATIENTS AND METHODS

Eleven consecutive adult patients with acute hypoxemic respiratory failure related to cardiogenic pulmonary edema (whether hypercapnic or not) were enrolled in the study, after failure of the initial medical treatment. Each patient treated with CPAP, using the helmet in addition to a standardized medical treatment, was matched with historical control-patient treated with CPAP using a standard facial mask, and selected by gender, age, and PaCO2 levels on admission. Primary end points were improvements of gas exchanges and clinical parameters of respiratory distress. tolerance was evaluated after each CPAP trial.

RESULTS

The 22 patients and controls had similar characteristics at baseline. PaCO2 levels, and clinical parameters improved similarly in both groups. No interface intolerance was reported whether using standard facial mask or the helmet. No complications were observed in either group. The helmet allowed CPAP administration for a longer period of time (p=0.045). In-hospital mortality was not different between the two groups.

CONCLUSION

Despite a high dead-space volume (9-15 l), this new helmet interface is an efficient alternative to standard face mask during CPAP, even in cases of severe respiratory acidosis and hypercapnia. It allowed to provide long-duration CPAP, without any adverse events or clinical intolerance.

Performance of police first responders in utilizing automated external defibrillation on victims of sudden cardiac arrest

OBJECTIVE

Rates of resuscitation from cardiac arrest are directly tied to time to defibrillation. To maximize results, the first arriving care provider should be equipped and trained to defibrillate. This would include police in those systems where they serve this function; to date, no training program has been examined for effectiveness in this group. The purpose of this study was to evaluate a training program designed to train police first responders in the use of an automated external defibrillator (AED).

METHODS

One hundred seventy police officers previously trained to the level of first responders underwent a four-hour course to teach incorporation of the AED in their practice. The evaluation of police performance was assessed by written tests prior to, immediately after, and six months post initial training. Actual field use was evaluated by using separate data collection forms filled out at the time of the resuscitation by both police and EMS providers. Each trip sheet was also reviewed. Cassette tapes from the AED were reviewed for continuous ECG tracings and audio recordings to validate and confirm the previous data.

RESULTS

One hundred twenty-eight police cases were reviewed. The officers performed with few errors in AED operation, with the only problem areas being incorrect airway management and delay in performance of CPR to use the AED to reanalyze a nonshockable rhythm. These results were compared with those of the only two other studies examining the performance of first responders, which were EMTs and firefighters. The police results compared favorably with, and in some instances exceeded, those results.

CONCLUSION

Police first responders trained in the use of AEDs performed at a level equivalent or superior to that in other reported studies. Future training strategies should stress proper integration of airway and CPR skills.

Physiological Evaluation of the U.S. Army One-Handed Tourniquet

OBJECTIVE

To provide a physiological assessment of the U.S. Army one-handed tourniquet (OHT).

METHODS

An OHT was self-applied by 26 subjects, to maximal tolerable tightness, to the proximal arm or thigh under different conditions and positions, and the presence of blood flow was assessed using Doppler ultrasonography or occlusion plethysmography.

RESULTS

Doppler sound was eliminated at the radial artery for all subjects with OHT application but was not stopped at the popliteal or dorsalis pedis artery for any subjects. The OHT reduced forearm blood flow by 79% but decreased leg blood flow by only approximately 50%, regardless of condition and position of application to the thigh.

CONCLUSIONS

The OHT appears to effectively minimize blood flow in the arm but not in the lower extremities, and clinical assessment of blood flow disappearance by Doppler ultrasonography may underestimate the magnitude of actual blood flow to the limb.

Tissue-interface pressures on three different support-surfaces for trauma patients

The purpose of this study was to evaluate and compare tissue-interface pressures on three different support-surfaces for trauma patients. The support-surfaces were a semi soft overlay mattress, a vacuum mattress and a spine board. Tissue-interface pressures were measured in a standardised way between the scapulae, the sacrum, the heels and the different support-surfaces in 20 healthy volunteers. Appreciation of comfort of the support-surface was assessed using a 10-point visual analog scale. High and potentially ischaemic interface pressures were found on all three support-surfaces, with the highest pressures (exceeding 170 mmHg) measured on the spine board. The spine board got the worst comfort score. It was also noted that no support was given to the normal lumbar lordosis by the spine board. There is a need for new support-surfaces for trauma patients, which reduce interface pressures and are comfortable.

Lymphocyte-to-monocyte ratio effectively predicts survival outcome of patients with obstructive colorectal cancer

BACKGROUND

Obstructive colorectal cancer (OCC) is always accompanied by severe complications, and the optimal strategy for patients with OCC remains undetermined. Different from emergency surgery (ES), self-expandable metal stents (SEMS) as a bridge to surgery (BTS), could increase the likelihood of primary anastomosis. However, the stent failure and related complications might give rise to a high recurrence rate. Few studies have focused on the indications for either method, and the relationship between preoperative inflammation indexes and the prognosis of OCC is still underestimated.

AIM

To explore the indications for ES and BTS in OCCs based on preoperative inflammation indexes.

METHODS

One hundred and twenty-eight patients who underwent ES or BTS from 2008 to 2015 were enrolled. Receiver operating characteristic (ROC) curve analysis was used to define the optimal preoperative inflammation index and its cutoff point. Kaplan–Meier analyses and Cox proportional hazards models were applied to assess the association between the preoperative inflammation indexes and the survival outcomes [overall survival (OS) and disease-free survival (DFS)]. Stratification analysis was performed to identify the subgroups that would benefit from ES or BTS.

RESULTS

OS and DFS were comparable between the ES and BTS groups (P > 0.05). ROC curve analysis showed derived neutrophil-to-lymphocyte ratio (dNLR) as the optimal biomarker for the prediction of DFS in ES (P < 0.05). Lymphocyte-to-monocyte ratio (LMR) was recommended for BTS with regard to OS and DFS (P < 0.05). dNLR was related to stoma construction (P = 0.001), pneumonia (P = 0.054), and DFS (P = 0.009) in ES. LMR was closely related to lymph node invasion (LVI) (P = 0.009), OS (P = 0.020), and DFS (P = 0.046) in the BTS group. dNLR was an independent risk factor for ES in both OS (P = 0.032) and DFS (P = 0.016). LMR affected OS (P = 0.053) and DFS (P = 0.052) in the BTS group. LMR could differentiate the OS between the ES and BTS groups (P < 0.05).

CONCLUSION

Preoperative dNLR and LMR could predict OS and DFS in patients undergoing ES and BTS, respectively. For OCC, as the potential benefit group, patients with a low LMR might be preferred for BTS via SEMS insertion.