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Manual ventilation with a bag-valve device (BVD) is a Basic Life Support skill. Prolonged manual ventilation may be required in resource-poor locations and in severe disasters such as hurricanes, pandemics, and chemical events. In such circumstances, trained operators may not be available and lay persons may need to be quickly trained to do the job.
Objectives:
The current study investigated whether minimally trained operators were able to manually ventilate a simulated endotracheally intubated patient for six hours.
Methods:
Two groups of 10 volunteers, previously unfamiliar with manual ventilation, received brief, structured BVD-tube ventilation training and performed six hours of manual ventilation on an electronic lung simulator. Operator cardiorespiratory variables and perceived effort, as well as the quality of the delivered ventilation, were recorded. Group One ventilated a “normal lung” (compliance 50cmH2O/L, resistance 5cmH2O/L/min). Group Two ventilated a “moderately injured lung” (compliance 20cmH2O/L, resistance 20cmH2O/L/min).
Results:
Volunteers’ blood pressure, heart rate (HR), respiratory rate (RR), and peripheral capillary oxygen saturation (SpO2) were stable throughout the study. Perceived effort was minimal. The two groups provided clinically adequate and similar RRs (13.3 [SD = 3.0] and 14.1 [SD = 2.5] breaths/minute, respectively) and minute volume (MV; 7.6 [SD = 2.1] and 7.7 [SD = 1.4] L/minute, respectively).
Conclusions:
The results indicate that minimally trained persons can effectively perform six hours of manual BVD-tube ventilation of normal and moderately injured lungs, without undue effort. Quality of delivered ventilation was clinically adequate.
This systemic review and meta-analysis was conducted to explore the impact of dispatcher-assisted bystander cardiopulmonary resuscitation (DA-BCPR) on bystander cardiopulmonary resuscitation (BCPR) probability, survival, and neurological outcomes with out-of-hospital cardiac arrest (OHCA).
Methods:
Electronically searching of PubMed, Embase, and Cochrane Library, along with manual retrieval, were done for clinical trials about the impact of DA-BCPR which were published from the date of inception to December 2018. The literature was screened according to inclusion and exclusion criteria, the baseline information, and interested outcomes were extracted. Two reviewers assessed the methodological quality of the included studies. Pooled odds ratio (OR) and 95% confidence interval (CI) were calculated by STATA version 13.1.
Results:
In 13 studies, 235,550 patients were enrolled. Compared with no dispatcher instruction, DA-BCPR tended to be effective in improving BCPR rate (I2 = 98.2%; OR = 5.84; 95% CI, 4.58-7.46; P <.01), return of spontaneous circulation (ROSC) before admission (I2 = 36.0%; OR = 1.17; 95% CI, 1.06-1.29; P <.01), discharge or 30-day survival rate (I2 = 47.7%; OR = 1.25; 95% CI, 1.06-1.46; P <.01), and good neurological outcome (I2 = 30.9%; OR = 1.24; 95% CI, 1.04-1.48; P = .01). However, no significant difference in hospital admission was found (I2 = 29.0%; OR = 1.09; 95% CI, 0.91-1.30; P = .36).
Conclusion:
This review shows DA-BPCR plays a positive role for OHCA as a critical section in the life chain. It is effective in improving the probability of BCPR, survival, ROSC before admission, and neurological outcome.
Assisting the increasing number of tourists and foreign nationals exposed to crises situations in third countries—many of them far from home and extremely vulnerable—presents significant challenges. Despite the need to explore consular crisis management from an operational perspective, there are few studies that address the issue. This paper aims to describe the characteristics and context of consular crisis management operations based on personal experiences, scientific papers, grey literature, and key informant interviews.
Consular crisis management operations are conducted in a context where the stakeholders and the legal environment may differ from humanitarian or civil protection operations. The physical distance causes logistical challenges and demands specific considerations for both civilian and medical evacuation. Consular crisis management operations often include medical care, psychosocial support activities, and disaster victim identification (DVI) activities. Political and media interest may also add significant challenges to such operations. Therefore, specific knowledge, skills, and preparations are needed for both diplomatic crisis management professionals and health professionals. Further research on consular crisis management activities—as well as the concept of consular crisis management itself—is strongly needed.
In response to the International Liaison Committee on Resuscitation (ILCOR; Niel, Belgium) release of an updated recommendation related to out-of-hospital spinal immobilization (SI) practice in 2015, a systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist of English-language studies published from January 2000 through July 2019 on the use of SI in resource-scarce environments (RSEs). Studies meeting the following criteria were included in the analysis: peer-reviewed statistical studies or reports detailing management of potential traumatic spinal injury in RSE, civilian, and military environments; as well as consensus clinical guidelines, academic center, or professional association protocols or policy statements detailing management of potential traumatic spinal injury in RSE, civilian, and military environments; statistical analysis; and subsequent management of spinal injuries after mass-casualty incidents, in complex humanitarian events or conflict zones, low-to middle-income countries, or prolonged transport times published by government and non-government organizations. Studies excluded from consideration were those not related to a patient with a potential traumatic spinal injury after a mass-casualty incident, in complex humanitarian event or conflict zones, in low-to middle-income countries, or with prolonged transport times.
There were one thousand twenty-nine (1029) studies initially identified. After removal of duplicates, nine hundred-nineteen (919) were screened with eight hundred sixty-three (863) excluded. The remaining fifty-six (56) received further review with fourteen (14) selected studies achieving inclusion. The reviewed articles comprised six (6) types of studies and represented research from institutions in seven (7) different countries (Israel, United States, Haiti, Wales, Pakistan, China, and Iran). Thirteen (13) references were case reports/narrative reviews, policy statements, retrospective observational studies, narrative literature reviews, scoping reviews, and one systematic review. The majority of literature describing spinal cord injury was predominantly associated with earthquakes and blast-related disasters. There were no SI evidence-based clinical guidelines (EBG) in RSE. Information was obtained that could be used to formulate statements in a modified Delphi study to present to experts to obtain consensus SI EBG in RSE.
There have been multiple inconsistencies in the manner the COVID-19 pandemic has been investigated and managed by countries. Population-based management (PBM) has been inconsistent, yet serves as a necessary first step in managing public health crises. Unfortunately, these have dominated the landscape within the United States and continue as of this writing. Political and economic influences have greatly influenced major public health management and control decisions. Responsibility for global public health crises and modeling for management are the responsibility of the World Health Organization (WHO) and the International Health Regulations Treaty (IHR). This review calls upon both to reassess their roles and responsibilities that must be markedly improved and better replicated world-wide in order to optimize the global public health protections and its PBM.
“Ask a big enough question, and you need more than one discipline to answer it.”
Liz Lerman, MacArthur “Genius” Fellow, Choreographer, Modern Dance legend, and 2011 Artist-in Residence, Harvard Music Department
Middle East Respiratory Syndrome Coronavirus (MERS-CoV) is a form of an infectious respiratory disease, discovered in November 2012 in Saudi Arabia. According to the World Health Organization (WHO; Geneva, Switzerland) reports, a total of 2,519 laboratory-confirmed cases and 866 MERS-CoV-related deaths were recorded as of March 5, 2016.1 The majority of reported cases originated from Saudi Arabia (2,121 cases). Also, MERS-CoV is believed to be of zoonotic origin and has been linked to camels in the Arabian area.1,2 In this report, the authors discuss the lessons learned from the MERS-CoV outbreak at King Abdul-Aziz Medical City-Riyadh (KAMC-R) from August through September 2015 from the Emergency Medical Services (EMS) perspective. The discussion includes the changes in policies and paramedic’s practice, the training and education in infection control procedures, and the process of transportation of these cases. The authors hope to share their experience in this unique situation and highlight the preparedness and response efforts that took place by the division of EMS during the outbreak.
Emergency Medical Services (EMS) systems have developed protocols for prehospital activation of the cardiac catheterization laboratory for patients with suspected ST-elevation myocardial infarction (STEMI) to decrease first-medical-contact-to-balloon time (FMC2B). The rate of “false positive” prehospital activations is high. In order to decrease this rate and expedite care for patients with true STEMI, the American Heart Association (AHA; Dallas, Texas USA) developed the Mission Lifeline PreAct STEMI algorithm, which was implemented in Los Angeles County (LAC; California USA) in 2015. The hypothesis of this study was that implementation of the PreAct algorithm would increase the positive predictive value (PPV) of prehospital activation.
Methods:
This is an observational pre-/post-study of the effect of the implementation of the PreAct algorithm for patients with suspected STEMI transported to one of five STEMI Receiving Centers (SRCs) within the LAC Regional System. The primary outcome was the PPV of cardiac catheterization laboratory activation for percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG). The secondary outcome was FMC2B.
Results:
A total of 1,877 patients were analyzed for the primary outcome in the pre-intervention period and 405 patients in the post-intervention period. There was an overall decrease in cardiac catheterization laboratory activations, from 67% in the pre-intervention period to 49% in the post-intervention period (95% CI for the difference, -14% to -22%). The overall rate of cardiac catheterization declined in post-intervention period as compared the pre-intervention period, from 34% to 30% (95% CI, for the difference -7.6% to 0.4%), but actually increased for subjects who had activation (48% versus 58%; 95% CI, 4.6%-15.0%). Implementation of the PreAct algorithm was associated with an increase in the PPV of activation for PCI or CABG from 37.9% to 48.6%. The overall odds ratio (OR) associated with the intervention was 1.4 (95% CI, 1.1-1.8). The effect of the intervention was to decrease variability between medical centers. There was no associated change in average FMC2B.
Conclusions:
The implementation of the PreAct algorithm in the LAC EMS system was associated with an overall increase in the PPV of cardiac catheterization laboratory activation.
Immobilization of the cervical spine by Emergency Medical Services (EMS) personnel is a standard procedure. In most EMS, multiple immobilization tools are available.
The aim of this study is the analysis of residual spine motion under different types of cervical spine immobilization.
Methods:
In this explorative biomechanical study, different immobilization techniques were performed on three healthy subjects. The test subjects’ heads were then passively moved to cause standardized spinal motion. The primary endpoints were the remaining range of motion for flexion, extension, bending, and rotation measured with a wireless human motion detector.
Results:
In the case of immobilization of the test person (TP) on a straight (0°) vacuum mattress, the remaining rotation of the cervical spine could be reduced from 7° to 3° by additional headblocks. Also, the remaining flexion and extension were reduced from 14° to 3° and from 15° to 6°, respectively. The subjects’ immobilization was best on a spine board using a headlock system and the Spider Strap belt system (MIH-Medical; Georgsmarienhütte, Germany). However, the remaining cervical spine extension increased from 1° to 9° if a Speedclip belt system was used (Laerdal; Stavanger, Norway). The additional use of a cervical collar was not advantageous in reducing cervical spine movement with a spine board or vacuum mattress.
Conclusions:
The remaining movement of the cervical spine is minimal when the patient is immobilized on a spine board with a headlock system and a Spider Strap harness system or on a vacuum mattress with additional headblocks. The remaining movement of the cervical spine could not be reduced by the additional use of a cervical collar.
The rapid insurgence and spread of coronavirus disease 2019 (COVID-19) exceeded the limit of the intensive care unit (ICU) contingency plan of the Maggiore della Carità University Hospital (Novara, Italy) generating a crisis management condition. This brief report describes how a prompt response to the sudden request of invasive mechanical ventilation (IMV) was provided by addressing the key elements of health care system surge capacity from contingency to crisis. In a short time and at a relatively low cost, a structural modification of a hospital aisle allowed to convert the general ICU into a COVID-19 unit, increasing the number of COVID-19 critical care beds by 107%.
The COVID-19 pandemic has strained health care system resources and reduced the availability of life-sustaining and medical-grade personal protective equipment (PPE) though the combination of increased demand and disrupted manufacturing supply chains. As a result of these shortages, many health care providers have temporarily used largely untested, improvised PPE (iPPE). Lack of quality control for makeshift PPE and frequent repurposing of used items to conserve supplies increase both the risk of provider infection and nosocomial spread to uninfected patients. One strategy to reduce risk of infection and preserve existing equipment is the implementation of secondary barrier devices placed directly over patients or providers. The authors describe an inexpensive, disposable, positive-pressure head isolation unit that can be rapidly constructed from materials readily available in nearly all health care settings for under five US dollars. The unit was successfully deployed in Taiwan during the 2003 Severe Acute Respiratory Syndrome (SARS) outbreak, and again during the COVID-19 pandemic. The iPPE worn directly by the health care workers (HCWs) can be donned prior to patient contact in the presence of an air source. This strategy may be more protective than a covering placed over the patient in an aerosol-generating environment, which requires the HCW to be in close contact with the patient prior to securing the protective device.
Physicians’ management of hazardous material (HAZMAT) incidents requires personal protective equipment (PPE) utilization to ensure the safety of victims, facilities, and providers; therefore, providing effective and accessible training in its use is crucial. While an emphasis has been placed on the importance of PPE, there is debate about the most effective training methods. Circumstances may not allow for a traditional in-person demonstration; an accessible video training may provide a useful alternative.
Hypothesis:
Video training of Emergency Medicine (EM) residents in the donning and doffing of Level C PPE is more effective than in-person training.
Null Hypothesis:
Video training of EM residents in the donning and doffing of Level C PPE is equally effective compared with in-person training.
Methods:
A randomized, controlled pilot trial was performed with 20 EM residents as part of their annual Emergency Preparedness training. Residents were divided into four groups, with Group 1 and Group 2 viewing a demonstration video developed by the Emergency Preparedness Team (EPT) and Group 3 and Group 4 receiving the standard in-person demonstration training by an EPT member. The groups then separately performed a donning and doffing simulation while blinded evaluators assessed critical tasks utilizing a prepared evaluation tool. At the drill’s conclusion, all participants also completed a self-evaluation survey about their subjective interpretations of their respective trainings.
Results:
Both video and in-person training modalities showed significant overall improvement in participants’ confidence in doffing and donning PPE equipment (P <.05). However, no statistically significant difference was found in the number of failed critical tasks in donning or doffing between the training modalities (P >.05). Based on these results, the null hypothesis cannot be rejected. However, these results were limited by the small sample size and the study was not sufficiently powered to show a difference between training modalities.
Conclusion:
In this pilot study, video and in-person training were equally effective in training for donning and doffing Level C PPE, with similar error rates in both modalities. Further research into this subject with an appropriately powered study is warranted to determine whether this equivalence persists using a larger sample size.
Pain management for patients with chest trauma in aeromedical prehospital and retrieval medicine is important in order to maintain respiratory function. However, it can be challenging to achieve with opioids alone due to side effects including sedation, respiratory depression, and nausea.
Reported are two trauma patients with uncontrolled pain despite multiple doses of opioids managed with a single-injection erector spinae plane block (ESB).
The sono-anatomy and performance of the block, indications, and possible complications associated with the ESB are described.
An ultrasound-guided ESB is useful for multimodal pain therapy following chest trauma in aeromedical retrieval medicine.
In August 2018, India’s southern state of Kerala experienced its worst flooding in over a century. This report describes the relief efforts in Kozhikode, a coastal region of Kerala, where Operation Navajeevan was initiated.
Sources:
Data were collected from a centralized database at the command center in the District Medical Office as well as first-hand accounts from providers who participated in the relief effort.
Observations:
From August 15 through September 8, 2018, 36,846 flood victims were seen at 280 relief camps. The most common cause for presentation was exacerbation of an on-going chronic medical condition (18,490; 50.2%). Other common presentations included acute respiratory infection (7,451; 20.2%), traumatic injuries (3,736; 10.4%), and psychiatric illness (5,327; 14.5%).
Analysis:
The prevalence of chronic disease exacerbation as the primary presentation during Operation Navajeevan represents an epidemiologic shift in disaster relief in India. It is foreseeable that as access to health care improves in low- and middle-income countries (LMICs), and climate change increases the prevalence of extreme weather events around the world, that this trend will continue.