A new study demonstrates an association between advanced prehospital airway management and worse clinical outcomes in patients with cardiac arrest. Done in Japan, the numbers of patients included are staggering: this nationwide population-based cohort study included 658 829 adult patients. They found that CPR with advanced airway management (use of tracheal tubes and even supraglottic airways) was a significant predictor of poor neurological outcome compared with conventional bag-valve-mask ventilation. Association of Prehospital Advanced Airway Management With Neurologic Outcome and Survival in Patients With Out-of-Hospital Cardiac Arrest JAMA 2013;309(3):257-66
[EXPAND Click to read abstract]
Importance It is unclear whether advanced airway management such as endotracheal intubation or use of supraglottic airway devices in the prehospital setting improves outcomes following out-of-hospital cardiac arrest (OHCA) compared with conventional bag-valve-mask ventilation.
Objective To test the hypothesis that prehospital advanced airway management is associated with favorable outcome after adult OHCA.
Design, Setting, and Participants Prospective, nationwide, population-based study (All-Japan Utstein Registry) involving 649 654 consecutive adult patients in Japan who had an OHCA and in whom resuscitation was attempted by emergency responders with subsequent transport to medical institutions from January 2005 through December 2010.
Main Outcome Measures Favorable neurological outcome 1 month after an OHCA, defined as cerebral performance category 1 or 2.
Results Of the eligible 649 359 patients with OHCA, 367 837 (57%) underwent bag-valve-mask ventilation and 281 522 (43%) advanced airway management, including 41 972 (6%) with endotracheal intubation and 239 550 (37%) with use of supraglottic airways. In the full cohort, the advanced airway group incurred a lower rate of favorable neurological outcome compared with the bag-valve-mask group (1.1% vs 2.9%; odds ratio [OR], 0.38; 95% CI, 0.36-0.39). In multivariable logistic regression, advanced airway management had an OR for favorable neurological outcome of 0.38 (95% CI, 0.37-0.40) after adjusting for age, sex, etiology of arrest, first documented rhythm, witnessed status, type of bystander cardiopulmonary resuscitation, use of public access automated external defibrillator, epinephrine administration, and time intervals. Similarly, the odds of neurologically favorable survival were significantly lower both for endotracheal intubation (adjusted OR, 0.41; 95% CI, 0.37-0.45) and for supraglottic airways (adjusted OR, 0.38; 95% CI, 0.36-0.40). In a propensity score–matched cohort (357 228 patients), the adjusted odds of neurologically favorable survival were significantly lower both for endotracheal intubation (adjusted OR, 0.45; 95% CI, 0.37-0.55) and for use of supraglottic airways (adjusted OR, 0.36; 95% CI, 0.33-0.39). Both endotracheal intubation and use of supraglottic airways were similarly associated with decreased odds of neurologically favorable survival.
Conclusion and Relevance Among adult patients with OHCA, any type of advanced airway management was independently associated with decreased odds of neurologically favorable survival compared with conventional bag-valve-mask ventilation.
Some good news for remote, rural, prehospital, and retrieval medicine clinicians who rely on point of care testing with the i-STAT® device. An animal study confirmed the reliability of testing aspirates from intraosseous samples taken from the tibia(1).
This is also good news for hospital practitioners when it comes to the acquisition of blood gas results, since there are concerns over the potential damage to blood gas analysers by bone marrow contents in the samples.
The researchers tested blood gases, acid–base status, lactate, haemoglobin, and electrolytes, and compared these with results from an arterial sample.
There was no malfunction of the equipment. Most of the acid–base parameters showed discrepancies between arterial and osseous samples: the average pH and base excess were consistently lower whilst pCO2 and lactate were higher in the intraosseous samples compared to the arterial. However the overall small degree and predictable direction of discrepancy in these values should preserve the clinical usefulness of intraosseous gases if these findings can be replicated in human subjects. pO2 was obviously very different between osseous and arterial samples.
They noted that aspiration of intraosseous samples was generally straightforward, especially immediately after placement of the cannulae, but on a few occasions more forceful aspiration was needed. They point out that this could possibly cause cellular lysis and affect the potassium analysis.
The authors consider the issue of how much aspirate should be discarded before taking a sample after intraosseous cannula insertion, and refer to a prior study which suggested that 2mL is adequate.
Summary
Intraosseous aspirate can be tested on an i-STAT® point-of-care analyser
Haemoglobin and electrolytes show good correlation with arterial samples
Acid-base, pCO2, and lactate differ slightly from arterial results but in a predictable direction and results are still likely to be clinically useful in an emergency
It may be worth discarding the first 2 ml of aspirate
These results require validation in human subjects
Analysis of intraosseous samples using point of care technology–an experimental study in the anaesthetised pig Resuscitation. 2012 Nov;83(11):1381-5
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BACKGROUND: Intraosseous access is an essential method in emergency medicine when other forms of vascular access are unavailable and there is an urgent need for fluid or drug therapy. A number of publications have discussed the suitability of using intraosseous access for laboratory testing. We aimed to further evaluate this issue and to study the accuracy and precision of intraosseous measurements. METHODS: Five healthy, anaesthetised pigs were instrumented with bilateral tibial intraosseous cannulae and an arterial catheter. Samples were collected hourly for 6h and analysed for blood gases, acid base status, haemoglobin and electrolytes using an I-Stat point of care analyser. RESULTS: There was no clinically relevant difference between results from left and right intraosseous sites. The variability of the intraosseous sample values, measured as the coefficient of variance (CV), was maximally 11%, and smaller than for the arterial sample values for all variables except SO2. For most variables, there seems to be some degree of systematic difference between intraosseous and arterial results. However, the direction of this difference seems to be predictable. CONCLUSION: Based on our findings in this animal model, cartridge based point of care instruments appear suitable for the analysis of intraosseous samples. The agreement between intraosseous and arterial analysis seems to be good enough for the method to be clinically useful. The precision, quantified in terms of CV, is at least as good for intraosseous as for arterial analysis. There is no clinically important difference between samples from left and right tibia, indicating a good reproducibility.
Fellow retrieval specialist and Royal North Shore Hospital emergency physician Dr Toby Fogg and coauthors have published their audit of intubations in an Australian Emergency Department(1). More important than the results themselves is that the process of monitoring ones practice inevitably leads to improvements. For example, at Toby’s institution an intubation checklist has been introduced since the audit began. Other Australasian EDs are encouraged to participate using the free resources at airwayregistry.org.au.
Recently we have also seen the publication of Korean registry data on paediatric intubations performed in 13 academic EDs over 5 years(2), in which first pass success rates (overall 67.6%) were higher with emergency physicians compared with paediatricians. Interestingly, a rapid sequence intubation technique was only used in 22.4% of intubations, which was more likely to be used by emergency physicians and was associated with a greater likelihood of first pass success.
This relatively low first pass success rate is reminiscent of the American study published in September(3) which raised some eyebrows with its 52% first pass intubation success rates in a paediatric ED, and which also showed that attending-level providers were 10 times more likely to be successful on the first attempt than all trainees combined. Possible reasons for such a low first pass success rate compared with adult registry data include the rigorous video analysis method used, or perhaps more likely that paediatric emergency subspecialists are exposed to fewer critical procedures, resuscitations, and intubations than their general emergency medicine counterparts(4).
As a specialty we must continue to seek to do better, and I salute all these brave authors who are telling it like it is. Particularly with children, whose airways are relatively easy, we have to develop the training, preparation, supervision, monitoring and feedback to aim for as high a success rate as possible.
Study authors Toby Fogg and Nick Annesley demonstrate the 'Happiness Triad'
1. Prospective observational study of the practice of endotracheal intubation in the emergency department of a tertiary hospital in Sydney, Australia Emerg Med Australas. 2012 Dec;24(6):617-24
[EXPAND Click to read abstract]
OBJECTIVE: To describe the practice of endotracheal intubation in the ED of a tertiary hospital in Australia, with particular emphasis on the indication, staff seniority, technique, number of attempts required and the rate of complications.
METHODS: A prospective observational study.
RESULTS: Two hundred and ninety-five intubations occurred in 18 months. Trauma was the indication for intubation in 30.5% (95% CI 25.3-36.0) and medical conditions in 69.5% (95% CI 64.0-74.5). Emergency physicians were team leaders in 69.5% (95% CI 64.0-74.5), whereas ED registrars or senior Resident Medical Officers made the first attempt at intubation in 88.1% (95% CI 83.9-91.3). Difficult laryngoscopy occurred in 24.0% (95% CI 19.5-29.3) of first attempts, whereas first pass success occurred in 83.4% (95% CI 78.7-87.2). A difficult intubation occurred in 3.4% (95% CI 1.9-6.1) and all patients were intubated orally in five or less attempts. A bougie was used in 30.9% (95% CI 25.8-36.5) of first attempts, whereas a stylet in 37.5% (95% CI 32.1-43.3). Complications occurred in 29.0% (95% CI 23.5-34.1) of the patients, with desaturation the commonest in 15.7% (95% CI 11.9-20.5). Cardiac arrest occurred in 2.2% (95% CI 0.9-4.4) after intubation. No surgical airways were undertaken.
CONCLUSION: Although the majority of results are comparable with overseas data, the rates of difficult laryngoscopy and desaturation are higher than previously reported. We feel that this data has highlighted the need for practice improvement within our department and we would encourage all those who undertake emergent airway management to audit their own practice of this high-risk procedure.
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2. The factors associated with successful paediatric endotracheal intubation on the first attempt in emergency departments: a 13-emergency-department registry study Resuscitation. 2012 Nov;83(11):1363-8
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BACKGROUND: We investigated which factors are associated with successful paediatric endotracheal intubation (ETI) on the first attempt in emergency department (EDs) from multicentre emergency airway registry data.
METHODS: We created a multicentre registry of intubations at 13 EDs and performed surveillance over 5 years. Each intubator filled out a data form after an intubation. We defined “paediatric patients” as patients younger than 10 years of age. We assessed the specialty and level of training of intubator, the method, the equipment, and the associated adverse events. We analysed the intubation success rates on the first attempt (first-pass success, FPS) based on these variables.
RESULTS: A total of 430 ETIs were performed on 281 children seen in the ED. The overall FPS rate was 67.6%, but emergency medicine (EM) physicians showed a significantly greater success rate of 74.4%. In the logistic regression analysis, the intubator’s specialty was the only independent predictive factor for paediatric FPS. In the subgroup analysis, the EM physicians used the rapid sequence intubation/intubation (RSI) method and Macintosh laryngoscope more frequently than physicians of other specialties. ETI-related adverse events occurred in 21 (7.2%) out of the 281 cases. The most common adverse event in the FPS group was mainstem bronchus intubation, and vomiting was the most common event in the non-FPS group. The incidence of adverse events was lower in the FPS group than in the non-FPS group, but this difference was not statistically significant.
CONCLUSIONS: The intubator’s specialty was the major factor associated with FPS in emergency department paediatric ETI, The overall ETI FPS rate among paediatric patients was 67.6%, but the EM physicians had a FPS rate of 74.4%. A well structured airway skill training program, and more actively using the RSI method are important and this could explain this differences.
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3.Rapid sequence intubation for pediatric emergency patients: higher frequency of failed attempts and adverse effects found by video review. Ann Emerg Med. 2012 Sep;60(3):251-9
[EXPAND Click to read abstract]
STUDY OBJECTIVE: Using video review, we seek to determine the frequencies of first-attempt success and adverse effects during rapid sequence intubation (RSI) in a large, tertiary care, pediatric emergency department (ED).
METHODS: We conducted a retrospective study of children undergoing RSI in the ED of a pediatric institution. Data were collected from preexisting video and written records of care provided. The primary outcome was successful tracheal intubation on the first attempt at laryngoscopy. The secondary outcome was the occurrence of any adverse effect during RSI, including episodes of physiologic deterioration. We collected time data from the RSI process by using video review. We explored the association between physician type and first-attempt success.
RESULTS: We obtained complete records for 114 of 123 (93%) children who underwent RSI in the ED during 12 months. Median age was 2.4 years, and 89 (78%) were medical resuscitations. Of the 114 subjects, 59 (52%) were tracheally intubated on the first attempt. Seventy subjects (61%) had 1 or more adverse effects during RSI; 38 (33%) experienced oxyhemoglobin desaturation and 2 required cardiopulmonary resuscitation after physiologic deterioration. Fewer adverse effects were documented in the written records than were observed on video review. The median time from induction through final endotracheal tube placement was 3 minutes. After adjusting for patient characteristics and illness severity, attending-level providers were 10 times more likely to be successful on the first attempt than all trainees combined.
CONCLUSION: Video review of RSI revealed that first-attempt failure and adverse effects were much more common than previously reported for children in an ED.
Ever been at a cardiac arrest resuscitation where someone’s opening and closing drawers at great speed but failing to retrieve the drugs or equipment you’ve asked for urgently?
What if your resus trolley were designed by team of clinicians, engineers, and designers? Such a project was achieved through a collaboration between Imperial College London and the Helen Hamlyn Centre for Design, and the award-winning result was called the ‘Resus:Station’.
The trolley separates into three trolleys for airway, drugs and defibrillation, and circulation. The contents are visible from the outside.
Image from Pubmed Free Full Text Article
As well as improving access to equipment, the trolley can log the team’s actions during each resuscitation attempt. It can also provide an instant display of its readiness for use by recording the removal and replacement of each item.
In a randomised comparison with a standard resus trolley, a number of measures of efficiency and team performance were significantly better using the Resus:Station during simulated cardiac arrest resuscitations.
It appears to be specifically designed for cardiac arrest situations rather than ‘resus’ in its wider context. The most recent article (cited below) reports that a newer prototype is being developed prior to the manufacture of the final product.
For an in depth discussion of how resus room layout can optimise efficiency, check out Minh Le Cong’s PHARM blog and podcast with James French and Scott Weingart on Clinical Logistics
The “Resus:Station”: the use of clinical simulations in a randomised crossover study to evaluate a novel resuscitation trolley. Resuscitation. 2012 Nov;83(11):1374-80Free full text
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BACKGROUND AND AIM: Inadequately designed equipment has been implicated in poor efficiency and critical incidents associated with resuscitation. A novel resuscitation trolley (Resus:Station) was designed and evaluated for impact on team efficiency, user opinion, and teamwork, compared with the standard trolley, in simulated cardiac arrest scenarios.
METHODS: Fifteen experienced cardiac arrest teams were recruited (45 participants). Teams performed recorded resuscitation simulations using new and conventional trolleys, with order of use randomised. After each simulation, efficiency (“time to drugs”, un-locatable equipment, unnecessary drawer opening) and team performance (OSCAR) were assessed from the video recordings and participants were asked to complete questionnaires scoring various aspects of the trolley on a Likert scale.
RESULTS: Time to locate the drugs was significantly faster (p=0.001) when using the Resus:Station (mean 5.19s (SD 3.34)) than when using the standard trolley (26.81s (SD16.05)). There were no reports of missing equipment when using the Resus:Station. However, during four of the fifteen study sessions using the standard trolley participants were unable to find equipment, with an average of 6.75 unnecessary drawer openings per simulation. User feedback results clearly indicated a highly significant preference for the newly designed Resus:Station for all aspects. Teams performed equally well for all dimensions of team performance using both trolleys, despite it being their first exposure to the Resus:Station.
CONCLUSION: We conclude that in this simulated environment, the new design of trolley is safe to use, and has the potential to improve efficiency at a resuscitation attempt.
A study on data from traumatic brain injury patients from the the TARN database examined the prognostic value of various scoring and classification systems and pathologies.
Contusion and haemorrhage appeared to be less significant predictors of outcome than the presence of brain swelling in this British dataset.
The brainstem was the most significant location of cerebral injury. Prognostic value of various intracranial pathologies in traumatic brain injury European Journal of Trauma and Emergency Surgery February 2012, Volume 38, Issue 1, pp 25-32
[EXPAND Click for abstract]
Objective Various intracranial pathologies in traumatic brain injury (TBI) can help to predict patient outcomes.
These pathologies can be categorised using the Marshall Classification or the Abbreviated Injury Scale (AIS) dictionary or can be described through traditional descriptive terms such as subarachnoid haemorrhage (SAH), subdural haemorrhage (SDH), epidural haemorrhage (EDH) etc. The purpose of this study is to assess the prognostic value of AIS scores, the Marshall Classification and various intracranial pathologies in TBI.
Methods A dataset of 802 TBI patients in the Trauma Audit and Research Network (TARN) database was analysed using logistic regression. First, a baseline model was constructed with age, Glasgow Coma Scale (GCS), pupillary reactivity, cause of injury and presence/absence of extracranial injury as predictors and survival at discharge as the outcome. Subsequently, AIS score, the Marshall Classification and various intracranial pathologies such as haemorrhage, SAH or brain swelling were added in order to assess the relative predictive strength of each variable and also to assess the improvement in the performance of the model.
Results Various AIS scores or Marshal classes did not appear to significantly affect the outcome. Among traditional descriptive terms, only brain stem injury and brain swelling significantly influenced outcome [odds ratios for survival: 0.17 (95% confidence interval [CI]; 0.08–0.40) and 0.48 (95% CI; 0.29–0.80), respectively].
Neither haemorrhage nor its subtypes, such as SAH, SDH and EDH, were significantly associated with outcome. Adding AIS scores, the Marshall Classification and various
intracranial pathologies to the prognostic models resulted in an almost equal increase in the predictive performance of the baseline model.
Conclusions In this relatively recent dataset, each of the brain injury classification systems enhanced equally the performance of an early mortality prediction model in traumatic brain injury patients. The significant effect of brain swelling and brain stem injury on the outcome in comparison to injuries such as SAH suggests the need to improve therapeutic approaches to patients who have sustained these injuries.
A subset of patients from the 2008 Vasopressin and Septic Shock Trial (VASST) trial had invasive haemodynamic monitoring measurements from pulmonary artery catheters. These data have now been analysed, revealing that vasopressin was associated with a lower heart rate compared with norepinephrine (noradrenaline) alone, without significant difference in cardiac index or stroke volume index. However, there was significantly greater use of inotropic drugs in the vasopressin group compared with the norepinephrine group.
Tachycardia and high quantities of catecholamine infusion are both associated with mortality in sepsis. The authors discuss: “The idea of decatecholaminization, reducing both endogenous and exogenous adrenergic stimulation, is now believed to be an important treatment strategy, and the use of beta-blockers in septic shock is being considered. The early use of vasopressin or specific V1a receptor agonists in early septic shock may be another possible treatment.”
This interesting post-hoc analysis may help further define the patients in whom vasopressin is to be considered, by those clinicians who are using it in septic shock. For those that aren’t, I wouldn’t worry about it. The cardiopulmonary effects of vasopressin compared with norepinephrine in septic shock Chest. 2012 Sep;142(3):593-605
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BACKGROUND: Vasopressin is known to be an effective vasopressor in the treatment of septic shock, but uncertainty remains about its effect on other hemodynamic parameters.
METHODS: We examined the cardiopulmonary effects of vasopressin compared with norepinephrine in 779 adult patients with septic shock recruited to the Vasopressin and Septic Shock Trial. More detailed cardiac output data were analyzed for a subset of 241 patients managed with a pulmonary artery catheter, and data were collected for the first 96 h after randomization. We compared the effects of vasopressin vs norepinephrine in all patients and according to severity of shock (< 15 or ≥ 15 μg/min of norepinephrine) and cardiac output at baseline.
RESULTS: Equal BPs were maintained in both treatment groups, with a significant reduction in norepinephrine requirements in the patients treated with vasopressin. The major hemodynamic difference between the two groups was a significant reduction in heart rate in the patients treated with vasopressin (P < .0001), and this was most pronounced in the less severe shock stratum (treatment × shock stratum interaction, P =.03). There were no other major cardiopulmonary differences between treatment groups, including no difference in cardiac index or stroke volume index between patients treated with vasopressin and those treated with norepinephrine. There was significantly greater use of inotropic drugs in the vasopressin group than in the norepinephrine group.
CONCLUSIONS: Vasopressin treatment in septic shock is associated with a significant reduction in heart rate but no change in cardiac output or other measures of perfusion.
I was lucky to be accompanied through much of my emergency medicine training and specialist work in the UK by Bruce Armstrong. We shared many resuscitation cases together in hospitals and in prehospital care.
When preparing the team in resus, Armstrong used to appoint a ‘safety officer’. This could be a nurse or physician – it didn’t matter. Their role was to stay hands-off and be the eyes, ears, and mouth that would identify impending hazards and verbally intervene to thwart them.
This process seemed so natural that I rarely gave it a thought, but its glaring absence from every place I’ve worked since has only recently hit me.
Because my son goes swimming. My three year old son attends a swimming class. There is usually one other child in the class. Recently a third child joined the class and I found myself getting uncomfortable. How could the instructor stay vigilant? What if while holding one child one of the others sank under water out of her field of view? My own obsessive reading about the limitations of human perception and cognition has convinced me that no-one can really focus on more than one thing at a time.
A friend of mine has coached kids at swimming so I asked him how they solve this. The answer was obvious – you rely on the life guards whose sole role is look out for everyone’s safety. Duh.
And then it came to me. Armstrong knew this all along. He got this idea from his prehospital experience working with fire & rescue crews and brought it into the ED. It didn’t occur to me that no-one else did this. It was just him.
Keen to explore whether anyone else had embraced this idea, I decided to go to the top when it comes to patient safety, and contacted Martin Bromiley. He told me he hadn’t come across the role in this specific setting, although did point out a great example from the BBC Documentary ‘Operation Iceberg’, in which ‘a group of scientists boarded an iceberg with someone watching over the big picture of polar bears and the berg cracking as well as fog etc’. Martin directed me to the Clinical Human Factors Group on LinkedIn, where interest was shown in the concept although it was apparent others haven’t come across it.
I went back to Armstrong to push him on further thoughts:
Yes a thought….in every other high risk environment they have a specific safety officer, whether it be nuclear industry, airline etc.
The role is specific not an add on to another role.
In healthcare we are seen as successful the more we do by one person. Think lean… think ‘efficiencies’ in the health service. Other industries focus on safety. Get safety right, your brand is safe and the public go with you. If you don’t put safety first it is only a matter of time before disaster strikes. In healthcare we have too many serious incidents. The time has come to believe in and practice safety in health care rather than ticking boxes and not applying CRM and human factors.
So here’s a proposed checklist for a Resuscitation Room Safety Officer. It’s a first draft to get the idea out there and start the conversation – just click the image below to enlarge. I’ve written (and used) checklists in resus before, but none specifically for a safety officer.
I would like to hear if anyone’s already doing this anywhere, and how it’s been working.
Primary percutaneous coronary intervention or fibrinolysis for STEMI? What if you don’t have PCI at your hospital?
The new 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction is out and you can get the summary here.
Here’s what they say about initial reperfusion therapy:
Onset of Myocardial Infarction: Recommendations
Regional Systems of STEMI Care, Reperfusion Therapy, and Time-to-Treatment Goals Class I
1. All communities should create and maintain a regional system of STEMI care that includes assessment and continuous quality improvement of emergency medical services and hospital-based activities. Performance can be facilitated by participating in programs such as Mission: Lifeline and the Door-to-Balloon Alliance.(Level of Evidence: B)
2. Performance of a 12-lead electrocardiogram (ECG) by emergency medical services personnel at the site of first medical contact (FMC) is recommended in patients with symptoms consistent with STEMI.(Level of Evidence: B)
3. Reperfusion therapy should be administered to all eligible patients with STEMI with symptom onset within the prior 12 hours. (Level of Evidence: A)
4. Primary PCI is the recommended method of reper- fusion when it can be performed in a timely fashion by experienced operators. (Level of Evidence: A)
5. Emergency medical services transport directly to a PCI-capable hospital for primary PCI is the recommended triage strategy for patients with STEMI, with an ideal FMC-to-device time system goal of 90 minutes or less.(Level of Evidence: B)
6. Immediate transfer to a PCI-capable hospital for primary PCI is the recommended triage strategy for patients with STEMI who initially arrive at or are transported to a non–PCI-capable hospital, with an FMC-to-device time system goal of 120 minutes or less.(Level of Evidence: B)
7. In the absence of contraindications, fibrinolytic therapy should be administered to patients with STEMI at non–PCI-capable hospitals when the anticipated FMC-to-device time at a PCI-capable hospital exceeds 120 minutes because of unavoidable delays.(Level of Evidence: B)
8. When fibrinolytic therapy is indicated or chosen as the primary reperfusion strategy, it should be administered within 30 minutes of hospital arrival.(Level of Evidence: B) Class IIa
1. Reperfusion therapy is reasonable for patients with STEMI and symptom onset within the prior 12 to 24 hours who have clinical and/or ECG evidence of ongoing ischemia. Primary PCI is the preferred strategy in this population. (Level of Evidence: B)
2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction: Executive Summary: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2012 Dec 17. [Epub ahead of print]
Two popular pelvic compression devices are the SAM Pelvic Sling II and the T-POD®.
In a direct comparison 50 health care volunteers secured both devices correctly 100% of the time.
The SAM Pelvic Sling II was quicker to apply, but participants preferred the T-POD®.
The authors conclude that very little separates the devices. Pelvic circumferential compression devices (PCCDs): a best evidence equipment review Eur J Trauma Emerg Surg (2012) 38:439–442
[EXPAND Click for abstract]
Purpose Traumatic disruption of the pelvis can lead to significant morbidity and mortality. ATLS® guidance advocates temporary stabilisation or ‘closure’ of the disrupted pelvis with a compression device or sheet. We undertook a best evidence equipment review to assess the ease and efficacy of the application of two leading commercially available devices, the T-POD® and the SAM Pelvic Sling™ II.
Methods Fifty health care professionals and medical students participated in pelvic circumferential compression device (PCCD) education and assessment. Participants received a 10-min lecture on the epidemiology and aetiology of pelvic fractures and the principles of circumferential compression, followed by a practical demonstration. Three volunteers acted as trauma victims. Assessment included the time taken to secure the devices and whether this was achieved correctly. All participants completed a post-assessment survey.
Results Both devices were applied correctly 100% of the time. The average time taken to secure the SAM Pelvic Sling™ II was 18 s and for the T-POD®, it was 31 s (p ≤ 0.0001). Forty-four participants (88%) agreed or strongly agreed that the SAM Pelvic Sling™ II was easy to use compared to 84% (n = 42) for the T-POD®. Thirty-nine participants (78%) reported that they preferred and, given the choice in the future, would select the T-POD® over the SAM Pelvic Sling™ II (n = 11, 22%).
Conclusions The results of this study indicate that both PCCDs are easy and acceptable to use and, once learned, can be applied easily and rapidly. Participants applied both devices correctly 100% of the time, with successful application taking, on average, less than 60 s.
High intensity focused ultrasound (HIFU) was hailed as the ‘surgery of the future’ a few years ago(1). As it’s now the future, where is it?
HIFU uses ultrasound to increase the heat within tissues at a specific area, causing local necrosis and cautery without injuring surrounding tissues. It is used to treat some cancers, but has shown promise in haemorrhage control. In animal studies it reduced or stopped bleeding in liver(2), spleen(3), and vascular injuries(4).
It has been proposed to offer a promising method for hemorrhage control in both civilivan and miltary trauma(5). Automated systems have been developed and tested that identify bleeding using Doppler ultrasound techniques that then allow targeting of the HIFU beam to the bleeding tissue(6). The United States Army has identified the need for a such systems and has designed a remotely operated robotic haemostatic system to save lives of soldiers. This was presented in 2006(7).
I would love to know where we are with this technology, and why nothing seems to have appeared about it in the literature for the last few years. If you have any information, please fill us in via the comments box.
1. High intensity focused ultrasound: surgery of the future? Br J Radiol. 2003 Sep;76(909):590-9 Full text
2. Liver hemostasis using high-intensity focused ultrasound Ultrasound Med Biol. 1997;23(9):1413-20
3. Control of splenic bleeding by using high intensity ultrasound J Trauma. 1999 Sep;47(3):521-5
4. Hemostasis of punctured blood vessels using high-intensity focused ultrasound Ultrasound Med Biol. 1998 Jul;24(6):903-10
5. Hemorrhage control using high intensity focused ultrasound Int J Hyperthermia. 2007 Mar;23(2):203-11
6. Focused ultrasound: concept for automated transcutaneous control of hemorrhage in austere settings. Aviat Space Environ Med. 2009 Apr;80(4):391-4
7. Remotely Operated Robotic High Intensity Focused Ultrasound (HIFU) Manipulator System for Critical Systems for Trauma and Transport (CSTAT) Presented at the IEEE Ultrasonics Symposium, October 3-6, 2006, Vancouver, Canada – Full Text Here
