Jouni Nurmi

Observations and warning signs prior to cardiac arrest. Should a medical emergency team intervene earlier

Background:  The Medical Emergency Team (MET) has evolved in some hospitals as a means of delivering effective treatment early enough to prevent cardiac arrests. Our aim was to analyze the effectiveness of observation practice to detect abnormalities in vital signs prior to cardiac arrest and to determine the need for a MET system in Finnish hospitals.

Early Increase in Blood Glucose in Patients Resuscitated From Out-of-Hospital Ventricular Fibrillation Predicts Poor Outcome

OBJECTIVE To describe the trend of blood glucose immediately after successful resuscitation from out-of-hospital ventricular fibrillation. RESEARCH DESIGN AND METHODS Data from cardiac arrest registry supplemented with blood glucose data were analyzed in this population-based observational study. Between 2005 and 2009, a total of 170 adult patients survived to hospital admission after resuscitation from bystander-witnessed cardiac arrest of cardiac origin and ventricular fibrillation as an initial rhythm. RESULTS Sufficient data for analysis were available in 134 (79%) patients, of whom 87 (65% [95% CI 57–73]) survived to hospital discharge in Cerebral Performance Category 1 or 2. Blood glucose did not change significantly between prehospital (10.5 ± 4.1 mmol/L) and admission (10.0 ± 3.7 mmol/L) in survivors (P = 0.3483), whereas in nonsurvivors, blood glucose increased from 11.8 ± 4.6 to 13.8 ± 3.3 mmol/L (P = 0.0025). CONCLUSIONS Patients who are resuscitated from out-of-hospital ventricular fibrillation, but whose outcome is unfavorable are characterized by significant increase of blood glucose in the ultraacute postresuscitation phase.

Teaching basic life support to nurses

Background and objective: Every member of healthcare personnel should be able to perform basic life support including defibrillation (CPR‐D). The biggest cost of implementation is training and these costs need to be reduced. The purpose of this randomized study was to evaluate the applicability of distance learning as a method to teach CPR‐D. Methods: Nurses (n = 56) working in a geriatric hospital were randomized into three groups. The first group was given the Internet‐based CPR‐D course and the second was given a traditional, small‐group CPR‐D course. A third group without specific training in CPR‐D served as a control group. An objective structured clinical examination (OSCE) was performed 2 weeks after the courses with a manikin patient having a cardiac arrest. Results: The median score of all participants was 31/49 (range 21–38). The reliability of the checklist was adequate (Cronbach alpha 0.77). Nurses receiving traditional CPR‐D performed better than those receiving the Internet‐based course (median score 34 vs. 28, P < 0.05) and the control group (median score 34 vs. 26, P < 0.0001). Nurses receiving Internet‐based course performed similarly as the control group (median score 28 vs. 26, ns). Conclusions: Distance learning cannot substitute for traditional small‐group learning.

Implementing RFID technology in a novel triage system during a simulated mass casualty situation

The purpose of this study is to determine the applicability of Radio Frequency Identification (RFID) technology and commercial cellular networks to provide an online triage system for handling mass casualty situations. This was tested by a using a pilot system for a simulated mass casualty situation during a military field exercise. The system proved to be usable. Compared to the currently used system, it also dramatically improves the general view of mass casualty situations and enhances medical emergency readiness in a military medical setting. The system can also be adapted without any difficulties by the civilian sector for the management of mass casualty disasters.

Assessment of CPR-D skills of nursing students in two institutions: reality versus recommendations in the guidelines

Significant differences in basic life support skills including cardiopulmonary resuscitation and defibrillation (CPR-D) were detected when nurses working in one Finnish and one Swedish hospital were tested using an Objective Structured Clinical Examination (OSCE). The purpose of this study was to use OSCE test in assessing guideline based CPR-D skills of newly qualified nurses. The CPR-D skills of newly qualified registered nurses studying in Halmstad University (n = 30), Sweden, Helsinki Metropolia University of Applied Sciences (n = 30), and Finland were assessed using an OSCE which was built up with a case of cardiac arrest with ventricular fibrillation as the initial rhythm. The Angoff average, 32.47, was calculated as cutoff point to pass the test. Forty-seven percent of the students in the Swedish group (mean score 32.47/49, range 26–39, SD 3.76) and 13% of the students in the Finnish group (mean score 23.80/49, range 13–35, SD 4.32) passed the OSCE (P<0.0001), the cutoff point being 32.47. Performance grade for the Swedish group was 2.9/5.0 and for the Finnish group 2.1/5.0 (P<0.0001). Good nontechnical skills correlated with high grading of the clinical skills. In conclusion, CPR-D skills of the newly qualified nurses in both the institutes were clearly under par and were not adequate according to the resuscitation guidelines. Current style of teaching is unlikely to result in students being able to perform adequate CPR-D. Standardized testing would help in controlling the quality of learning.

Strict Glucose Control After Acute Stroke Can Be Provided in the Prehospital Setting

OBJECTIVES The objective was to assess the feasibility of insulin infusion and subcutaneous insulin administered in the prehospital setting and their relative effect on hyperglycemia, a predictor of unfavorable outcome, in acute stroke patients. METHODS Hyperglycemic patients (plasma glucose >6.0 mmol/L) with stroke symptoms were randomized prior to or during transport to the hospital to receive either 1) a single subcutaneous dose of short-acting insulin (n = 11) or 2) a continuous intravenous (IV) insulin infusion (n = 12) at a rate adjusted by glucose levels measured every 10 minutes and targeted to plasma glucose 4.5-6.0 mmol/L. The changes in plasma glucose concentration were compared with a nonrandomized control group (n = 38) receiving standard care. RESULTS The baseline characteristics did not differ between the study groups. Plasma glucose concentration was significantly decreased during the prehospital phase in the IV-treated group in comparison to the control group (difference between groups -1.9 mmol/L, 95% confidence interval [CI] = -3.5 to -0.27) with no serious adverse events. In contrast, subcutaneous insulin did not achieve significant lowering of plasma glucose (-0.9 mmol/L, 95% CI = -2.4 to 0.6). CONCLUSIONS This small sample suggests that adjusted insulin infusion efficiently lowers blood glucose in the ultra-acute phase of stroke and is feasible in the prehospital setting.

Cardiac arrest teams and medical emergency teams in Finland: a nationwide cross-sectional postal survey

The implementation, characteristics and utilisation of cardiac arrest teams (CATs) and medical emergency teams (METs) in Finland are unknown. We aimed to evaluate how guidelines on advanced in‐hospital resuscitation have been translated to practice.

Preparedness for cardiopulmonary resuscitation in primary care.

Objective – To evaluate preparedness for resuscitation of patients in cardiac arrest in primary care. Design – Questionnaire study sent to every health centre in Finland (n=277). Setting – Primary care. Main outcome measures – Resuscitation training frequency and prevalence of automated external defibrillators and nurse-performed early defibrillation. Results – One-hundred-and-forty-one health centres (51%) responded to the survey. Fifty-nine percent had appointed one person to be in charge of resuscitation training. The nurses in these health centres were trained to defibrillate (p<0.001), physicians had advanced life support training (p<0.001) and the first defibrillation was likely to be performed by a nurse on the ward (p<0.01) of often. In 87% of health centres, it was not customary to defibrillate before the physician arrived beside the patient. Forty-four percent of the health centres used only manual defibrillators, 26% used automated external defibrillators and 30% used both. Only 18% of respondents considered resuscitation training in their health centre to be sufficient and systematic. Conclusion – Resuscitation training appears insufficient and non-systematic in most health centres in Finland. Automated external defibrillators are not in common use. In health centres with an appointed person in charge of resuscitation training, the training is more often regular.

A before-and-after observational study of a protocol for use of the C-MAC videolaryngoscope with a Frova introducer in pre-hospital rapid sequence intubation

Results using videolaryngoscopy in pre‐hospital rapid sequence intubation are mixed. A bougie is not commonly used with videolaryngoscopy. We hypothesised that using videolaryngoscopy and a bougie as core elements of a standardised protocol that includes a drugs and a laryngoscopy algorithm would result in a high first‐pass tracheal intubation success rate. We employed videolaryngoscopy (C‐MAC) combined with a bougie (Frova intubating introducer) in an anaesthetist‐staffed helicopter emergency medical service. Data for adult tracheal intubation were collected prospectively as part of the airway registry of our unit for 22 months after implementation of the protocol (n = 543) and compared with controls (n = 238) treated in the previous year before the implementation. The mean first‐pass success rate (95%CI) was 98.2% (96.6–99.0%) in the study group and 85.7% (80.7–89.6%) in the control group, p < 0.0001. Combining C‐MAC videolaryngoscopy and bougie with a standardised rapid sequence induction protocol leads to a high first attempt intubation success rate when performed by an anaesthetist‐led helicopter emergency medical service team.

EFFECT OF PERITONEAL DIALYSIS ON ABDOMINAL CIRCUMFERENCE

♦ Background: Peritoneal dialysis (PD) is probably underused because of fears concerning the body image of patients. For the purposes of providing exact information for patients when choosing between PD and hemodialysis, we studied the extent of increase in waist circumference by infusing dialysate. ♦ Methods: The abdominal circumference of 44 PD patients was measured before and after infusion of dialysate. The change in circumference was compared to body mass index (BMI) and length of the abdominal cavity, defined by the distance between the processus xiphoideus and the os pubis. ♦ Results: Mean abdominal circumferences at the umbilicus and the iliac crest increased from 92.6 ± 10.1 to 95.5 ± 10.0 cm and from 95.2 ± 8.5 to 96.2 ± 6.3 cm, respectively, when dialysate was infused (p value for both < 0.01). A dialysate volume of 2000 mL increased the circumference only slightly more than the increase seen with 1500 mL. The change in circumference was not correlated with the circumference before the infusion, BMI, height of the patient, or length of the abdominal cavity. ♦ Conclusions: This study shows that normal PD fill volumes increase the waist circumference only a little. This finding should ease the patients presumption of PD changing the body image.