Marek Dabrowski

A comparison of McGrath MAC® and standard direct laryngoscopy in simulated immobilized cervical spine pediatric intubation: a manikin study

AbstractEmergency airway management in children is generally considered to be challenging, and endotracheal intubation requires a high level of personal skills and experience. Immobilization of the cervical spine is indicated in all patients with the risk of any cervical spine injury but significantly aggravates endotracheal intubation. The best airway device in this setting has not been established yet, although the use of videolaryngoscopes is generally promising. Seventy-five moderately experienced paramedics of the Emergency Medical Service of Poland performed endotracheal intubations in a pediatric manikin in three airway scenarios: (A) normal airway, (B) manual in-line cervical immobilization, and (C) cervical immobilization using a Patriot cervical extrication collar and using two airway techniques: (1) McGrath videolaryngoscope and (2) Macintosh blade in a randomized sequence. First-attempt intubation success rate, time to intubation, glottis visualization, and subjective ease of intubation were investigated in this study. Intubation of difficult airways, including manual in-line and cervical collar immobilization, using the McGrath was significantly faster, with a higher first-attempt intubation success rate, better glottic visualization, and ease of intubation, compared to Macintosh-guided intubation. In the normal airway, both airway techniques performed equal. Conclusion: Our manikin study indicates that the McGrath may be a reasonable first intubation technique option for endotracheal intubation in difficult pediatric emergencies. Further clinical studies are therefore indicated.What is known: • Airway management in pediatrics is challenging and requires a high level of skills and experience. Cervical immobilization is indicated in all patients with any risk of cervical spine injury, but it significantly aggravates endotracheal intubation in these patients. Videolaryngoscopes have been reported to ease intubation and provide better airway visualization in the regular clinical setting.What is new: • The McGrath is an easy-to-use and clinically often used videolaryngoscope, but it has never been investigated in pediatrics with an immobilized cervical spine. In the normal airway, the McGrath provided better airway visualization compared to Macintosh laryngoscopy. However, better visualization did not lead to decreased time to intubation and a higher success rate of the first intubation attempt. In difficult airways, the McGrath provided better airway visualization and this led to faster intubation, a higher first-attempt intubation success rate, and better ease of intubation compared to Macintosh-guided intubation.

High-fidelity simulation — the first DCD-ECMO procedure in Poland

Mateusz Puslecki, Marcin Ligowski, Marek Dabrowski, Maciej Sip, Sebastian Stefaniak, Tomasz Klosiewicz, Lukasz Gasiorowski, Marek Karczewski, Tomasz Malkiewicz, Malgorzata Ladzinska, Marcin Zielinski, Aleksander Pawlak, Agata Dabrowska, Piotr Ziemak, Bartlomiej Perek, Marcin Misterski, Slawomir Katarzynski, Piotr Buczkowski, Wojciech Telec, Ilona Kiel-Puslecka, Michal Kiel, Michael Czekajlo, Marek Jemielity Poznan University of Medical Sciences, Department of Cardiac Surgery and Transplantology, Clinical Hospital SKPP, Poznan, Poland Poznan University of Medical Sciences, Department of Rescue and Disaster Medicine, Poznan, Poland Polish Society of Medical Simulation, Poland Poznan University of Medical Sciences, Center for Medical Simulation, Poznan, Poland Poznan University of Medical Sciences, Department of Intensive Care and Pain Treatment, Poznan, Poland Poznan University of Medical Sciences, Department of Transplantology, General, Vascular and Plastic Surgery, Poznan, Poland Poznan University of Medical Sciences, Department of Anesthesiology and Intensive Care, Clinical Hospital H. Święcickiego, Poznan, Poland Voivodeship Emergency Medical Services, Poznan, Poland Poznan University of Medical Sciences, Department of Palliative Medicine, Poznan, Poland ZF RTW, Częstochowa, Poland Hunter Holmes McGuire VA Medical Center, Department of Surgery, Richmond, United States of America Lublin Medical University, Lublin, Poland

ETView® video-tube versus Intubrite® laryngoscope for endotracheal intubation during cardiopulmonary resuscitation: Preliminary data ☆

Sir, Securing the airway is one of the basic procedures performed in patients in cardiac arrest. European Resuscitation Council Guidelines strongly suggests minimizing interruptions in chest compressions [1,2]. The effectiveness of direct laryngoscopy performed by the Emergency Medical Service staff assessed in many studies is insufficient [3]. Therefore, it may be helpful to use alternative methods of intubation, including the ETView VivaSight SL (ETView; ETView Ltd., Misgav, Israel), which is a endotracheal tube with integrated camera [4,5] supgraglottic airway devices [2,6,7], or different videolaryngoscopes [3,8]. The aim of this studywas to evaluate the effectiveness of the first attempt of endotracheal intubation and the time to perform the procedure during the simulated adult CPR. The study involved 35 novice physicians with no previous experience in videolaryngoscopy. All participants declared their ability to perform endotracheal intubation using a Macintosh laryngoscope. Before the study, all the participants took part in a 10-min demonstration. During the study we used the ETView VivaSight SL and Intubrite (Intubrite Llc, Vista, CA, USA) videolaryngoscope. In both cases, we used the endotracheal tube size 7.0 ID with the previously

ET-View compared to direct laryngoscopy in patients with immobilized cervical spine by unexperienced physicians: A randomized crossover manikin trial

BACKGROUND Immobilization of the cervical spine is indicated in all patients with the potential risk of any cervical spine injury. Airway management in these patients is challenging and direct laryngoscopy is the standard of care. Videolaryngoscopes like the ET-View were introduced into clinical practice to provide better airway visualization and ease intubation. The ET-View is essentially a conventional endotracheal tube, but is equipped with a miniature camera on the tip. The ET-View has not been investigated in patients with immobilized cervical spine so far. The aim was to evaluate the performance of the VivaSight SL compared with Macintosh when performed in patients with immobilized cervical spine by unexperienced physicians. METHODS This was prospective, randomized, cross-over manikin trial. 50 novice physicians were randomly assigned to intubate a manikin in three airway scenarios including a normal airway and two cervical immobilization techniques. Overall and first intubation attempt success rate, time to intubation, dental compression and airway visualization according to the Cormack&Lehane graduation were assessed. RESULTS All physicians were able to intubate the manikin in all scenarios using the ETView, whereas direct laryngoscopy failed in 16 % with immobilized cervical spine using the patriot cervical extraction collar. First intubation attempt success rate was higher and airway visualization was better in all three scenarios using the ET-View compared to direct laryngoscopy. CONCLUSION The ET-View offered much better 62 airway visualization and provided higher overall and first intubation attempt success rates. Therefore, the ET-View is a valuable alternative in patients with difficult intubation due to immobilized cervical spine. Further clinical trials are indicated to confirm these findings. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT02733536.

Post-traumatic acute thoracic aortic injury (TAI)—a single center experience

Background We assess the effectiveness and our experience in emergency thoracic endovascular aortic repair (TEVAR) in patients with post-traumatic acute thoracic aortic injury (TAI) and associated multiorgan trauma. TAI is a life-threatening condition. It usually results from a sudden deceleration caused by vehicle accident, a fall or some other misfortune. Techniques of endovascular aortic repair have become promising methods to treat emergent TAI. Methods Since 2007, 114 patients with thoracic aorta pathologies have been treated by TEVAR. Our study involved 15 (incl. 14 men) of them (13%) who underwent stent graft implantation for post-traumatic either aortic rupture or pseudoaneurysm. The procedural access was limited to small skin incision in one groin and percutaneous puncture of the contralateral femoral artery. We evaluated technical success, early and long-term mortality, complication rate of procedure and throughout clinical and instrumental follow-up. Results Technical success rate was 100%. All patients survived the endovascular interventions. No additional procedures or conversions to open surgery were necessary. After the operation, none of the patients had symptoms of stroke or spinal cord ischemia (SCI). No serious stent-graft-related adverse events such as endoleak, infection or migration were noted during follow-up period that ranged from 6 to 108 months. Conclusions In our department, techniques of TEVAR with stentgraft implantation have become methods of choice in treatment of traumatic TAIs since they have enabled to minimize operational risk, particularly in unstable multitrauma patients in severe clinical status. TEVAR for TAI performed in emergency settings provide favorable long-term results.

Intraosseous access — future, present and everyday life

Today, intraosseous access (IO) is not only an alternative method of administration of pharmacotherapy or fluids; it is often used in life-threatening conditions. Although previously, it was a method commonly used in paediatrics or in the military, for several years it has been advocated as the primary access point for patients in a critical condition. While this applies mainly to children, it may also include adults in a hospital setting, as well as in the emergency department. Oftentimes it is used when intravenous access is difficult or the patient is seriously ill. Many scientific circles at the American Heart Association (AHA) and European Resuscitation Council (ERC) approve this method.

Active shooters — how close are they?

Recent terrorist attacks in the United States, Canada and Western Europe have shown an increase in the incidence of “Active Shooters” [1]. These ruthless and desperate assassins usually attack urban and poorly protected areas (lack of armed protection) that are densely populated [2]. Utilizing their strength, they realize that their plan is to maximize the number of casualties, without counting on the consequences of their actions. The basis of their action may be based on extremely radical views. Frequent outcomes for active shooters include suicide during an attack (90%) or the resolution of the threat by the authorities [3]. In response to the ever-increasing number of assassinations and the risk of such incidents in one’s immediate surroundings, comprehensive education should be widely spread. Thus, it is important to promote appropriate behaviour, rules of reaction during an attack by an armed assailant, as well as cooperation with incoming service personnel. Such actions will not only help one prevent, but also allow one to prepare for such incidences.

Comparison of four laryngoscopes in cervical immobilization scenario. Pilot data

Emergency management in patients with airway obstruction includes clearing and securing the airway most often with the use of the endotracheal intubation [1,2]. However, in pre-hospital settings, endotracheal intubation is associated with the pressure of time and the need to protect the airway in adverse conditions, including those resulting from the inability to use “the sniffing position” in patients with suspected cervical spine injury [3,4]. Trauma life support guidelines recommend that the cervical spine be immobilized in any patient with suspected injury. The most commonly used method for stabilizing the cervical spine is the orthopedic collar and the orthopedic board, however, if this method is unavailable or in a large number of victims, the Kendrick Extrication Device (KED) may also be helpful. Correctly set up device together with the orthopedic collar fully stabilizes the cervical spine in all planes. In such a protected patient, there is a difficulty in opening the mouth and thus the effectiveness of direct intubation using standardMiller orMacintosh laryngoscopesmay be impeded [3,5]. The aim of this studywas to compare the efficacy of endotracheal intubation with the use of four different laryngoscopes in case of cervical immobilization using orthopedic collar and KED. The study was designed as a randomized, cross-sectional and was performed in medical simulation conditions. The study protocol was approved by the Institutional Review Board of the Polish Society of Disaster Medicine (Approval no. 15.05.2017.IRB). The study involved sixty-three paramedics who performed the endotracheal intubation in a randomized sequence using four laryngoscopes: Miller laryngoscope with 2 blade (Mercury Medical, Clearwater, FL, USA), McGrath MAC EMS® with blade size 2 (Aircraft Medical Ltd., UK), Intubrite® videolaryngoscope, with a Macintosh blade size 2 (Intubrite Lic, Vista, CA, USA), and C-MAC with Macintosh blade size 2 (Karl Storz, Tuttlingen, Germany). A standard, lubricated 5.0 ID endotracheal tube (Covidien, Mansfield, MA), equipped with a hockey-stick shaped stylet was used in all intubation attempts. To simulate the scenario of a patient with external Advanced Skill Trainer manikin, with a regular airway (Laerdal, Stavenger, Norway) was placed on a floor level in neutral position, and the neck immobilization was performed (Fig. 1). The primary endpoint was time to intubation, defined as the time of picking up the airway device and ending with the first effective manual ventilation of the manikins lungs, identified by the participant as

AED use in public places: a study of acquisition time

BACKGROUND Sudden cardiac arrest (SCA) is a frequent cause of death in the developed world. Early defibrillation, preferably within the first minutes of the incident, significantly increases survival rates. Accessible automated external defibrillators (AED) in public areas have been promoted for many years, and several locations are equipped with these devices. AIM The aim of the study was to assess the real-life availability of AEDs and assess possible sources of delay. METHODS The study took place in the academic towns of Poznan, Lodz, and Warsaw, Poland. The researchers who were not aware of the exact location of the AED in the selected public locations had to deliver AED therapy in simulated SCA scenarios. For the purpose of the trial, we assumed that the SCA takes place at the main entrance to the public areas equipped with an AED. RESULTS From approximately 200 locations that have AEDs, 78 sites were analysed. In most places, the AED was located on the ground floor and the median distance from the site of SCA to the nearest AED point was 15 m (interquartile range [IQR] 7-24; range: 2-163 m). The total time required to deliver the device was 96 s (IQR 52-144 s). The average time for discussion with the person responsible for the AED (security officer, staff, etc.) was 16 s (IQR 0-49). The AED was located in open access cabinets for unrestricted collection in 29 locations; in 10 cases an AED was delivered by the personnel, and in 29 cases AED utilisation required continuous personnel assistance. The mode of accessing the AED device was related to the longer discussion time (p < 0.001); however, this did not cause any significant delay in therapy (p = 0.132). The AED was clearly visible in 34 (43.6%) sites. The visibility of AED did not influence the total time of simulated AED implementation. CONCLUSIONS We conclude that the access to AED is relatively fast in public places. In the majority of assessed locations, it meets the recommended time to early defibrillation of under 3 min from the onset of the cardiac arrest; however, there are several causes for possible delays. The AED signs indicating the location of the device should be larger. AEDs should also be displayed in unrestricted areas for easy access rather than being kept under staff care or in cabinets.

Zastosowanie AED w miejscach publicznych: badanie czasu użycia

BACKGROUND Sudden cardiac arrest (SCA) is a frequent cause of death in the developed world. Early defibrillation, preferably within the first minutes of the incident, significantly increases survival rates. Accessible automated external defibrillators (AED) in public areas have been promoted for many years, and several locations are equipped with these devices. AIM The aim of the study was to assess the real-life availability of AEDs and assess possible sources of delay. METHODS The study took place in the academic towns of Poznan, Lodz, and Warsaw, Poland. The researchers who were not aware of the exact location of the AED in the selected public locations had to deliver AED therapy in simulated SCA scenarios. For the purpose of the trial, we assumed that the SCA takes place at the main entrance to the public areas equipped with an AED. RESULTS From approximately 200 locations that have AEDs, 78 sites were analysed. In most places, the AED was located on the ground floor and the median distance from the site of SCA to the nearest AED point was 15 m (interquartile range [IQR] 7-24; range: 2-163 m). The total time required to deliver the device was 96 s (IQR 52-144 s). The average time for discussion with the person responsible for the AED (security officer, staff, etc.) was 16 s (IQR 0-49). The AED was located in open access cabinets for unrestricted collection in 29 locations; in 10 cases an AED was delivered by the personnel, and in 29 cases AED utilisation required continuous personnel assistance. The mode of accessing the AED device was related to the longer discussion time (p < 0.001); however, this did not cause any significant delay in therapy (p = 0.132). The AED was clearly visible in 34 (43.6%) sites. The visibility of AED did not influence the total time of simulated AED implementation. CONCLUSIONS We conclude that the access to AED is relatively fast in public places. In the majority of assessed locations, it meets the recommended time to early defibrillation of under 3 min from the onset of the cardiac arrest; however, there are several causes for possible delays. The AED signs indicating the location of the device should be larger. AEDs should also be displayed in unrestricted areas for easy access rather than being kept under staff care or in cabinets.