Raoul Breitkreutz

Focused echocardiographic evaluation in resuscitation management: concept of an advanced life support-conformed algorithm.

Emergency ultrasound is suggested to be an important tool in critical care medicine. Time-dependent scenarios occur during preresuscitation care, during cardiopulmonary resuscitation, and in postresuscitation care. Suspected myocardial insufficiency due to acute global, left, or right heart failure, pericardial tamponade, and hypovolemia should be identified. These diagnoses cannot be made with standard physical examination or the electrocardiogram. Furthermore, the differential diagnosis of pulseless electrical activity is best elucidated with echocardiography. Therefore, we developed an algorithm of focused echocardiographic evaluation in resuscitation management, a structured process of an advanced life support–conformed transthoracic echocardiography protocol to be applied to point-of-care diagnosis. The new 2005 American Heart Association/European Resuscitation Council/International Liaison Committee on Resuscitation guidelines recommended high-quality cardiopulmonary resuscitation with minimal interruptions to reduce the no-flow intervals. However, they also recommended identification and treatment of reversible causes or complicating factors. Therefore, clinicians must be trained to use echocardiography within the brief interruptions of advanced life support, taking into account practical and theoretical considerations. Focused echocardiographic evaluation in resuscitation management was evaluated by emergency physicians with respect to incorporation into the cardiopulmonary resuscitation process, performance, and physicians’ ability to recognize characteristic pathology. The aim of the focused echocardiographic evaluation in resuscitation management examination is to improve the outcomes of cardiopulmonary resuscitation.

Focused echocardiographic evaluation in life support and peri-resuscitation of emergency patients: A prospective trial ,

PURPOSE OF THE STUDY Focused ultrasound is increasingly used in the emergency setting, with an ALS-compliant focused echocardiography algorithm proposed as an adjunct in peri-resuscitation care (FEEL). The purpose of this study was to evaluate the feasibility of FEEL in pre-hospital resuscitation, the incidence of potentially treatable conditions detected, and the influence on patient management. PATIENTS, MATERIALS AND METHODS A prospective observational study in a pre-hospital emergency setting in patients actively undergoing cardio-pulmonary resuscitation or in a shock state. The FEEL protocol was applied by trained emergency doctors, following which a standardised report sheet was completed, including echo findings and any echo-directed change in management. These reports were then analysed independently. RESULTS A total of 230 patients were included, with 204 undergoing a FEEL examination during ongoing cardiac arrest (100) and in a shock state (104). Images of diagnostic quality were obtained in 96%. In 35% of those with an ECG diagnosis of asystole, and 58% of those with PEA, coordinated cardiac motion was detected, and associated with increased survival. Echocardiographic findings altered management in 78% of cases. CONCLUSIONS Application of ALS-compliant echocardiography in pre-hospital care is feasible, and alters diagnosis and management in a significant number of patients. Further research into its effect on patient outcomes is warranted.

International Evidence-Based Recommendations for Focused Cardiac Ultrasound

BACKGROUND Focused cardiac ultrasound (FoCUS) is a simplified, clinician-performed application of echocardiography that is rapidly expanding in use, especially in emergency and critical care medicine. Performed by appropriately trained clinicians, typically not cardiologists, FoCUS ascertains the essential information needed in critical scenarios for time-sensitive clinical decision making. A need exists for quality evidence-based review and clinical recommendations on its use. METHODS The World Interactive Network Focused on Critical UltraSound conducted an international, multispecialty, evidence-based, methodologically rigorous consensus process on FoCUS. Thirty-three experts from 16 countries were involved. A systematic multiple-database, double-track literature search (January 1980 to September 2013) was performed. The Grading of Recommendation, Assessment, Development and Evaluation method was used to determine the quality of available evidence and subsequent development of the recommendations. Evidence-based panel judgment and consensus was collected and analyzed by means of the RAND appropriateness method. RESULTS During four conferences (in New Delhi, Milan, Boston, and Barcelona), 108 statements were elaborated and discussed. Face-to-face debates were held in two rounds using the modified Delphi technique. Disagreement occurred for 10 statements. Weak or conditional recommendations were made for two statements and strong or very strong recommendations for 96. These recommendations delineate the nature, applications, technique, potential benefits, clinical integration, education, and certification principles for FoCUS, both for adults and pediatric patients. CONCLUSIONS This document presents the results of the first International Conference on FoCUS. For the first time, evidence-based clinical recommendations comprehensively address this branch of point-of-care ultrasound, providing a framework for FoCUS to standardize its application in different clinical settings around the world.

Prehospital ultrasound imaging improves management of abdominal trauma

Blunt abdominal trauma with intra‐abdominal bleeding is often underdiagnosed or even overlooked at trauma scenes. The purpose of this prospective, multicentre study was to compare the accuracy of physical examination and prehospital focused abdominal sonography for trauma (PFAST) to detect abdominal bleeding.

Echocardiography practice, training and accreditation in the intensive care: document for the World Interactive Network Focused on Critical Ultrasound (WINFOCUS).

Echocardiography is increasingly used in the management of the critically ill patient as a non-invasive diagnostic and monitoring tool. Whilst in few countries specialized national training schemes for intensive care unit (ICU) echocardiography have been developed, specific guidelines for ICU physicians wishing to incorporate echocardiography into their clinical practice are lacking. Further, existing echocardiography accreditation does not reflect the requirements of the ICU practitioner. The WINFOCUS (World Interactive Network Focused On Critical UltraSound) ECHO-ICU Group drew up a document aimed at providing guidance to individual physicians, trainers and the relevant societies of the requirements for the development of skills in echocardiography in the ICU setting. The document is based on recommendations published by the Royal College of Radiologists, British Society of Echocardiography, European Association of Echocardiography and American Society of Echocardiography, together with international input from established practitioners of ICU echocardiography. The recommendations contained in this document are concerned with theoretical basis of ultrasonography, the practical aspects of building an ICU-based echocardiography service as well as the key components of standard adult TTE and TEE studies to be performed on the ICU. Specific issues regarding echocardiography in different ICU clinical scenarios are then described.Obtaining competence in ICU echocardiography may be achieved in different ways – either through completion of an appropriate fellowship/training scheme, or, where not available, via a staged approach designed to train the practitioner to a level at which they can achieve accreditation. Here, peri-resuscitation focused echocardiography represents the entry level – obtainable through established courses followed by mentored practice. Next, a competence-based modular training programme is proposed: theoretical elements delivered through blended-learning and practical elements acquired in parallel through proctored practice. These all linked with existing national/international echocardiography courses. When completed, it is anticipated that the practitioner will have performed the prerequisite number of studies, and achieved the competency to undertake accreditation (leading to Level 2 competence) via a recognized National or European examination and provide the appropriate required evidence of competency (logbook). Thus, even where appropriate fellowships are not available, with support from the relevant echocardiography bodies, training and subsequently accreditation in ICU echocardiography becomes achievable within the existing framework of current critical care and cardiological practice, and is adaptable to each countries needs.

Guidelines for the Appropriate Use of Bedside General and Cardiac Ultrasonography in the Evaluation of Critically Ill Patients-Part I: General Ultrasonography.

Objective: To establish evidence-based guidelines for the use of bedside ultrasound by intensivists and specialists in the ICU and equivalent care sites for diagnostic and therapeutic purposes for organs of the chest, abdomen, pelvis, neck, and extremities. Methods: The Grading of Recommendations, Assessment, Development and Evaluation system was used to determine the strength of recommendations as either strong or conditional/weak and to rank the “levels” of quality of evidence into high (A), moderate (B), or low (C) and thus generating six “grades” of recommendation (1A-1B-1C-2A-2B-2C). Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used for all questions with clinically relevant outcomes. RAND appropriateness method, incorporating modified Delphi technique, was used in steps of GRADE that required panel judgment and for those based purely on expert consensus. The process was conducted by teleconference and electronic-based discussion, following clear rules for establishing consensus and agreement/disagreement. Individual panel members provided full disclosure and were judged to be free of any commercial bias. The process was conducted independent of industry funding. Results: Twenty-four statements regarding the use of ultrasound were considered—three did not achieve agreement and nine were approved as conditional recommendations (strength class 2). The remaining 12 statements were approved as strong recommendations (strength class 1). Each recommendation was also linked to its level of quality of evidence. Key strong recommendations included the use of ultrasonography for ruling-in pleural effusion and assisting its drainage, ascites drainage, ruling-in pneumothorax, central venous cannulation, particularly for internal jugular and femoral sites, and for diagnosis of deep venous thrombosis. Conditional recommendations were given to the use of ultrasound by the intensivist for diagnosis of acalculous cholecystitis, renal failure, and interstitial and parenchymal lung diseases. No recommendations were made regarding static (vs dynamic) ultrasound guidance of vascular access or the use of needle guide devices. Conclusions: There was strong agreement among a large cohort of international experts regarding several recommendations for the use of ultrasound in the ICU. Evidence-based recommendations regarding the appropriate use of this technology are a step toward improving patient outcomes in relevant patients.

Brief report: Tracheal intubation using the Bonfils intubation fibrescope or direct laryngoscopy for patients with a simulated difficult airway

Background: The Bonfils intubation fibrescope (BIF), a rigid, straight and reusable fibreoptic device, is being used increasingly to facilitate endotracheal intubation after direct laryngoscopy has failed. We tested the hypothesis that, with the BIF compared to direct laryngoscopy, the rate of failed endotracheal intubation could be reduced in patients with a difficult airway, simulated by means of a rigid cervical immobilization collar.Methods: Seventy-six adults undergoing elective gynecological surgery under general anesthesia were randomly assigned to have endotracheal intubation, facilitated with either a standard size 3 Macintosh laryngoscope blade, or the BIF. A rigid cervical immobilization collar was used to simulate a difficult airway, by reducing mouth opening and limiting neck extension. If endotracheal intubation could not be achieved within two attempts, the cervical collar was removed, and direct laryngoscopy was performed thereafter, using a Macintosh blade in all subjects. The success rate of endotracheal tube placement was the primary outcome variable.Results: Patient characteristics were similar in the two groups. After neck immobilization, the inter-incisor distance was reduced to 2.6±0.7 cm (Macintosh) and 2.6±0.8 cm (BIF). Tube placement was successful in 15/38 (39.5%) patients with a Macintosh blade, and in 31/38 patients with the BIF (81.6%;P=0.0003). Time required for tube placement was 53±22 sec (Macintosh) and 64±24 sec (BIF;P=0.15). Conclusion: The Bonfils intubation fibrescope is a more effective intubating device for patients with immobilized cervical spine and significantly limited inter-incisor distance, when compared to direct laryngoscopy.RésuméContexte: Le fibroscope d’intubation Bonfils (BIF) est un appareil fibroscopique rigide, droit et réutilisable qui est de plus en plus utilisé pour faciliter l’intubation endotrachéale lors de l’échec d’une laryngoscopie directe. Nous avons testé l’hypothèse que lorsque le BIF est comparé à la laryngoscopie directe, le taux d’échec de l’intubation endotrachéale pouvait tre réduit chez des patients présentant des voies aériennes difficiles, lesquelles ont été simulées gr?ce à un collier d’immobilisation cervicale rigide.Méthode: Soixante-seize adultes devant subir une chirurgie gynécologique programmée sous anesthésie générale ont été randomisées à recevoir une intubation endotrachéale, facilitée soit par une lame de laryngoscope Macintosh de taille standard 3 ou par le BIF. Un collier d’immobilisation cervicale rigide a été placé pour simuler des voies aériennes difficiles en réduisant l’ouverture de la bouche et en limitant l’extension du cou. Si l’intubation trachéale ne réussissait pas après deux essais, le collier cervical était retiré et une laryngoscopie directe réalisée ensuite à l’aide d’une lame Macintosh chez toutes les patientes. Le critère d’efficacité principal était le taux de positionnement correct de la sonde endotrachéale.Résultats: Les caractéristiques des patientes étaient similaires dans les deux groupes. Après immobilisation du cou, l’espace entre les incisives a été réduit à 2,6±0,7 cm (Macintosh) et 2,6±0,8 cm (BIF). La sonde a été placée correctement chez 15/38 (39,5%) patientes avec une lame Macintosh et chez 31/38 patientes avec le BIF (81,6%; P=0,0003). Le temps requis pour le positionnement de la sonde était de 53±22 sec (Macintosh) et 64±24 sec (BIF; P=0,15).Conclusion: Comparé à la laryngoscopie directe, le fibroscope d’intubation Bonfils est un appareil d’intubation plus efficace pour les patients ayant la colonne cervicale immobilisée et un espace entre les incisives considérablement limité.

Low Intestinal Glutamine Level and Low Glutaminase Activity in Crohn’s Disease: A Rational for Glutamine Supplementation?

Intestinal glutamine utilization is integral to mucosal regeneration. We analyzed the systemic and intestinal glutamine status in Crohn’s disease (CD) and evaluated the therapeutic effect of glutamine supplementation in an animal model of ileitis. In CD, glutamine concentrations were decreased systemically and in noninflamed and inflamed ileal/colonic mucosa. Mucosal glutaminase activities were depressed in the ileum independent of inflammation but were not different from controls in the colon. In experimental ileitis, oral glutamine feeding prevented macroscopic inflammation, enhanced ileal and colonic glutaminase activities above controls, and normalized the intestinal glutathione redox status. However, glutamine supplementation enhanced myeloperoxidase activity along the gastrointestinal tract and potentiated lipid peroxidation in the colon. In conclusion, glutamine metabolism is impaired in CD. In experimental ileitis, glutamine supplementation prevents inflammatory tissue damage. In the colon, however, which does not use glutamine as its principal energy source, immune enhancement of inflammatory cells by glutamine increases oxidative tissue injury.

Peri-resuscitation echocardiography: Training the novice practitioner☆

AIMS Echocardiography performed in an ALS-compliant manner provides a tool whereby some of the potentially reversible causes of cardiac arrest can be diagnosed in real time by minimally trained practitioners. One of the major concerns this raises is how to deliver effective training to the required standard. The objective of this study was to determine the effectiveness of number of different educational methods used teach echocardiography to novices. This involved assessment of cognitive, psychomotor skills and affective aspects in five key areas. METHODS The study population was a convenience sample from participants attending standardised structured one-day training courses in peri-resuscitation echocardiography (n=204). Subjects were assessed for five learning outcomes including knowledge and image interpretation, practical performance of echocardiography including time taken to obtain a diagnostic view, integration into the ALS algorithm and overall compliance with established resuscitation guidelines. RESULTS There was a significant improvement in knowledge and interpretation of echocardiographic images before and after completion of the one-day course (pre 62%, post 78%, p<0.01). Skills acquisition resulted in 100% of participants being able to obtain a subcostal view of diagnostic quality by the end of the course, and 86% with a mean time to acquisition of <10s. On completion of the training programme, incorporation of echocardiography into current resuscitation practice did not compromise ALS-compliance. CONCLUSION Novice echocardiographers can obtain knowledge and skills relevant to ALS-compliant peri-resuscitation echocardiography using a range of educational techniques. In addition to the standard one-day training courses available, continued mentored practice and didactic adherence to ALS algorithms is required.

Initiation of risk management: Incidence of failures in simulated emergency medical service scenarios

AIM This study is a description of the rate of unsafe acts and communication events in simulations of Emergency Medical Service (EMS) mission-based scenarios as first response for risk management and patient safety. SUBJECTS AND METHODS The study involved video-based observation of German paramedic teams (n=40) during simulated EMS missions. Teams were randomised to four types of scenarios: advanced life support (ALS), bronchial asthma (BA), pulmonary embolism (PE) and multiple trauma (MT). All predefined events were analysed. RESULTS In a total of 40 scenarios, paramedics committed more than seven unsafe acts per scenario (7.4+/-3.8, mean+/-standard deviation, 95% confidence interval (CI): 6.6-8.3). In detail, there were unsafe acts for ALS (6.8+/-3.9, 95% CI: 5.2-8.5), in BA (8.1+/-3.9, 95% CI: 6.4-9.8), in PE (4.0+/-1.6, 95% CI: 3.0-5.0) and in MT (9.3+/-3.2, 95% CI: 7.8-10.7). Strategies of diagnosis and treatment were heterogeneous chronologically and methodically. Bad communication events were noted with a mean of 3.9+/-1.6 (95% CI: 3.1-4.6) within the scenarios. All the handovers (100%) between paramedics and emergency physician were incomplete, and 53.7+/-11.0% (95% CI: 48.5-58.8%) of information of realised actions and status of patient were missed in handover. CONCLUSION A subset of German paramedics caused many unsafe acts and dangerous communication in simulations that may affect real-life work. We suggest paramedics should take part in a need-based education programme and communication training.