Roman Fleischhackl

Prehospital Analgesia with Acupressure in Victims of Minor Trauma: A Prospective, Randomized, Double-blinded Trial

Untreated pain during the transportation of patients after minor trauma is a common problem in emergency medicine. Because paramedics usually are not allowed to perform invasive procedures or to give drugs for pain treatment, a noninvasive, nondrug-based method would be helpful. Acupressure is a traditional Chinese treatment for pain that is based on pain relief followed by a short mechanical stimulation of specific points. Consequently, we tested the hypothesis that effective pain therapy is possible by paramedics who are trained in acupressure. In a double-blinded trial we included 60 trauma patients. We randomly assigned them into three groups (“true points,” “sham-points,” and “no acupressure”). An independent observer, blinded to the treatment assignment, recorded vital variables and visual analog scales for pain and anxiety before and after treatment. At the end of transport, we asked for ratings of overall satisfaction. For statistical evaluation, one-way analysis of variance and the Scheffé F test were used. P < 0.05 was considered statistically significant. Morphometric and demographic data and potential confounding factors such as age, sex, pain, anxiety, blood pressure, and heart rate before treatment did not differ among the groups. At the end of transport we found significantly less pain, anxiety, and heart rate and a greater satisfaction in the “true points” groups (P < 0.01). Our results show that acupressure is an effective and simple-to-learn treatment of pain in emergency trauma care and leads to an improvement of the quality of care in emergency transport. We suggest that this technique is easy to learn and risk free and may improve paramedic-based rescue systems.

School children sufficiently apply life supporting first aid: a prospective investigation

IntroductionThe usefulness of CPR training in schools has been questioned because young students may not have the physical and cognitive skills needed to correctly perform such complex tasks correctly.MethodsIn pupils, who received six hours of CPR training from their teachers during a standard school semester at four months post training the following outcome parameters were assessed: CPR effectiveness, AED deployment, accuracy in checking vital signs, correctness of recovery position, and whether the ambulance service was effectively notified. Possible correlations of age, gender, body mass index (BMI), and outcome parameters were calculated.ResultsOf 147 students (mean age 13 ± 2 years), 86% performed CPR correctly. Median depth of chest compressions was 35 mm (inter quartile range (IQR) 31 to 41), and the median number of compressions per minute was 129 bpm (IQR 108 to 143). Sixty nine percent of the students tilted the mannequin head sufficiently for mouth to mouth resuscitation, and the median air volume delivered was 540 ml (IQR 0 to 750). Scores on other life supporting techniques were at least 80% or higher. Depth of chest compressions showed a correlation with BMI (r = 0.35; P < 0.0001), body weight (r = 0.38; P < 0.0001), and body height (r = 0.31; P = 0.0002) but not with age. All other outcomes were found to be unrelated to gender, age, or BMI.ConclusionsStudents as young as 9 years are able to successfully and effectively learn basic life support skills including AED deployment, correct recovery position and emergency calling. As in adults, physical strength may limit depth of chest compressions and ventilation volumes but skill retention is good.

Gender modifies the influence of age on outcome after successfully resuscitated cardiac arrest: a retrospective cohort study.

Abstract: Age is an important risk factor for mortality and unfavorable outcome after successfully resuscitated cardiac arrest. Other risk factors may interact with this relationship. We conducted the current study to quantify the influence of age on mortality and unfavorable neurologic outcome of patients surviving out-of-hospital cardiac arrest, and to determine the role of other confounding variables. This study was based on a cardiac arrest registry comprising all patients with witnessed out-of-hospital cardiac arrest of cardiac origin after successful resuscitation admitted to a department of emergency medicine between September 1991 and December 2004. We assessed the association between age and mortality and the degree of neurologic impairment, adjusting for multiple risk factors. We tested for interaction between age and all other risk factors with outcome. With each year of age the adjusted odds ratio for in-hospital death increased by 1.05 (95% confidence interval [CI], 1.04-1.07), and the adjusted odds ratio for an unfavorable neurologic outcome increased by 1.04 (95% CI, 1.03-1.06). Interaction between age and sex was present, and the analysis was stratified to sex. For men we found a steep risk increase for death and unfavorable outcome after being resuscitated from cardiac arrest, with the highest risk in the oldest age quartile. For women we observed only a slight risk increase for death and almost no risk increase for unfavorable outcome. Age is a strong independent risk factor for mortality and neurologic impairment after successfully resuscitated cardiac arrest. The risk increase with advancing age is much greater in men than in women. Therefore, in women, the influence of age on prognosis after cardiac arrest may not be very important, while in men it still plays an important role. This should be considered especially when treating successfully resuscitated women and discussing the prognosis with the medical team or the patients family. Abbreviations: CI = confidence intervals, CPC = cerebral performance category, IQR = interquartile range, SD = standard deviation.

Korean Hand Acupressure for Motion Sickness in Prehospital Trauma Care: A Prospective, Randomized, Double-blinded Trial in a Geriatric Population

Patients with trauma or medical illnesses transported to the hospital by ambulance have a frequent incidence of motion sickness. Because the administration of drugs in the ambulance is prohibited by law in Austria, the noninvasive Korean hand acupressure point at K-K9 may be an alternative against nausea and vomiting. We enrolled 100 geriatric patients with minor trauma, randomizing them into a K-K9 group and a sham acupressure group. We recorded visual analog scores (VAS) for nausea and for the patient’s overall satisfaction with the treatment, hemodynamic variables, and peripheral vasoconstriction. In the K-K9 group, a significant (P < 0.01) increase in nausea was recorded in all cases: from VAS of 0 mm to 25 ± 6 mm. A similarly significant (P < 0.01) increase was registered in the sham group: from VAS of 0 mm to 83 ± 8 mm. However, at the time of arrival in the hospital, nausea scores were significantly different between the K-K9 group and the sham group (P < 0.01). Although all patients had been vasoconstricted at the emergency site before treatment, there was a significant difference (P < 0.01) between groups with regard to the number of vasoconstricted patients at the hospital (4 and 46 constricted and dilated, respectively, in the K-K9 group versus 48 and 2 constricted and dilated, respectively, in the sham group). On arrival in the hospital, a significant difference (P < 0.01) in heart rate was noted between the K-K9 group and the sham group (65 ± 6 bpm versus 98 ± 8 bpm). The patients’ overall satisfaction with the provided care was significantly higher (P < 0.01) in the K-K9 group (19 ± 9 mm VAS) than in the sham group (48 ± 12 mm VAS). Neither group experienced a significant change in blood pressure. K-K9 stimulation was an effective and simple treatment for nausea during emergency care and significantly improved patient satisfaction.

Bench study of the accuracy of a commercial AED arrhythmia analysis algorithm in the presence of electromagnetic interferences.

This paper presents a bench study on a commercial automated external defibrillator (AED). The objective was to evaluate the performance of the defibrillation advisory system and its robustness against electromagnetic interferences (EMI) with central frequencies of 16.7, 50 and 60 Hz. The shock advisory system uses two 50 and 60 Hz band-pass filters, an adaptive filter to identify and suppress 16.7 Hz interference, and a software technique for arrhythmia analysis based on morphology and frequency ECG parameters. The testing process includes noise-free ECG strips from the internationally recognized MIT-VFDB ECG database that were superimposed with simulated EMI artifacts and supplied to the shock advisory system embedded in a real AED. Measurements under special consideration of the allowed variation of EMI frequency (15.7-17.4, 47-52, 58-62 Hz) and amplitude (1 and 8 mV) were performed to optimize external validity. The accuracy was reported using the American Heart Association (AHA) recommendations for arrhythmia analysis performance. In the case of artifact-free signals, the AHA performance goals were exceeded for both sensitivity and specificity: 99% for ventricular fibrillation (VF), 98% for rapid ventricular tachycardia (VT), 90% for slow VT, 100% for normal sinus rhythm, 100% for asystole and 99% for other non-shockable rhythms. In the presence of EMI, the specificity for some non-shockable rhythms (NSR, N) may be affected in some specific cases of a low signal-to-noise ratio and extreme frequencies, leading to a drop in the specificity with no more than 7% point. The specificity for asystole and the sensitivity for VF and rapid VT in the presence of any kind of 16.7, 50 or 60 Hz EMI simulated artifact were shown to reach the equivalence of sensitivity required for non-noisy signals. In conclusion, we proved that the shock advisory system working in a real AED operates accurately according to the AHA recommendations without artifacts and in the presence of EMI. The results may be affected for specificity in the case of a low signal-to-noise ratio or in some extreme frequency setting.

Detection of malintubation via defibrillator pads

AIM OF THE STUDY Endotracheal intubation is the preferred method to ensure proper artificial ventilation. Early detection of esophageal intubation is important for an individual patients outcome. The aim of the study was to see if impedance measurements can be used to detect esophageal intubation, using the impedance measurement system of an experimental defibrillator. MATERIALS AND METHODS Patients who died at the emergency department of a tertiary care hospital were eligible to be studied. After death was declared, patients were ventilated with a predefined tidal volume alternately via the conventional tracheal tube and via an additionally tube placed into the esophagus. The lowest and respectively highest median impedance amplitude for the first three ventilations was used as cut-off to calculate predictive values. RESULTS We enrolled 10 patients (mean age 65 years (S.D. 14), 7 male) of whom 9 underwent CPR prior to death, 30% of the patients had a BMI>30. Severe lung-edema was present in 2 cases. The lowest tracheal impedance value was 0.736 ohms and the highest esophageal was 0.496 ohms. A ROC curve for this individualised approach gave an area under the curve of 1 (95% CI 0.001, 0.249). CONCLUSION There is a large and significant reduction in transthoracic impedance when the tube is malpositioned in the esophagus. It may therefore be feasible to detect malintubation via thoracic impedance changes as an aid to improve the survival of critical ill patients. Further investigations on a larger population are needed.

Cardiopulmonary resuscitation and the 2005 universal algorithm: Has the quality of CPR improved?

ZusammenfassungHINTERGRUND: Eine optimale Herz-Druck-Massage stellt die Grundlage jeder erfolgreichen Reanimation dar. Das ideale Verhältnis von Thoraxkompressionen zu Atemspenden ist weiterhin Gegenstand von Untersuchungen, die Wichtigkeit des sofortigen Beginnes einer ausreichend tiefen Herzdruckmassage nach Eintreten des Herzkreislaufstillstandes sowie die Reduktion von Unterbrechungen der Herzdruckmassage ist jedoch eindeutig bewiesen. Im Jahr 2005 wurden die Richtlinien für Basisreanimationsmaßnahmen durch das European Resuscitation Council grundlegend verändert. Ziel war es, Unterbrechungen der Herz-Druck-Massage zu minimieren. Im Rahmen der vorliegenden Studie wurden Ersthelferreanimationen am Übungsphantom nach den Richtlinien 2000 mit jenen von 2005 verglichen. METHODEN: Nach positivem Votum der Ethikkommission wurde die Studie im randomisierten cross-over Design durchgeführt. Teilnehmer wurden nach einer jeweils zehn Minuten dauernden Unterrichts- und Übungsperiode aufgefordert, fünf Minuten Basisreanimation am Übungsphantom durchzuführen. Endpunkte der Studie waren die hands-off-Zeit (Zeit im Herzkreislaufstillstand ohne Herzdruckmassage) sowie Gesamtzahl der Thoraxkompressionen. ERGEBNIS: Fünfzig Probanden wurden eingeschlossen, eine Probandin zog sich nach der Randomisierung aus der Studie zurück. Die hands-off-Zeit war unter den Reanimationsrichtlinien 2005 signifikant kürzer als unter den Richtlinien 2000 (MW ± SD: 107 ± 19 sec vs. 139 ± 15 sec.; p < 0.0001). Weiters war auch die Gesamtzahl der Thoraxkompressionen unter den Reanimationsrichtlinien 2005 gegenüber den Richtlinien 2000 signifikant verbessert (347 ± 64 vs. 233 ± 51 Kompressionen; p < 0.0001). SCHLUSSFOLGERUNG: Basisreanimation nach den Richtlinien 2005 zeigte am Übungsphantom eine signifikante Verbesserung wesentlicher Qualitätsparameter der Herz-Lungen Wiederbelebung.SummaryBACKGROUND AND AIM: Chest compressions are crucial in cardiopulmonary resuscitation (CPR), although the optimal number, rate and sequence are unknown. The 2005 CPR guidelines of the European Resuscitation Council (ERC) brought major changes to the basic life support algorithm. One of the major aims of the ERC was to decrease hands-off time in order to improve perfusion of the coronary vessels and the brain. Using a manikin model of basic life support in simulated cardiac arrest, we compared hands-off time and total number of chest compressions according to the guidelines of 2000 and those of 2005. METHODS: A total of 50 volunteers performed CPR according to the guidelines of 2000 (Group 2000) and 2005 (Group 2005) in a randomized unblinded cross-over study. Volunteers received 10 min of standardized teaching and 10 min of training, including corrective feedback, for each set of guidelines before performing 5 min of basic life support on a manikin. We compared hands-off time as the primary outcome parameter and the total number of chest compressions as the secondary outcome parameter. RESULTS: Fifty volunteers were enrolled in the study, one individual dropped out after randomization. In Group 2005, hands-off time was significantly lower (mean 107 ± 19 [SD] s vs. 139 ± 15 s in Group 2000 (P < 0.0001) and the total number of chest compressions was significantly higher (347 ± 64 compressions vs. 233 ± 51 compressions; P < 0.0001). CONCLUSION: In this manikin setting, both hands-off time and the total number of chest compressions improved with basic life support performed according to the ERC guidelines of 2005.

Automated external defibrillators do not recommend false positive shocks under the influence of electromagnetic fields present at public locations.

Electromagnetic fields (EMF) reduce the signal quality of electrocardiograms and may lead to the misinterpretation by automated external defibrillators (AED). We designed this investigation as a prospective study, with a randomized sequence of AED applications on healthy volunteers. We chose busy public places where public access defibrillation was possible as test locations. Strong EMF were sought and found at train stations next to accelerating and decelerating trains. The primary outcome variable was the absolute number of shocks advised in the presence of sinus rhythm by five commonly used AED in Austria. For data analysis, the statistician was blinded in regard to the AED models tested. Data analysis was based on a per protocol evaluation. Of 390 tests run, 0 cases of false positive results occurred (95% CI: 0–0.77). AED can be regarded as safe, even with the interference of EMF present at train stations.

Out-of-hospital surface cooling with a cooling-blanket to induce mild hypothermia in humans after cardiac arrest: a feasibility trial

Mild hypothermia (32–34°C) is a promising new therapy for patients resuscitated from cardiac arrest. Animal studies suggest that early and fast cooling is crucial for beneficial effect on neurological outcome. Inducing mild hypothermia immediately after successful restoration of spontaneous circulation (ROSC) in the out-of-hospital setting remains a challenge. Therefore, a novel cooling-blanket (EMCOOLSpad®), independent of any energy source during use, was developed. The aim of the study was to evaluate feasibility and safety of out-of-hospital surface cooling with EMCOOLSpad® in patients successfully resuscitated from cardiac arrest.