Sabine Lemoyne

Excessive chest compression rate is associated with insufficient compression depth in prehospital cardiac arrest

UNLABELLED BACKGROUND AND GOAL OF STUDY: The relationship between chest compression rate and compression depth is unknown. In order to characterise this relationship, we performed an observational study in prehospital cardiac arrest patients. We hypothesised that faster compressions are associated with decreased depth. MATERIALS AND METHODS In patients undergoing prehospital cardiopulmonary resuscitation by health care professionals, chest compression rate and depth were recorded using an accelerometer (E-series monitor-defibrillator, Zoll, U.S.A.). Compression depth was compared for rates <80/min, 80-120/min and >120/min. A difference in compression depth ≥0.5 cm was considered clinically significant. Mixed models with repeated measurements of chest compression depth and rate (level 1) nested within patients (level 2) were used with compression rate as a continuous and as a categorical predictor of depth. Results are reported as means and standard error (SE). RESULTS AND DISCUSSION One hundred and thirty-three consecutive patients were analysed (213,409 compressions). Of all compressions 2% were <80/min, 62% between 80 and 120/min and 36% >120/min, 36% were <4 cm deep, 45% between 4 and 5 cm, 19% >5 cm. In 77 out of 133 (58%) patients a statistically significant lower depth was observed for rates >120/min compared to rates 80-120/min, in 40 out of 133 (30%) this difference was also clinically significant. The mixed models predicted that the deepest compression (4.5 cm) occurred at a rate of 86/min, with progressively lower compression depths at higher rates. Rates >145/min would result in a depth <4 cm. Predicted compression depth for rates 80-120/min was on average 4.5 cm (SE 0.06) compared to 4.1 cm (SE 0.06) for compressions >120/min (mean difference 0.4 cm, P<0.001). Age and sex of the patient had no additional effect on depth. CONCLUSIONS This study showed an association between higher compression rates and lower compression depths. Avoiding excessive compression rates may lead to more compressions of sufficient depth.

Combining video instruction followed by voice feedback in a self-learning station for acquisition of Basic Life Support skills: a randomised non-inferiority trial.

INTRODUCTION Current computerised self-learning (SL) stations for Basic Life Support (BLS) are an alternative to instructor-led (IL) refresher training but are not intended for initial skill acquisition. We developed a SL station for initial skill acquisition and evaluated its efficacy. METHODS In a non-inferiority trial, 120 pharmacy students were randomised to IL small group training or individual training in a SL station. In the IL group, instructors demonstrated the skills and provided feedback. In the SL group a shortened Mini Anne™ video, to acquire the skills, was followed by Resusci Anne Skills Station™ software (both Laerdal, Norway) with voice feedback for further refinement. Testing was performed individually, respecting a seven week interval after training for every student. RESULTS One hundred and seventeen participants were assessed (three drop-outs). The proportion of students achieving a mean compression depth 40-50mm was 24/56 (43%) IL vs. 31/61 (51%) SL and 39/56 (70%) IL vs. 48/61 (79%) SL for a mean compression depth ≥ 40 mm. Compression rate 80-120/min was achieved in 49/56 (88%) IL vs. 57/61 (93%) SL and any incomplete release (≥ 5 mm) was observed in 31/56 (55%) IL and 35/61 (57%) SL. Adequate mean ventilation volume (400-1000 ml) was achieved in 29/56 (52%) IL vs. 36/61 (59%) SL. Non-inferiority was confirmed for depth and although inconclusive, other areas came close to demonstrate it. CONCLUSIONS Compression skills acquired in a SL station combining video-instruction with training using voice feedback were not inferior to IL training.

Patients with cardiac arrest are ventilated two times faster than guidelines recommend: An observational prehospital study using tracheal pressure measurement

AIM To measure ventilation rate using tracheal airway pressures in prehospitally intubated patients with and without cardiac arrest. METHODS Prospective observational study. In 98 patients (57 with and 41 without cardiac arrest) an air-filled catheter was inserted into the endotracheal tube and connected to a custom-made portable device allowing tracheal airway pressure recording and subsequent calculation of ventilation rate. RESULTS In manually ventilated patients with cardiac arrest 39/43 (90%) had median ventilation rates higher than 10/min (overall median 20, min 4, max 74). During mechanical ventilation, 35/38 (92%) had ventilation rates higher than 10/min. The ventilation rate in patients with cardiac arrest was higher than in patients without cardiac arrest, both for manual and mechanical ventilation. Subanalysis comparing episodes with and without compression in cardiac arrest patients showed no clinically significant difference in ventilation rate after compressions were terminated. CONCLUSION Cardiac arrest patients were ventilated two times faster than recommended by the guidelines. Tracheal airway pressure measurement is feasible during resuscitation and may be developed further to provide real-time feedback on airway pressure and ventilation rate during resuscitation.

Training to deeper compression depth reduces shallow compressions after six months in a manikin model.

INTRODUCTION Studies show that students, trained to perform compressions between 40 and 50mm deep, often do not achieve sufficient depth at retention testing. We hypothesized that training to achieve depths >50mm would decrease the proportion of students with depth <40mm after 6 months, compared to students trained to a depth interval of 40-50mm. METHODS A basic life support (BLS) self-learning station was attended by 190 third year medicine students. They were first offered the possibility to refresh their skills, following the instructions of a 15min abbreviated Mini Anne™ video (Laerdal, Norway) using a full size torso and a face shield. This was followed by further training using Resusci Anne Skills Station™ software (Laerdal, Norway). Voice feedback was provided according to randomisation to a standard group (SG) 40-50mm and a deeper group (DG) >50mm. Quality of compressions was tested after 6 months. RESULTS The SG and DG groups consisted of 90 (67% female) and 100 (58% female) participants respectively. At the end of training, all students reached the target depth without overlap between groups. After 6 months, the proportion of students achieving a depth <40mm was 26/89 (29%) in the SG vs. 12/89 (14%) in the DG (P=0.01). The proportion of students with a depth >50mm was 5/89 (6%) for the SG and 44/89 (49%) in the DG (P<0.001). CONCLUSIONS The educational strategy to train students to a deeper depth, reduced shallow compressions 6 months after training.

European Board Examination in Emergency Medicine (EBEEM): assessment of excellence.

Emergency medicine has been recognized as a basic speciality in 17 countries in Europe and it is a supraspeciality in a further five countries. The European Society for Emergency Medicine has achieved the legal status of an international nonprofit organization wherein individuals and national societies for emergency medicine may find help and support from colleagues throughout Europe and beyond [1,2].

LAT gel for laceration repair in the emergency department: not only for children?

Objective LAT (lidocaine, adrenaline, and tetracaine) gel is a topical anesthetic that can be applied on lacerations before suturing. It is considered easy to use and less painful than infiltrative anesthesia. Its use in laceration management has been studied the most in younger children. We aimed to describe the potential value of the use of LAT gel in older children and adults with simple lacerations. Materials and methods As part of a quality audit project, we reviewed all emergency department records of patients who had LAT gel applied for laceration repair in a 3-month period following the initial protocol implementation. Patients younger than 8 years of age, under the influence of alcohol or drugs, or those who received additional sedation were excluded. The need for additional anesthesia after needle probing was used as the primary endpoint. Results Of the 89 patients included, 21 (23.6%) needed additional anesthesia. The length of the wound was significantly longer in the group who needed additional anesthesia (difference between medians 1 cm; 95% confidence interval 0.5–2; P<0.005). Lacerations located on the extremities/trunk/fingers/toes needed significantly more additional anesthesia compared with lacerations located on the head (19.1% difference between proportions; 95% confidence interval 1–34.8%; P<0.05). Conclusion LAT gel is a valuable alternative to infiltrative anesthesia for laceration repair. Its use should not be limited to children. The application of LAT gel seems to be specifically suitable for short lacerations (<4 cm), lacerations located on the head, and simple finger lacerations.

An inquiry on pain management in the emergency department of training hospitals

Abstract Introduction Improving pain management in the ED might be attained by adequate teaching of medical students. We assessed the skills in pain treatment of ED physicians who teach the students. Methods All physicians working in an ED who provide elective training to undergraduate medical students from the Ghent University were asked to complete a questionnaire consisting of vignette patient cases concerning acute pain management of abdominal colic pain, and non-traumatic abdominal pain. Results Thirty two physicians completed the cases. In the renal colic case 91% of the respondents proposed a NSAID as first line treatment. Butylhyoscine was still suggested by 18%. After initial failure of analgesia 31% administered a strong opioid. In biliary colic pain NSAIDs and butylhyoscine were proposed as first line analgesics by 59% and 31% respectively. In second line, butylhyoscine would be given by 22%. The patient case with right fossa abdominal pain would initially be treated with acetaminophen by 81%. Thirteen % of the respondents would not give further analgesia if the first line treatment was insufficient. Conclusion Our results indicate that adherence by teachers to evidence based guidelines of acute pain management is insufficient. Therefore improving knowledge and skills in pain management of the teachers should receive more attention.

Disorders of Consciousness Induced by Intoxication

The prognosis of patients with altered consciousness is mainly determined by early diagnosis and appropriate therapeutic interventions and by the type of toxin. The potential causes of altered consciousness are many and may reflect systemic illness, isolated organ system dysfunction, drug intoxications or withdrawal, psychiatric illness, or neurologic disease. In this article, a comprehensive approach to patients with altered consciousness and suspected poisoning is discussed. This survey, however, does not intend to be a substitute for the need for consultation with a clinical toxicologist qualified in the diagnosis and treatment of poisoned patients.