Zui-Shen Yen

A systematic review of retention of adult advanced life support knowledge and skills in healthcare providers

OBJECTIVE Advanced life support (ALS) guidelines are widely adopted for healthcare provider training with recommendations for retraining every two years or longer. This systematic review studies the retention of adult ALS knowledge and skills following completion of an ALS course in healthcare providers. METHODS We retrieved original articles using Medline, CINAHL, Cochrane Library, and PubMed, and reviewed reference citations to identify additional studies. We extracted data from included articles using a structured approach and organized outcomes by evaluation method, and knowledge and skills retention. RESULTS Among 336 articles retrieved, 11 papers were included. Most studies used multiple-choice questionnaires to evaluate knowledge retention and cardiac arrest simulation or other skills tests to evaluate skills retention. All studies reported variable rates of knowledge or skills deterioration over time, from 6 weeks to 2 years after training. Two studies noted retention of knowledge at 18 months and up to 2 years, and one reported skills retention at 3 months. Clinical experience, either prior to or after the courses, has a positive impact on retention of knowledge and skills. CONCLUSION There is a lack of large well-designed studies examining the retention of adult ALS knowledge and skills in healthcare providers. The available evidence suggests that ALS knowledge and skills decay by 6 months to 1 year after training and that skills decay faster than knowledge. Additional studies are needed to help provide evidence-based recommendations for assessment of current knowledge and skills and need for refresher training to maximize maintenance of ALS competency.

Ultrasonographic screening of clinically-suspected necrotizing fasciitis

OBJECTIVE To determine the accuracy of ultrasonography for the diagnosis of necrotizing fasciitis. METHODS This study was a prospective observational review of patients with clinically-suspected necrotizing fasciitis presenting to the emergency department of an urban (Taipei) medical center between October 1996 and May 1998. All patients underwent ultrasonographic examination, with the ultrasonographic diagnosis of necrotizing fasciitis based on the criterion of a diffuse thickening of the subcutaneous tissue accompanied by a layer of fluid accumulation more than 4 millimeters in depth along the deep fascial layer, when compared with the contralateral position on the corresponding normal limb. The final diagnosis of necrotizing fasciitis was determined by pathological findings for patients who underwent fasciotomy or biopsy results for patients managed nonoperatively. RESULTS Data were collected for 62 patients, of whom 17 (27.4%) were considered to suffer from necrotizing fasciitis. Ultrasonography revealed a sensitivity of 88.2%, a specificity of 93.3%, a positive predictive value of 83.3%, a negative predictive value of 95.4%, and an accuracy of 91.9% as regards the diagnosis of necrotizing fasciitis. CONCLUSIONS Ultrasonography can provide accurate information for emergency physicians for the diagnosis of necrotizing fasciitis.

Tracheal rapid ultrasound exam (T.R.U.E.) for confirming endotracheal tube placement during emergency intubation

OBJECTIVES This study aimed to assess the diagnostic accuracy and timeliness of using tracheal ultrasound to examine endotracheal tube placement during emergency intubation. METHODS This was a prospective, observational study, conducted at the emergency department of a national university teaching hospital. Patients received emergency intubation because of impending respiratory failure, cardiac arrest, or severe trauma. The tracheal rapid ultrasound exam (T.R.U.E.) was performed during emergency intubation with the transducer placed transversely at the trachea over the suprasternal notch. Quantitative waveform capnography was used as the criterion standard for confirmation of tracheal intubation. The main outcome was the concordance between the T.R.U.E. and the capnography. RESULTS A total of 112 patients were included in the analysis, and 17 (15.2%) had esophageal intubations. The overall accuracy of the T.R.U.E. was 98.2% (95% confidence interval [CI]: 93.7-99.5%). The kappa (κ) value was 0.93 (95% CI: 0.84-1.00), indicating a high degree of agreement between the T.R.U.E. and capnography. The sensitivity, specificity, positive predictive value, and negative predictive value of the T.R.U.E. were 98.9% (95% CI: 94.3-99.8%), 94.1% (95% CI: 73.0-99.0%), 98.9% (95% CI: 94.3-99.8%) and 94.1% (95% CI: 73.0-99.0%). The median operating time of the T.R.U.E. was 9.0s (interquartile range [IQR]: 6.0, 14.0). CONCLUSIONS The application of the T.R.U.E. to examine endotracheal tube placement during emergency intubation is feasible, and can be rapidly performed.

High-Dose vs Non-High-Dose Proton Pump Inhibitors After Endoscopic Treatment in Patients With Bleeding Peptic Ulcer A Systematic Review and Meta-analysis of Randomized Controlled Trials

BACKGROUND High-dose proton pump inhibitors (PPIs) (80-mg bolus, followed by 8-mg/h continuous infusion for 72 hours) have been widely studied and used. However, to date no concrete evidence has shown that high-dose PPIs are more effective than non-high-dose PPIs. METHODS We performed a literature search for randomized controlled trials that compared the use of high-dose PPIs vs non-high-dose PPIs in patients with bleeding peptic ulcer and determined their effects on rebleeding, surgical intervention, and mortality. Outcomes data were combined in a meta-analysis and were reported as odds ratios (ORs) with 95% confidence intervals (CIs). RESULTS A total of 1157 patients from 7 high-quality randomized studies were included in this meta-analysis. High-dose PPIs and non-high-dose PPIs did not differ in their effects on the rates of rebleeding (7 studies and 1157 patients; OR, 1.30; 95% CI, 0.88-1.91), surgical intervention (6 studies and 1052 patients; 1.49; 0.66-3.37), or mortality (6 studies and 1052 patients; 0.89; 0.37-2.13). Post hoc subgroup analyses revealed that summary outcomes measures were unaffected by severity of signs of recent hemorrhage at initial endoscopy, route of PPI administration, or PPI dose. CONCLUSION Compared with non-high-dose PPIs, high-dose PPIs do not further reduce the rates of rebleeding, surgical intervention, or mortality after endoscopic treatment in patients with bleeding peptic ulcer.

Effect of different resuscitation fluids on cytokine response in a rat model of hemorrhagic shock

This study was designed to determine the effects of different resuscitation fluids on the production of proinflammatory and anti-inflammatory cytokines in an animal model of hemorrhagic shock. Wistar male rats (n = 24; 8/group) were subjected to a volume-controlled hemorrhagic shock for 30 minutes and resuscitated as follows: (1) sham group without resuscitation, (2) lactated Ringer solution (LR), 3:1; (3) 4% hydroxyethyl starch (HES) solution, 1:1; and (4) 4% modified fluid gelatin (GEL), 1:1. Hemodynamic parameters were recorded, and blood samples were collected at 0 min and 30, 90, 150, 210, 270, and 330 min after hemorrhage for plasma levels of IL-6, IL-10, and TNFα. The circulating concentrations of IL-6 at 90, 150, 210, 270, and 330 min and TNFα levels at 150, 210, and 270 min after hemorrhage were significantly elevated in animals resuscitated with GEL compared with HES or LR (P < 0.05). At 210, 270, and 330 min, IL-10 concentration was decreased significantly in GEL-resuscitated rats compared with rats resuscitated with LR or HES (P < 0.05). Mean blood pressure and serum levels of lactate after resuscitation were not different among three kinds of fluids. LR, HES, and GEL are comparable in volume efficacy for resuscitation of hemorrhagic shock but are associated with different postresuscitation immune responses. Resuscitation with GEL may be associated with cytokine production favoring a proinflammatory response. The marked elevation of IL-6 observed in the GEL-treated animals may play a role in the relatively high frequency of anaphylactoid reaction in clinical use of GEL.

Cardioprotective effect of therapeutic hypothermia for postresuscitation myocardial dysfunction.

Mild-to-moderate therapeutic hypothermia after resuscitation from cardiac arrest is neuroprotective, but its effect on postresuscitation myocardial dysfunction is not clear. We hypothesized that therapeutic hypothermia is cardioprotective in postresuscitation. Male adult Wistar rats underwent asphyxia-induced cardiac arrest and manual resuscitation with epinephrine. Therapeutic hypothermia is induced immediately after successful resuscitation and the return of spontaneous circulation (ROSC). One hour after ROSC, the rats achieved a target temperature of 30°C to 31°C, which was maintained for 1.5 h and then transitioned to the passive rewarming process in the hypothermia group. A temperature between 36.5°C and 37.5°C was maintained in the normothermia group. Echocardiography revealed that hypothermia resulted in significantly better systolic function of fractional shortening in 60 and 120 min after ROSC (both P < 0.05). The benefit of cardioprotection was also confirmed by the general linear mixed-models analysis of dP/dt, which revealed significantly better systolic function in positive dP/dtR(40) and diastolic function in maximal negative dP/dt (both P < 0.001). The 4-h and 3-day survival analyses both revealed better outcomes in the hypothermia groups in the log-rank test (P < 0.001 for the 4-h analysis, and P < 0.05 for the 3-day analysis). Serum level of heart-type, fatty acid-binding protein at 4 h after resuscitation as the myocardium damage marker was also significantly lower in the hypothermia group (52.4 ng/mL vs 186.5 ng/mL in the normothermia group; P < 0.05). Western blotting of myocardium showed that myocardial Akt and ERK1/2 were more activated in the hypothermia group 2 h after spontaneous circulation returned. In conclusion, postresuscitation mild-to-moderate therapeutic hypothermic is cardioprotective in the asphyxia-induced cardiac arrest animal model. It stabilizes hemodynamics, improves short-term survival, and decreases myocardial damage. The cardioprotective effect is associated with Akt and ERK1/2 activation in signal transduction.

Interactive video instruction improves the quality of dispatcher-assisted chest compression-only cardiopulmonary resuscitation in simulated cardiac arrests.

Objective:Bystander cardiopulmonary resuscitation (CPR) significantly improves survival of cardiac arrest victims. Dispatch assistance increases bystander CPR, but the quality of dispatcher-assisted CPR remains unsatisfactory. This study was conducted to assess the effect of adding interactive video communication to dispatch instruction on the quality of bystander chest compressions in simulated cardiac arrests. Design:A randomized controlled study with a scenario developed to simulate cardiac arrest in a public place. Setting:The victim was simulated by a mannequin and the cell phone for dispatch assistance was a video cell phone with both voice and video modes. Chest compression-only CPR instruction was used in the dispatch protocol. Subjects:Ninety-six adults without CPR training within 5 years were recruited. Interventions:The subjects were randomized to receive dispatch assistance on chest compression with either voice instruction alone (voice group, n = 53) or interactive voice and video demonstration and feedback (video group, n = 43) via a video cell phone. Measurements and Main Results:Performance of chest compression-only CPR throughout the scenario was videotaped. The quality of CPR was evaluated by reviewing the videos and mannequin reports. Chest compressions among the video group were faster (median rate 95.5 vs. 63.0 min−1, p < 0.01), deeper (median depth 36.0 vs. 25.0 mm, p < 0.01), and of more appropriate depth (20.0% vs. 0%, p < 0.01). The video group had more “hands-off” time (5.0 vs. 0 second, p < 0.01), longer time to first chest compression (145.0 vs. 116.0 seconds, p < 0.01) and total instruction time (150.0 vs. 121.0 seconds, p < 0.01). Conclusion:The addition of interactive video communication to dispatcher-assisted chest compression-only CPR initially delayed the commencement of chest compressions, but subsequently improved the depth and rate of compressions. The benefit was achieved mainly through real-time feedback.

Ultrasonographic lung sliding sign in confirming proper endotracheal intubation during emergency intubation.

AIM OF STUDY Unrecognized one-lung intubations (also known as main-stem intubation) can lead to hypoventilation, atelectasis, barotrauma, and even patient death. Many traditional methods can be employed to detect one-lung intubation; however, each of these methods has limitations and is not consistently reliable in emergency settings. This study aimed to assess the accuracy and timeliness of ultrasound to confirm proper endotracheal intubation. METHODS This was a prospective, single-center, observational study conducted at the emergency department of a national university teaching hospital. Patients received emergency tracheal intubation because of respiratory failure or cardiac arrest. After intubation, bedside ultrasound was performed with a transducer placed on the chest bilaterally at the mid-axillary line, to identify lung sliding over the lungs bilaterally during ventilation. Chest radiography was used as the criterion standard for confirmation of endotracheal tube position. RESULTS One hundred and fifteen patients needing tracheal intubation were included, and nine (7.8%) had one-lung intubations. The overall accuracy of ultrasound to confirm proper endotracheal intubation was 88.7% (95% confidence interval (CI): 81.6-93.3%). The positive predictive value was 94.7% (95% CI: 87.1-97.9%) in the non-cardiac-arrest group and 100% (95% CI: 87.1-100.0%) in the cardiac-arrest group. The median operating time of ultrasound was 88 s (interquartile range [IQR]: 55.0, 193.0), and of chest radiography was 1349 s (IQR: 879.0, 2221.0) post intubation. CONCLUSIONS In this study, the positive predictive value of bilateral lung sliding in confirming proper endotracheal intubation was high, especially among patients with cardiac arrest. Considerable time advantage of ultrasound over chest radiography was demonstrated.

Impact of Adding Video Communication to Dispatch Instructions on the Quality of Rescue Breathing in Simulated Cardiac Arrests- a Randomized Controlled Study

OBJECTIVE Both ventilations and compressions are important for victims of prolonged cardiopulmonary resuscitation (CPR) and asphyxial arrest. Dispatch assistance increases bystander CPR, but the quality of dispatcher-assisted CPR (DA-CPR), especially rescue breathing, remains unsatisfactory. This study was conducted to assess the impact of adding interactive video communication to dispatch instructions on the quality of rescue breathing in simulated cardiac arrests. METHODS In this simulation-based study, adults without CPR training within 5 years were recruited between April and July 2007 and randomized to receive dispatch assistance with either voice instruction alone (voice group, n=53) or interactive voice and video instruction (video group, n=43) via a video cell phone. The quality of rescue breathing was evaluated by reviewing the videos and mannequin reports. RESULTS Subjects in the video group were more likely to open the airway correctly (95.3% vs. 58.5%, P<0.01) and to lift the chin properly (95.3% vs. 62.3%, P<0.01), but had similar rates of head-tilt (95.3% vs. 84.9%, P=0.10). Volunteers in the video group had larger volume of ventilation (median volume 540 ml vs. 0 ml, P<0.01), greater possibility to sustain an open airway (88.4% vs. 60.4%, P<0.01) and a tendency towards better nose-pinch (97.7% vs. 86.8%, P=0.06). The video group spent longer time to open the airway (59 s vs. 56 s, P<0.05) and to give the first rescue breathing (139 s vs. 102 s, P<0.01). CONCLUSION Adding video communication to dispatch instructions improved the quality of bystander rescue breathing, including higher proportion of airway opened, and larger volume of ventilation delivered, in simulated cardiac arrests.

Validation of the Taiwan triage and acuity scale: a new computerised five-level triage system

Objective An ideal emergency department (ED) triage system accurately prioritises patients on the basis of the urgency of interventions required to avoid under- or over-triage. The objective of this study was to develop and validate a five-level Taiwan triage and acuity scale (TTAS) with an electronic decision support tool. Methods This prospective, multicentre, observational study included 10533 patients triaged at 11 academic medical centres, 18 regional and four district hospitals. Adult patients presenting to the ED were independently triaged by the duty triage nurse in the usual way and trained research nurses using TTAS with a computerised decision support system. Weighted κ statistics were used to assess the reproducibility. Hospitalisation, length of stay, and medical resource consumption were analysed by TTAS acuity levels. Results Most cases were stratified into levels 2 to 3 by the existing four-level triage system, whereas the TTAS stratified most patients to levels 3 (41.4%) and 4 (25.0%), and only a small number to level 1 (3.9%) (resuscitation; most urgent). Weighted κ for TTAS assignment was 0.87 (95% CI 0.85 to 0.89). The decrease in mean medical resource consumption and hospitalisation rate was statistically significant with each decrease in the TTAS triage acuity level. The length of stay also decreased significantly as the TTAS level acuity fell from levels 2 to 5. Conclusions The TTAS was found to be a reliable triage system that accurately prioritises the treatment needed to avoid overtriage, more efficiently deploying the appropriate resources to ED patients.