The recovery position for maintenance of adequate ventilation and the prevention of cardiac arrest: A systematic review.

Aim: To conduct a systematic review of the use of the recovery position in adults and children with non-traumatic decreased levels of responsiveness changes outcomes in comparison with other positioning strategies. Methods: We searched Medline (Ovid), Embase, Cochrane Library, CINAHL, medRxiv and Google Scholar from inception to 15 March 2021 for studies involving adults and children in an out-of-hospital, first aid setting who had reduced levels of responsiveness of non-traumatic aetiology but did not require resuscitative interventions. We used the ROBINS-I tool to assess risk of bias and GRADE methodology to determine the certainty of evidence. Results: Of 17,947 citations retrieved, three prospective observational studies and four case series were included. The prone and semi-recumbent positions were associated with a decreased rate of suspected aspiration pneumonia in acute poisoning. Use of the recovery position in paediatric patients with decreased levels of responsiveness was associated with a deceased admission rate and the prone position was the position most commonly associated with sudden unexpected death in epilepsy. High risk of bias, imprecision and indirectness of evidence limited our ability to perform pooled analyses. Conclusion: We identified a limited number of observational studies and case series comparing outcomes following use of the recovery position with outcomes when other patient positions were used. There was limited evidence to support or revise existing first aid guidance; however, greater emphasis on the initial assessment of responsiveness and need for CPR, as well as the detection and management of patient deterioration of a person identified with decreased responsiveness, is recommended.

Cardiac Arrest Quality Improvement: A Single-Center Evaluation of Resuscitations Using Defibrillator, Feedback Device, and Survey Data.

BACKGROUND: High-quality cardiopulmonary resuscitation is foundational to cardiac arrest care. Visual feedback devices can improve chest compression quality, but are infrequently used. Quality improvement data were examined to determine whether handheld visual feedback and backboard use improved chest compression quality, whether resuscitation team size affected resuscitation indicators, and whether feedback sources are comparable. METHODS: From August 2019 to December 2020, data from 50 resuscitations were collected using a handheld device (n = 35), defibrillator (n = 23), and surveys (n = 35) and shared with providers. Aggregated and individual case data, along with education and research, were distributed to staff as quality improvement measures. RESULTS: The mean duration of resuscitation was 1080 compressions (SD = 858); there were no differences in the durations of resuscitations that did or did not use handheld feedback; 50% of resuscitations used handheld feedback and had more compressions at target rate (74.68% vs 42.18%, t(21) = 2.99, P = .007). Moreover, 25% of resuscitations used backboards; these had more chest compressions at target depth (72.92% vs 48.73%, t(25) = 2.08, P = .048). Team size was not associated with duration of resuscitation or chest compressions quality. There was no improvement in other quality indicators (leadership, family presence, or debriefing) during the data collection period. Feedback sources (defibrillator and feedback device) had good agreement and correlation (r = 0.77, P = .01). CONCLUSIONS: Incorporating handheld feedback and backboards improved chest compressions quality. Further work to improve the frequency of device use and to examine their relationship to patient-specific outcomes is needed. Study is needed to find interventions that improve other teamwork metrics, inclusion of family during the resuscitation, referral for tissue donation, and rates of postevent debriefing.

The effects of trained observers (dofficers) and audits during a facility-wide COVID-19 outbreak: A mixed-methods quality improvement analysis.

BACKGROUND: In response to a facility-wide COVID-19 outbreak, our tertiary acute care hospital implemented an evidence-based bundle of infection control practices including the use of audits and trained observers "dofficers" to provide real-time constructive feedback. METHODS: We trained furloughed staff to perform the role of dofficer. They offered support and corrective feedback on proper PPE use and completed 21-point audits during a 4-week intervention period. Audits tracked appropriate signage, placement and availability of supplies (equipment), correct PPE use, enhanced environmental cleaning, along with cohorting and social distancing rates. Audit data was used to provide weekly quality improvement reports to units. RESULTS: Nine hundred and sixty two separate audits recorded 36,948 observations, over 7,696 observer-hours. The most common errors were with environmental cleaning and PPE use; the least common were with regards to equipment availability and cohorting and social distancing. Mean error rates decreased from 9.81% to 2.88% (P < .001). The largest reduction, 22.57%, occurred in the category of PPE doffing errors. CONCLUSIONS: Dofficer led audits effectively identified areas for improvement. Feedback through weekly reports and real-time correction of PPE errors by dofficers led to statistically significant improvements; however, error rates remained high. Further research is needed establish if these relationships are causal.

A gap analysis of the potential use of resuscitative endovascular balloon occlusion of the aorta (REBOA) in trauma at two major Canadian trauma centers.

OBJECTIVE: Uncontrolled hemorrhage poses significant morbidity and mortality among injured patients. Resuscitative endovascular balloon occlusion of the aorta (REBOA) utilizes a rapidly-administered minimally invasive transfemoral balloon catheter that is inflated for aortic occlusion, allowing for time to arrange definitive surgical or angiographic intervention. As indications for its use continue to evolve, this study sought to evaluate whether there is a potential need for REBOA implementation in two high-volume trauma centers in Edmonton. METHODS: Patient data within our provincial trauma registry was reviewed between 2015 and 2017 to identify major trauma patients (Injury Severity Score ≥ 12). Patients eligible for REBOA included patients with blunt or penetrating trauma to the torso or pelvis, AND death prior to discharge; and patients taken to the operating room or interventional radiology suite within 4 h of arrival. Charts were reviewed to determine if patients met current conventional criteria for REBOA. RESULTS: Out of 3415 trauma patients during our study period, 237 patients met the registry screen as potentially eligible for REBOA. After primary researcher review, 67 patients underwent full chart review and then 2 trauma surgeons determined that 38 (1.1% of the study population) met criteria for deploying REBOA. CONCLUSION: A small but significant number of trauma patients at the two trauma centers were identified as potential candidates for REBOA use. Implementation of a REBOA program should be done in alignment with existing clinical practice guidelines and professional society recommendations.

RéSUMé: OBJECTIF: L'hémorragie incontrôlée entraîne une morbidité et une mortalité importantes chez les patients blessés. Le clampage aortique par sonde d'occlusion aortique endovasculaire (resuscitative endovascular balloon occlusion of the aorta [REBOA]) utilise un cathéter à ballonnet transfémoral mini-invasif à administration rapide qui est gonflé pour l'occlusion aortique, ce qui laisse le temps d'organiser une intervention chirurgicale ou angiographique définitive. Alors que les indications de son utilisation continuent d'évoluer, cette étude a cherché à évaluer s'il y avait un besoin potentiel de mise en œuvre de REBOA dans deux centres de traumatologie à haut volume à Edmonton. MéTHODES: Les données sur les patients dans notre registre provincial des traumatismes ont été examinées entre 2015 et 2017 afin d'identifier les patients traumatisés majeurs (Score de gravité des blessures ≥ 12). Les patients éligibles au REBOA comprenaient des patients présentant un traumatisme contondant ou pénétrant au torse ou au bassin, ET le décès avant la sortie; et les patients conduits à la salle d'opération ou à la salle de radiologie interventionnelle dans les 4 heures suivant leur arrivée. Les graphiques ont été examinés pour déterminer si les patients répondaient aux critères conventionnels actuels de REBOA. RéSULTATS: Sur les 3 415 patients traumatisés pendant notre période d'étude, 237 patients ont répondu à l'examen du registre comme étant potentiellement éligibles pour le REBOA. Après examen par le chercheur principal, soixante-sept patients ont été soumis à un examen complet de leur dossier, puis deux chirurgiens traumatologues ont déterminé que 38 (1,1 % de la population étudiée) répondaient aux critères de déploiement de la REBOA. CONCLUSION: Un nombre restreint mais significatif de patients traumatisés dans les deux centres de traumatologie a été identifié comme des candidats potentiels à l'utilisation de REBOA. La mise en œuvre d'un programme REBOA doit se faire en conformité avec les directives de pratique clinique existantes et les recommandations de la société professionnelle.

Prone cardiopulmonary resuscitation: A scoping and expanded grey literature review for the COVID-19 pandemic.

AIM: To identify and summarize the available science on prone resuscitation. To determine the value of undertaking a systematic review on this topic; and to identify knowledge gaps to aid future research, education and guidelines. METHODS: This review was guided by specific methodological framework and reporting items (PRISMA-ScR). We included studies, cases and grey literature regarding prone position and CPR/cardiac arrest. The databases searched were MEDLINE, Embase, CINAHL, Cochrane CENTRAL, Cochrane Database of Systematic Reviews, Scopus and Google Scholar. Expanded grey literature searching included internet search engine, targeted websites and social media. RESULTS: Of 453 identified studies, 24 (5%) studies met our inclusion criteria. There were four prone resuscitation-relevant studies examining: blood and tidal volumes generated by prone compressions; prone compression quality metrics on a manikin; and chest computed tomography scans for compression landmarking. Twenty case reports/series described the resuscitation of 25 prone patients. Prone compression quality was assessed by invasive blood pressure monitoring, exhaled carbon dioxide and pulse palpation. Recommended compression location was zero-to-two vertebral segments below the scapulae. Twenty of 25 cases (80%) survived prone resuscitation, although few cases reported long term outcome (neurological status at hospital discharge). Seven cases described full neurological recovery. CONCLUSION: This scoping review did not identify sufficient evidence to justify a systematic review or modified resuscitation guidelines. It remains reasonable to initiate resuscitation in the prone position if turning the patient supine would lead to delays or risk to providers or patients. Prone resuscitation quality can be judged using end-tidal CO2, and arterial pressure tracing, with patients turned supine if insufficient.

Temporizing Life-Threatening Abdominal-Pelvic Hemorrhage Using Proprietary Devices, Manual Pressure, or a Single Knee: An Integrative Review of Proximal External Aortic Compression and Even "Knee BOA".

INTRODUCTION: Abdominal-pelvic hemorrhage (i.e., originates below the diaphragm and above the inguinal ligaments) is a major cause of death. It has diverse etiology but is typically associated with gunshot or stab wounds, high force or velocity blunt trauma, aortic rupture, and peripartum bleeds. Because there are few immediately deployable, temporizing measures, and the standard approaches such as direct pressure, hemostatics, and tourniquets are less reliable than they are with compressible extremity injuries, risk for death resulting from abdominal-pelvic hemorrhage is high. This review concerns the exciting potential of proximal external aortic compression (PEAC) as a temporizing technique for life-threatening lower abdominal-pelvic hemorrhage. PEAC can be accomplished by means of a device, two locked arms (manual), or a single knee (genicular) to press over the midline supra-umbilical abdomen. The goal is to compress the descending aorta and slow or halt downstream hemorrhage while not delaying more definitive measures such as hemostatic packing, tourniquets, endovascular balloons, and ultimately operative repair. METHODS: Clinical review of the Ovid MEDLINE, In-Process, & Other Non-Indexed, and Google Scholar databases was performed for the period ranging from 1946 to 3 May 2019 for studies that included the following search terms: [proximal] external aortic compression OR vena cava compression AND (abdomen or pelvis) OR (hemorrhage) OR (emergency or trauma). In addition, references from included studies were assessed. CONCLUSION: Sixteen studies met the inclusion criteria. Evidence was grouped and summarized from the specialties of trauma, aortic surgery, and obstetrics to help prehospital responders and guide much-needed additional research, with the goal of decreasing the high risk for death after life-threatening abdominal-pelvic hemorrhage.

A Randomized Crossover Trial of Conventional versus Modified "Koch" Chest Compressions in a Height-Restricted Aeromedical Helicopter.

Aim: Low overhead height can negatively affect chest compression performance. An adapted compression technique has been proposed by paramedic H. Koch (pron. "Cook"). This study compares conventional to Koch technique in a height-restricted aeromedical helicopter. Methods: Eighteen clinicians were randomized to 2 minutes of conventional or Koch compressions, then crossed-over. Koch technique uses a forearm/elbow instead of overlapping hands. Compression quality was assessed with a Skill Reporting Laerdal Resusci-Anne manikin. Quality variables were: the number and rate of compressions, compression depth, release, land marking, and overall aggregate quality score. Participant feedback was collected using the Borg Scale of Perceived Exertion, and compression difficulty using a zero-to-ten scale. Furthermore, we solicited open-ended descriptive responses. Results: The average overall quality score was 63% for conventional compressions versus 79% for Koch compressions (p = 0.04). On average, the Koch compression method increased compression depth by 5 mm (95% CI 4.3 to 5.7) and the proportion of compressions at the correct depth by 17% (95% CI 7.55 to 26.45), although these were not statistically significant. Correct release and land marking showed no statistically significant difference between techniques. Koch compressions resulted in statistically significant reductions in physical exertion and difficulty (p < 0.001). Qualitative feedback described modified compressions as easier and more sustainable. Conclusions: In a height-restricted aeromedical helicopter, the average overall quality score improved using Koch compressions, although the mean rate, mean depth, correct release and land marking were found to be similar between techniques. Qualitative feedback described Koch compressions as easier and more sustainable. In settings where the compressor is affected by reduced overhead working height, Koch compressions may be an advisable alternative.

Proximal External Aortic Compression for Life-Threatening Abdominal-Pelvic and Junctional Hemorrhage: An Ultrasonographic Study in Adult Volunteers.

Introduction: Following life-threatening junctional trauma, the goal is to limit blood loss while expediting transfer to operative rescue. Unfortunately, life-threatening abdominal-pelvic or junctional hemorrhage is often not amenable to direct compression and few temporizing strategies are available beyond hemostatic dressings, hypotensive resuscitation, and balanced transfusion. Objectives: In this study, we evaluated proximal external aortic compression to arrest blood flow in healthy adult men. Methods: This was a simulation trial of proximal external aortic compression, for life-threatening abdominal-pelvic and junctional hemorrhage, in a convenience sample of healthy adult male volunteers. The primary end points were cessation of femoral blood flow as assessed by pulse wave Doppler ultrasound at the right femoral artery, caudal to the inguinal ligament. Secondary end points were discomfort and negative sequelae. Results: Aortic blood flow was arrested in 12 volunteers. Median time to blood flow cessation was 12.5 seconds. Median reported discomfort was 5 out of 10. No complications or negative sequelae were reported. Conclusion: This trial suggests that it may be reasonable to attempt temporization of major abdominal-pelvic and junctional hemorrhage using bimanual proximal external aortic compression. In the absence of immediate alternatives for this dangerous and vexing injury pattern, there appear to be few downsides to prehospital proximal external aortic compression while concomitantly expediting definite care.

Insights From a Tertiary Care Intraosseous Insertion Practice Improvement Registry: A 2-Year Descriptive Analysis.

INTRODUCTION: Few practice improvement registries exist that describe opportunities to improve intraosseous (IO) use. The goal of this project was to assess the success rate of the procedure by emergency nurses and identify opportunities to improvement. Secondary goals were to assess success rates based on clinician type, age of patient, and procedural factors. METHODS: Emergency nurses assigned to the resuscitation area of a tertiary care emergency department completed an education module and skill lab on IO placement. Tracking forms were completed whenever IO access was attempted, and the clinical nurse educator collated the forms. RESULTS: Over 2 years, quality improvement forms were submitted for 17 pediatric patients (receiving 23 IO insertions) and 35 adult patients (receiving 40 intraosseous insertions). Prior to an IO attempt, the average number of IV attempts for pediatric and adult patients was 4 (range 0 to 10) and 2 (0 to 5), respectively. Successful pediatric IO insertion rate was 6/15 (40%) for physicians (both residents and attending physicians) and 6/7 (86%) for emergency nurses. Physicians were more likely to perform IO insertions in children <12 months of age and emergency nurses in patients >12 months of age. The leading cause of failed insertions in pediatrics was selecting a needle that was too short: either not reaching the intramedullary canal or quickly becoming dislodged, especially with flushing the IO cannula after insertion. For adult patients, IO insertion success rates for physicians were 13/14 (93%) and 18/20 (90%) for emergency nurses. DISCUSSION: The registry identified opportunities to improve clinical practice on the clinical threshold for IO use in pediatric patients and the appropriate selection of IO cannula.

Blood on board: The development of a prehospital blood transfusion program in a Canadian helicopter emergency medical service.

OBJECTIVE: Prehospital blood transfusion has been adopted by many civilian helicopter emergency medical services agencies, and early outcomes are positive. The Shock Trauma Air Rescue Society operates six bases in Western Canada and started a blood on board process in 2013 in Regina that has expanded to all bases. Two units of O negative packed red blood cells are carried on every mission. We describe the processes and standard work ensuring safe storage, administration, and stewardship of this important resource. METHODS: The packed red blood cells are stored in an inexpensive, reusable temperature controlled cooler at 1°C-6°C. Close collaboration with local transfusion services and adherence to Canadian transfusion standards contributes to safety and sustainability. RESULTS: From October 1, 2013 to October 10, 2017, the Shock Trauma Air Rescue Society administered blood to 431 patients. Of this total, 62.9% received blood carried on our aircraft. A total of 463 blood box units were administered, and the majority of patients (69.0%) received both units. Blood used in Calgary, Alberta was 100% traceable, and only 1.2% of total units dispensed was wasted. The vast majority of unused units were returned to circulation. CONCLUSION: We describe the process to set up and monitor a prehospital blood transfusion program. Our standard work and stewardship processes minimize wastage of blood while keeping it readily available for our critically ill and injured patients.

Utilization Criteria for Prehospital Ultrasound in a Canadian Critical Care Helicopter Emergency Medical Service: Determining Who Might Benefit.

Introduction Prehospital ultrasound (PHUS) assessments by physicians and non-physicians are performed on medical and trauma patients with increasing frequency. Prehospital ultrasound has been shown to be of benefit by supporting interventions. Problem Which patients may benefit from PHUS has not been clearly identified. METHODS: A multi-variable logistic regression analysis was performed on a previously created retrospective dataset of five years of physician- and non-physician-performed ultrasound scans in a Canadian critical care Helicopter Emergency Medical Service (HEMS). For separate medical and trauma patient groups, the a-priori outcome assessed was patient characteristics associated with the outcome variable of "PHUS-supported intervention." RESULTS: Both models were assessed (Likelihood Ratio, Score, and Wald) as a good fit. For medical patients, the characteristics of heart rate (HR) and shock index (SI) were found to be most significant for an intervention being supported by PHUS. An extremely low HR was found to be the most significant (OR=15.86 [95% confidence interval (CI), 1.46-171.73]; P=.02). The higher the SI, the more likely that an intervention was supported by PHUS (SI 0.9 to<1.3: OR=9.15 [95% CI, 1.36-61.69]; P=.02; and SI 1.3+: OR=8.37 [95% CI, 0.69-101.66]; P=.09). For trauma patients, the characteristics of Prehospital Index (PHI) and SI were found to be most significant for PHUS support. The greatest effect was PHI, where increasing ORs were seen with increasing PHI (PHI 14-19: OR=13.36 [95% CI, 1.92-92.81]; P=.008; and PHI 20-24: OR=53.10 [95% CI, 4.83-583.86]; P=.001). Shock index was found to be similar, though, with lower impact and significance (SI 0.9 to<1.3: OR=9.11 [95% CI, 1.31-63.32]; P=.025; and SI 1.3+: OR=35.75 [95% CI, 2.51-509.81]; P=.008). CONCLUSIONS: In a critical care HEMS, markers of higher patient acuity in both medical and trauma patients were associated with occurrences when an intervention was supported by PHUS. Prospective study with in-hospital follow-up is required to confirm these hypothesis-generating results. O'Dochartaigh D , Douma M , Alexiu C , Ryan S , MacKenzie M . Utilization criteria for prehospital ultrasound in a Canadian critical care Helicopter Emergency Medical Service: determining who might benefit. Prehosp Disaster Med. 2017;32(5):536-540.

Five-year Retrospective Review of Physician and Non-physician Performed Ultrasound in a Canadian Critical Care Helicopter Emergency Medical Service.

OBJECTIVE: To describe the use of prehospital ultrasonography (PHUS) to support interventions, when used by physician and non-physician air medical crew (AMC), in a Canadian helicopter emergency medical service (HEMS). METHODS: A retrospective review was conducted of consecutive patients who underwent ultrasound examination during HEMS care from January 1, 2009 through March 10, 2014. An a priori created data form was used to record patient demographics, type of ultrasound scan performed, ultrasound findings, location of scan, type of interventions supported by PHUS, factors that affected PHUS completion, and quality indicator(s). Data analysis was performed through descriptive statistics, Student's t-test for continuous variables, Z-test for proportions, and Mann-Whitney U Test for nonparametric data. Outcomes included interventions supported by PHUS, factors associated with incomplete scans, and quality indicators associated with PHUS use. Differences between physician and AMC groups were also assessed. RESULTS: PHUS was used in 455 missions, 318 by AMC and 137 by physicians. In combined trauma and medical patients, in the AMC group interventions were supported by PHUS in 26% of cases (95% CI 18-34). For transport physicians the percentage support was found to be significantly greater at 45% of cases (95% CI 34-56) p = < 0.006. Incomplete PHUS scans were common and reasons included patient obesity, lack of time, patient access, and clinical reasons. Quality indicators associated with PHUS were rarely identified. CONCLUSIONS: The use of PHUS by both physicians and non-physicians was found to support interventions in select trauma and medical patients. Key words: emergency medical services; aircraft; helicopter; air ambulance; ultrasonography; emergency care, prehospital; prehospital emergency care.

A Pragmatic Randomized Evaluation of a Nurse-Initiated Protocol to Improve Timeliness of Care in an Urban Emergency Department.

STUDY OBJECTIVE: Emergency department (ED) crowding is a common and complicated problem challenging EDs worldwide. Nurse-initiated protocols, diagnostics, or treatments implemented by nurses before patients are treated by a physician or nurse practitioner have been suggested as a potential strategy to improve patient flow. METHODS: This is a computer-randomized, pragmatic, controlled evaluation of 6 nurse-initiated protocols in a busy, crowded, inner-city ED. The primary outcomes included time to diagnostic test, time to treatment, time to consultation, or ED length of stay. RESULTS: Protocols decreased the median time to acetaminophen for patients presenting with pain or fever by 186 minutes (95% confidence interval [CI] 76 to 296 minutes) and the median time to troponin for patients presenting with suspected ischemic chest pain by 79 minutes (95% CI 21 to 179 minutes). Median ED length of stay was reduced by 224 minutes (95% CI -19 to 467 minutes) by implementing a suspected fractured hip protocol. A vaginal bleeding during pregnancy protocol reduced median ED length of stay by 232 minutes (95% CI 26 to 438 minutes). CONCLUSION: Targeting specific patient groups with carefully written protocols can result in improved time to test or medication and, in some cases, reduce ED length of stay. A cooperative and collaborative interdisciplinary group is essential to success.

Optimization of indirect pressure in order to temporize life-threatening haemorrhage: A simulation study.

BACKGROUND: Minimizing haemorrhage using direct pressure is intuitive and widely taught. In contrast, this study examines the use of indirect-pressure, specifically external aortic compression (EAC). Indirect pressure has great potential for temporizing bleeds not amenable to direct tamponade i.e. abdominal-pelvic, junctional, and multi-site trauma. However, it is currently unclear how to optimize this technique. METHODS: We designed a model of central vessel compression using the Malbrain intra-abdominal pressure monitor and digital weigh scale. Forty participants performed simulated external aortic compression on the ground, on a stretcher mattress, and with and without a backboard. RESULTS: The greater the rescuer's bodyweight the greater was their mean compression (Pearson's correlation 0.93). Using one-hand, a mean of 28% participant bodyweight (95% CI, 26-30%) could be transmitted at sustainable effort, waist-height, and on a stretcher. A second compressing hand increased the percentage of rescuer bodyweight transmission 10-22% regardless of other factors (i.e. presence/absence or a backboard; rescuer position) (p<0.001). Adding a backboard increased transmission of rescuer bodyweight 7-15% (p<0.001). Lowering the patient from waist-height backboard to the floor increased transmission of rescuer bodyweight 4-9% (p<0.001). Kneeling on the model was the most efficient method and transmitted 11% more weight compared to two-handed maximal compression (p<0.001). CONCLUSIONS: Efficacy is maximized with larger-weight rescuers who use both hands, position themselves atop victims, and compress on hard surfaces/backboards. Knee compression is most effective and least fatiguing, thus assisting rescuers of lower weight and lesser strength, where no hard surfaces exist (i.e. no available backboard or trauma on soft ground), or when lengthy compression is required (i.e. remote locations). Our work quantifies methods to optimize indirect pressure as a temporizing measure following life-threatening haemorrhage not amenable to direct compression, and while expediting compression devices or definitive treatment.

Double-barrelled resuscitation: A feasibility and simulation study of dual-intraosseous needles into a single humerus.

INTRODUCTION: Resuscitation can be delayed, or impaired, by insufficient vascular access. This study examines whether dual-intraosseous needles, inserted into a single porcine humerus, can facilitate rapid and concomitant fluid and medication delivery. METHODS: After inserting one- and then two-intraosseous needles into the same porcine humerus, we determined the rate of fluid administration using (i) an infusion pump set to 999mL/h, and (ii) a standard pressure-bag set to 300mmHg. Next, we concomitantly infused blood, crystalloid and medications into the same medullary canal, using the two-needle set-up. Humeri were inspected for fluid-leakage, needle-displacement, and bone damage. RESULTS: Using an infusion pump, the mean normal-saline infusion-rate was significantly higher with dual-intraosseous needles compared to a single-intraosseous needle: the infusion-rate was 16mL/min using dual-needles versus 8mL/min for a single needle set-up (p<0.001). In contrast, using the pneumatic pressure-bag, the infusion rate was not statistically different when comparing dual-intraosseous needles versus single-intraosseous: the infusion-rate was 22mL/min versus 21ml/min (p=0.4) for 500mL, and 22ml/min versus 21ml/min (p=0.64) for one-litre, respectively. Blood product could be infused at a mean rate of 20mL/min through one needle while tranexamic acid was simultaneously infused through a second. There were no complications with a dual-intraosseous set-up (no fluid leakage; no needle-displacement; no high-pressure alarms, and no external bone-fractures or internal macrohistological damage) during any of our simulated resuscitation scenarios. CONCLUSIONS: This is the first published study evaluating dual-intraosseous needles in a single bone. Despite limitations, this preliminary study (using a porcine humerus) suggests that dual-intraosseous needles are feasible. For critically-ill patients with limited insertion sites, dual-intraosseous (a.k.a. 'double-barrelled resuscitation') may facilitate rapid and concurrent resuscitation.

How intravenous nitroglycerine transit time from bag-to-bloodstream can be affected by infusion technique: a simulation study.

OBJECTIVE: To measure the possible delays in intravenous nitroglycerine administration. METHODS: This was a simulation study of sham intravenous nitroglycerine using a standard nitroglycerine titration protocol. Variables studied were (i) common cannulae/needles, (ii) infusion accessories and (iii) presence of a parallel intravenous saline carrier line (or drive line) infusing at 30 mL/h. Outcomes were (i) delay from bag-to-bloodstream arrival and (ii) the dosage showing on the infusion pump when the sham drug first exits the cannula (aka the 'presumed initial dosage'). RESULTS: There was a statistically significant difference in both (i) time-to-bloodstream arrival and (ii) the dosage showing on the infusion pump as the sham first exits the cannula with (i) different cannulae, (ii) different accessories and (iii) presence of a carrier line. The bag-to-bloodstream time varied 10-fold: 197-2062 s. The 'presumed initial dosage' varied sixfold: 5-30 µg/min. Adding the medication to an already flowing carrier line reduced the time for the sham to exit the cannula fourfold: from 2062 to 469 s. CONCLUSIONS: Despite limitations, this study outlines the importance of cannula type, infusion accessories and carrier lines. Larger cannulae and greater priming volumes substantially delay drug delivery, whereas carrier lines/drive lines substantially accelerate drug delivery. Our study also shows how patients could be exposed to clinical delays, as well as incorrect presumptions about drug dosage. Guidelines, and education efforts, should highlight the clinical importance of factors that affect bag-to-bloodstream time.

Factors Associated with Failure of Non-invasive Positive Pressure Ventilation in a Critical Care Helicopter Emergency Medical Service.

INTRODUCTION: Non-invasive positive pressure ventilation (NIPPV) is used to treat severe acute respiratory distress. Prehospital NIPPV has been associated with a reduction in both in-hospital mortality and the need for invasive ventilation. HYPOTHESIS/PROBLEM: The authors of this study examined factors associated with NIPPV failure and evaluated the impact of NIPPV on scene times in a critical care helicopter Emergency Medical Service (HEMS). Non-invasive positive pressure ventilation failure was defined as the need for airway intervention or alternative means of ventilatory support. METHODS: A retrospective chart review of consecutive patients where NIPPV was completed in a critical care HEMS was conducted. Factors associated with NIPPV failure in univariate analyses and from published literature were included in a multivariable, logistic regression model. RESULTS: From a total of 44 patients, NIPPV failed in 14 (32%); a Glasgow Coma Scale (GCS)<15 at HEMS arrival was associated independently with NIPPV failure (adjusted odds ratio 13.9; 95% CI, 2.4-80.3; P=.003). Mean scene times were significantly longer in patients who failed NIPPV when compared with patients in whom NIPPV was successful (95 minutes vs 51 minutes; 39.4 minutes longer; 95% CI, 16.2-62.5; P=.001). CONCLUSION: Patients with a decreased level of consciousness were more likely to fail NIPPV. Furthermore, patients who failed NIPPV had significantly longer scene times. The benefits of NIPPV should be balanced against risks of long scene times by HEMS providers. Knowing risk factors of NIPPV failure could assist HEMS providers to make the safest decision for patients on whether to initiate NIPPV or proceed directly to endotracheal intubation prior to transport.