Prehospital Ultrasound-Guided Pediatric Fascia Iliaca Block.

The fascia iliaca block (FIB) provides effective regional anesthesia for fractures of the femur. There is 1 previous case report of a prehospital FIB in a child using a landmark technique. We report the successful prehospital application of a FIB using ultrasound guidance in a 7-year-old girl.

Prehospital Care: An International Comparison of Independently Developed Training Courses.

OBJECTIVE: Prehospital and retrieval medicine (PHRM) occurs in a complex work environment. Appropriate training is essential to ensure high standards of clinical care and logistic decision making. Before commencing the role, PHRM doctors have varying levels of experience. This narrative review article aims to describe and compare 6 internationally accepted PHRM courses. METHODS: Six PHRM course directors were asked to describe their course in terms of education methods used, course content, and assessment processes. Each of the directors contributed to the discussion process. RESULTS: Although developed independently, all 6 courses use a comparable combination of lectures, simulations, and discussion groups. The amount of each pedagogical modality varies between the courses. CONCLUSION: We have identified significant similarities and some important differences among some well-accepted independently developed PHRM courses worldwide. Differences in content and the methods of delivery appear linked to the background of participants and service case mix. The authors believe that even in the small niche of PHRM, courses need to be tailored to the participants and the "destination of the participants" (ie, where they are going to use their skills).

Fentanyl versus placebo with ketamine and rocuronium for patients undergoing rapid sequence intubation in the emergency department: The FAKT study-A randomized clinical trial.

OBJECTIVE: The objective was to determine whether the use of fentanyl with ketamine for emergency department (ED) rapid sequence intubation (RSI) results in fewer patients with systolic blood pressure (SBP) measurements outside the pre-specified target range of 100-150 mm Hg following the induction of anesthesia. Methods This study was conducted in the ED of five Australian hospitals. A total of 290 participants were randomized to receive either fentanyl or 0.9% saline (placebo) in combination with ketamine and rocuronium, according to a weight-based dosing schedule. The primary outcome was the proportion of patients in each group with at least one SBP measurement outside the prespecified range of 100-150 mm Hg (with adjustment for baseline abnormality). Secondary outcomes included first-pass intubation success, hypotension, hypertension and hypoxia, mortality, and ventilator-free days 30 days following enrollment. RESULTS: A total of 142 in the fentanyl group and 148 in the placebo group commenced the protocol. A total of 66% of patients receiving fentanyl and 65% of patients receiving placebo met the primary outcome (difference = 1%, 95% CI = -10 to 12). Hypotension (SBP ≤ 99 mm Hg) was more common with fentanyl (29% vs. 16%; difference = 13%, 95% CI = 3% to 23%), while hypertension (≥150 mm Hg) occurred more with placebo (69% vs. 55%; difference = 14%, 95% CI = 3 to 24). First-pass success rate, 30 day mortality, and ventilator-free days were similar. CONCLUSIONS AND RELEVANCE: There was no difference in the primary outcome between groups, although lower blood pressures were more common with fentanyl. Clinicians should consider baseline hemodynamics and postinduction targets when deciding whether to use fentanyl as a coinduction agent with ketamine.

Crisis Resource Management and High-Performing Teams in Hyperacute Stroke Care.

BACKGROUND AND PURPOSE: Management of stroke patients in the acute setting is a high-stakes task with several challenges including the need for rapid assessment and treatment, maintenance of high-performing team dynamics, management of cognitive load affecting providers, and factors impacting team communication. Crisis resource management (CRM) provides a framework to tackle these challenges and is well established in other resuscitative disciplines. The current Coronavirus Disease 2019 (COVID-19) pandemic has exposed a potential quality gap in emergency preparedness and the ability to adapt to emergency scenarios in real time. METHODS: Available resources in the literature in other disciplines and expert consensus were used to identify key elements of CRM as they apply to acute stroke management. RESULTS: We outline essential ingredients of CRM as a means to mitigate nontechnical challenges providers face during acute stroke care. These strategies include situational awareness, triage and prioritization, mitigation of cognitive load, team member role clarity, communication, and debriefing. Incorporation of CRM along with simulation is an established tool in other resuscitative disciplines and can be incorporated into acute stroke care. CONCLUSIONS: As stroke care processes evolve during these trying times, the importance of consistent, safe, and efficacious care facilitated by CRM principles offers a unique avenue to alleviate human factors and support high-performing teams.

FentAnyl or placebo with KeTamine for emergency department rapid sequence intubation: The FAKT study protocol.

BACKGROUND: Some critically ill patients require rapid sequence intubation in the emergency department, and ketamine is one sedative agent employed, due to its relative haemodynamic stability. Tachycardia and hypertension are frequent side effects, and in less stable patients, shock can be unmasked or exacerbated. The use of fentanyl as a co-induction agent may lead to a smoother haemodynamic profile post-induction, which may lead to reduced mortality in this critically ill cohort. This randomised controlled trial aims to compare the effect of administering fentanyl vs placebo in a standardised induction regimen with ketamine and rocuronium on (a) the percentage of patients in each group with a systolic blood pressure outside the range of 100-150 mm Hg within 10 minutes of induction, (b) the laryngoscopic view, and (c) 30-day mortality. METHODS/DESIGN: Three hundred patients requiring rapid sequence intubation in participating emergency departments will be randomised to receive either fentanyl or placebo (0.9% saline) in addition to ketamine and rocuronium according to a standardised, weight-based induction regimen. The primary outcome measure is the percentage of patients in each group with a systolic blood pressure outside the range of 100-150 mm Hg within 10 minutes of induction. Secondary outcome measures include the laryngoscopic view, percentage of first pass success, 30-day mortality and number of ventilator-free days at 30 days. DISCUSSION: The effect of adding fentanyl to an induction regimen of ketamine and rocuronium will be evaluated, both in terms of post-intubation physiology, the effect on intubating conditions, and 30-day mortality.

Zero point survey: a multidisciplinary idea to STEP UP resuscitation effectiveness.

The primary survey assessment is a cornerstone of resuscitation processes. The name itself implies that it is the first step in resuscitation. In this article, we argue that in an organized resuscitation the primary survey must be preceded by a series of steps to optimize safety and performance and set the stage for the execution of expert team behavior. Even in the most time critical situations, an effective team will optimize the environment, perform self-assessments of personal readiness and participate in a preemptive team brief. We call these processes the 'zero point survey' as it precedes the primary survey. This paper explains the rationale for the zero point survey and describes a structured approach designed to be suitable for all resuscitation situations.

Pre-hospital advanced airway management in children: a challenge that training can handle.

We respond to the Tarpgaard et al. article reporting on pre-hospital endotracheal intubation (PHETI) success and complications by Danish critical care teams including critical care anaesthetists. We compare the authors' results with previously published results from our service's experience with PHETI in a similar patient population, also with physician and paramedic medical teams. From 25 children <16 years of age, the Danish study reports overall success, and first-pass success, and complication rates of 96, 75 and 20%, respectively. A recently published study of 82 patients that we completed revealed the following results: 100, 91 and 14%, respectively. We propose training and operating protocols we believe contribute to this relative success in paediatric PHETI.

Analysis of Out-of-Hospital Pediatric Intubation by an Australian Helicopter Emergency Medical Service.

STUDY OBJECTIVE: We examine first-look success in emergency pediatric intubation by a physician-staffed helicopter emergency medical service (EMS). METHODS: A database analysis of all pediatric (<16 years) intubations during a 64-month period was undertaken, using data from a prospectively enrolled electronic airway registry form. Recorded findings included patient demographics, operator background, airway intervention including intubation attempts, complications, and critical timings. RESULTS: Eighty-two subjects were identified during the 64-month study. All patients were successfully intubated. The overall first-look success rate was 75 of 82 (91%), registrars achieving a first-look success rate of 26 of 26 (100%), consultants 16 of 17 (94%), and paramedics 33 of 39 (85%). Overall complication rate was 14%; 84% of cases were rapid sequence induction, whereas 16% were "cold intubations." Difficult airway indicators were present in 77% of patients. CONCLUSION: A high first-look success rate for pediatric intubation was achieved by adult helicopter EMS physicians and intensive care paramedics. To our knowledge, this compares favorably with the rate in published literature in pediatric emergency departments and critical care units.

Does end-tidal capnography confirm tracheal intubation in fresh-frozen cadavers?

BACKGROUND: Life-like end-tidal capnography (ETCO2) waveforms have been demonstrated in recently deceased and fresh-frozen cadavers following tracheal intubation, offering potential for high fidelity airway simulation training. As the mechanism for carbon dioxide production is not fully understood, it is possible that oesophageal intubation may also generate a capnograph. Our aim was to measure ETCO2 levels following (1) oesophageal and (2) tracheal intubation in fresh-frozen cadavers, and to observe the size, shape and duration of any capnographic waveform. METHODS: Four fresh frozen cadavers underwent oesophageal intubation by an emergency medicine specialist with confirmation by a second specialist. Hand ventilation with room air via a self-inflating resuscitation bag was provided at 12 breaths per minute for 2 min or until ETCO2 was zero for 10 consecutive breaths. ETCO2 and waveform morphology were examined and video recorded. The oesophagus was then extubated and the process was repeated for tracheal intubation. RESULTS: In no case was oesophageal ETCO2 detected. For two cadavers, life-like ETCO2 waveforms were achieved immediately after tracheal intubation, with maximum ETCO2 achieved by the second breath. In these cases waveform morphology was normal and persistent. CONCLUSIONS: Cadaveric oesophageal intubation did not result in a capnography waveform, simulating live patients. When present, ETCO2 following tracheal intubation showed normal morphology which was sustained for 2 min. However, ETCO2 was not present following tracheal intubation in all cadavers. These results represent instrumentation on the cadavers for the first time after thawing and further work should assess the repeatability of the findings with subsequent intubations.

Hemodynamic Response After Rapid Sequence Induction With Ketamine in Out-of-Hospital Patients at Risk of Shock as Defined by the Shock Index.

STUDY OBJECTIVE: Ketamine is considered a stable induction agent for rapid sequence induction; however, hypotension rates up to 24% are reported. The shock index (shock index=pulse rate/systolic blood pressure [SBP]) may identify patients at risk of adverse hemodynamic change. We investigate whether SBP and pulse rate response to ketamine induction differ when patients are classified as being at risk of shock by their shock index. METHODS: We conducted a prospective observational study of electronically collected vital sign data from patients undergoing rapid sequence induction with ketamine. Patients were grouped into low shock index (shock index <0.9) or high shock index (shock index ≥0.9) preinduction. Pulse rate and SBP were compared between 3 minutes preinduction and for 3 measurements postinduction (3-minute intervals) by repeated-measures ANOVA. Proportions of patients developing hypotension or hypertension are also reported. RESULTS: One hundred twelve patients were enrolled (81 low shock index, 31 high shock index). Low shock index patients had increased SBP after induction (16 mm Hg; 95% confidence interval [CI] 11 to 21 mm Hg), whereas high shock index patients did not (2 mm Hg; 95% CI -4 to 7 mm Hg). Pulse rate in low shock index patients increased after induction (20 beats/min; 95% CI 16 to 25 beats/min) and remained elevated, whereas in high shock index patients a difference occurred at the second postinduction measurement only (15 beats/min; 95% CI 11 to 18 beats/min). More high shock index patients became hypotensive (26%; 95% CI 12% to 45%) than low shock index ones (2%; 95% CI 0% to 9%), whereas more low shock index patients became hypertensive (40%; 95% CI 29% to 51%) than high shock index ones (13%; 95% CI 4% to 30%). CONCLUSION: After ketamine induction, high shock index patients exhibited blunted hypertensive responses and more frequent hypotension, whereas low shock index patients had sustained increases in pulse rate and SBP.