Search Results (21)

Objectives: To assess risk factors for post-extubation stridor in children and its impact on clinical outcomes. Methods: Prospective cohort study with children aged from 0 to 13 years who were intubated or underwent orotracheal intubation in the pediatric intensive care units (PICU) of two tertiary public hospitals. The outcome of interest was the occurrence of post-extubation stridor. The information collected included patient characteristics, comorbidities, history of airway manipulation, and factors related to orotracheal intubation. A logistic regression was used to identify potential risk factors for post-extubation stridor; data were analyzed until hospital discharge, death, or referral to another facility. Results: A total of 239 children were included, with a median age of 1.3 years and a duration of intubation of three days. Post-extubation stridor was observed in 57.3% of children. A multivariate analysis included prehospital or non-specialized hospital intubation, trauma or complications during intubation, and orotracheal intubation longer than seven days as risk factors for stridor. Children with stridor had a longer PICU length of stay, longer duration of invasive mechanical ventilation, and were often managed with non-invasive ventilation (p < 0.05). Most children with extubation failure (p = 0.001) and cardiorespiratory arrest (p = 0.03) presented with stridor. Conclusions: Risk factors for post-extubation stridor included intubation performed in prehospital or non-specialized hospitals, orotracheal intubation longer than seven days, and trauma or complications during intubation. Children with stridor had a worse prognosis, with longer stays in the PICU and on mechanical ventilation and higher rates of extubation failure. Full article

Background: Airway management forms the most important component of pre-hospital trauma patients’ care. In such a setting, the definitive airways may be difficult to establish. This study aimed to evaluate four newer supraglottic airway devices in a simulated condition of an entrapped trauma patient with restricted access. Methods: An intubation manikin with a cervical collar on was placed on the driver’s seat of a passenger car, which was positioned on its left side. The access to the manikin was only allowed from the front. The insertion to successful ventilation (T_iv) time was recorded. First-pass success and the ease of use were also evaluated. Results: The AuraGain device required the shortest median T_iv at 7.5 s (Interquartile Range, IQR 4) vs. 9.5 s (IQR 11), p < 0.001. The AuraGain achieved the highest first-pass success—90%. The Baska mask was the most user-friendly, achieving a mean score of 8.6. Conclusions: The AuraGain outperformed other studied devices concerning the T_iv as well as the first-pass success. The Baska mask was the easiest to use. Full article

Background/Objectives: Out-of-hospital cardiac arrest (OHCA) has persistently low survival rates. While advanced airway management (AAM) is crucial during cardiopulmonary resuscitation, optimal timing remains unclear. This study examined the association between early AAM and clinical outcomes in adult OHCA patients. Methods: This retrospective study analyzed Korean nationwide OHCA registry data (August 2019–December 2022). Adult patients with emergency medical service-treated OHCA of presumed medical origin receiving AAM were included. Early AAM was defined as airway placement within 5 min of CPR initiation. Time-dependent propensity score matching controlled for selection bias and time-related confounding. Structural equation modeling examined associations between AAM timing and other prehospital interventions. Primary outcome was survival to hospital discharge with good neurological recovery (cerebral performance category 1–2). Results: Among 51,869 patients receiving AAM, 27,591 received early AAM and 24,278 received delayed AAM. After propensity score matching, 12,014 patients were included per group with balanced characteristics. Early AAM was associated with higher prehospital return of spontaneous circulation (11.8% vs. 10.5%; adjusted RR 1.21, 95% CI 1.12–1.29) and favorable neurological recovery (5.8% vs. 5.1%; adjusted RR 1.12, 95% CI 1.01–1.23). AAM timing correlated with timing of other critical interventions, including rhythm analysis and epinephrine administration. Conclusions: Early AAM within 5 min of CPR initiation was associated with improved neurological outcomes and increased prehospital ROSC in OHCA. Airway timing may indicate overall resuscitation quality, emphasizing the importance of coordinated, timely prehospital interventions. Full article

Background: Emergency airway management is a crucial and complex procedure frequently performed in the emergency department (ED). Airway contamination usually caused by blood, secretions, and emesis impairs ventilation, reduces successful intubation, and increases the complication rates, leading to difficult laryngoscopy, delayed intubation, and increased mortality rates. One technique employed to decontaminate these airways when standard approaches fail is Suction-Assisted Laryngoscopy and Airway Decontamination (SALAD). Methods: A comprehensive literature search was conducted across PubMed, Cochrane, and Science direct databases following a specific search strategy. All search results were screened in a two-stage process (title–abstract and full-text screening) in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) 2020 guidelines. Data from finalized articles were extracted using a standardized excel file developed a priori. Lastly, quality and risk of bias were assessed using appropriate tools according to respective study designs, and data were narratively synthesized. Results: A total of 224 records were identified. Upon screening, seven studies were included consisting of five simulation-based studies and two clinical case reports. Simulation studies reported that SALAD training significantly improved first-pass intubation success (53.7–90.2%), reduced time to intubation (up to 30 s), and enhanced airway visualization. Clinical cases further reported successful first-pass intubation in patients with massive airway contamination without complications. Overall, across both study types, the SALAD technique improved airway management performance, provider confidence, and airway contamination control compared to standard suction techniques. Conclusions: This systematic review highlights the benefits of the SALAD technique by enhancing airway visualization, reinforcing it as a significant tool for contaminated airway management. Trainees who underwent SALAD training demonstrated improved first-pass intubation success, reduced intubation time, and increased operator confidence. While data from the included studies seems promising, most studies are small simulation-based studies with limited clinical outcome data. Given its clinical relevance and educational value, future studies must prioritize high-quality research in clinical environments to establish SALAD’s efficacy and to define its role in integration into prehospital protocols. Full article

Introduction: Supraglottic airway devices play an important role in airway management in both pre-hospital as well as in-hospital settings. They are a well-recognised alternative to definitive airways in current medical practice. However, despite their wide use in clinical practice, little is known about their performance in patients with restricted access. This study aims to evaluate the time required to insert a supraglottic airway device and achieve a successful ventilation of four different devices in a simulated condition of an entrapped trauma patient with simultaneous cervical spine immobilisation. The ease-of-use and first-attempt success rate were also assessed. Methods: Fully qualified paramedics participated in this randomised, controlled manikin trial. A manikin with the cervical collar on was placed on the driver’s seat of a passenger car. Access to the manikin was only allowed from the front. The I-gel, the SLIPA, the LMA Supreme, and the Ambu AuraGain were evaluated. The time required to insert the device and achieve successful ventilation was recorded. The first-attempt success rate and the ease-of-use by the operator were also assessed. Results: The LMA Supreme required the shortest mean time to insert and ventilate the manikin, 10.5 s (±1.7) vs. 16.4 s (±8.4), p < 0.001. The use of the LMA Supreme was associated with the highest first-attempt success rate—88%. The SLIPA device outperformed all other studied devices with regard to ease-of-use and user-friendliness. Its mean score was 8.3 out of 10. Conclusions: The LMA Supreme was superior in terms of both the insertion-to-ventilation time as well as the first-attempt success rate. The SLIPA device was found to be easier to use and more user-friendly. Full article

Background/Objectives: Acute obstructions of the upper respiratory tract are emergencies that may require a cricothyrotomy as ultima ratio. For this, precise identification of the conic ligament is essential. Point-of-care ultrasound (POCUS) offers a reliable tool for anatomical localization in challenging cases and could be used by a range of emergency medicine workers. This prospective, controlled observational study assesses the development of competencies of paramedics (PMs) in point-of-care ultrasound (POCUS) assisted identification of the conic ligament after structured training, and compares their competence level to emergency physicians (EPs). Methods: PMs and a control group of EPs received an identical structured training program as part of an ultrasound course. It included a 10-min theoretical introduction, a 10-min video, and a 45-min practical session with ultrasound devices. Questionnaires and a practical test assessed both group’s previous experiences, satisfaction with training, and the development of subjective and objective competencies before (T₁) and after (T₂) the training. Results: A total of 120 participants (N = 92 PMs and N = 28 EPs) participated. A minority had previously performed a cricothyrotomy even in training settings (PMs 17%; EPs 11%), and none had identified the conic ligament using POCUS. The study group’s subjective and objective competencies increased significantly (p < 0.001). At T2, the study group demonstrated comparable subjective (p = 0.22) and objective (p = 0.81) competencies to those of the control group. The study group needed significantly (p < 0.01) less time to perform the DOPS. While both groups were satisfied with the study material (PMs 2.2 ± 1.2 vs. Eps 1.6 ± 1.0; p = 0.02) and the training (PMs 1.8 ± 1.0 vs. EPs 1.4 ± 0.7, p = 0.03), the study group rated both significantly better. Conclusions: After structured training, paramedics successfully identified the conic ligament using POCUS comparably to emergency physicians. Integrating POCUS into paramedic training may improve prehospital airway management and enhance patient safety. Further studies should investigate long-term skill retention and real-life application. Full article

Automated ventilator controllers have the potential to simplify oxygen and carbon dioxide management for trauma. In the pre-hospital or military medicine environment, trauma care can be required for prolonged periods by personnel with limited ventilator management training. As such, there is a need for closed-loop control systems that can adapt ventilator management to a complex, ever-changing medical environment. Here, we present a novel hardware-in-loop test platform for the independent troubleshooting and evaluation of oxygen and carbon dioxide automated ventilator management capabilities. The oxygen management system provides an analogue blood oxygen signal that is responsive to the fraction of inspired oxygen and the peak inspiratory pressure ventilator settings. A tested oxygenation controller successfully reached the target oxygen saturation within 5 min. The carbon dioxide removal system integrates with commercial ventilator technology and mimics carbon dioxide generation, lung compliance, and airway resistance while providing an end-tidal carbon dioxide level that is responsive to changes in the tidal volume and respiratory rate settings. A test mechanical ventilator controller was able to regulate EtCO₂ regardless of the starting value within 10 min. This highlights the system’s functionality and provides proof-of-concept demonstrations for how the hardware-in-loop test platforms can be used for evaluating closed-loop controller technologies. Full article

Cystic fibrosis (CF) is a multisystemic disease caused by a genetic defect, namely a mutation in the CFTR gene, that results in the production of an abnormal protein that regulates the flow of chloride ions through epithelial cells, leading to the dehydration of secreted mucus and changes in its biological properties. Chronic inflammation and recurrent respiratory infections progressively damage lung tissue, leading to respiratory and cardiorespiratory failure. This study aims to present a clinical case and explore the clinical changes in CF that may influence the provision of pre-hospital first aid. The study presents a case report of a 23-year-old CF patient undergoing evaluation for lung transplantation, infected with Pseudomonas aeruginosa and Staphylococcus aureus with the MSSA phenotype, and in a severe condition due to infectious exacerbation. Despite antibiotic treatment, the patient’s condition deteriorated, leading to respiratory failure and cardiac arrest. Emergency measures were taken to maintain airway patency—the patient was sedated, intubated, and connected to a ventilator. CF involves systemic complications that, during exacerbations, may require urgent interventions. Cystic fibrosis is associated with multiple systemic complications, some of which may, during exacerbations, require emergency medical interventions. Providing care to this patient group involves specific procedures addressing the consequences of the underlying disease. Due to increasing survival rates and the emergence of new phenotypes, there is a need for the continuous education of medical personnel, including emergency responders, regarding the management of genetically determined diseases. This study underscores the importance of recognizing CF’s complex nature and adapting emergency care accordingly to ensure timely and effective intervention in life-threatening situations. Full article

Background: Trauma is a major global public health concern. Many countries are working to reduce preventable deaths; however, the mortality rate remains higher than their goal, indicating a need for continuous development in trauma care, including further improvements across the system. This article explores recent developments and updated guidelines for both prehospital emergency care and in-hospital trauma management, emphasizing evidence-based and patient-centered approaches. Current concepts: In the prehospital phase, the primary focus is on early and aggressive hemorrhage control using techniques such as tourniquet application, wound packing, and permissive hypotension as standard practices. Advancements in this field, including intraosseous vascular access and tranexamic acid administration, have improved patient outcomes. The emphasis on structured assessments, particularly “circulation, airway, breathing” (CAB) assessments, underscores the importance of managing life-threatening hemorrhages. During the in-hospital phase, the primary focus is on controlling bleeding. Protocols emphasize the judicious administration of fluids to prevent over-resuscitation and mitigate the risk of exacerbating coagulopathy. Efficient transfusion strategies are implemented to address hypovolemia, while ensuring balanced ratios of blood products. Furthermore, the implementation of advanced interfacility transfer systems and communication tools such as “Situation, Background, Assessment, Recommendation” (SBAR) plays a pivotal role in optimizing patient care and reducing delays in definitive treatment. Discussion and Conclusions: This review highlights the importance of implementing advanced strategies to align with international standards and further decrease the rate of preventable trauma-related deaths. Strengthening education and optimizing resource allocation for both prehospital and hospital-based trauma care are essential steps toward achieving these objectives. Full article

Introduction: Airway management in pre-hospital settings is often challenging and difficult to perform. This is particularly true during tracheal intubation of entrapped patients with difficult airway access. There are various airway adjuncts available in the current practice. Their aim is to facilitate tracheal intubation. One of the recently introduced devices is the flexible tip bougie. The aim of this study was to evaluate the flexible tip bougie for intubation in a simulated condition of an entrapped trauma patient with simultaneous cervical spine immobilisation. Methods: An intubation manikin with the cervical collar on was placed on and secured to the driver’s seat of a passenger car. The car was then positioned on its left side. The first attempt success rate as well as the intubation and successful ventilation time were recorded. The ease of use by the operator and user-friendliness were also assessed. Results: The standard gum elastic bougie required the shortest mean intubation to successful ventilation time, 38.4 s (±9.6) vs. 41.4 s (±6.8), p = 0.46. The first attempt success rate was higher in the standard gum elastic bougie group, 92% vs. 88%, p = 0.04. There were no failed intubations when the standard gum elastic bougie was used. The flexible tip bougie was found to be more difficult to use and less user-friendly, 7.6 (±1.5) vs. 5.8 (±2.9), p = 0.02. Conclusions: The standard gum elastic bougie was superior in terms of the first attempt success and the time required for intubation and successful ventilation. Moreover, it was found to be easier to use and more user-friendly. Full article

Children who sustain major injuries are at risk of receiving insufficient pain relief and sedation, which can have physical and psychological repercussions. Heightened emotional distress can increase the likelihood of developing symptoms of post-traumatic stress. Providing sufficient analgesia and sedation for children with major trauma presents specific challenges, given the potential for drug-related adverse events, particularly in non-intubated patients. The current literature suggests that a relatively low percentage of pediatric patients receive adequate analgesia in pre-hospital and emergency department settings following major trauma. There are only sparse data on the safety of the provision of analgesia and sedation in children with major trauma in the pre-hospital and ED settings. The few studies that examined sedation protocols in this context highlight the importance of physician training and competency in managing pediatric airways. There is a pressing need for prospective studies that focus upon pediatric major trauma in the pre-hospital and emergency department setting to evaluate the benefits and risks of administering analgesia and sedation to these patients. The aim of this narrative review was to offer an updated overview of analgesia and sedation management in children with major trauma in pre-hospital and ED settings. Full article

Most pediatric out-of-hospital cardiac arrests (OHCAs) are caused by hypoxia, which is generally consecutive to respiratory failure. To restore oxygenation, prehospital providers usually first use basic airway management techniques, i.e., bag-valve-mask (BVM) devices. These devices present several drawbacks, most of which could be avoided using supraglottic airway devices. These intermediate airway management (IAM) devices also present significant advantages over tracheal intubation: they are associated with higher success and lower complication rates in the prehospital setting. There are, however, few data regarding the effect of early IAM in pediatric OHCA. This paper details the protocol of a trial designed to evaluate the impact of this airway management strategy on ventilation parameters through a simulated, multicenter, randomized, crossover trial. The hypothesis underlying this study protocol is that early IAM without prior BVM ventilations could improve the ventilation parameters in comparison with the standard approach, which consists in BVM ventilations only. Full article

The performance of ambulance crew affects the quality of pre-hospital treatment, which is vital to the survival for out-of-hospital cardiac arrest (OHCA) patients, yet remains suboptimal in China. In this retrospective analysis study, we aimed to examine the effect of a citywide quality improvement programme on provision of prehospital advanced life support (ALS) by emergency medical service (EMS) system. EMS-treated adult OHCA patients after the implementation of the programme (1 January 2021 to 30 June 2022) were compared with historical controls (1 June 2019 to 31 August 2020) in Suzhou. Multivariable logistic regression analysis and propensity score matching procedures were applied to compare the outcomes between two periods for total OHCA cases and subgroup of cases treated by fixed or non-fixed ambulance crews. A total of 1465 patients (pre-period/post-period: 610/855) were included. In the 1:1 matched analysis of 591 cases for each period, significant improvement (p < 0.05) was observed for the proportion of intravenous (IV) access (23.4% vs. 68.2%), advanced airway management (49.2% vs. 57.0%), and return of spontaneous circulation (ROSC) at handover (5.4% vs. 9.0%). The fixed ambulance crews performed better than non-fixed group in IV access and advanced airway management for both periods. There were significant increases in IV access (AOR 12.66, 95%CI 9.02–18.10, p < 0.001), advanced airway management (AOR 1.67, 95% CI 1.30–2.16, p < 0.001) and ROSC at handover (AOR 2.37, 95%CI 1.38–4.23, p = 0.002) after intervention in unfixed group, while no significant improvement was observed in fixed group except for IV access (AOR 7.65, 95%CI 9.02–18.10, p < 0.001). In conclusion, the quality improvement program was positively associated with the provision of prehospital ALS interventions and prehospital ROSC following OHCA. The fixed ambulance crews performed better in critical care provision and prehospital outcome, yet increased protocol adherence and targeted training could fill the underperformance of non-fixed crews efficaciously. Full article

Background and Objectives: Acute respiratory distress syndrome is a life-threatening lung condition that prevents enough oxygen from getting to the lungs and blood. The causes can be varied, although since the COVID-19 pandemic began there have been many cases related to this virus. The management and evolution of ARDS in emergency situations in the last 5 years was analyzed. Materials and Methods: A systematic review was carried out in the PubMed and Scopus databases. Using the descriptors Medical Subject Headings (MeSH), the search equation was: “Emergency health service AND acute respiratory distress syndrome”. The search was conducted in December 2021. Quantitative primary studies on the care of patients with ARDS in an emergency setting published in the last 5 years were included. Results: In the initial management, adherence to standard treatment with continuous positive airway pressure (CPAP) is recommended. The use of extracorporeal membrane reduces the intensity of mechanical ventilation or as rescue therapy in acute respiratory distress syndrome (ARDS). The prone position in both intubated and non-intubated patients with severe ARDS is associated with a better survival of these patients, therefore, it is very useful in these moments of pandemic crisis. Lack of resources forces triage decisions about which patients are most likely to survive to start mechanical ventilation and this reflects the realities of intensive care and emergency care in a resource-limited setting. Conclusions: adequate prehospital management of ARDS and in emergency situations can improve the prognosis of patients. The therapeutic options in atypical ARDS due to COVID-19 do not seem to vary substantially from conventional ARDS. Full article

Prehospital airway devices are often classified as either basic or advanced, with this latter category including both supraglottic airway (SGA) devices and instruments designed to perform endotracheal intubation (ETI). Therefore, many authors analyze the impact of SGA and ETI devices jointly. There are however fundamental differences between these instruments. Indeed, adequate airway protection can only be achieved through ETI, and SGA devices all have relatively low leak pressures which might compromise both oxygenation and ventilation when lung compliance is decreased. In addition, there is increasing evidence that SGA devices reduce carotid blood flow in case of cardiac arrest. Nevertheless, SGA devices might be particularly useful in the prehospital setting where many providers are not experienced enough to safely perform ETI. Compared to basic airway management (bag-valve-mask) devices, SGA devices enable better oxygenation, decrease the odds of aspiration, and allow for more reliable capnometric measurement by virtue of their enhanced airtightness. For all these reasons, we strongly believe that SGA devices should be categorized as “intermediate airway management devices” and be systematically analyzed separately from devices designed to perform ETI. Full article