Randomized Crossover Simulation Study Research Articles

How Does Rescuer's Position Setting Impact Quality of Chest Compression: A Randomized Crossover Simulation Study on Unexperienced Clinicians.

High-quality chest compression (CC) is the crux of survival for cardiac arrest patients. While, rescuers' position setting relative to patients during CC was unrecommended in the present guidelines. We aimed to assess the impact of position settings on CC quality during cardiopulmonary resuscitation (CPR) and to test the heterogeneity related to rescuers' characteristics. We conducted randomized, crossover, simulation trials with clinical students unfamiliar with CPR. The participants received standard training on performing CC and were divided randomly into two groups. The two groups separately performed CC with standing and kneeling positions in turn, forming the crossover design. The trials were performed with standard manikin models. CC quality indicator data were recorded by the tracking and feedback system automatically. 156 participants finished at least one round of trial, with 126 participants finishing both rounds. Records for CC with kneeling and standing positions showed statistically significant differences in the correct rate, pause happening, average depth, and happening of over-depth compression. Regression analysis also implied that larger compression depths with the standing position were related to larger height and BMI of the participants. When performing CC, the standing position will lead to lower CC quality by larger chance of pause happening and over-depth compression. In addition, compression depth gaps between CC with kneeling and standing position were related with rescuer characteristics including height and BMI, with a threshold effect.

CPR quality with rotation of every 1 versus 2 minutes as characteristics of rescuers: A randomized crossover simulation study.

Fatigue and rotation time are key factors affecting the quality of cardiopulmonary resuscitation (CPR). This study aimed to investigate the effects of rotation time on CPR duration, and sex on chest compression quality. In this randomized crossover simulation study, we enrolled 100 paramedic students stratified by sex and randomly grouped into 28 male and 22 female pairs. In the 2- and 1-minute scenarios, 2 participants performed CPR for 20 minutes with a rotation cycle of 2 minutes and 1 minute, respectively. After taking a break, they changed over and performed CPR again for 20 minutes. The switching of roles was performed with the students positioned on opposite sides of the mannequin. For chest compression quality, a set was defined as CPR performed by 1 pair in a 2-minute scenario for 4 minutes. The quality of CPR in each set was compared between the 2 groups. The 1-minute group showed significantly higher chest compression depth than the 2-minute group (54.0 [51.5-57.0] vs 52.5 [48.5-56.5] mm, P = .001, respectively). The female 2-minute group showed decreased chest compression depth over time, and the 1-minute group showed significantly increased chest compression depth during all sets except the 2nd set (54.0 [51.9-55.1] vs 50.5 [48.5-53.8] mm [P = .030], 52.3 [49.4-54.5] vs 50.8 [47.0-53.1] mm [P = .080], 52.8 [49.8-54.5] vs 48.8 [45.4-51.6] mm [P = .002], 51.5 [48.5-53.3] vs 48.3 [44.5-50.6] mm [P = .004], and 50.8 [48.9-54.1] vs 47.5 [44.6-50.1] mm [P = .001], respectively). The fatigue scores in the 2-minute group were significantly higher during sets 4 and 5 than those in the 1-minute group. When rescuer fatigue increases during prolonged CPR owing to their physical strength and skill levels, the rotation of rescuers every minute would be helpful in maintaining high-quality CPR.

Usability testing of a blind intubation device for intubation novices: a randomized crossover simulation study.

A new blind intubation device (BID) has been developed for endotracheal intubation. This study aimed to test the usability of the BID in comparison to direct laryngoscopy (DL) and video laryngoscopy (VL) with inexperienced healthcare providers for endotracheal intubation. This was a randomized crossover simulation study. Participants who had conducted fewer than five live intubation sessions were included in the study. The manikin simulation was conducted using a Laerdal trainer airway manikin. Participants performed intubation using all three devices, DL, VL, and BID. The primary outcome was intubation success rate in the first pass the secondary outcome was intubation time to first ventilation, and the tertiary outcome was dental injury. A total of 45 healthcare workers who were novices in intubation participated in this study, including 13 physicians (interns), 14 emergency medical technicians, and 18 nurses. The intubation success rates in the first pass with BID, DL, and VL were 93.3%, 91.1%, and 97.8%, respectively (P=0.53). The intubation times to first ventilation with BID, DL, and VL were 13.15±6.16, 19.07±7.71, and 17.31±6.57 seconds, respectively (P<0.01). The proportions of dental injuries associated with BID, DL, and VL were 0% for physicians; 28.6%, 14.3%, and 0%, respectively for emergency medical technicians; and 27.8%, 11.1%, and 16.7%, respectively for nurses. We performed a pilot study to test the usability of the new BID. There was no significant difference in intubation success rate in the first pass among BID, DL, and VL. The intubation time to first ventilation was shorter with the BID compared to DL and VL.

Use of combined laryngo-bronchoscopy intubation approach in a simulated difficult airway scenario with cervical stabilization

The occurrence of unexpected difficult airway management (DAM) during endotracheal intubation (ETI) attempts represents a life-threatening scenario. The management of such challenges may improve with training in simulated DAM scenarios. Moreover, simulation allows investigation at the potential value of new devices and techniques for DAM. The combined use of laryngoscopy with fiberoptic bronchoscope (CLBI) has been proposed in this regard, but its performance by novices facing DAM remain unexplored. We performed a randomized crossover simulation study evaluating the performance of ninety-six anesthesiology residents during ETI with four approaches: direct laryngoscopy (DL), Glidescope®, McGrath® and CLBI. Increased difficulty was produced by placement of a cervical collar. Residents had maximum of 3 attempts per device/technique (up to 60 seconds per attempt). The main outcomes were success rate (SR) and corrected time-to-intubation (cTTI, with 60 seconds added for each failed attempt). Subgroup analyses were performed separating residents according to their experience (junior, n = 60; senior, n = 36).The CLBI had significantly lower SR at both 1st and 3rd attempt (31% and 64%, respectively) as compared to DL (93% and 98%), Glidescope® (70% and 86%) and McGrath® (58% and 84%), with all p &lt; 0.001. Moreover, CLBI had significantly longer cTTI (158.5 seconds; (54.3; 180)) than other devices: Glidescope® (37.6 seconds; (24.7; 88.2)), McGrath® (39.3 seconds; (20.6; 105.1)), and DL (19 seconds; (15.4; 27.2)), all p &lt; 0.002. CLBI and McGrath® were the only approaches performing better in senior as compared to junior residents. In a DAM simulated setting, anesthesiology residents had lower SR and longer cTTI with the CLBI as compared to direct and video-laryngoscopy.

A Comparison between Three Different Techniques Considering Quality Skills, Fatigue and Hand Pain during a Prolonged Infant Resuscitation: A Cross-Over Study with Lifeguards.

The aim of the study was to compare the quality of CPR (Q-CPR), as well as the perceived fatigue and hand pain in a prolonged infant cardiopulmonary resuscitation (CPR) performed by lifeguards using three different techniques. A randomized crossover simulation study was used to compare three infant CPR techniques: the two-finger technique (TF); the two-thumb encircling technique (TTE) and the two-thumb-fist technique (TTF). 58 professional lifeguards performed three tests in pairs during a 20-min period of CPR. The rescuers performed compressions and ventilations in 15:2 cycles and changed their roles every 2 min. The variables of analysis were CPR quality components, rate of perceived exertion (RPE) and hand pain with numeric rating scale (NRS). All three techniques showed high Q-CPR results (TF: 86 ± 9%/TTE: 88 ± 9%/TTF: 86 ± 16%), and the TTE showed higher values than the TF (p = 0.03). In the RPE analysis, fatigue was not excessive with any of the three techniques (values 20 min between 3.2 for TF, 2.4 in TTE and 2.5 in TTF on a 10-point scale). TF reached a higher value in RPE than TTF in all the intervals analyzed (p < 0.05). In relation to NRS, TF showed significantly higher values than TTE and TTF (NRS minute 20 = TF 4.7 vs. TTE 2.5 & TTF 2.2; p < 0.001). In conclusion, all techniques have been shown to be effective in high-quality infant CPR in a prolonged resuscitation carried out by lifeguards. However, the two-finger technique is less efficient in relation to fatigue and hand pain compared with two-thumb technique (TF vs. TTF, p = 0.01).

Infant Cardiopulmonary Resuscitation Quality While Walking Fast: A Simulation Study.

This study focuses on the characteristics (feasibility, resuscitation quality, and physical demands) of infant cardiopulmonary resuscitation (CPR) on the forearm during fast walking, performed by a trained lay rescuer. Twenty-one university students from the infant education degree participated in a randomized crossover simulation study to compare a standard pediatric CPR versus a walking pediatric CPR with a manikin on the rescue forearm. Each rescuer performed 2 resuscitation tests of 2 minutes on the infant manikin. Cardiopulmonary resuscitation, physiological, and perceived effort variables were measured. The quality of chest compressions was higher in standard pediatric CPR than in walking pediatric CPR (72% vs 51%; P < 0.001) and overall CPR quality (59% vs 49%; P = 0.02). There were no differences between ventilation quality (47% vs 46%). Walking pediatric CPR presented a higher percentage of maximum heart rate (52% vs 69%; P < 0.001) and perceived exertion rate (2 vs 5; P < 0.001). Participants walked an average of 197 m during the test. In conclusion, pediatric walking CPR is feasible although it represents a slight quality decrease in a simulation infant CPR setting. The option "CPR while walking fast to a safe place" seems to be suitable in terms of safety both for the victim and the rescuer, as well as CPR quality in special circumstances.

Utility of a Modified Oropharyngeal Airway for Performing Tracheal Intubation Using a Fiberoptic Bronchoscope and Video Stylet: A Randomized Crossover Trial Using a Manikin.

Purpose The purpose of this study was to assess if a modified airway (MA), developed by the authors, would act as a guide and improve the performance of intubation when used with a video stylet (VS) or fiberoptic bronchoscope (FOB) for endotracheal intubation. Methods This randomized crossover simulation study using manikins was conducted with 36 novice operators. Time to complete intubation, time to see the glottis, and success rate of intubation of each device were measured and compared with or without use of MA. Results For intubation using FOB with MA, the median time to complete intubation significantly reduced from 46 to 31 seconds with a medium effect size (p=0.004, r = 0.483), and the median time to see the glottis significantly reduced from 7 to 5 seconds with a medium effect size (p=0.032, r = 0.357). The overall success rate was not statistically different between FOB with MA (33/36, 91.7%) and FOB alone (31/36, 86.1%); however, the cumulative success rate over time for FOB with MA was higher than that for FOB alone (p=0.333). For intubation using VS, there were no differences in the time to see the glottis and time to complete intubation between VS with MA and VS alone (p=0.065 and p=0.926, respectively), and the cumulative success rate was not statistically significant (p=0.594). Conclusion Adjunct use of MA helped reduce time to complete intubation in FOB, but not in VS. If an inexperienced operator uses FOB, it would be helpful to use MA as an adjunct device.

Comparison of Chest Compression Quality Using Wing Boards versus Walking Next to a Moving Stretcher: A Randomized Crossover Simulation Study.

Background: When a rescuer walks alongside a stretcher and compresses the patient’s chest, the rescuer produces low-quality chest compressions. We hypothesized that a stretcher equipped with wing boards allows for better chest compressions than the conventional method. Methods: In this prospective, randomized, crossover study, we enrolled 45 medical workers and students. They performed hands-on chest compressions to a mannequin on a moving stretcher, while either walking (the walk method) or riding on wings attached to the stretcher (the wing method). The depths of the chest compressions were recorded. The participants’ vital signs were measured before and after the trials. Results: The average compression depth during the wing method (5.40 ± 0.50 cm) was greater than during the walk method (4.85 ± 0.80 cm; p < 0.01). The average compression rates during the two minutes were 215 ± 8 and 217 ± 5 compressions in the walk and wing methods, respectively (p = ns). Changes in blood pressure (14 ± 11 vs. 22 ± 14 mmHg), heart rate (32 ± 13 vs. 58 ± 20 bpm), and modified Borg scale (4 (interquartile range: 2–4) vs. 6 (5–7)) were significantly lower in the wing method cohort compared to the walking cohort (p < 0.01). The rescuer’s size and physique were positively correlated with the chest compression depth during the walk method; however, we found no significant correlation in the wing method. Conclusions: Chest compressions performed on the stretcher while moving using the wing method can produce high-quality chest compressions, especially for rescuers with a smaller size and physique.

Pre-filled syringes with adrenaline during cardiopulmonary resuscitation in nonshockable rhythms. Pilot randomised crossover simulation study

Background: Pre-filled syringes are increasingly popular in medicine, especially in emergency medicine, where fast intervention is crucial. Additionally, as indicated by numerous studies, the use of drugs in prefilled syringes reduces the risk of medical errors associated with inadequate preparation of the drug and reduces the risk of contamination as a result of tissue injury due to rupture of a standard ampoule with the drug. The aim of the study was to compare the use of pre-filled syringes with adrenaline and standard adrenaline in ampoules during simulated CPR during simulated cardiopulmonary resuscitation in non-shockable rhythms performed by two-person teams. Methods: The study was a randomised cross-over study and was based on medical simulation. The study involved 40 paramedics assigned randomly to 20 two-person rescue teams. These teams were to perform 10-minute cardiopulmonary resuscitation in three research scenarios: Scenario A — During CPR, access to the median basilic vein and preparation and administration of adrenaline infusions from generally available ampoules at concentration 1:1000 were required (Adrenaline WZF 0.1%; Polfa, Warsaw, Poland) with a standard syringe; Scenario B — During resuscitation, the median basilic vein was accessed and adrenaline was to be administered from an adrenaline pre-filled syringe (Aguettant Sante, Lyon, France); Scenario C — During CPR, intraosseous tibial vascular access was obtained using a NIO Adult kit, and adrenaline was administered using a pre-filled syringe with adrenaline (Aguettant Sante, Lyon, France). Both the order of resuscitation and medication administration as well as the order of participants were random. Results : The time to obtain vascular access in the examined scenarios varied and was 240 sec [IQR; 220–265] for Scenario A, 236 sec [IQR; 210–270] for Scenario B, and 165 sec [IQR; 90–180] for Scenario C; A vs. C, (p < 0.001), B vs. C (p < 0.001). In scenarios A, B, and C, the duration of adrenaline administration varied and was 55 sec [IQR; 50–85] vs. 20 sec [IQR; 18–35] vs. 20 sec [IQR; 20–30] (A vs. B, and A vs. C, p < 0.001). Conclusion: A simulation study has shown that paramedics in two-person teams are unable to deliver adrenaline at the time recommended by CPR guidelines. The delay of CPM adrenaline supply compared to PFS adrenaline is statistically significant. In the opinion of paramedics participating in the study, adrenaline during resuscitation should be administered by means of pre-filled syringes, which eliminates the delays in rescue operations resulting from the time needed to prepare drugs as well as limited human resources in rescue teams.

Effect of a feedback system on the quality of 2-minute chest compression-only cardiopulmonary resuscitation: a randomised crossover simulation study.

ObjectiveWe evaluated the quality of 2-minute continuous chest compressions (CCCs) performed by emergency staff in 30-second intervals to determine the effect of a feedback system on maintaining the quality of CCCs.MethodsTwo hundred three physicians and nurses were randomised into two groups. Each participant performed 2-minute CCCs both with and without feedback. Group A performed CCCs under the guidance of a feedback device followed by performance without feedback, and Group B performed these tasks in reverse order. The primary outcome was the proportion of optimal compressions; i.e., compressions at both the correct rate (100–120 beats/minute) and correct depth (5–6 cm).ResultsDuring 2-minute CCCs, the proportion of optimal compressions was poor in personnel without feedback. The proportion of optimal compressions was unchanged and low from 2.4% (interquartile range, 0.0%–32.8%) in the first 30 seconds to 3.3% (0.0%–47.7%) in the last 30 seconds of the 2-minute period. Use of the feedback device significantly improved and maintained the quality of compressions from the first 30 seconds (53.3%; 29.2%–70.4%) to the last 30 seconds (82.8%; 50.8%–96.2%).ConclusionUse of the feedback device was helpful for maintaining the quality of CCCs.

Pediatric Intraosseous Access Performed by Emergency Department Nurses Using Semiautomatic Devices: A Randomized Crossover Simulation Study.

No study has examined the performance of emergency department (ED) nurses in establishing intraosseous access (IO) access. This study aimed to evaluate ED nurses' success rate in establishing pediatric IO access using semiautomatic devices. A randomized crossover simulation study was conducted. The success rates of ED nurses were compared with those of paramedics with similar years of experience. The study instruments were the new spring-loaded injector (NIO) and the battery power drill (EZ-IO). Uncooked piglets' bones were used as the study model. All attempts were filmed by a video camera. Successful placement was defined as the visualization of flow from the marrow cavity. Participants recorded their ranking of the "ease of use" of each device. No differences in 1-attempt success rate was found between nurses and paramedics (27/34 [79.4%] vs 25/30 [83.3%], P = 0.68). Nurses and paramedics had similar success rates with the 2 semiautomatic IO devices (12/17 vs 12/15 with the spring-loaded injector, P = 0.69, and 15/17 vs 13/15 with the battery power drill, P = 0.9). The number of failed attempts and the causes for failure were equally distributed between nurses and paramedics. Median ease-of-use Likert-scale scores of the spring-loaded injector and the battery power drill were 4 (interquartile range [IQR] = 3-4) and 5 (IQR = 5-5) (P < 0.04) for the nurses and 5 (IQR = 4-5) and 5 (IQR = 4-5) (P = 0.44) for the paramedics, respectively. Emergency department nurses and paramedics had a similarly high insertion success rates on a pediatric bone model. This pilot study suggests that ED nurses can successfully perform this procedure.

Securing the airway patency by firefighters with the use of CombiTube. A pilot data

INTRODUCTION: The protection of the airways with the use of vomer devices for ventilation is one of the elements of the procedure in cardiopulmonary resuscitation. One of the alternative ways to protect the airways from endotracheal intubation is the CombiTube tube. The aim of the study was to assess the ability to protect airway patency using CombiTube during simulated cardiopulmonary resuscitation performed by firefighters. METHOD: This study was a prospective randomized crossover simulation study. The study included 56 firefighters who performed airway patency protection with the use of CombiTube during simulated cardiopulmonary resuscitation with and without chest compressions. RESULTS: The median duration of securing airway patency with CombiTube device during scenario without and with chest compressions was: 21 s (IQR; 14−25.5) vs. 21.5 s (IQR; 15−27), respectively. The vast majority of attempts to insert CombiTube resulted in the insertion of the device to the esophagus: 92.8% vs. 91.1% (with and without chest compressions, respectively). The insertion of CombiTube to the trachea was observed in 7.1% vs. 8.9% during scenarios with and without chest compression, respectively. Study participants assessed the easiness of performing the procedure at 19 points (IQR, 13−22) for scenario without chest compression, and 18.5 points (IQR, 14−21.5) for scenario with uninterrupted chest compressions. CONCLUSIONS: Firefighters are able to secure the airway patency with the use of CombiTube tube after a short training. Compressing the chest during resuscitation does not prolong the procedure of maintaining the airway patency with CombiTube. The tip of the CombiTube tube is inserted into the esophagus in over 91% of cases.

A Novel Method of Newborn Chest Compression: A Randomized Crossover Simulation Study.

Objective: To compare a novel two-thumb chest compression technique with standard techniques during newborn resuscitation performed by novice physicians in terms of median depth of chest compressions, degree of full chest recoil, and effective compression efficacy.Patients and Methods: The total of 74 novice physicians with less than 1-year work experience participated in the study. They performed chest compressions using three techniques: (A) The new two-thumb technique (nTTT). The novel method of chest compressions in an infant consists in using two thumbs directed at the angle of 90° to the chest while closing the fingers of both hands in a fist. (B) TFT. With this method, the rescuer compresses the sternum with the tips of two fingers. (C) TTHT. Two thumbs are placed over the lower third of the sternum, with the fingers encircling the torso and supporting the back.Results: The median depth of chest compressions for nTTT was 3.8 (IQR, 3.7–3.9) cm, for TFT−2.1 (IQR, 1.7–2.5) cm, while for TTHT−3.6 (IQR, 3.5–3.8) cm. There was a significant difference between nTTT and TFT, and TTHT and TFT (p < 0.001) for each time interval during resuscitation. The degree of full chest recoil was 93% (IQR, 91–97) for nTTT, 99% (IQR, 96–100) for TFT, and 90% (IQR, 74–91) for TTHT. There was a statistically significant difference in the degree of complete chest relaxation between nTTT and TFT (p < 0.001), between nTTT and TTHT (p = 0.016), and between TFT and TTHT (p < 0.001).Conclusion: The median chest compression depth for nTTT and TTHT is significantly higher than that for TFT. The degree of full chest recoil was highest for TFT, then for nTTT and TTHT. The effective compression efficiency with nTTT was higher than for TTHT and TFT. Our novel newborn chest compression method in this manikin study provided adequate chest compression depth and degree of full chest recoil, as well as very good effective compression efficiency. Further clinical studies are necessary to confirm these initial results.

Intubating extremely premature newborns: a randomised crossover simulation study

ObjectiveDetermine whether tracheal intubation of extremely low birthweight (ELBW) neonates is more successful with a size-0 or size-00 Miller laryngoscope blade.DesignRandomised crossover simulation studySettingSimulated neonatal intensive care unit environmentStudy subjectsNeonatology...

Comparative Safety, Efficiency, and Nursing Preference Among 3 Methods for Intravenous Push Medication Preparation: A Randomized Crossover Simulation Study.

ObjectiveThe aim of this study was to compare total time for drug preparation, associated errors, and nurses' preferences among 3 different intravenous (IV) push medication methods.Research DesignA randomized crossover simulation design was used to compare total time for drug preparation and incidence of medication preparation errors between BD Simplist (BDS), Carpuject (CJ), and traditional vial-and-syringe process (TVSP). Three medication preparation areas were created to mimic a hospital setting. Twenty-four critical care nurses were asked to prepare an IV dose of diphenhydramine, ketorolac, and morphine in random order using BDS, CJ, and TVSP, also in random order. Total time for the preparation of each drug was measured. Medication preparation errors were noted. At the start of the study, nurses were surveyed about their stress levels regarding aspects of IV push medications. At completion, nurses were asked to rank order from the most to the least preferred administration method.ResultsMean time in seconds for drug preparation was significantly shorter (P < 0.004) with BDS (28.7; 95% confidence interval [CI], 23.3–34.2) and CJ (28.3; 95% CI, 23.1–33.5) compared with TSVP (65.8; 95% CI, 57.7–73.9). The time difference between BDS and CJ was not statistically significant. Medication preparation errors were significantly reduced with BDS compared with both CJ and TVSP (1.4% versus 77.8% versus 73.6%; P < 0.001). The BDS was ranked by nurses as the most preferred method.ConclusionsThe BD Simplist system for IV push medications may offer nurses an opportunity to reduce steps and reduce errors during medication preparation.

Comparison of Miller and Airtraq laryngoscopes for orotracheal intubation by physicians wearing CBRN protective equipment during infant resuscitation: a randomized crossover simulation study.

BackgroundThe purpose of this study was to evaluate the performance of orotracheal intubation with the Miller laryngoscope compared with the Airtraq laryngoscope by emergency and pediatric physicians wearing CBRN-PPE type III on infant manikins with conventional airway. We hypothesized that in this situation, the orotracheal intubation with the Airtraq laryngoscope would be faster and more effective than with the Miller laryngoscope.MethodsThis was a prospective, randomized, crossover, single-center study who recruited emergency department physicians on a voluntary basis. Each physician performed a total of 20 intubation trials while in CBRN-PPE with the two intubation techniques, Miller and Airtraq. Intubations by each airway device were tested over ten consecutive runs. The order of use of one or the other devices was randomized with a ratio of 1:1. The primary endpoint was overall orotracheal intubation success.ResultsFifty-five emergency and pediatric physicians were assessed for eligibility. Forty-one physicians were included in this study and 820 orotracheal intubation attempts were performed. The orotracheal intubation success rate with the Airtraq laryngoscope was higher than with the Miller (99 % vs. 92 %; p-adjusted <.001). The orotracheal intubation and glottis visualization times decreased with the number of attempts (p <.001). The median orotracheal intubation time with the Airtraq laryngoscope was lower than with the Miller laryngoscope (15 s vs. 20 s; p-adjusted <.001). The median glottis visualization time with the Airtraq laryngoscope and with the Miller laryngoscope were not different (6.0 s vs. 7.5 s; p-adjusted =.237). Thirty-four (83 %) physicians preferred the Airtraq laryngoscope versus 6 (15 %) for the Miller (p-adjusted <.001).DiscussionFor tracheal intubation by physicians wearing CBRN-PPE during infant resuscitation simulation, we showed that the orotracheal intubation success rate with the Airtraq laryngoscope was higher than with the Miller laryngoscope and that orotracheal intubation time with the Airtraq laryngoscope was lower than with the Miller laryngoscope.ConclusionsIt seems useful to train the physicians in emergency departments in the use of pediatric Airtraq and for the management of CBRN risks.

Establishing a definitive airway in the trauma patient by novice intubators: A randomised crossover simulation study

BackgroundEstablishing a definitive airway, defined as a tube placed in the trachea with cuff inflated below the vocal cords, is standard of care in pre-hospital airway management of the trauma patient. However, in this setting, and using manual in-line stabilisation of the neck, success rate of intubation by inexperience providers is suboptimal. The use of supraglottic airway devices that allow blind tracheal intubation has been suggested as an alternative method by the Advanced Trauma Life Support (ATLS) programme of the American College of Surgeons. We aimed to compare intubation with the standard intubation technique (direct laryngoscopy [DL]) with blind intubation through an intubating-laryngeal mask airway (I-LMA) during manual in-line stabilisation of the neck. Materials and methodsA randomised, crossover manikin study was performed with 29 emergency medical technicians undergoing training for paramedic status. Outcome measures were success rate in one intubation attempt, duration of intubation, and assessment of ease-of-use. ResultsStudy subjects had a higher success rate of tracheal intubation with I-LMA than with DL (27/29 vs. 18/29, p<0.025), and I-LMA was assessed as easier to use (4 vs. 3, p<0.0001). Longer duration of intubation was found with I-LMA compared to DL (54.2 vs. 42.8s, p<0.002). Success rate of correct placement of I-LMA within the airway was 28/29 (96.5%). Time to achieve correct placement of I-LMA within the airway was shorter than duration of tracheal intubation with DL (26.9 vs. 42.8s, p<0.0001). ConclusionsNovice intubators had a higher success rate of intubation with I-LMA than with DL, but duration of intubation was longer with I-LMA. Time to achieve correct placement of I-LMA within the airway was shorter than duration of tracheal intubation with DL. Findings of this simulation study suggest that in the presence of manual in-line stabilisation of the neck, I-LMA-guided intubation is the preferred technique for novice intubators.

A vertical two-thumb technique is superior to the two-thumb encircling technique for infant cardiopulmonary resuscitation.

The two-thumb encircling (TTE) technique often results in suboptimal cardiac compression and does not meet the requirements of current resuscitation guidelines. We compared this technique with the vertical two-thumb (VTT) technique, our novel modification of the TTE technique. This was a prospective randomised crossover simulation study of out-of-hospital infant cardiopulmonary resuscitation (CPR). Participants who had completed a basic life support course performed 10 cycles of cardiac compressions on a manikin for each technique. We enrolled 36 medical doctors who had applied for a hospital internship in this study. The VTT generated significantly higher pressure than the TTE and the pressure difference ranged from 26.8 to 62.9mmHg for each cycle, with a mean difference of 43.5mmHg (95% CI, 37.8-49.2). The difference in pressure showed a tendency to increase with increasing cycles of cardiac compressions. The participants' heart and respiratory rate was higher with the VTT, but they said that it was easier to perform cardiac compressions with this technique. The VTT technique generated more pressure than the TTE technique in a simulated model of infant out-of-hospital CPR. It can provide an alternative compression technique for effective infant CPR, especially for the rescuers with small hands or a weak grip.

Over-the-head two-thumb encircling technique as an alternative to the two-finger technique in the in-hospital infant cardiac arrest setting: a randomised crossover simulation study

ObjectiveTo determine if the over-the-head two-thumb encircling technique (OTTT) provides better quality cardiopulmonary resuscitation (CPR) than the conventional two-finger technique (TFT) when performed by a lone rescuer in an in-hospital...

Chest compression with kneeling posture in hospital cardiopulmonary resuscitation: A randomised crossover simulation study.

We suggest an alternative chest compression (CC) in kneeling posture using a 'kneeling stool' on which the performer kneels beside the patient on a bed in-hospital. In kneeling posture, we can maintain high quality cardiopulmonary resuscitation (CPR) without the bed height adjustment, which is necessary and inconvenient in standing posture. This study is a randomised crossover trial with 38 participants working in one ED. The first group knelt on the kneeling stool beside a manikin placed on a bed, whereas the second group stood on a step stool with the manikin at knee level using bed height adjustment. All the participants performed continuous chest compression for 5 min without audio-visual feedback. After that, the posture was changed in each group. The parameters of CC quality (CC depth, rate, accuracy, and incomplete chest recoil), visual analogue scale (VAS) for fatigue and pain, and preference of participants were compared between the two groups. The data of 33 participants in both postures were analysed following exclusion of five participants. In the comparisons overall and per minute between the two postures, the parameters and VAS do not differ significantly (all P > 0.05) except for the median 1st CC rate that was faster in kneeling posture than in standing posture, P = 0.01). Twenty-three performers preferred the kneeling posture. A kneeling posture with a kneeling stool were preferred by participants, which have shown similar results in CC parameters and VAS with a standing posture on a stepstool with bed height adjustment during in-hospital CPR.