A novel CPR-assist device vs. established chest compression techniques in infant CPR: A manikin study.

INTRODUCTION: Guidelines for infant CPR recommend the two-thumb encircling hands technique (TTT) and the two-finger technique (TFT) for chest compression. Some devices have been designed to assist with infant CPR, but are often not readily available. Syringe plungers may serve as an alternative infant CPR assist device given their availability in most hospitals. In this study, we aimed to determine whether CPR using a syringe plunger could improve CPR quality measurements on the Resusci-Baby manikin compared with traditional methods of infant CPR. METHODS: Compression area with a diameter of 1 to 2 cm is recommended in previous infant CPR device researches. In this is a randomized crossover manikin study, we examined the efficacy of the Syringe Plunger Technique (SPT) which uses the plunger of the 20 ml syringe with a 2 cm diameter flat piston, commonly available in hospital, for infant External Chest Compressions (ECC). Participants performed TTT, TFT and SPT ECC on Resusci® Baby QCPR® according to 2020 BLS guidelines. RESULTS: Sixty healthcare providers participated in this project. The median (IQR) ECC depths in the TTT, TFT and SPT in the first minute were 41 mm (40-42), 40 mm (38-41) and 40 mm (39-41), respectively, with p < 0.001. The median (IQR) ECC recoil in the TTT, TFT and SPT groups in the first minute was 15% (1-93), 64% (18-96) and 53% (8-95), respectively, with p = 0.003. The result in the second minute had similar findings. The SPT had the best QCPR score and less fatigue. CONCLUSION: The performance of chest compression depth and re-rebound ratio was statistically different among the three groups. TTT has good ECC depth and depth accuracy but poor recoil. TFT is the complete opposite. SPT can achieve a depth close to TTT and has a good recoil performance as TFT. Regarding comprehensive performance, SPT obtains the highest QCPR score, and SPT is also less fatigued. SPT may be an effective alternative technique for infant CPR.

The risk factors of the 72-h unscheduled return visit admission to emergency department in adults below 50 years old.

BACKGROUND: An unscheduled return visit (URV) to the emergency department (ED) within 72-h is an indicator of ED performance. An unscheduled return revisit (URV) within 72-h was used to monitor adverse events and medical errors in a hospital quality improvement program. The study explores the potential factors that contribute to URV to the ED within 72-h and the unscheduled return revisit admission (URVA) in adults below 50 years old. METHODS: The case-control study enrolled 9483 URV patients during 2015-2020 in National Cheng-Kung University Hospital. URVA and URV non-admission (URVNA) patients were analyzed. The Gini impurity index was calculated by decision tree (DT) to split the variables capable of partitioning the groups into URVA and URVNA. Logistic regression is applied to calculate the odds ratio (OR) of candidate variables. The α level was set at 0.05. RESULTS: Among patients under the age of 50, the percentage of females in URVNA was 55.05%, while in URVA it was 53.25%. Furthermore, the average age of URVA patients was 38.20 ± 8.10, which is higher than the average age of 35.19 ± 8.65 observed in URVNA. The Charlson Comorbidity Index (CCI) of the URVA patients (1.59 ± 1.00) was significantly higher than that of the URVNA patients (1.22 ± 0.64). The diastolic blood pressure (DBP) of the URVA patients was 85.29 ± 16.22, which was lower than that of the URVNA (82.89 ± 17.29). Severe triage of URVA patients is 21.1%, which is higher than the 9.7% of URVNA patients. The decision tree suggests that the factors associated with URVA are "severe triage," "CCI higher than 2," "DBP less than 86.5 mmHg," and "age older than 34 years". These risk factors were verified by logistic regression and the OR of CCI was 2.42 (1.50-3.90), the OR of age was 1.84 (1.50-2.27), the OR of DBP less than 86.5 was 0.71 (0.58-0.86), and the OR of severe triage was 2.35 (1.83-3.03). CONCLUSIONS: The results provide physicians with a reference for discharging patients and could help ED physicians reduce the cognitive burden associated with the diagnostic errors and stress.

Effect of thoracic stiffness on chest compression performance - A prospective randomized crossover observational manikin study.

Introduction: Human thoracic stiffness varies and may affect the performance during external chest compression (ECC). The Extra Compression Spring Resusci® QCPR Anne manikin is a high-fidelity training model developed for ECC training that can account for varying levels of thoracic stiffness. The aim of this study was to use this training model to investigate the effects of thoracic stiffness on ECC biomechanics and qualities. Methods: Fifty-two participants performed standard ECC on the manikin with different thoracic springs to simulate varying levels of thoracic stiffness. The MatScan Pressure Measurement system was used to investigate the ECC pressure and force distribution. Results: The hard spring group's performance had a better complete recoil ratio (90.06 ± 24.84% vs. 79.75 ± 32.17% vs. 56.42 ± 40.15%, p < 0.001 at second minute), but was more inferior than the standard and soft spring groups in overall quality, ECC depth (34.17 ± 11.45 mm vs. 41.25 ± 11.42 mm vs. 51.88 ± 7.56, p < 0.001 at second minutes), corrected depth ratio, and corrected rate ratio. The hard spring group had less radial-ulnar peak pressure difference (kgf/cm2) than the other two groups (-0.28 ± 0.38 vs. -0.30 ± 0.43 vs. -0.47 ± 0.34, p = 0.01), demonstrating that more symmetrical pressure was applied in the hard spring group. The soft spring group had better ECC depth, corrected depth ratio, corrected rate ratio, and overall quality, but its performance in complete recoil was inferior, and unbalanced pressure was more liable to cause injury. Hard springs caused operator fatigue easily. Conclusion: The thoracic stiffness greatly affected the performance of ECC. Our findings provided information for more effective ECC practices and training.

Biomechanical analysis of force distribution in one-handed and two-handed child chest compression- a randomized crossover observational study.

BACKGROUND: Even force distribution would generate efficient external chest compression (ECC). Little research has been done to compare force distribution between one-hand (OH) and two-handed (TH) during child ECC. Therefore, this study was to investigate force distribution, rescuer perceived fatigue and discomfort/pain when applying OH and TH ECC in children. METHODS: Crossover manikin study. Thirty-five emergency department registered nurses performed lone rescuer ECC using TH and OH techniques, each for 2 min at a rate of at least 100 compressions/min. A Resusci Junior Basic manikin equipped with a MatScan pressure measurement system was used to collect data. The perceived exertion scale (modified Borg scale) and numerical rating scale (NRS) was applied to evaluate the fatigue and physical pain of delivering chest compressions. RESULTS: The maximum compression force (kg) delivered was 56.58 ± 13.67 for TH and 45.12 ± 7.90 for OH ECC (p <  0.001). The maximum-minimum force difference force delivered by TH and OH ECC was 52.24 ± 13.43 and 41.36 ± 7.57, respectively (p <  0.001). The mean caudal force delivered by TH and OH ECC was 29.45 ± 16.70 and 34.03 ± 12.01, respectively (p = 0.198). The mean cranial force delivered by TH and OH ECC was 27.13 ± 11.30 and 11.09 ± 9.72, respectively (p <  0.001). The caudal-cranial pressure difference delivered by TH and OH ECC was 19.14 ± 15.96 and 26.94 ± 14.48, respectively (p = 0.016). The perceived exertion and NRS for OH ECC was higher than that of the TH method (p < 0.001, p = 0.004, respectively). CONCLUSIONS: The TH method produced greater compression force, had more efficient compression, and delivered a more even force distribution, and produced less fatigue and physical pain in the rescuer than the OH method. TRIAL REGISTRATION: The Cheng Kung University Institutional Review Board A-ER-103-387. http://nckuhirb.med.ncku.edu.tw/sitemap.php.

Biomechanical analysis of force distribution in one-handed and two-handed adult chest compression: a randomised crossover observational study.

INTRODUCTION: The standard method of chest compression for adults is a two-handed procedure. One-handed external chest compression (ECC) is used in some situations such as during transport of patients who had an out-of-hospital cardiac arrest, but the quality of one-handed ECC is still not well known. The distribution of force is related to the quality of chest compression and may affect the risk of injury. This study aimed to determine the differences in the quality and potential safety concern between one-handed ECC and two- handed ECC. METHODS: In this randomised crossover study, participants recruited from National Cheng Kung University Hospital and the ambulance team from the fire bureau were asked to perform one-handed and two-handed ECC on the Resusci Anne manikin according to standard 2015 ECC guidelines. The MatScan Pressure Measurement system was used to investigate the compression pressure and force distribution. RESULTS: Two-handed ECC had better results than one-handed ECC in terms of the median (IQR) depth (51.00 (41.50-54.75) mm vs 42.00 (27.00-49.00) mm, p=0.018), the proportion of depth accuracy (82.05% (13.95%-99.86%) vs 11.17% (0.00%-42.13%), p=0.028) and the proportion of incomplete recoil (0.23% (0.01%-0.44%) vs 2.42% (0.60%-4.21%), p=0.002). The maximum force (45.72 (36.10-80.84) kgf vs 35.64 (24.13-74.34) kgf, p<0.001) and ulnar-radial force difference (7.13 (-16.58 to 21.07) kgf vs 23.93 (11.19-38.74) kgf, p<0.001) showed statistically significant differences. The perceived fatigue of two-handed ECC versus one-handed ECC was 5.00 (3.00-6.00) vs 6.00 (5.00-8.00), p<0.001. CONCLUSION: The quality of one-handed ECC, based on depth and recoil, is worse than that of standard two-handed ECC. The pressure and force distribution of one-handed ECC result in greater ulnar pronation of the hand than that of two-handed ECC. One-handed ECC more easily causes operator fatigue. Acknowledging these findings and adjusting training for one-handed ECC would potentially improve the quality of cardiopulmonary resuscitation during transport.

Dry Wearable Textile Electrodes for Portable Electrical Impedance Tomography.

Electrical impedance tomography (EIT), a noninvasive and radiation-free medical imaging technique, has been used for continuous real-time regional lung aeration. However, adhesive electrodes could cause discomfort and increase the risk of skin injury during prolonged measurement. Additionally, the conductive gel between the electrodes and skin could evaporate in long-term usage and deteriorate the signal quality. To address these issues, in this work, textile electrodes integrated with a clothing belt are proposed to achieve EIT lung imaging along with a custom portable EIT system. The simulation and experimental results have verified the validity of the proposed portable EIT system. Furthermore, the imaging results of using the proposed textile electrodes were compared with commercial electrocardiogram electrodes to evaluate their performance.

How does the side of approach impact the force delivered during external chest compression?

BACKGROUND: We investigated the biomechanics of four external chest compression (ECC) approaches involving different sides of approach and hand placement during cardiopulmonary resuscitation (CPR). METHODS: A total of 60 participants (30 women and 30 men) with CPR certification performed standard continuous 2-min ECC on a Resusci Anne manikin with real-time feedback in four scenarios: rescuer at the manikin's right side with right hand chest contact (RsRc), rescuer at the manikin's right side with left hand chest contact (RsLc), rescuer at the manikin's left side with left hand chest contact (LsLc), and rescuer at the manikin's left side with right hand chest contact (LsRc). Pressure distribution maps of the palm, peak compression pressure, and compression forces were analysed. RESULTS: The participants' mean age, height, and weight was 24.8 ± 4.8 years, 165.8 ± 8.7 cm, and 62.7 ± 13.5 kg, respectively. Of the participants, 58 and 2 were right- and left-handed, respectively. Significant between-scenario differences were observed in ulnar-side palm pressure. Ulnar-radial pressure differences were higher in the LsLc and RsRc groups than in the LsRc and RsLc groups (0.69 ± 0.62 and 0.73 ± 050 kg/cm2 vs. 0.49 ± 0.49 and 0.50 ± 0.59 kg/cm2; respectively; p < 0.05). Ulnar-radial force differences were higher in the LsLc and RsRs groups than in the sLsLc and RsRs groups. CONCLUSIONS: The higher differences in pressure and force under the LsLc and RsRc approaches may lead to higher risks of potential injury. When performing standard-quality ECC, the LsRc and RsLc approaches, in which compression pressure and force are better distributed, may be more suitable than RsRc or LsLc.

Implementation of a radiation injury management curriculum for health-care professionals in Taiwan.

AIM: Radiation-related injury in the general population due to accidents or incidents is a rare but significant event that merits serious study and planning in the health-care system. Therefore, we developed different levels of training courses targeting medical emergency response and treatment for radiation-related injury in patients, for different health-care professionals and medical students. METHODS: The curriculum, teaching instructions, and objectives were based on the working group consensus of first responders of radiation-related injury. The working group included different specialists from hospitals, medical schools, and government radiation emergency response agencies. RESULTS: Several different course levels, including lectures, group discussions, case and scenario discussions, hands-on practice, tabletop drills, and drills were included. The curriculums have shown that developing different levels of courses for medical students and health-care professionals was feasible. CONCLUSION: Through the cooperation of different specialties and different interactive courses, the training programs were able to meet the initial education goals for medical emergency and radiation-related injury for medical students and health-care professionals.

Validation of MEDS score in predicting short-term mortality of adults with community-onset bacteremia.

BACKGROUND: The Mortality in Emergency Department Sepsis (MEDS) score can be used to stratify ED patients with suspected infections according to mortality risk. However, it has yet to be externally validated for patients having bloodstream infections. METHODS: We retrospectively computed clinical information for the MEDS score, Pitt bacteremia score (PBS), Charlson comorbidity index (CCI), and McCabe-Jackson comorbid classification (MJCC) for adults with community-onset bacteremia. The MEDS score was validated by the comparisons with the following scoring systems: the PBS, CCI, MJCC, PBS plus MJCC, and PBS plus CCI. We evaluated goodness-of-fit statistics and c-statistics as measures of model calibration and discrimination, respectively. RESULTS: Of 2328 adults, a good calibration for 28-day crude mortality was obtained only in the MEDS score and PBS plus MJCC; a higher c-statistic (0.870, P < 0.001) were achieved by the MEDS score, compared to the PBS, CCI MJCC, PBS plus MJCC, and PBS plus CCI. A high c-statistic was observed in two combinative scoring system: the PBS plus CCI (0.855, P < 0.001) and PBS plus MJCC (0.843, P < 0.001). According to the Kaplan-Meier curves, 28-day crude mortality significantly differed between patients with scores equal to or higher than selected cutoff values and those with scores lower than selected cutoff values: 10 in the MEDS score and 5 in the PBS plus MJCC, respectively. CONCLUSION: The MEDS score is an excellent predictor of short-term outcomes in patients with community-onset bacteremia because it provides estimates with higher calibration and discrimination than those of the other scoring systems.

Biomechanics of two-thumb versus two-finger chest compression for cardiopulmonary resuscitation in an infant manikin model.

OBJECTIVE: The loading force applied in infant external chest compression (ECC) has not been determined. The objective of this crossover study was to quantify the actual force involved in two-thumb (TT)-encircling hands and two-finger (TF) methods during infant cardiopulmonary resuscitation. METHODS: A total of 42 emergency medical professionals performed lone rescuer infant external chest compression (ECC) with TF and TT methods. The order of two methods was arranged randomly, with an interval of 30 min in between. The force was collected by MatScan as primary outcomes. The secondary outcomes, quality of chest compressions, and fatigue level were also recorded by SkillReporter and perceived exertion scale. RESULTS: Using the TT method, the rescuers performed cardiopulmonary resuscitation (CPR) with higher ECC quality, but more incomplete recoil than they did using the TF method. The mean compression forces delivered in the first and second minutes were 3.53 ± 1.27 kg and 3.22 ± 1.11 kg (P = 0.012) for TF and 4.11 ± 1.80 kg and 4.04 ± 1.83 kg (P = 0.568) for TT, respectively. Pairwise comparison indicates that the compression force delivered through the TF method during the first and second minute of ECC were inferior to that delivered through the TT method. The TF method involved greater perceived exertion than the TT method (5.27 ± 4.69 vs. 4.02 ± 2.31; P = 0.007). The median perceived exertions for the TF and TT methods were 5 and 4, respectively. CONCLUSION: For infant CPR, the TT method involved greater loading force, lower fatigue, and higher overall ECC quality than the TF method. The optimal compression force is about 3.8-4.3 kg.

Association of injury pattern and entrapment location inside damaged buildings in the 2016 Taiwan earthquake.

BACKGROUND/PURPOSE: To explore the association of patient injury patterns and entrapped locations inside damaged buildings in the 2016 Taiwan earthquake. METHODS: A retrospective analysis was conducted using the Tainan incident registry system. Residents inside nine conjunctive, 16-story (49.3 m in height) reinforced concrete buildings were categorized as non-injured, injured, and dead. Residents were classified into different groups according to their entrapped locations in height and the severity of building damage. The field triage acuity and trauma severity among groups were compared. Statistical significance was set at the level of 0.05. RESULTS: There were 309 enrollees with 76 (24.6%) non-injured, 118 (38.2%) injured, and 115 (37.2%) dead. Residents either in the high floors (odds ratio [OR] = 2.9, 95% CI: 1.5-5.8, p = 0.003) or in the collapsed buildings (OR = 18.2, 95% CI: 7.6-43.6, p < 0.001) were more likely to be dead. Injured patients who were located in the high floors were more likely to have severe field triage acuities (adjusted OR = 14.7, 95% CI: 1.8-118.0, p = 0.012); intracranial hemorrhage (12.5%), intrathoracic injury (18.8%), or intra-abdominal damage (12.5%) (All p < 0.05); the need for emergency surgical intervention (31.3%, p = 0.035); and major trauma (18.8%, p = 0.001). Residents in the collapsed buildings were more likely to have a crush injury (80.0%, p < 0.001) or crush syndrome (80.0%, p < 0.001). CONCLUSION: People entrapped at different heights of floors or in differently damaged buildings could have a distinct pattern of injury. Our findings may facilitate strategic approaches of patients entrapped in damaged buildings and may contribute to future training for field searches and rescues after earthquakes.

Ambulance traffic accidents in Taiwan.

BACKGROUND/PURPOSE: Ambulance traffic accidents (ATAs) are the leading cause of occupation-related fatalities among emergency medical service (EMS) personnel. We aim to use the Taiwan national surveillance system to analyze the characteristics of ATAs and to assist EMS directors in developing policies governing ambulance operations. METHODS: A retrospective, cross-sectional and largely descriptive study was conducted using Taiwan national traffic accidents surveillance data from January 1, 2011 to October 31, 2016. RESULTS: Among the 1,627,217 traffic accidents during the study period, 715 ATAs caused 8 deaths within 24 h and 1844 injured patients. On average, there was one ATA for every 8598 ambulance runs. Compared to overall traffic accidents, ATAs were 1.7 times more likely to result in death and 1.9 times more likely to have injured patients. Among the 715 ATAs, 8 (1.1%) ATAs were fatal and 707 (98.9%) were nonfatal. All 8 fatalities were associated with motorcycles. The urban areas were significantly higher than the rural areas in the annual number of ATAs (14.2 ± 7.3 [7.0-26.7] versus 3.1 ± 1.9 [0.5-8.4], p = 0.013), the number of ATA-associated fatalities per year (0.2 ± 0.2 [0.0-0.7] versus 0.1 ± 0.1 [0.0-0.2], p = 0.022), and the annual number of injured patients (who needed urgent hospital visits) in ATAs (19.4 ± 7.3 [10.5-30.9] versus 5.2 ± 3.8 [0.9-15.3], p < 0.001). CONCLUSION: The ATA-associated fatality rate in Taiwan was high, and all fatalities were associated with motorcycles. ATAs in a highly motorcycle-populated area may require further investigation. An ambulance traffic accident reporting system should be built to provide EMS policy guidance for ATA reduction and outcome improvements.

A simple scoring algorithm predicting extended-spectrum ß-lactamase producers in adults with community-onset monomicrobial Enterobacteriaceae bacteremia: Matters of frequent emergency department users.

The incidence of community-onset bacteremia caused by extended-spectrum-ß-lactamase (ESBL) producers is increasing. The adverse effects of ESBL production on patient outcome have been recognized and this antimicrobial resistance has significant implications in the delay of appropriate therapy. However, a simple scoring algorithm that can easily, inexpensively, and accurately be applied to clinical settings was lacking. Thus, we established a predictive scoring algorithm for identifying patients at the risk of ESBL-producer infections among patients with community-onset monomicrobial Enterobacteriaceae bacteremia (CoMEB).In a retrospective cohort, multicenter study, adults with CoMEB in the emergency department (ED) were recruited during January 2008 to December 2013. ESBL producers were determined based on ESBL phenotype. Clinical information was obtained from chart records.Of the total 1141 adults with CoMEB, 65 (5.7%) caused by ESBL producers were identified. Four independent multivariate predictors of ESBL-producer bacteremia with high odds ratios (ORs)-recent antimicrobial use (OR, 15.29), recent invasive procedures (OR, 12.33), nursing home residents (OR, 27.77), and frequent ED user (OR, 9.98)-were each assigned +1 point to obtain the CoMEB-ESBL score. Using the proposed scoring algorithm, a cut-off value of +2 yielded a high sensitivity (84.6%) and an acceptable specificity (92.5%); the area under the receiver operating characteristic curve was 0.92.In conclusion, this simple scoring algorithm can be used to identify CoMEB patients with a high ESBL-producer infection risk. Of note, frequent ED user was firstly demonstrated to be a crucial predictor in predicting ESBL-producer infections. ED clinicians should consider adequate empirical therapy with coverage of these pathogens for patients with risk factors.