Efficacy of endotracheal intubation in helicopter cabin vs. ground: a systematic review and meta-analysis.

BACKGROUND: Pre-hospital endotracheal intubation (ETI) is a sophisticated procedure with a comparatively high failure rate. Especially, ETI in confined spaces may result in higher difficulty, longer times, and a higher failure rate. This study analyses if Helicopter Emergency Medical Services (HEMS) intubation (time-to) success are influenced by noise, light, and restricted space in comparison to ground intubation. Available literature reporting these parameters was very limited, thus the reported differences between ETI in helicopter vs. ground by confronting parameters such as time to secure airway, first pass success rate and Cormack-Lehane Score were analysed. METHODS: A systematic review and meta-analysis were conducted using PUBMED, EMBASE, Cochrane Library, and Ovid on October 15th, 2022. The database search provided 2322 studies and 6 studies met inclusion and quality criteria. The research was registered with the International Prospective Register of Systematic Reviews (CRD42022361793). RESULTS: A total of six studies were selected and analysed as part of the systematic review and meta-analysis. The first pass success rate of ETI was more likely to fail in the helicopter setting as compared to the ground (82,4% vs. 87,3%), but the final success rate was similar between the two settings (96,8% vs. 97,8%). The success rate of intubation in literature was reported higher in physician-staffed HEMS than in paramedic-staffed HEMS. The impact of aircraft type and location inside the vehicle on intubation success rates was inconclusive across studies. The meta-analysis revealed inconsistent results for the mean duration of intubation, with one study reporting shorter intubation times in helicopters (13,0s vs.15,5s), another reporting no significant differences (16,5s vs. 16,8s), and a third reporting longer intubation times in helicopters (16,1s vs. 15,0s). CONCLUSION: Further research is needed to assess the impact of environmental factors on the quality of ETI on HEMS. While the success rate of endotracheal intubation in helicopters vs. on the ground is not significantly different, the duration and time to secure the airway, and Cormack-Lehane Score may be influenced by environmental factors. However, the limited number of studies reporting on these factors highlights the need for further research in this area.

Cardiopulmonary resuscitation during hyperbaric oxygen therapy: a comprehensive review and recommendations for practice.

BACKGROUND: Cardiopulmonary resuscitation (CPR) during hyperbaric oxygen therapy (HBOT) presents unique challenges due to limited access to patients in cardiac arrest (CA) and the distinct physiological conditions present during hyperbaric therapy. Despite these challenges, guidelines specifically addressing CPR during HBOT are lacking. This review aims to consolidate the available evidence and offer recommendations for clinical practice in this context. MATERIALS AND METHODS: A comprehensive literature search was conducted in PubMed, EMBASE, Cochrane Library, and CINAHL using the search string: "(pressure chamber OR decompression OR hyperbaric) AND (cardiac arrest OR cardiopulmonary resuscitation OR advanced life support OR ALS OR life support OR chest compression OR ventricular fibrillation OR heart arrest OR heart massage OR resuscitation)". Additionally, relevant publications and book chapters not identified through this search were included. RESULTS: The search yielded 10,223 publications, with 41 deemed relevant to the topic. Among these, 18 articles (primarily case reports) described CPR or defibrillation in 22 patients undergoing HBOT. The remaining 23 articles provided information or recommendations pertaining to CPR during HBOT. Given the unique physiological factors during HBOT, the limitations of current resuscitation guidelines are discussed. CONCLUSIONS: CPR in the context of HBOT is a rare, yet critical event requiring special considerations. Existing guidelines should be adapted to address these unique circumstances and integrated into regular training for HBOT practitioners. This review serves as a valuable contribution to the literature on "CPR under special circumstances".

Evaluation of free-floating tracheal intubation in weightlessness via ice-pick position with a direct laryngoscopy and classic approach with indirect videolaryngoscopy.

Long duration spaceflights to the Moon or Mars are at risk for emergency medical events. Managing a hypoxemic distress and performing an advanced airway procedure such as oro-tracheal intubation may be complicated under weightlessness due to ergonomic constraints. An emergency free-floating intubation would be dangerous because of high failure rates due to stabilization issues that prohibits its implementation in a space environment. Nevertheless, we hypothesized that two configurations could lead to a high first-pass success score for intubation performed by a free-floating operator. In a non-randomized, controlled, cross-over simulation study during a parabolic flight campaign, we evaluated and compared the intubation performance of free-floating trained operators, using either a conventional direct laryngoscope in an ice-pick position or an indirect laryngoscopy with a video-laryngoscope in a classic position at the head of a high-fidelity simulation manikin, in weightlessness and in normogravity. Neither of the two tested conditions reached the minimal terrestrial ILCOR recommendations (95% first-pass success) and therefore could not be recommended for general implementation under weightlessness conditions. Free-floating video laryngoscopy at the head of the manikin had a significant better success score than conventional direct laryngoscopy in an ice-pick position. Our results, combined with the preexisting literature, emphasis the difficulties of performing oro-tracheal intubation, even for experts using modern airway devices, under postural instability in weightlessness. ClinicalTrials registration number NCT05303948.

Oral fructose intake does not improve exercise, visual, or cognitive performance during acute normobaric hypoxia in healthy humans.

Introduction: The ability to metabolize fructose to bypass the glucose pathway in near-anaerobic conditions appears to contribute to the extreme hypoxia tolerance of the naked-mole rats. Therefore, we hypothesized that exogenous fructose could improve endurance capacity and cognitive performance in humans exposed to hypoxia. Methods: In a randomized, double-blind, crossover study, 26 healthy adults (9 women, 17 men; 28.8 ± 8.1 (SD) years) ingested 75 g fructose, 82.5 g glucose, or placebo during acute hypoxia exposure (13% oxygen in a normobaric hypoxia chamber, corresponding to oxygen partial pressure at altitude of ~3,800 m) on separate days. We measured exercise duration, heart rate, SpO2, blood gasses, and perceived exertion during a 30-min incremental load test followed by Farnsworth-Munsell 100 Hue (FM-100) color vision testing and the unstable tracking task (UTT) to probe eye-hand coordination performance. Results: Exercise duration in hypoxia was 21.13 ± 0.29 (SEM) min on fructose, 21.35 ± 0.29 min on glucose, and 21.35 ± 0.29 min on placebo (p = 0.86). Heart rate responses and perceived exertion did not differ between treatments. Total error score (TES) during the FM-100 was 47.1 ± 8.0 on fructose, 45.6 ± 7.6 on glucose and 53.3 ± 9.6 on placebo (p = 0.35) and root mean square error (RMSE) during the UTT was 15.1 ± 1.0, 15.1 ± 1.0 and 15.3 ± 0.9 (p = 0.87). Discussion: We conclude that oral fructose intake in non-acclimatized healthy humans does not acutely improve exercise performance and cognitive performance during moderate hypoxia. Thus, hypoxia tolerance in naked mole-rats resulting from oxygen-conserving fructose utilization, cannot be easily reproduced in humans.

Actionable loss of SLF2 drives B-cell lymphomagenesis and impairs the DNA damage response.

The DNA damage response (DDR) acts as a barrier to malignant transformation and is often impaired during tumorigenesis. Exploiting the impaired DDR can be a promising therapeutic strategy; however, the mechanisms of inactivation and corresponding biomarkers are incompletely understood. Starting from an unbiased screening approach, we identified the SMC5-SMC6 Complex Localization Factor 2 (SLF2) as a regulator of the DDR and biomarker for a B-cell lymphoma (BCL) patient subgroup with an adverse prognosis. SLF2-deficiency leads to loss of DDR factors including Claspin (CLSPN) and consequently impairs CHK1 activation. In line with this mechanism, genetic deletion of Slf2 drives lymphomagenesis in vivo. Tumor cells lacking SLF2 are characterized by a high level of DNA damage, which leads to alterations of the post-translational SUMOylation pathway as a safeguard. The resulting co-dependency confers synthetic lethality to a clinically applicable SUMOylation inhibitor (SUMOi), and inhibitors of the DDR pathway act highly synergistic with SUMOi. Together, our results identify SLF2 as a DDR regulator and reveal co-targeting of the DDR and SUMOylation as a promising strategy for treating aggressive lymphoma.

Cardiac arrest in the perioperative period: a consensus guideline for identification, treatment, and prevention from the European Society of Anaesthesiology and Intensive Care and the European Society for Trauma and Emergency Surgery.

INTRODUCTION: Cardiac arrest in the operating room is a rare but potentially life-threatening event with mortality rates of more than 50%. Contributing factors are often known, and the event is recognised rapidly as patients are usually under full monitoring. This guideline covers the perioperative period and is complementary to the European Resuscitation Council guidelines. MATERIAL AND METHODS: The European Society of Anaesthesiology and Intensive Care and the European Society for Trauma and Emergency Surgery jointly nominated a panel of experts to develop guidelines for the recognition, treatment, and prevention of cardiac arrest in the perioperative period. A literature search was conducted in MEDLINE, EMBASE, CINAHL and the Cochrane Central Register of Controlled Trials. All searches were restricted to publications from 1980 to 2019 inclusive and to the English, French, Italian and Spanish languages. The authors also contributed individual, independent literature searches. RESULTS: This guideline contains background information and recommendation for the treatment of cardiac arrest in the operating room environment, and addresses controversial topics such as open chest cardiac massage, resuscitative endovascular balloon occlusion and resuscitative thoracotomy, pericardiocentesis, needle decompression, and thoracostomy. CONCLUSIONS: Successful prevention and management of cardiac arrest during anaesthesia and surgery requires anticipation, early recognition, and a clear treatment plan. The ready availability of expert staff and equipment must also be taken into consideration. Success not only depends on medical knowledge, technical skills and a well-organised team using crew resource management, but also on an institutional safety culture embedded in everyday practice through continuous education, training, and multidisciplinary co-operation.

Cardiac arrest in the perioperative period: a consensus guideline for identification, treatment, and prevention from the European Society of Anaesthesiology and Intensive Care and the European Society for Trauma and Emergency Surgery.

INTRODUCTION: Cardiac arrest in the operating room is a rare but potentially life-threatening event with mortality rates of more than 50%. Contributing factors are often known, and the event is recognised rapidly as patients are usually under full monitoring. This guideline covers the perioperative period and is complementary to the European Resuscitation Council (ERC) guidelines. MATERIAL AND METHODS: The European Society of Anaesthesiology and Intensive Care and the European Society for Trauma and Emergency Surgery jointly nominated a panel of experts to develop guidelines for the recognition, treatment and prevention of cardiac arrest in the perioperative period. A literature search was conducted in MEDLINE, EMBASE, CINAHL and the Cochrane Central Register of Controlled Trials. All searches were restricted to publications from 1980 to 2019 inclusive and to the English, French, Italian and Spanish languages. The authors also contributed individual, independent literature searches. RESULTS: This guideline contains background information and recommendation for the treatment of cardiac arrest in the operating room environment, and addresses controversial topics such as open chest cardiac massage (OCCM), resuscitative endovascular balloon occlusion (REBOA) and resuscitative thoracotomy, pericardiocentesis, needle decompression and thoracostomy. CONCLUSION: Successful prevention and management of cardiac arrest during anaesthesia and surgery requires anticipation, early recognition and a clear treatment plan. The ready availability of expert staff and equipment must also be taken into consideration. Success not only depends on medical knowledge, technical skills and a well organised team using crew resource management but also on an institutional safety culture embedded in everyday practice through continuous education, training and multidisciplinary co-operation.

Effectiveness of CPR in Hypogravity Conditions-A Systematic Review.

(1) Background: Cardiopulmonary resuscitation (CPR), as a form of basic life support, is critical for maintaining cardiac and cerebral perfusion during cardiac arrest, a medical condition with high expected mortality. Current guidelines emphasize the importance of rapid recognition and prompt initiation of high-quality CPR, including appropriate cardiac compression depth and rate. As space agencies plan missions to the Moon or even to explore Mars, the duration of missions will increase and with it the chance of life-threatening conditions requiring CPR. The objective of this review was to examine the effectiveness and feasibility of chest compressions as part of CPR following current terrestrial guidelines under hypogravity conditions such as those encountered on planetary or lunar surfaces; (2) Methods: A systematic literature search was conducted by two independent reviewers (PubMed, Cochrane Register of Controlled Trials, ResearchGate, National Aeronautics and Space Administration (NASA)). Only controlled trials conducting CPR following guidelines from 2010 and after with advised compression depths of 50 mm and above were included; (3) Results: Four different publications were identified. All studies examined CPR feasibility in 0.38 G simulating the gravitational force on Mars. Two studies also simulated hypogravity on the Moon with a force of 0.17 G/0,16 G. All CPR protocols consisted of chest compressions only without ventilation. A compression rate above 100/s could be maintained in all studies and hypogravity conditions. Two studies showed a significant reduction of compression depth in 0.38 G (-7.2 mm/-8.71 mm) and 0.17 G (-12.6 mm/-9.85 mm), respectively, with nearly similar heart rates, compared to 1 G conditions. In the other two studies, participants with higher body weight could maintain a nearly adequate mean depth while effort measured by heart rate (+23/+13.85 bpm) and VO2max (+5.4 mL·kg-1·min-1) increased significantly; (4) Conclusions: Adequate CPR quality in hypogravity can only be achieved under increased physical stress to compensate for functional weight loss. Without this extra effort, the depth of compression quickly falls below the guideline level, especially for light-weight rescuers. This means faster fatigue during resuscitation and the need for more frequent changes of the resuscitator than advised in terrestrial guidelines. Alternative techniques in the straddling position should be further investigated in hypogravity.

Fixed-Wing Motorized Aircraft Accidents: Analysis of Injury Severity and Concomitant Factors (2000-2019).

BACKGROUND: There is a paucity of research on general aviation accidents in Germany. The authorities investigate only a fraction of all national accidents. The current study analyzes existing accident reports and aims to identify injury severity in regard to concomitant risk factors.METHODS: Data of flight accidents was analyzed for aircraft of <5700 kg maximum takeoff weight (MTOW) over a 20-yr period. Besides descriptive data, concomitant factors (type and category of aircraft, date, occupants and outcome, flight phase, etc.) were analyzed. Statistical analysis was performed using the Chi-squared test.RESULTS: The authorities list 1595 aircraft accidents between 2000 and 2019, but only 17.9% of these were analyzed in detail. Accidents of aircraft of <2000 kg MTOW were over-represented between May and September and between Friday and Sunday. The fraction of fatal accidents was highest during cruise. During landing, significantly more mishaps of larger aircraft occurred. The number of seriously injured or deceased occupants was significantly higher for accidents involving private pilots. An occupancy rate of more than three persons on board correlated significantly with fewer number of deaths.CONCLUSIONS: The annual count of aircraft accidents has almost halved during the previous 20 yr. Unfortunately, only a small number of mishaps were further investigated by authorities, which leads to a lack of evaluable data needed for in-depth investigations. The accumulation of larger aircraft mishaps in winter and the superior outcome of professional pilots in terms of safety, as well as the fewer number of mishaps in larger aircraft, should be further investigated.Liebold F, Hippler C, Schmitz J, Yücetepe S, Rothschild M, Hinkelbein J. Fixed-wing motorized aircraft accidents: analysis of injury severity and concomitant factors (2000-2019). Aerosp Med Hum Perform. 2022; 93(5):442-449.

Influence of 30 and 60 Min of Hypobaric Hypoxia in Simulated Altitude of 15,000 ft on Human Proteome Profile.

The human body reacts to hypobaric hypoxia, e.g., during a stay at high altitude, with several mechanisms of adaption. Even short-time exposition to hypobaric hypoxia leads to complex adaptions. Proteomics facilitates the possibility to detect changes in metabolism due to changes in proteins. The present study aims to identify time-dependent changes in protein expression due to hypobaric hypoxia for 30 and 60 min at a simulated altitude of 15,000 ft. N = 80 male subjects were randomized and assigned into four different groups: 40 subjects to ground control for 30 (GC30) and 60 min (GC60) and 40 subjects to 15,000 ft for 30 (HH30) and 60 min (HH60). Subjects in HH30 and HH60 were exposed to hypobaric hypoxia in a pressure chamber (total pressure: 572 hPa) equivalent to 15,000 ft for 30 vs. 60 min, respectively. Drawn blood was centrifuged and plasma frozen (-80 °C) until proteomic analysis. After separation of high abundant proteins, protein expression was analyzed by 2-DIGE and MALDI-TOF. To visualize the connected signaling cascade, a bio-informatical network analysis was performed. The present study was approved by the ethical committee of the University of Cologne, Germany. The study registry number is NCT03823677. In comparing HH30 to GC30, a total of seven protein spots had a doubled expression, and 22 spots had decreased gene expression. In a comparison of HH60 to GC60, a total of 27 protein spots were significantly higher expressed. HH60, as compared to GC30, revealed that a total of 37 spots had doubled expression. Vice versa, 12 spots were detected, which were higher expressed in GC30 vs. HH60. In comparison to GC, HH60 had distinct differences in the number of differential protein spots (noticeably more proteins due to longer exposure to hypoxia). There are indicators that changes in proteins are dependent on the length of hypobaric hypoxia. Some proteins associated with hemostasis were differentially expressed in the 60 min comparison.

Extracellular vesicles and PD-L1 suppress macrophages, inducing therapy resistance in TP53-deficient B-cell malignancies.

Genetic alterations in the DNA damage response (DDR) pathway are a frequent mechanism of resistance to chemoimmunotherapy (CIT) in B-cell malignancies. We have previously shown that the synergy of CIT relies on secretory crosstalk elicited by chemotherapy between the tumor cells and macrophages. Here, we show that loss of multiple different members of the DDR pathway inhibits macrophage phagocytic capacity in vitro and in vivo. Particularly, loss of TP53 led to decreased phagocytic capacity ex vivo across multiple B-cell malignancies. We demonstrate via in vivo cyclophosphamide treatment using the Eµ-TCL1 mouse model that loss of macrophage phagocytic capacity in Tp53-deleted leukemia is driven by a significant downregulation of a phagocytic transcriptomic signature using small conditional RNA sequencing. By analyzing the tumor B-cell proteome, we identified a TP53-specific upregulation of proteins associated with extracellular vesicles (EVs). We abrogated EV biogenesis in tumor B-cells via clustered regularly interspaced short palindromic repeats (CRISPR)-knockout (KO) of RAB27A and confirmed that the EVs from TP53-deleted lymphoma cells were responsible for the reduced phagocytic capacity and the in vivo CIT resistance. Furthermore, we observed that TP53 loss led to an upregulation of both PD-L1 cell surface expression and secretion of EVs by lymphoma cells. Disruption of EV bound PD-L1 by anti-PD-L1 antibodies or PD-L1 CRISPR-KO improved macrophage phagocytic capacity and in vivo therapy response. Thus, we demonstrate enhanced EV release and increased PD-L1 expression in TP53-deficient B-cell lymphomas as novel mechanisms of macrophage function alteration in CIT resistance. This study indicates the use of checkpoint inhibition in the combination treatment of B-cell malignancies with TP53 loss.

Randomized Comparison of Two New Methods for Chest Compressions during CPR in Microgravity-A Manikin Study.

BACKGROUND: Although there have been no reported cardiac arrests in space to date, the risk of severe medical events occurring during long-duration spaceflights is a major concern. These critical events can endanger both the crew as well as the mission and include cardiac arrest, which would require cardiopulmonary resuscitation (CPR). Thus far, five methods to perform CPR in microgravity have been proposed. However, each method seems insufficient to some extent and not applicable at all locations in a spacecraft. The aim of the present study is to describe and gather data for two new CPR methods in microgravity. MATERIALS AND METHODS: A randomized, controlled trial (RCT) compared two new methods for CPR in a free-floating underwater setting. Paramedics performed chest compressions on a manikin (Ambu Man, Ambu, Germany) using two new methods for a free-floating position in a parallel-group design. The first method (Schmitz-Hinkelbein method) is similar to conventional CPR on earth, with the patient in a supine position lying on the operator's knees for stabilization. The second method (Cologne method) is similar to the first, but chest compressions are conducted with one elbow while the other hand stabilizes the head. The main outcome parameters included the total number of chest compressions (n) during 1 min of CPR (compression rate), the rate of correct chest compressions (%), and no-flow time (s). The study was registered on clinicaltrials.gov (NCT04354883). RESULTS: Fifteen volunteers (age 31.0 ± 8.8 years, height 180.3 ± 7.5 cm, and weight 84.1 ± 13.2 kg) participated in this study. Compared to the Cologne method, the Schmitz-Hinkelbein method showed superiority in compression rates (100.5 ± 14.4 compressions/min), correct compression depth (65 ± 23%), and overall high rates of correct thoracic release after compression (66% high, 20% moderate, and 13% low). The Cologne method showed correct depth rates (28 ± 27%) but was associated with a lower mean compression rate (73.9 ± 25.5/min) and with lower rates of correct thoracic release (20% high, 7% moderate, and 73% low). CONCLUSIONS: Both methods are feasible without any equipment and could enable immediate CPR during cardiac arrest in microgravity, even in a single-helper scenario. The Schmitz-Hinkelbein method appears superior and could allow the delivery of high-quality CPR immediately after cardiac arrest with sufficient quality.

Proteomics-Based Serum Alterations of the Human Protein Expression after Out-of-Hospital Cardiac Arrest: Pilot Study for Prognostication of Survivors vs. Non-Survivors at Day 1 after Return of Spontaneous Circulation (ROSC).

BACKGROUND: Targeted temperature management (TTM) is considered standard therapy for patients after out-of-hospital cardiac arrest (OHCA), cardiopulmonary resuscitation (CPR), and return of spontaneous circulation (ROSC). To date, valid protein markers do not exist to prognosticate survivors and non-survivors before the end of TTM. The aim of this study is to identify specific protein patterns/arrays, which are useful for prediction in the very early phase after ROSC. MATERIAL AND METHODS: A total of 20 adult patients with ROSC (19 male, 1 female; 69.9 ± 9.5 years) were included and dichotomized in two groups (survivors and non-survivors at day 30). Serum samples were drawn at day 1 after ROSC (during TTM). Three panels (organ failure, metabolic, neurology, inflammation; OLINK, Uppsala, Sweden) were utilised. A total of four proteins were found to be differentially regulated (>2- or <-0.5-fold decrease; t-test). Bioinformatic platforms were utilised to analyse pathways and identify signalling cascades and to screen for potential biomarkers. RESULTS: A total of 276 proteins were analysed and revealed only 11 statistically significant protein alterations (Siglec-9, LAYN, SKR3, JAM-B, N2DL-2, TNF-B, BAMBI, NUCB2, STX8, PTK7, and PVLAB). Following the Bonferroni correction, no proteins were found to be regulated as statistically significant. Concerning the protein fold change for clinical significance, four proteins (IL-1 alpha, N-CDase, IL5, CRH) were found to be regulated in a clinically relevant context. CONCLUSIONS: Early analysis at 1 day after ROSC was not sufficiently possible during TTM to prognosticate survival or non-survival after OHCA. Future studies should evaluate protein expression later in the course after ROSC to identify promising protein candidates.

Inequality, role reversal and cooperation in multiple group membership settings.

We investigate the role of endowment inequality in a local and global public goods setting with multiple group membership and examine the effect of temporal role reversal on cooperation decisions. Subjects can contribute to a global public good which benefits all subjects and two local public goods which benefit only subjects of either their own group or the group of the other endowment type. Endowment inequality per-se decreases contributions of subjects with a high endowment to the global public good, but increases cooperation of subjects with a low endowment on their local public good, thereby aggravating income disparities. Exogenously induced role reversal for several periods affects cooperation behavior of subjects with a high endowment positively and induces them to contribute more to the global good. Cooperation in unequal environments thus appears to be more stable when all parties have experienced the public goods game from the disadvantageous perspective. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s10683-021-09705-y.

SUMO: Glue or Solvent for Phase-Separated Ribonucleoprotein Complexes and Molecular Condensates?

Spatial organization of cellular processes in membranous or membrane-less organelles (MLOs, alias molecular condensates) is a key concept for compartmentalizing biochemical pathways. Prime examples of MLOs are the nucleolus, PML nuclear bodies, nuclear splicing speckles or cytosolic stress granules. They all represent distinct sub-cellular structures typically enriched in intrinsically disordered proteins and/or RNA and are formed in a process driven by liquid-liquid phase separation. Several MLOs are critically involved in proteostasis and their formation, disassembly and composition are highly sensitive to proteotoxic insults. Changes in the dynamics of MLOs are a major driver of cell dysfunction and disease. There is growing evidence that post-translational modifications are critically involved in controlling the dynamics and composition of MLOs and recent evidence supports an important role of the ubiquitin-like SUMO system in regulating both the assembly and disassembly of these structures. Here we will review our current understanding of SUMO function in MLO dynamics under both normal and pathological conditions.

Using supraglottic airways by paramedics for airway management in analogue microgravity increases speed and success of ventilation.

In the next few years, the number of long-term space missions will significantly increase. Providing safe concepts for emergencies including airway management will be a highly challenging task. The aim of the present trial is to compare different airway management devices in simulated microgravity using a free-floating underwater scenario. Five different devices for airway management [laryngeal mask (LM), laryngeal tube (LT), I-GEL, direct laryngoscopy (DL), and video laryngoscopy (VL)] were compared by n = 20 paramedics holding a diving certificate in a randomized cross-over setting both under free-floating conditions in a submerged setting (pool, microgravity) and on ground (normogravity). The primary endpoint was the successful placement of the airway device. The secondary endpoints were the number of attempts and the time to ventilation. A total of 20 paramedics (3 female, 17 male) participated in this study. Success rate was highest for LM and LT and was 100% both during simulated microgravity and normogravity followed by the I-GEL (90% during microgravity and 95% during normogravity). However, the success rate was less for both DL (60% vs. 95%) and VL (20% vs. 60%). Fastest ventilation was performed with the LT both in normogravity (13.7 ± 5.3 s; n = 20) and microgravity (19.5 ± 6.1 s; n = 20). For the comparison of normogravity and microgravity, time to ventilation was shorter for all devices on the ground (normogravity) as compared underwater (microgravity). In the present study, airway management with supraglottic airways and laryngoscopy was shown to be feasible. Concerning the success rate and time to ventilation, the optimum were supraglottic airways (LT, LM, I-GEL) as their placement was faster and associated with a higher success rate. For future space missions, the use of supraglottic airways for airway management seems to be more promising as compared to tracheal intubation by DL or VL.

On-board emergency medical equipment of European airlines.

BACKGROUND: Medical emergencies frequently occur in commercial airline flights, but valid data on causes and consequences are rare. Therefore, optimal extent of onboard emergency medical equipment remains largely unknown. Whereas a minimum standard is defined in regulations, additional material is not standardized and may vary significantly between airlines. METHODS: European airlines operating aircrafts with at least 30 seats were selected and interviewed with a 5-page written questionnaire including 81 items. Besides pre-packed and required emergency medical material, drugs, medical devices, and equipment lists were queried. If no reply was received, airlines were contacted up to three times by email and/or phone. Descriptive analysis was used for data interpretation. RESULTS: From a total of 305 European airlines, 253 were excluded from analysis (e.g., no passenger transport). 52 airlines were contacted and data of 22 airlines were available for analysis (one airline was excluded due to insufficient data). A first aid kit is available on all airlines. 82% of airlines (18/22) reported to have a "doctor's kit" (DK) or an "Emergency Medical Kit" (EMK) onboard. 86% of airlines (19/22) provide identical equipment in all aircraft of the fleet, and 65% (14/22) airlines provide an automated external defibrillator. CONCLUSIONS: Whereas minimal required material according to European aviation regulations is provided by all airlines for medical emergencies, there are significant differences in availability of the additional material. The equipment of most airlines is not sufficient for treatment of specific emergencies according to published in-flight medical guidelines (e.g., for CPR or acute myocardial infarction).

Time to ventilation and success rate of airway devices in microgravity: A randomized crossover manikin-trial using an underwater setting.

BACKGROUND: Medical support for space exploration missions must prepare for severe medical events in conditions of microgravity. A key component to managing these events is techniques of airway management. The aim of the present trial is to compare airway management devices in simulated microgravity. METHODS: In this randomized cross-over trial (RCT), four different devices were compared under simulated microgravity conditions utilizing a neutrally buoyant free-floating underwater manikin and poolside in normal gravity (control group). The primary endpoint was the successful placement of the airway device. The secondary endpoints were the number of attempts and the duration of each attempt. RESULTS: A total of 20 participants performed placement of each device in both gravity conditions in an Airway mannequin. The fastest time to initial ventilation in simulated microgravity was possible with the laryngeal tube (18.9 ± 8 seconds) followed by laryngeal mask (20.1 ± 9 seconds). The I-gel® supraglottic airway device required substantially more time for successful insertion in simulated microgravity (35.4 ± 25 seconds) as did endotracheal tube intubation by direct laryngoscopy (70.4 ± 35 seconds). Simulated microgravity conditions prolonged time to initial ventilation by 3.3 seconds (LM), 3.9 seconds (LT), 19.9 seconds (I-gel) and 43.1 seconds (endotracheal intubation, ETI) when compared to poolside attempts in normogravity. CONCLUSION: In simulated microgravity conditions, use of the laryngeal tube or laryngeal mask provided the quickest time to initial ventilation, without deliberate tethering of the mannequin and rescuer to a fixed surface. Endotracheal intubation required significantly longer procedure times and, thus, was considered insufficient for clinical use in microgravity.

Performance of the laryngeal tube for airway management during cardiopulmonary resuscitation.

INTRODUCTION: Sudden cardiac arrest is one of the leading causes of death in Europe and the whole world. Effective chest compressions and advanced airway management have been shown to improve survival rates. Supraglottic airway devices such as the laryngeal tube (LT) are a well-known strategy for patients with cardiac arrest during both basic (BLS) and advanced life support (ALS). This systematic literature review aimed to summarize current data for using the LT when performing BLS and ALS. EVIDENCE ACQUISITION: Recent data on the use of the LT during cardiopulmonary resuscitation (CPR) was gathered by using the Medline database and a specific search strategy. Terms were used in various order and combinations without time restrictions. A total of N.=1005 studies were identified and screened by two experienced anesthesiologists/emergency physicians independently. Altogether, data of N.=19 relevant papers were identified and included in the analysis. EVIDENCE SYNTHESIS: Using the LT showed fast and easy placement with high success rates (76% to 94%) and was associated with higher short-term survival as compared to other strategies for initial airway management (2.2% vs. 1.4%). Quality of CPR such as chest compression fraction (CCF) before and after LT-insertion is improved (75% vs. 59%). For long-term survival, the LT showed lower survival rates. CONCLUSIONS: Especially as initial device of airway management (for inexperienced staff), the use of a LT is easy and results in a fast insertion. The advantages of the LT as compared to bag mask ventilation and endotracheal intubation are inhomogeneous in recent literature.