An Individual Barrier Enclosure Actively Removing Aerosols for Airborne Isolation: A Vacuum Tent.

BACKGROUND: Aerosol barrier enclosure systems have been designed to prevent airborne contamination, but their safety has been questioned. A vacuum tent was designed with active continuous suctioning to minimize risks of aerosol dispersion. We tested its efficacy, risk of rebreathing, and usability on a bench, in healthy volunteers, and in an ergonomic clinical assessment study. METHODS: First, a manikin with airway connected to a breathing simulator was placed inside the vacuum tent to generate active breathing, cough, and CO2 production; high-flow nasal cannula (HFNC) was applied in the manikin's nares. Negative pressure was applied in the vacuum tent's apex port using wall suction. Fluorescent microparticles were aerosolized in the vacuum tent for qualitative assessment. To quantify particles inside and around vacuum tent (aerosol retention), an airtight aerosol chamber with aerosolized latex microparticles was used. The vacuum tent was tested on healthy volunteers breathing with and without HFNC. Last, its usability was assessed in 5 subjects by 5 different anesthesiologists for delivery of full anesthesia, including intubation and extubation. RESULTS: The vacuum tent was adjusted until no leak was visualized using fluorescent particles. The efficacy in retaining microparticles was confirmed quantitatively. CO2 accumulation inside the vacuum tent showed an inverse correlation with the suction flow in all conditions (normal breathing and HFNC 30 or 60 L/min) in bench and healthy volunteers. Particle removal efficacy and safe breathing conditions (CO2, temperature) were reached when suctioning was at least 60 L/min or 20 L/min > HFNC flow. Five subjects were successfully intubated and anesthetized without ergonomic difficulties and with minimal interference with workflow and an excellent overall assessment by the anesthesiologists. CONCLUSIONS: The vacuum tent effectively minimized aerosol dispersion. Its continuous suction system set at a high suction flow was crucial to avoid the spread of aerosol particles and CO2 rebreathing.

Prognostic factors associated with risk of stroke following blunt cerebrovascular injury: A systematic review and meta-analysis.

BACKGROUND & OBJECTIVES: Blunt cerebrovascular injury (BCVI) includes carotid and/or vertebral artery injury following trauma, and conveys an increased stroke risk. We conducted a systematic review and meta-analysis to provide a comprehensive summary of prognostic factors associated with risk of stroke following BCVI. METHODS: We searched the EMBASE and MEDLINE databases from January 1946 to June 2023. We identified studies reporting associations between patient or injury factors and risk of stroke following BCVI. We performed meta-analyses of odds ratios (ORs) using the random effects method and assessed individual study risk of bias using the QUIPS tool. We separately pooled adjusted and unadjusted analyses, highlighting the estimate with the higher certainty. RESULTS: We included 26 cohort studies, involving 20,458 patients with blunt trauma. The overall incidence of stroke following BCVI was 7.7 %. Studies were predominantly retrospective cohorts from North America and included both carotid and vertebral artery injuries. Diagnosis of BCVI was most commonly confirmed with CT angiography. We demonstrated with moderate to high certainty that factors associated with increased risk of stroke included carotid artery injury (as compared to vertebral artery injury, unadjusted odds ratio [uOR] 1.94, 95 % CI 1.62 to 2.32), Grade III Injury (as compared to grade I or II) (uOR 2.45, 95 % CI 1.88 to 3.20), Grade IV injury (uOR 3.09, 95 % CI 2.20 to 4.35), polyarterial injury (uOR 3.11 (95 % CI 2.05 to 4.72), occurrence of hypotension at the time of hospital admission (adjusted odds ratio [aOR] 1.32, 95 % CI 0.87 to 2.03) and higher total body injury severity (aOR 5.91, 95 % CI 1.90 to 18.39). CONCLUSION: Local anatomical injury pattern, overall burden of injury and flow dynamics contribute to BCVI-related stroke risk. These findings provide the foundational evidence base for risk stratification to support clinical decision making and further research.

Pharmacological agents for procedural sedation and analgesia in the emergency department and intensive care unit: a systematic review and network meta-analysis of randomised trials.

BACKGROUND: We aimed to evaluate the comparative effectiveness and safety of various i.v. pharmacologic agents used for procedural sedation and analgesia (PSA) in the emergency department (ED) and ICU. We performed a systematic review and network meta-analysis to enable direct and indirect comparisons between available medications. METHODS: We searched Medline, EMBASE, Cochrane, and PubMed from inception to 2 March 2023 for RCTs comparing two or more procedural sedation and analgesia medications in all patients (adults and children >30 days of age) requiring emergent procedures in the ED or ICU. We focused on the outcomes of sedation recovery time, patient satisfaction, and adverse events (AEs). We performed frequentist random-effects model network meta-analysis and used the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach to rate certainty in estimates. RESULTS: We included 82 RCTs (8105 patients, 78 conducted in the ED and four in the ICU) of which 52 studies included adults, 23 included children, and seven included both. Compared with midazolam-opioids, recovery time was shorter with propofol (mean difference 16.3 min, 95% confidence interval [CI] 8.4-24.3 fewer minutes; high certainty), and patient satisfaction was better with ketamine-propofol (mean difference 1.5 points, 95% CI 0.3-2.6 points, high certainty). Regarding AEs, compared with midazolam-opioids, respiratory AEs were less frequent with ketamine (relative risk [RR] 0.55, 95% CI 0.32-0.96; high certainty), gastrointestinal AEs were more common with ketamine-midazolam (RR 3.08, 95% CI 1.15-8.27; high certainty), and neurological AEs were more common with ketamine-propofol (RR 3.68, 95% CI 1.08-12.53; high certainty). CONCLUSION: When considering procedural sedation and analgesia in the ED and ICU, compared with midazolam-opioids, sedation recovery time is shorter with propofol, patient satisfaction is better with ketamine-propofol, and respiratory adverse events are less common with ketamine.

Are we talking about practice? A randomized study comparing simulation-based deliberate practice and mastery learning to self-guided practice.

OBJECTIVES: Simulation-based technical skills training is now ubiquitous in medicine, particularly for high acuity, low occurrence (HALO) procedures. Mastery learning and deliberate practice (ML + DP) are potentially valuable educational methods, however, they are resource intensive. We sought to compare the effect of deliberate practice and mastery learning versus self-guided practice on skill performance of the rare, life-saving procedure, a bougie-assisted cricothyroidotomy (BAC). METHODS: We conducted a multi-center, randomized study at five North American emergency medicine (EM) residency programs. We randomly assigned 176 EM residents to either the ML + DP or self-guided practice groups. Three blinded airway experts independently evaluated BAC skill performance by video review before (pre-test), after (post-test) and 6-12 months (retention) after the training session. The primary outcome was post-test skill performance using a global rating score (GRS). Secondary outcomes included performance time and skill performance at the retention test. RESULTS: Immediately following training, GRS scores were significantly higher as mean performance improved from pre-test, (22, 95% CI = 21-23) to post-test (27, 95% CI = 26-28), (p < 0.001) for all participants. However, there was no difference between the groups on GRS scores (p = 0.2) at the post-test or at the retention test (p = 0.2). At the retention test, participants in the ML + DP group had faster performance times (66 s, 95% CI = 57-74) compared to the self-guided group (77 s, 95% CI = 67-86), (p < 0.01). CONCLUSIONS: There was no significant difference in skill performance between groups. Residents who received deliberate practice and mastery learning demonstrated an improvement in skill performance time.

ABSTRAIT: OBJECTIFS: La formation aux compétences techniques fondée sur la simulation est maintenant omniprésente en médecine, en particulier pour les procédures de grande acuité et de faible occurrence (HALO). L'apprentissage de la maîtrise et la pratique délibérée (ML+DP) sont des méthodes éducatives potentiellement précieuses, mais elles exigent beaucoup de ressources. Nous avons cherché à comparer l'effet de la pratique délibérée et de l'apprentissage de la maîtrise par rapport à la pratique autoguidée sur le rendement des compétences de la rare intervention de sauvetage, une cricothyroïdotomie à la bougie. MéTHODES: Nous avons mené une étude multicentrique randomisée dans le cadre de cinq programmes nord-américains de résidence en médecine d'urgence. Nous avons affecté au hasard 176 résidents en SE aux groupes de ML+DP ou de pratique autoguidée. Trois experts des voies respiratoires aveuglés ont évalué de façon indépendante la performance des compétences en BAC par examen vidéo avant (pré-test), après (post-test) et 6 à 12 mois (rétention) après la séance de formation. Le principal résultat a été le rendement des compétences après le test au moyen d'une cote globale (SRC). Les résultats secondaires comprenaient le temps consacré au rendement et le rendement des compétences au test de rétention. RéSULTATS: Immédiatement après la formation, les résultats des SRC étaient beaucoup plus élevés, car le rendement moyen s'est amélioré entre le prétest (22, IC à 95 % = 21 à 23) et le post-test (27, IC à 95 % = 26 à 28), (p < 0,001) pour tous les participants. Cependant, il n'y avait aucune différence entre les groupes sur les scores GRS (p = 0,2) au post-test ou au test de rétention (p = 0,2). Au test de rétention, les participants du groupe ML+DP avaient des temps de performance plus rapides (66 secondes, IC à 95 % = 57 à 74) que ceux du groupe autoguidé (77 secondes, IC à 95 % = 67 à 86) (p < 0,01). CONCLUSIONS: Il n'y avait pas de différence significative dans le rendement des compétences entre les groupes. Les résidents qui ont bénéficié d'une pratique délibérée et d'un apprentissage de la maîtrise ont démontré une amélioration du temps consacré aux compétences.

Massive Hemorrhage Protocol: A Practical Approach to the Bleeding Trauma Patient.

Damage-control resuscitation is the standard of care for the hemorrhaging trauma patient. This approach combines rapid hemostasis and early-ratio-based blood product administration. These patients often require initiation of a massive hemorrhage protocol to support the systematic and coordinated delivery of care during this critical phase of resuscitation. Emerging evidence supports that this includes more than blood product administration alone but rather a comprehensive suite of treatments. In this article, we review the existing evidence and provide a pragmatic framework, the 7 Ts of massive hemorrhage protocol, to guide the care of patients with life-threatening traumatic hemorrhage.

Is in situ simulation in emergency medicine safe? A scoping review.

OBJECTIVES: To provide an overview of the available evidence regarding the safety of in situ simulation (ISS) in the emergency department (ED). DESIGN: Scoping review. METHODS: Original articles published before March 2021 were included if they investigated the use of ISS in the field of emergency medicine. INFORMATION SOURCES: MEDLINE, EMBASE, Cochrane and Web of Science. RESULTS: A total of 4077 records were identified by our search strategy and 2476 abstracts were screened. One hundred and thirty full articles were reviewed and 81 full articles were included. Only 33 studies (40%) assessed safety-related issues, among which 11 chose a safety-related primary outcome. Latent safety threats (LSTs) assessment was conducted in 24 studies (30%) and the cancellation rate was described in 9 studies (11%). The possible negative impact of ISS on real ED patients was assessed in two studies (2.5%), through a questionnaire and not through patient outcomes. CONCLUSION: Most studies use ISS for systems-based or education-based applications. Patient safety during ISS is often evaluated in the context of identifying or mitigating LSTs and rarely on the potential impact and risks to patients simultaneously receiving care in the ED. Our scoping review identified knowledge gaps related to the safe conduct of ISS in the ED, which may warrant further investigation.

The Future of Emergency Medicine (EM) Sim Cases: A Modified Massive Online Needs Assessment.

Objective Emergency Medicine (EM) Sim Cases was initially developed in 2015 as a free open-access simulation resource. To ensure the future of EM Sim Cases remains relevant and up to date, we performed a needs assessment to better define our audience and facilitate long-term goals. Methods We delivered a survey using a modified massive-online-needs-assessment methodology through an iterative process with simulation experts from the EM Simulation Educators Research Collaborative. We distributed the survey via email and Twitter and analyzed the data using descriptive statistics and thematic analysis. Results We obtained 106 responses. EM Sim Cases is commonly used by physicians primarily as an educational resource for postgraduate level trainees. Perceived needs included resuscitation, pediatrics, trauma, and toxicology content. Prompted needs included non-simulation-case educational resources, increased case database, and improved website organization. Conclusions Data collected from our needs assessment has defined our audience allowing us to design our long-term goals and strategies.

Introducing the Safety Threats and Adverse events in Trauma (STAT) taxonomy: standardized classification system for evaluating safety during trauma resuscitation.

PURPOSE: Adverse events (AEs) during trauma resuscitation are common and heterogeneity in reporting limits comparisons between hospitals and systems. A recent modified Delphi study established a taxonomy of AEs that occur during trauma resuscitation. This tool was further refined to yield the Safety Threats and Adverse events in Trauma (STAT) taxonomy. The objective of this study was to evaluate the inter-rater reliability of the STAT taxonomy using in-situ simulation resuscitations. METHODS: Two reviewers utilized the STAT taxonomy to score 12 in-situ simulated trauma resuscitations. AEs were reported for each simulation and timestamped in the case of multiple occurrences of a single AE. Inter-rater reliability was assessed using Gwet's AC1. RESULTS: The agreement on all AEs between reviewers was 90.1% (973/1080). The Gwet's AC1 across AE categories were: EMS handover (median 0.72, IQR [0.54, 0.82]), airway and breathing (median 0.91, IQR [0.60, 1.0]), circulation (median 0.91, IQR [0.72, 1.0]), assessment of injuries (median 0.80, IQR [0.24, 0.91]), management of injuries (median 1.00, IQR [1.00, 1.00]), procedure related (median 1.00, IQR [81, 1.00]), patient monitoring and IV access (median 1.00, IQR [1.00, 1.00]), disposition (median 1.00, IQR [1.00, 1.00]), team communication and dynamics (median 0.80, IQR [0.62, 1.00]). CONCLUSIONS: The STAT taxonomy yielded 90.1% agreement and demonstrated excellent inter-rater reliability between reviewers in the in-situ simulation scenario. The STAT taxonomy may serve as a standardized evaluation tool of latent safety threats and adverse events in the trauma bay. Future work should focus on applying this tool to live trauma patients.

Defining adverse events during trauma resuscitation: a modified RAND Delphi study.

BACKGROUND: The majority of preventable adverse event (AEs) in trauma care occur during the initial phase of resuscitation, often within the trauma bay. However, there is significant heterogeneity in reporting these AEs that limits performance comparisons between hospitals and trauma systems. The objective of this study was to create a taxonomy of AEs that occur during trauma resuscitation and a corresponding classification system to assign a degree of harm. METHODS: This study used a modified RAND Delphi methodology to establish a taxonomy of AEs in trauma and a degree of harm classification system. A systematic review informed the preliminary list of AEs. An interdisciplinary panel of 22 trauma experts rated these AEs through two rounds of online surveys and a final consensus meeting. Consensus was defined as 80% for each AE and the final checklist. RESULTS: The Delphi panel consisted of 22 multidisciplinary trauma experts. A list of 57 evidence-informed AEs was revised and expanded during the modified Delphi process into a finalized list of 67 AEs. Each AE was classified based on degree of harm on a scale from I (no harm) to V (death). DISCUSSION: This study developed a taxonomy of 67 AEs that occur during the initial phases of a trauma resuscitation with a corresponding degree of harm classification. This taxonomy serves to support a standardized evaluation of trauma care between centers and regions. LEVEL OF EVIDENCE: Level 5.

Protocol for a multicentre, randomised, parallel-control, superiority trial comparing administration of clotting factor concentrates with a standard massive haemorrhage protocol in severely bleeding trauma patients: the FiiRST 2 trial (a 2020 EAST multicentre trial).

INTRODUCTION: Acute traumatic coagulopathy (ATC) in bleeding trauma patients increase in-hospital mortality. Fibrinogen concentrate (FC) and prothrombin complex concentrate (PCC) are two purified concentrates of clotting factors that have been used to treat ATC. However, there is a knowledge gap on their use compared with the standard of care, the transfusion of plasma. METHODS AND ANALYSIS: The factors in the initial resuscitation of severe trauma 2 trial is a multicentre, randomised, parallel-control, single-blinded, phase IV superiority trial. The study aims to address efficacy and safety of the early use of FC and PCC compared with a plasma-based resuscitation. Adult trauma patients requiring massive haemorrhage protocol activation on hospital arrival will receive FC 4 g and PCC 2000 IU or plasma 4 U, based on random allocation. The primary outcome is a composite of the cumulative number of all units of red cells, plasma and platelets transfused within 24 hours following admission. Secondary outcomes include measures of efficacy and safety of the intervention. Enrolment of 350 patients will provide an initial power >80% to demonstrate superiority for the primary outcome. After enrolment of 120 patients, a preplanned adaptive interim analysis will be conducted to reassess assumptions, check for early superiority demonstration or reassess the sample size for remainder of the study. ETHICS AND DISSEMINATION: The study has been approved by local and provincial research ethics boards and will be conducted according to the Declaration of Helsinki, Good Clinical Practice guidelines and regulatory requirements. As per the Tri-Council Policy Statement, patient consent will be deferred due to the emergency nature of the interventions. If superiority is established, results will have a major impact on clinical practice by reducing exposure to non-virally inactivated blood products, shortening the time for administration of clotting factors, correct coagulopathy more efficaciously and reduce the reliance on AB plasma. TRIAL REGISTRATION NUMBER: NCT04534751, pre results.

The clock is ticking: using in situ simulation to improve time to blood administration for bleeding trauma patients.

INTRODUCTION: Massive hemorrhage protocols are widely used to facilitate the administration of blood components to bleeding trauma patients. Delays in this process are associated with worse patient outcomes. We used in situ simulation as a novel and iterative quality improvement technique to reduce the mean time between massive hemorrhage protocol activation and blood administration during actual trauma resuscitations. METHODS: We completed monthly, risk-informed unannounced in situ trauma simulations at a Canadian Level 1 trauma centre. We identified three major latent safety threats: (1) massive hemorrhage protocol activation; (2) transport of blood components; and (3) situational awareness of team members. Process improvements for each latent safety threats were tested and implemented during subsequent in situ simulation sessions. We evaluated the effect of this simulation-based intervention on the care of patients before, during and after the intervention. Demographic, clinical and massive hemorrhage protocol data were collected. The primary outcome was mean time between massive hemorrhage protocol activation and blood administration during actual trauma resuscitations as analyzed using a two-sample t test. RESULTS: Each group was similar in demographic and injury characteristics. The time from massive hemorrhage protocol activation to blood administration decreased from 11.6 min pre-intervention to 9.1 min post-intervention. This represented a significant reduction (2.5 min, 95% confidence interval, 0.03-5.08) following the in situ simulation-based quality improvement intervention. CONCLUSIONS: A comprehensive, in situ simulation-based quality improvement project was associated with a significant reduction in the mean time between massive hemorrhage protocol activation and blood administration among injured patients. In situ simulation represents a novel approach to the identification and mitigation of latent safety threats during massive hemorrhage protocol activation.

RéSUMé: INTRODUCTION: Les protocoles d'hémorragie massive sont largement utilisés pour faciliter l'administration de composants sanguins aux patients souffrant de traumatismes hémorragiques. Les retards dans ce processus sont associés à de pires résultats pour les patients. Nous avons utilisé la simulation in situ comme une technique novatrice et itérative d'amélioration de la qualité pour réduire le temps moyen entre l'activation du protocole d'hémorragie massive et l'administration de sang lors des réanimations de traumatismes réels. LES MéTHODES: Nous avons effectué des simulations mensuelles de traumatismes in situ, sans préavis et en tenant compte des risques, dans un centre de traumatologie de niveau 1 au Canada. Nous avons identifié trois grandes menaces latentes pour la sécurité : 1) l'activation du protocole d'hémorragie massive ; 2) le transport de composants sanguins ; et 3) la connaissance de la situation des membres de l'équipe. Des améliorations de processus pour chaque menace latente à la sécurité ont été testées et mises en œuvre lors de séances de simulation in situ subséquentes. Nous avons évalué l'effet de cette intervention basée sur la simulation sur la prise en charge des patients avant, pendant et après l'intervention. Des données démographiques, cliniques et de protocole d'hémorragie massive ont été recueillies. Le critère de jugement principal était le temps moyen entre l'activation du protocole d'hémorragie massive et l'administration de sang pendant les réanimations traumatiques réelles, tel qu'analysé à l'aide d'un test t à deux échantillons. RéSULTATS: Chaque groupe était similaire en termes de caractéristiques démographiques et de blessures. Le temps entre l'activation du protocole d'hémorragie massive et l'administration de sang est passé de 11,6 minutes avant l'intervention à 9,1 minutes après l'intervention. Cela a représenté une réduction significative (2,5 minutes, intervalle de confiance de 95%, 0,03 à 5,08) suite à l'intervention d'amélioration de la qualité basée sur la simulation in situ. CONCLUSIONS: Un projet exhaustif d'amélioration de la qualité basé sur une simulation in situ a été associé à une réduction significative du temps moyen entre l'activation du protocole d'hémorragie massive et l'administration de sang chez les patients blessés. La simulation in situ représente une nouvelle approche pour l'identification et l'atténuation des menaces latentes pour la sécurité lors de l'activation du protocole d'hémorragie massive.

Translational simulation: from description to action.

This article describes an operational framework for implementing translational simulation in everyday practice. The framework, based on an input-process-output model, is developed from a critical review of the existing translational simulation literature and the collective experience of the authors' affiliated translational simulation services. The article describes how translational simulation may be used to explore work environments and/or people in them, improve quality through targeted interventions focused on clinical performance/patient outcomes, and be used to design and test planned infrastructure or interventions. Representative case vignettes are used to show how the framework can be applied to real world healthcare problems, including clinical space testing, process development, and culture. Finally, future directions for translational simulation are discussed. As such, the article provides a road map for practitioners who seek to address health service outcomes using translational simulation.

Latent safety threat identification during in situ simulation debriefing: a qualitative analysis.

Background: Latent safety threats (LSTs) in healthcare are hazards or conditions that risk patient safety but are not readily apparent without system stress. In situ simulation (ISS), followed by post-scenario debriefing is a common method to identify LSTs within the clinical environment. The function of post-ISS debriefing for LST identification is not well understood. Objectives: This study aims to qualitatively characterise the types of LSTs identified during ISS debriefing. Methods: We conducted 12 ISS trauma scenarios followed by debriefing at a Canadian, Level 1 trauma centre. We designed the scenarios and debriefing for 15 and 20 min, respectively. Debriefings focused on LST identification, and each session was audio recorded and transcribed. We used an inductive approach with qualitative content analysis to code text data into an initial coding tree. We generated refined topics from the coded text data. Results: We identified five major topics: (1) communication and teamwork challenges, (2) system-level issues, (3) resource constraints, (4) positive team performance and (5) potential improvements to the current systems and processes. Conclusions: During simulation debriefing sessions for LST identification, participants discussed threats related to communication and interpersonal issues. Safety issues relating to equipment, processes and the physical space received less emphasis. These findings may guide health system leaders and simulation experts better understanding of the strengths and limitations of simulation debriefing for LST identification. Further studies are required to compare ISS-based LST identification techniques.

Efficacy and safety of tranexamic acid in acute traumatic brain injury: a systematic review and meta-analysis of randomized-controlled trials.

PURPOSE: With the publication of a large randomized-controlled trial (RCT) suggesting that tranexamic acid (TXA) may improve head-injury-related deaths, we aimed to determine the safety and efficacy of TXA in acute traumatic brain injury (TBI). METHODS: In this systematic review and meta-analysis, we searched MEDLINE, PubMed, EMBASE, CINHAL, ACPJC, Google Scholar, and unpublished sources from inception until June 24, 2020 for randomized-controlled trials comparing TXA and placebo in adults and adolescents (≥ 15 years of age) with acute TBI. We screened studies and extracted summary estimates independently and in duplicate. We assessed the quality of evidence using the grading of recommendations assessment, development, and evaluation approach. This study is registered with PROSPERO (CRD42020164232). RESULTS: Nine RCTs enrolled 14,747 patients. Compared to placebo, TXA had no effect on mortality (RR 0.95; 95% CI 0.88-1.02; RD 1.0% reduction; 95% CI 2.5% reduction to 0.4% increase, moderate certainty) or disability assessed by the Disability Rating Scale (MD, - 0.18 points; 95% CI - 0.43 to 0.08; moderate certainty). TXA may reduce hematoma expansion on subsequent imaging (RR 0.77; 95% CI 0.58-1.03, RD 3.6%, 95% CI 6.6% reduction to 0.5% increase, low certainty). Risks of adverse events (all moderate, low, or very low certainty) were similar between placebo and TXA. CONCLUSIONS: In patients with acute TBI, TXA probably has no effect on mortality or disability. TXA may decrease hematoma expansion on subsequent imaging; however, this outcome is likely of less importance to patients. The use of TXA probably does not increase the risk of adverse events.