Capabilities of a mobile extracorporeal membrane oxygenation service for severe respiratory failure delivered by intensive care specialists.

We conducted a single-centre observational study of retrievals for severe respiratory failure over 12 months. Our intensivist-delivered retrieval service has mobile extracorporeal membrane oxygenation capabilities. Sixty patients were analysed: 34 (57%) were female and the mean (SD) age was 44.1 (13.6) years. The mean (SD) PaO2 /FI O2 ratio at referral was 10.2 (4.1) kPa and median (IQR [range]) Murray score was 3.25 (3.0-3.5 [1.5-4.0]). Forty-eight patients (80%) required veno-venous extracorporeal membrane oxygenation at the referring centre. There were no cannulation or extracorporeal membrane oxygenation-related complications. The median (IQR [range]) retrieval distance was 47.2 (14.9-77.0 [2.3-342.0]) miles. There were no major adverse events during retrieval. Thirty-seven patients (77%) who received extracorporeal membrane oxygenation survived to discharge from the intensive care unit and 36 patients (75%) were alive after six months. Senior intensivist-initiated and delivered mobile extracorporeal membrane oxygenation is safe and associated with a high incidence of survival.

Lethal triad in severe burns.

INTRODUCTION: Hypothermia, acidaemia and coagulopathy in trauma is associated with significant mortality. This study aimed to identify the incidence of the lethal triad in major burns, and describe demographics and outcomes. METHODS: Patients admitted during a 71 month period with a total body surface area burn (TBSA)≥30% were identified. A structured review of a prospective database was conducted. The lethal triad was defined as a combination of coagulopathy (International normalised ratio>1.2), hypothermia (temperature≤35.5°C) and acidaemia (pH≤7.25). RESULTS: Fifteen of 117 patients fulfilled the criteria for the lethal triad on admission. Lethal triad patients had a higher median (IQR) abbreviated burn severity index (ABSI) (12 (9-13) vs. 8.5 (6-10), p=0.001), mean (SD) TBSA burn (59.2% (18.7) vs. 47.9% (18.1), p=0.027), mean (SD) age (46 (22.6) vs. 33 (28.3) years, p=0.033), and had a higher incidence of inhalational injury (p<0.0001) and full-thickness burns (p=0.021). Both groups received similar volumes of fluid (p>0.05). The lethal triad was associated with increased mortality (66.7% vs. 13.7%, p<0.0001). With logistic regression analysis and adjustment for ABSI, the lethal triad was not shown to be a predictor of mortality (p>0.05). CONCLUSION: Burn patients with the lethal triad have a high mortality rate which reflects the severity of the injury sustained.

Acute burn induced coagulopathy.

BACKGROUND: Acute traumatic coagulopathy is well described in the trauma population. Major burns are characterised by a similar endothelial injury and cellular hypoperfusion. These features could be a driver for an acute burn induced coagulopathy (ABIC). METHODS: Patients admitted to a regional burn centre over a 71 months period with a total body surface area burn of 30% or more were identified. The metavision electronic patient database was scrutinised for a predetermined list of demographics, interventions and admission investigations to identify any clinically significant ABIC. RESULTS: On admission 39.3% of the 117 patients analysed met our criteria for a coagulopathy. Of the patients with a coagulopathy, 71.7% had an elevated Prothrombin Time (PT), 2.2% had an elevated Activated Partial Thromboplastin time (APPT) and 26.1% had an elevation of both. Patients with a coagulopathy received a similar volume of fluid (p=0.08). There was a statistically significant correlation between the PT and the abbreviated burn severity index (p=0.0013, r=0.292) and serum lactate (p=0.0013, r=0.292). ABIC was an independent predictor of 28 day mortality, OR 3.42(1.11-10.56). CONCLUSION: In patients with major thermal injuries a clinically significant ABIC exists. Early diagnosis and treatment of ABIC should be considered particularly in those undergoing total burn wound excision.

The effects of bed height and time on the quality of chest compressions delivered during cardiopulmonary resuscitation: a randomised crossover simulation study.

INTRODUCTION: The 2010 International Liaison Committee on Resuscitation gave a detailed update on best practice for cardiopulmonary resuscitation (CPR) with a discussion on appropriate patient and CPR provider position, based largely on expert opinion. The objective of this study was to ascertain robust evidence on the effect of bed height and fatigue on chest compression effectiveness. METHODS: A modified Laerdal manikin was connected to a Dragor ventilator (to measure intrathoracic pressures generated). The manikin was placed on a hospital trolley and CPR was performed by candidates at three different bed heights in a randomised order: (1) mid-thigh, (2) anterior superior iliac spine and (3) xiphisternum. Chest compressions were continuous and asynchronous with ventilation, and were allowed to continue for 30 s before recordings were taken. At the anterior superior iliac spine level, chest compressions were continued for 2 min, when further measurements were taken. RESULTS: 101 subjects took part. The differences in intrathoracic pressures generated at different bed heights were compared using analysis of variance testing for multiple groups and were statistically significant for p<0.05. The authors also found that the effectiveness of CPR decreased 17% over a 2-minute period (p<0.05). CONCLUSIONS: The most effective bed height position, allowing CPR providers to achieve the highest intrathoracic pressures during CPR, was one where the patient's chest was in line with the CPR provider's mid-thigh. The provider performing CPR should change every 2 min.

Comparison of the Mapleson C system and adult and paediatric self-inflating bags for delivering guideline-consistent ventilation during simulated adult cardiopulmonary resuscitation.

There is a discrepancy between resuscitation teaching and witnessed clinical practice. Furthermore, deleterious outcomes are associated with hyperventilation. We therefore conducted a manikin-based study of a simulated cardiac arrest to evaluate the ability of three ventilating devices to provide guideline-consistent ventilation. Mean (SD) minute ventilation was reduced with the paediatric self-inflating bag (7.0 (3.2) l.min⁻¹) compared with the Mapleson C system (9.8 (3.5) l.min⁻¹) and adult self-inflating bag (9.7 (4.2) l.min⁻¹ ; p = 0.003). Tidal volume was also lower with the paediatric self-inflating bag (391 (52) ml) compared with the others (582 (87) ml and 625 (103) ml, respectively; p < 0.001), as was peak airway pressure (14.5 (5.2) cmH2O vs 20.7 (9.0) cmH2O and 30.3 (11.4) cmH2O, respectively; p < 0.001). Participants hyperventilated patients' lungs in simulated cardiac arrest with all three devices. The paediatric self-inflating bag delivered the most guideline-consistent ventilation. Its use in adult cardiopulmonary resuscitation may ensure delivery of more guideline-consistent ventilation in patients with tracheal intubation.

Therapeutic hypothermia following out-of-hospital cardiac arrest; does it start in the emergency department?

BACKGROUND: The use of therapeutic hypothermia after cardiac arrest is a well-practised treatment modality in the intensive care unit (ICU). However, recent evidence points to advantages in starting the cooling process as soon as possible after the return of spontaneous circulation (ROSC). There are no data on implementation of this treatment in the emergency department. METHODS: A telephone survey was conducted of the 233 emergency departments in the UK. The most senior available clinician was asked if, in cases where they have a patient with a ROSC after an out-of-hospital cardiac arrest, would therapeutic hypothermia be started in the emergency department. RESULTS: Of the 233 hospitals called, 230 responded, of which 35% would start cooling in the emergency department. Of this 35%, over half (56%) said the decision to start cooling was made by the emergency physician before consultation with the ICU. Also, of the 35% who would begin cooling in the emergency department, 55% would cool only for ventricular fibrillation/ventricular tachycardia, 66% would monitor temperature centrally, and 14% would use specialised cooling equipment. CONCLUSIONS: There is often a delay in getting patients to ICU from the emergency department, and thus the decision not to start cooling in the emergency department may impact significantly on patient outcome. The dissemination of these data may persuade emergency physicians that starting treatment in the emergency department is an appropriate and justifiable decision that is becoming a more accepted practice throughout the UK.