Comparing the stress response using heart rate variability during real and simulated crises: a pilot study.

Medical personnel often experience stress when responding to a medical emergency. A known stress-response is a measurable reduction in heart rate variability. It is currently unknown if crisis simulation can elicit the same stress response as real clinical emergencies. We aim to compare heart rate variability changes amongst medical trainees during simulated and real medical emergencies. We performed a single center prospective observational study, enrolling 19 resident physicians. Heart rate variability was measured in real time, using a 2-lead heart rate monitor (Bodyguard 2, Firstbeat Technologies Ltd) worn during 24 h critical care call shifts. Data was collected at baseline, during crisis simulation and when responding to medical emergencies. 57 observations were made to compare participant's heart rate variability. Each heart rate variability metric changed as expected in response to stress. Statistically significant differences were observed between baseline and simulated medical emergencies in Standard Deviation of the N-N interval (SDNN), Root mean square standard deviation of the N-N interval (RMSSD), Percentage of successive R-R intervals that differ by more than 50 ms (PNN50), Low Frequency (LF) and Low Frequency: High Frequency ratios (LF:HF). No statistically significant differences between simulated and real medical emergencies were identified in any heart rate variability metrics. We have shown using objective results, that simulation can elicit the same psychophysiological response as actual medical emergencies. Therefore, simulation may represent a reasonable way to practice not only essential skills in a safe environment but has the additional benefit of creating a realistic, physiological response in medical trainees.

Contextual interference for skills development and transfer in laparoscopic surgery: a randomized controlled trial.

INTRODUCTION: Past education literature has shown benefits for random practice schedules (termed contextual interference) for skills retention and transfer to novel tasks. The purpose of fundamentals of laparoscopic surgery (FLS) training is to develop skills in simulation and transfer to new in vivo intraoperative experiences. The study objective was to assess whether individuals trained over a fixed number of trials in the FLS tasks would outperform untrained controls on an unpracticed previously validated bile duct cannulation task and scoring system and to determine whether random training schedules conferred any relative advantage. METHODS: 44 trainees with no laparoscopic experience were recruited to participate. 35 were randomized to practice the FLS tasks using either a blocked or random training schedule. Nine were randomized to no additional training (controls). Participant performance was measured throughout training to monitor skills acquisition and were then tested on an unpracticed bile duct cannulation simulation task 4 to 6 weeks later. Outcomes included previously validated FLS scores and hand-motion analyses. RESULTS: All 44 participants completed the study. Trained individuals in both groups showed significant improvements in all FLS tasks after training. There were no differences between groups in performance on the cannulation task median scores (Blocked: 89.8 [IQR:37.6]; Random: 83.2 [32.3]; Control: 83.6 [19.1]; p = 0.955), number of hand motions (Blocked: 42.5 [IQR:130.3]; Random: 75.3 [111.3]; Control: 63.0 [71.8]; p = 0.912), or distance traveled by participants hands (Blocked: 2.0 m [IQR:5.8]; Random: 3.8 [8.9]; Control: 2.6 [2.5]; p = 0.816). Cannulation task performance had no correlation with total FLS performance, R2 linear = 0.014, p = 0.445. CONCLUSIONS: Skills acquired from conventional FLS tasks did not effectively transfer to a laparoscopic bile duct cannulation task. Neither blocked nor random practice schedules conferred a relative advantage. These findings provide evidence that cannulation is a distinct skill from what is taught and assessed in FLS.

Resuscitative endovascular balloon occlusion of the aorta in Canada: a context-specific position paper from the Canadian Collaborative for Urgent Care Surgery (CANUCS).

SummaryResuscitative endovascular balloon occlusion of the aorta (REBOA) is a well-described intervention for noncompressible torso hemorrhage. Several Canadian centres have included REBOA in their hemorrhagic shock protocols. However, REBOA has known complications and equipoise regarding its use persists. The Canadian Collaborative on Urgent Care Surgery (CANUCS) comprises surgeons who provide acute trauma care and leadership in Canada, with experience in REBOA implementation, use, education and research. Our goal is to provide evidence- and experience-based recommendations regarding institutional implementation of a REBOA program, including multidisciplinary educational programs, attention to device and care pathway logistics, and a robust quality assurance program. This will allow Canadian trauma centres to maximize patient benefits and minimize risks of this potentially life-saving technology.

A randomized, controlled, blinded evaluation of augmenting point-of-care ultrasound and remote telementored ultrasound in inexperienced operators.

BACKGROUND: Handheld ultrasound devices present an opportunity for prehospital sonographic assessment of trauma, even in the hands of novice operators commonly found in military, maritime, or other austere environments. However, the reliability of such point-of-care ultrasound (POCUS) examinations by novices is rightly questioned. A common strategy being examined to mitigate this reliability gap is remote mentoring by an expert. OBJECTIVES: To assess the feasibility of utilizing POCUS in the hands of novice military or civilian emergency medicine service (EMS) providers, with and without the use of telementoring. To assess the mitigating or exacerbating effect telementoring may have on operator stress. METHODS: Thirty-seven inexperienced physicians and EMTs serving as first responders in military or civilian EMS were randomized to receive or not receive telementoring during three POCUS trials: live model, Simbionix trainer, and jugular phantom. Salivary cortisol was obtained before and after the trial. Heart rate variability monitoring was performed throughout the trial. RESULTS: There were no significant differences in clinical performance between the two groups. Iatrogenic complications of jugular venous catheterization were reduced by 26% in the telementored group (P < 0.001). Salivary cortisol levels dropped by 39% (P < 0.001) in the telementored group. Heart rate variability data also suggested mitigation of stress. CONCLUSIONS: Telementoring of POCUS tasks was not found to improve performance by novices, but findings suggest that it may mitigate caregiver stress.

Multidisciplinary, multisite trauma team training during COVID-19: lessons from the first virtual E-S.T.A.R.T.T. course.

Trauma care delivery is a complex team-based task that requires deliberate practice. The COVID-19 pandemic has not diminished the importance of excellent trauma team dynamics. However, the pandemic hampers our ability to gather safely and train together. A mitigating solution is the provision of high-fidelity simulation training in a virtual setting. The Simulated Trauma and Resuscitation Team Training (S.T.A.R.T.T.) course has provided multidisciplinary trauma team members with skills in crisis resource management (CRM) for nearly 10 years. It has promoted collaborative learning from coast to coast, as the course typically runs at our national surgical and trauma meetings. In response to COVID-19 challenges, the course content has been modified to virtually connect 2 centres in different provinces simultaneously. High participant satisfaction suggests that the new virtual E-S.T.A.R.T.T course is able to continue to help providers develop important CRM skills in a multidisciplinary setting while remaining compliant with COVID-19 safety precautions.

A New Inexpensive Simulation Model for Ultrasound Assessment of Optic Nerve Sheath Diameter.

BACKGROUND: Sonographic measurement of optic nerve sheath diameter (ONSD) is becoming increasingly accepted as a diagnostic modality to detect elevations in intracranial pressure. As this technique becomes more widespread, methods to address the inherent operator-dependent nature of this modality will need to be developed. We propose a novel low-cost model to accurately simulate sonographic ONSD measurement for purposes of training and assessment. METHODS: We designed models composed of medical tubing of various diameters readily available from typical hospital supplies and suspended them in gelatin. The models were evaluated by ultrasound by three expert point-of-care sonographers using a standard linear array probe and technique proposed in the literature. RESULTS: This model generates faithful simulation of the ONS that closely approximates in vivo images and can be used to produce accurate, reproducible measurements. Materials are low cost and easy to acquire and assemble. CONCLUSIONS: Our model provides realistic simulated images of the ONS. Through comparison of sonographic measurements to the known tube diameters, this model serves as a promising inexpensive tool to teach the method of ultrasound assessment of ONSD or as a way to determine accuracy of this novel ultrasound technology.

Fidelity in surgical simulation: further lessons from the S.T.A.R.T.T. course

Summary: Simulation has become a popular and ubiquitous medical education tool. In response to learner demands, and because of technological advancement, there is a trend toward increasing the realism of simulation. However, there is a paucity of evidence regarding what degree of fidelity is needed to deliver optimal simulation-based medical education. Feedback from the Simulated Trauma And Resuscitation Team Training (S.T.A.R.T.T.) course suggests that higherfidelity simulation is viewed as highly valuable to learners. Research is needed in order to guide the growing demand for higher-fidelity simulation in our medical training curricula and in order to justify or mitigate the associated costs and logistical challenges.

Strategies to improve communication in telementoring in acute care coordination: a scoping review.

Background: Telementoring facilitates the coordination of advanced medical care in rural, remote or austere environments. Because the interpersonal element of telementoring has been relatively underexplored, we conducted a scoping review to identify strategies to improve communication in telementoring. Methods: Two independent reviewers searched all English-language articles in MEDLINE and Scopus from 1964 to 2017, as well as reference lists of relevant articles to identify articles addressing telementored interactions between health care providers. Search results were gathered in June 2017 and updated in January 2018. Identified articles were categorized by theme. Results: We identified 144 articles, of which 56 met our inclusion criteria. Forty-one articles focused on improving dispatcher-directed cardiopulmonary resuscitation (CPR). Major themes included the importance of language in identifying out-of-hospital cardiac arrest and how to provide instructions to enable administration of effective CPR. A standardized approach with scripted questions was associated with improved detection of out-of-hospital cardiac arrest, and a concise script was associated with improved CPR quality compared to no mentoring, unscripted mentoring or more complex instructions. Six articles focused on physician-physician consultation. Use of a handover tool that highlighted critical information outperformed an unstructured approach regarding transmission of vital information. Nine articles examined telementoring in trauma resuscitation. A common theme was the need to establish an understanding between mentor and provider regarding the limitations of the provider and his or her environment. Conclusion: The available data suggest that standardization coupled with short, concise validated scripts could improve efficacy, safety and engagement. Improvements will require multidisciplinary input, practice and deliberate efforts to address barriers.

Contexte: Le mentorat en ligne facilite la coordination des soins médicaux de pointe dans les environnements ruraux, éloignés ou rudimentaires. Toutefois, le facteur relationnel de ce type d'interaction est resté plutôt sous-exploré. C'est pourquoi nous avons réalisé une revue exploratoire pour dégager des stratégies d'amélioration de la communication en contexte de mentorat en ligne. Méthodes: Deux réviseurs indépendants ont cherché à recenser les articles portant sur les interactions de mentorat en ligne entre professionnels de la santé parmi tous les articles de langue anglaise publiés entre 1964 et 2017 indexés dans les bases de données MEDLINE et Scopus, ainsi que dans les listes bibliographiques des articles pertinents. Les résultats de recherche ont été recueillis en juin 2017 et actualisés en janvier 2018, et les articles recensés ont été regroupés par thèmes. Résultats: Nous avons retenu 144 articles, dont 56 répondant à nos critères d'inclusion. De ce total, 41 portaient sur l'amélioration de la réanimation cardiorespiratoire (RCR) dirigée par un répartiteur. Parmi les thèmes principaux, on retrouve l'importance du langage dans l'identification des arrêts cardiaques hors de l'hôpital, ainsi que la manière de fournir des instructions permettant de pratiquer une RCR efficace. Une approche normalisée avec des questions scénarisées a été associée à une meilleure détection des arrêts cardiaques hors de l'hôpital, alors qu'un scénario concis a été associé à une amélioration de la qualité de la RCR comparativement à une approche sans mentorat, avec mentorat non scénarisé ou avec des instructions plus complexes. Six des articles retenus portaient sur la consultation de type médecin­médecin. Ils ont conclu que l'utilisation d'un outil de transfert mettant en évidence l'information importante était plus efficace qu'une approche non structurée pour la transmission de renseignements vitaux. Finalement, 9 articles portaient sur le mentorat en ligne en réanimation traumatologique. Un des thèmes communs de ces articles était le besoin d'établir une compréhension mutuelle entre mentors et professionnels en ce qui concerne les restrictions de ces derniers et de leur environnement. Conclusion: Les données disponibles semblent indiquer que la normalisation associée à des scénarios courts, concis et éprouvés pourrait améliorer l'efficacité, la sécurité et l'engagement. Cependant, toute amélioration nécessitera un encadrement multidisciplinaire, de la pratique et des efforts délibérés pour surmonter les obstacles.

Ultrasound in the surgical ICU: uses, abuses, and pitfalls.

PURPOSE OF REVIEW: Point-of-care ultrasound (POCUS) has become an integral component of daily care in the surgical ICU. There have been many novel advancements in the past two decades, too numerous to count. Many are of critical importance to the intensive care physician, whereas others are still accumulating evidence. Without appropriate training, diligence, and incorporation of the ultrasound findings into the whole clinical picture, this technique can be gravely misused. This review examines POCUS use in the surgical ICU, as well as highlights potential hazards and common pitfalls. RECENT FINDINGS: POCUS is essential for guidance of vascular access procedures, as well as in the characterization and treatment of respiratory failure, shock, and unstable blunt abdominal trauma. Ultrasound has growing evidence for rapidly evaluating many other diseases throughout the entire body, as well as guidance for procedures. Using advanced ultrasound techniques should only be done with corresponding levels of training and experience. SUMMARY: Ultrasound in the critical care setting has become an essential component of the assessment of most ICU patients. As more evidence accumulates, along with ever-increasing availability of ultrasound technology, its use will continue to expand. It, thus, behoves clinicians to not only ensure they are adept at obtaining and interpreting POCUS images but also efficiently incorporate these skills into holistic bedside care without delaying lifesaving therapies.

Effect of rater training on the reliability of technical skill assessments: a randomized controlled trial.

BACKGROUND: Rater training improves the reliability of observational assessment tools but has not been well studied for technical skills. This study assessed whether rater training could improve the reliability of technical skill assessment. METHODS: Academic and community surgeons in Royal College of Physicians and Surgeons of Canada surgical subspecialties were randomly allocated to either rater training (7-minute video incorporating frame-of-reference training elements) or no training. Participants then assessed trainees performing a suturing and knot-tying task using 3 assessment tools: a visual analogue scale, a task-specific checklist and a modified version of the Objective Structured Assessment of Technical Skill global rating scale (GRS). We measured interrater reliability (IRR) using intraclass correlation type 2. RESULTS: There were 24 surgeons in the training group and 23 in the no-training group. Mean assessment tool scores were not significantly different between the 2 groups. The training group had higher IRR than the no-training group on the visual analogue scale (0.71 v. 0.46), task-specific checklist (0.46 v. 0.33) and GRS (0.71 v. 0.61). However, confidence intervals were wide and overlapping for all 3 tools. CONCLUSION: For education purposes, the reliability of the visual analogue scale and GRS would be considered "good" for the training group but "moderate" for the no-training group. However, a significant difference in IRR was not shown, and reliability remained below the desired level of 0.8 for high-stakes testing. Training did not significantly improve assessment tool reliability. Although rater training may represent a way to improve reliability, further study is needed to determine effective training methods.

CONTEXTE: La formation des évaluateurs améliore la fiabilité des outils d'évaluation observationnels, mais n'a pas été rigoureusement étudiée au plan des habiletés techniques. Cette étude a tenté de vérifier si la formation des évaluateurs permettait d'améliorer la fiabilité de l'évaluation des habiletés techniques. MÉTHODES: On a assigné des chirurgiens universitaires et communautaires appartenant aux surspécialités chirurgicales du Collège royal des médecins et chirurgiens du Canada, soit à une formation des évaluateurs (vidéo de 7 minutes comprenant des éléments de formation afférents au cadre de référence), soit à l'absence de formation. les participants ont ensuite évalué des stagiaires qui effectuaient tâches, telles sutures et nœuds, à l'aide de trois outils d'évaluation : échelle analogique visuelle, liste de vérification spécifique à la tâche et version modifiée de l'échelle d'appréciation globale (ÉAG) de l'Objective Structured Assessment of Technical Skill. Nous avons mesuré la fiabilité interévaluateurs (FIÉ) à l'aide de la corrélation intraclasse de type 2. RÉSULTATS: Il y avait 24 chirurgiens dans le groupe soumis à la formation et 23 dans le groupe non soumis à la formation. Les scores moyens des outils d'évaluation n'ont pas été significativement différents entre les deux groupes. Le groupe soumis à la formation a présenté une FIÉ plus élevée que l'autre groupe à l'échelle analogique visuelle (0,71 c. 0,46), à la liste de vérification spécifique à la tâche (0,46 c. 0,33) et à l'ÉAG (0,71 c. 0,61). Par contre, les intervalles de confiance étaient larges et se recoupaient pour les trois outils. CONCLUSION: Aux fins de la formation, la fiabilité de l'échelle analogique visuelle et de l'ÉAG serait considérée «.bonne.¼ pour le groupe soumis à la formation, mais «.modérée.¼ pour le groupe non soumis à la formation. On n'a toutefois pas démontré de différence significative quant à la FIÉ et la fiabilité est demeurée inférieure au niveau souhaité de 0,8 pour les tests importants. La formation n'a pas significativement amélioré la fiabilité de l'outil d'évaluation. Même si la formation des évaluateurs représente potentiellement une façon d'améliorer la fiabilité, il faudra approfondir la recherche pour déterminer quelles méthodes de formation sont efficaces.

A day in the life of emergency general surgery in Canada: a multicentre observational study.

BACKGROUND: Emergency general surgery (EGS) services are gaining popularity in Canada as systems-based approaches to surgical emergencies. Despite the high volume, acuity and complexity of the patient populations served by EGS services, little has been reported about the services' structure, processes, case mix or outcomes. This study begins a national surveillance effort to define and advance surgical quality in an important and diverse surgical population. METHODS: A national cross-sectional study of EGS services was conducted during a 24-hour period in January 2017 at 14 hospitals across 7 Canadian provinces recruited through the Canadian Association of General Surgeons Acute Care Committee. Patients admitted to the EGS service, new consultations and off-service patients being followed by the EGS service during the study period were included. Patient demographic information and data on operations, procedures and complications were collected. RESULTS: Twelve sites reported resident coverage. Most services did not include trauma. Ten sites had protected operating room time. Overall, 393 patient encounters occurred during the study period (195/386 [50.5%] operative and 191/386 [49.5%] nonoperative), with a mean of 3.8 operations per service. The patient population was complex, with 136 patients (34.6%) having more than 3 comorbidities. There was a wide case mix, including gallbladder disease (69 cases [17.8%]) and appendiceal disease (31 [8.0%]) as well as complex emergencies, such as obstruction (56 [14.5%]) and perforation (23 [5.9%]). CONCLUSION: The characteristics and case mix of these Canadian EGS services are heterogeneous, but all services are busy and provide comprehensive operative and nonoperative care to acutely ill patients with high levels of comorbidity.

CONTEXTE: Les services de chirurgie générale d'urgence (CGU) gagnent en popularité au Canada en tant qu'approches systémiques aux urgences chirurgicales. Malgré le volume élevé, le caractère urgent et la complexité des populations de patients desservies en CGU, peu de rapports ont porté sur la structure, les processus, les clientèles ou les résultats de ces services. La présente étude instaure une démarche de surveillance nationale qui servira à définir et à améliorer la qualité des chirurgies destinées à cette population importante et hétérogène. MÉTHODES: Une étude transversale nationale sur les services de CGU a été réalisée sur une période de 24 heures en janvier 2017 dans 14 hôpitaux de 7 provinces canadiennes recrutés par l'entremise du comité pour les soins aigus de l'Association canadienne des chirurgiens généraux. On y a inclus les patients admis dans les services de CGU, les nouvelles consultations et les patients de l'extérieur suivis par les services de CGU pendant la période de l'étude. On a recueilli les caractéristiques démographiques des patients et les données sur les interventions, les procédures et les complications. RÉSULTATS: Douze sites ont fait état de la couverture assurée par les résidents. La plupart des services ont exclu la traumatologie. Dix sites disposaient de temps protégé au bloc opératoire. En tout, 393 rencontres avec des patients ont eu lieu pendant la période de l'étude (195/386 [50,4 %] chirurgicales, 191/386 [49,5 %] non chirurgicales), avec une moyenne de 3,8 chirurgies par service. La population regroupait des cas complexes : 136 patients (34,6 %) présentaient plus de 3 comorbidités. La clientèle était diversifiée et comprenait des cas de maladie de la vésicule biliaire (69 cas [17,8 %]) et de l'appendice (31 [8,0 %]), de même que des situations d'urgence délicates, telle qu'obstruction (56 [14,5 %]) et perforation (23 [5,9 %]). CONCLUSION: Leurs caractéristiques et leurs clientèles sont hétérogènes, mais les services de CGU sont tous achalandés et ils offrent tous des soins chirurgicaux et non chirurgicaux complets à des patients gravement malades porteurs d'importantes comorbidités.

Evaluating Extravascular Lung Water in Sepsis: Three Lung-Ultrasound Techniques Compared against Transpulmonary Thermodilution.

BACKGROUND: Excessive extravascular lung water (EVLW) is associated with increased morbidity and mortality. We compared three lung-ultrasound (L-US) techniques against the reference-standard transpulmonary thermodilution (TPTD) technique to access EVLW. MATERIALS AND METHODS: This was a prospective, single-blind, cross-sectional study. Forty-four septic patients were enrolled. EVLW index was measured by the TPTD method, and an index of ≥10 mL/kg was considered diagnostic of pulmonary edema. EVLW index was then compared to three established bedside L-US protocols that evaluate sonographic B-lines: (1) a 28-zone protocol (total B-line score [TBS]) (2) a scanning 8-region examination, and (3) a 4-point examination. RESULTS: Eighty-nine comparisons were obtained. A statistically significant positive correlation was found between L-US TBS and an EVLW index ≥10 mL/kg (r = 0.668,P < 0.001). The 28-zone protocol score ≥39 has a sensitivity of 81.6% and a specificity of 76.5% to define EVLW index ≥10 mL/kg. In contrast, the positive 4-point examination and scanning 8-regions showed low sensitivity (23.7% and 50.0%, respectively) but high specificity (96.1% and 88.2%, respectively). Ten patients with a total of 21 comparisons met criteria for acute respiratory distress syndrome (ARDS). In this subgroup, only the TBS had statistically significant positive correlation to EVLW (r = 0.488,P = 0.025). CONCLUSION: L-US is feasible in patients with severe sepsis. In addition, L-US 28-zone protocol demonstrated high specificity and better sensitivity than abbreviated 4- and 8-zone protocols. In ARDS, the L-US 28-zone protocol was more accurate than the 4- and 8-zone protocols in predicting EVLW. Consideration of limitations of the latter protocols may prevent clinicians from reaching premature conclusions regarding the prediction of EVLW. TRIAL REGISTRATION: ISRCTN11419081. Registered 4 February 2015 retrospectively.

Burst Suppression for ICP Control.

BACKGROUND: The goal of our study was to perform a systematic review of the literature to determine the effect that burst suppression has on intracranial pressure (ICP) control. METHODS: All articles from MEDLINE, BIOSIS, EMBASE, Global Health, Scopus, Cochrane Library, the International Clinical Trials Registry Platform (inception to January 2015), reference lists of relevant articles, and gray literature were searched. The strength of evidence was adjudicated using both the Oxford and the Grading of Recommendation Assessment Development and Education (GRADE) methodology. RESULTS: Seven articles were considered for review. A total of 108 patients were studied, all receiving burst suppression therapy. Two studies failed to document a decrease in ICP with burst suppression therapy. There were reports of severe hypotension and increased infection rates with barbiturate-based therapy. Etomidate-based suppressive therapy was linked to severe renal dysfunction. CONCLUSIONS: There currently exists both Oxford level 2b and GRADE C evidence to support that achieving burst suppression reduces ICP, and also has no effect on ICP, in severe traumatic brain injury. The literature suggests burst suppression therapy may be useful for ICP reduction in certain cases, although these situations are currently unclear. In addition, the impact on patient functional outcome is unclear. Further prospective study is warranted.

Point of care ultrasonography use and training among trauma providers across Canada.

SUMMARY: Point of care ultrasonography (POCUS) is revolutionizing care of critically ill patients. However, training in POCUS is extremely variable, with no accepted curriculum or certification process. We aimed to delineate the training experience and use of POCUS among trauma providers across Canada via a secure e-questionnaire sent to members of the Trauma Association of Canada. This commentary discusses our survey results and argues for the standardization of POCUS training and certification in Canada.

S.T.A.R.T.T. plus: addition of prehospital personnel to a national multidisciplinary crisis resource management trauma team training course.

SUMMARY: The Simulated Trauma and Resuscitation Team Training (S.T.A.R.T.T.) course is a unique multidisciplinary trauma team training course deliberately designed to address the common crisis resource management (CRM) skills of trauma team members. Moreover, the curriculum has been updated to also target the specific learning needs of individual participating professionals: physicians, nurses and respiratory therapists. This commentary outlines further modifications to the course curriculum in order to address the needs of a relatively undertargeted group: prehospital personnel (i.e., emergency medical services). Maintenance of high participant satisfaction, regardless of profession, suggests that the S.T.A.R.T.T. course can be readily modified to incorporate prehospital personnel without losing its utility or popularity.

Trauma simulation in bilingual Canada: Insurmountable barrier or unexpected strength? Insights from the first bilingual S.T.A.R.T.T. course.

SUMMARY: The Standardized Trauma and Resuscitation Team Training (S.T.A.R.T.T.) course focuses on training multidisciplinary trauma teams: surgeons/physicians, registered nurses (RNs), respiratory therapists (RTs) and, most recently, prehospital personnel. The S.T.A.R.T.T. curriculum highlights crisis management (CRM) skills: communication, teamwork, leadership, situational awareness and resource utilization. This commentary outlines the modifications made to the course curriculum in order to satisfy the learning needs of a bilingual audience. The results suggest that bilingual multidisciplinary CRM courses are feasible, are associated with high participant satisfaction and have no clear detriments.

Therapeutic Hypothermia for Refractory Status Epilepticus.

BACKGROUND: Our goal was to perform a systematic review of the literature on the use of therapeutic hypothermia for refractory status epilepticus (RSE) and its impact on seizure control. METHODS: All articles from MEDLINE, BIOSIS, EMBASE, Global Health, HealthStar, Scopus, Cochrane Library, the International Clinical Trials Registry Platform (inception to May 2014), reference lists of relevant articles, and gray literature were searched. The strength of evidence was adjudicated by two independent reviewers, using both the Oxford and GRADE methodology. RESULTS: Overall, 13 studies were identified, with 10 manuscripts and 3 meeting abstracts. A total of 40 patients were treated. The common target temperature was 33 degrees Celsius, sustained for a median 48 hours. Patients displayed a 62.5%, 15% and 22.5% rate of seizure cessation, seizure reduction, and failure of treatment respectively. External cooling was utilized in the majority of cases. Deep venous thrombosis, coagulopathy and infections were the commonly reported complications. Two ongoing clinical trials were identified. CONCLUSIONS: Oxford level 4, GRADE D evidence exists to support the use of therapeutic hypothermia to control seizures in RSE. Further prospective study is warranted.

Modern inhalational anesthetics for refractory status epilepticus.

BACKGROUND: Our goal was to perform a systematic review of the literature on the use of modern inhalational anesthetic agents for refractory status epilepticus and their impact on seizure control. METHODS: All articles from MEDLINE, BIOSIS, EMBASE, Global Health, HealthStar, Scopus, Cochrane Library, the International Clinical Trials Registry Platform (inception to March 2014), reference lists of relevant articles, and gray literature were searched. The strength of evidence was adjudicated using both the Oxford and Grading of Recommendation Assessment Development and Education methodology by two independent reviewers. RESULTS: Overall, 19 studies were identified, with 16 manuscripts and 3 meeting abstracts. A total of 46 patients were treated. Adult (n=28) and pediatric patients (n=18) displayed 92.9% and 94.4% seizure control with treatment, respectively. Isoflurane was used in the majority of cases. Hypotension was the only complication described. CONCLUSIONS: Oxford level 4, Grading of Recommendation Assessment Development and Education D evidence exists to support the use of isoflurane in refractory status epilepticus to obtain burst suppression. Insufficient data exist to comment on the efficacy of desflurane and xenon at this time.

Lidocaine for Status Epilepticus in Pediatrics.

BACKGROUND: Our goal was to perform a systematic review of the literature on the use of intravenous lidocaine in pediatrics for status epilepticus (SE) and refractory status epilepticus (RSE) to determine its impact on seizure control. METHODS: All articles from MEDLINE, BIOSIS, EMBASE, Global Health, HealthStar, Scopus, Cochrane Library, the International Clinical Trials Registry Platform (inception to November 2014), and gray literature were searched. The strength of evidence was adjudicated using both the Oxford and Grading of Recommendations Assessment, Development, and Evaluation methodologies by two independent reviewers. RESULTS: Overall, 20 original studies were identified, with 19 manuscripts and one meeting abstract. Two hundred and thirty-five pediatric patients were treated for 252 episodes of SE/RSE. Patients had varying numbers of antiepileptic drugs (two to eight) on board before lidocaine therapy. During 20 of the 252 (7.9%) episodes of SE/RSE, phenytoin was on board. The dose regimen of lidocaine varied, with some using bolus dosing alone; others used a combination of bolus and infusion therapy. Overall, 60.0% of seizures responded to lidocaine, with complete cessation and greater than 50% reduction seen in 57.6% and 12.3%, respectively. Patient outcomes were sparingly reported. CONCLUSIONS: There currently exists Oxford level 2b, Grading of Recommendations Assessment Development, and Evaluation C evidence to support the consideration of lidocaine for SE and RSE in the pediatric population. Further prospective studies of lidocaine administration in this setting are warranted.

Indomethacin for control of ICP.

UNLABELLED: Our goal was to perform a systematic review of the literature on the use of indomethacin and its effects on intracranial pressure (ICP) in patients with neurological illness. All articles from MEDLINE, BIOSIS, EMBASE, Global Health, Scopus, Cochrane Library, the International Clinical Trials Registry Platform (inception to July 2014), reference lists of relevant articles, and gray literature were searched. Two reviewers independently identified all manuscripts utilizing the following inclusion and exclusion criteria. INCLUSION CRITERIA: Humans, prospective studies (five or more patients), documented ICP response to indomethacin, and English. EXCLUSION CRITERIA: non-English, retrospective studies, no documentation of ICP response to indomethacin, and animal studies. A two-tier filter of references was conducted. First, we screened manuscripts by title and abstract. Second, those references passing the first filter were pulled, and the full manuscript was checked to see if it matched the criteria for inclusion. Two reviewers independently extracted data including population characteristics and treatment characteristics. The strength of evidence was adjudicated using both the Oxford and GRADE methodology. Our search strategy produced a total of 208 citations. Twelve original articles, 10 manuscripts, and 2 meeting proceeding, were considered for the review with all utilizing indomethacin, while documenting ICP in neurological patients. All studies were prospective. Across all studies, there were a total of 177 patients studied, with 152 receiving indomethacin and 25 serving as controls in a variety of heterogeneous studies. All but one study documented a decrease in ICP with indomethacin administration, with both bolus and continuous infusions. No significant complications were described. There currently exists Oxford level 2b, GRADE C evidence to support that indomethacin reduces ICP in the severe TBI population. Similar conclusions in other populations cannot be made at this time. Comments on its impact, on patient outcome, and side effects cannot be made given the available data. At this time, indomethacin for ICP control remains experimental and further prospective study is warranted.