Empowering medical students: bridging gaps with high-fidelity simulations; a mixed-methods study on self-efficacy.

BACKGROUND: High-fidelity simulations play a crucial role in preparing for high-mortality events like cardiopulmonary arrest, emphasizing the need for rapid and accurate intervention. Proficiency in cardiopulmonary resuscitation(CPR) requires a strong self-efficacy(SE); training for both is crucial. This study assesses the impact of Advanced Life Support(ALS) simulation on SE changes in final-year medical students. METHODS: This mixed-methods prospective simulation study involved medical students in emergency medicine internships, examining self-efficacy perceptions regarding ALS technical skills(ALS-SEP). A comparison was made between students who underwent scenario-based ALS simulation training and those who did not. Competencies in chest compression skills were assessed, and the concordance between ALS-SEP scores and observed CPR performances were evaluated. Focus group interviews were conducted and analyzed using content analysis techniques. RESULTS: The study involved 80 students, with 53 in the experimental group(EG) and 27 in the control group(CG). The EG, underwent simulation training, showed a significantly higher ALS-SEP change than the CG(p < 0.05). However, there was low concordance between pre-simulation SEP and actual performance. Compression skills success rates were inadequate. Qualitative analysis revealed main themes as"learning"(32.6%), "self-efficacy"(29%), "simulation method"(21.3%), and "development"(16.5%). DISCUSSION: Post-simulation, students reported improved SEP and increased readiness for future interventions. The findings and qualitative statements support the effectiveness of simulation practices in bridging the gap between SEP and performance. Utilizing simulation-based ALS training enhances learners' belief in their capabilities, raises awareness of their competencies, and encourages reflective thinking. Given the importance of high SEP for ALS, simulation trainings correlating self-efficacy perception and performance may significantly reduce potential medical errors stemming from a disparity between perceived capability and actual performance.

Effectiveness of combinations of active compression-decompression cardiopulmonary resuscitation, impedance threshold devices and head-up cardiopulmonary resuscitation in adult out-of-hospital cardiac arrest: A systematic review.

Objective: This review summarises the current evidence base for combinations of neuroprotective CPR adjuncts (active compression-decompression chest compressions, impedance threshold devices, and head-up positioning) during out-of-hospital cardiac arrest. Methods: A systematic search (PROSPERO registration CRD42023432302) was performed in English on MEDLINE, EMBASE, and the Cochrane Library in August 2023, and repeated in February 2024. All randomised and observational studies (not abstracts) reporting on any combination of the aforementioned CPR adjuncts were included. Papers were screened independently by two researchers, with a third reviewer acting as tiebreaker. Out-of-hospital, non-traumatic, cardiac arrests in patients >18 years were eligible for inclusion. Risk of bias was assessed using the Risk of Bias 2 tool and the Newcastle-Ottawa scale. Results: Eight of 1172 unique articles identified in the initial searches were included, with five randomised controlled trials and three observational studies. No randomised trial investigated a bundle of all three interventions. All randomised controlled trials were at intermediate or high risk of bias. Neurologically favourable survival was greater in patients treated with an impedance threshold device and active compression-decompression CPR when compared to standard CPR (8.9% vs 5.8%, p = 0.019) in the largest existing randomised trial. Conflicting results were found in observational studies comparing the complete neuroprotective bundle to standard CPR. Conclusions: This review was limited by small study numbers and overlapping samples, which precluded a meta-analysis. Limited data suggests that combinations of adjuncts to improve cerebral perfusion during CPR may improve survival with favourable neurological outcome. A randomised controlled trial is required to establish whether combining all three together results in improved outcomes.

Alternative techniques for cardiopulmonary resuscitation in extreme environments - A scoping review.

Background: Cardiopulmonary resuscitation (CPR) is essential for saving lives during cardiac arrest, but performing CPR in extreme environments poses unique challenges. In scenarios ranging from hypogravity or microgravity to confined spaces like aeroplanes and underwater scenarios, traditional CPR techniques may be inadequate. This scoping review aims to identify alternative chest compression techniques, synthesise current knowledge, and pinpoint research gaps in resuscitation for cardiac arrest in extreme conditions. Methods: PubMed and the Cochrane Register of Controlled Trials as well as the website of ResearchGate was searched to identify relevant literature. Studies were eligible for inclusion if they evaluated alternative chest compression techniques, including manual or mixed CPR approaches, whilst assessing feasibility and effectiveness based on compression depth, rate, and/or impact on rescuer effort. Results: The database search yielded 9499 references. After screening 26 studies covering 6 different extreme environments were included (hypogravity: 2; microgravity: 9, helicopter: 1, aeroplane: 1, confined space: 11; avalanche: 2). 13 alternative chest compression techniques were identified, all of which tested using manikins to simulate cardiac arrest scenarios. Conclusion: To address the unique challenges in extreme environments, novel CPR techniques are emerging. However, evidence supporting their effectiveness remains limited.

Ventilation and Oxygenation During and After Adult Cardiopulmonary Resuscitation: Changing Paradigms.

Cardiac arrest (CA) remains a major cause of death despite advancements in cardiopulmonary resuscitation (CPR), post-resuscitation care, and international efforts to develop evidence-based guidelines. Effectively managing ventilation and oxygenation during and after CPR is vital for patient survival and neurological outcomes, yet it remains a challenging task. This review examines current strategies for ventilation and oxygenation during and after CPR, focusing on evidence-based guidelines, the balance between ventilation effectiveness and risks, and proposed methods for monitoring ventilation quality. It emphasizes the need to provide adequate ventilation and oxygenation during and after CPR while avoiding hyperventilation and hypoventilation, which can negatively impact resuscitation and post-CA outcomes. The review also explores mechanical ventilation as an alternative to manual methods and the use of feedback devices. The impact of post-CA ventilation and oxygenation on patient outcomes and recommended management strategies are discussed. Finally, the review highlights current gaps in the literature and the need for more well-designed large clinical studies, such as the impact of different ventilation variables (tidal volume and respiratory rate) on the return of spontaneous circulation (ROSC) and long-term outcomes.

What Mistakes Can Be Made When Performing the Electrical Cardioversion Procedure?-Analysis of Emergency Medical Team Performance during the Championships in Emergency Medicine.

BACKGROUND: Medical personnel carrying out electrical cardioversion (EC) procedures must remember to have the R-wave sync mode switched on, use the correct energy and maintain personal safety. The defibrillators used by medical response teams most often switch out of cardioversion mode once a shock is delivered. Therefore, this mode must be switched on again before subsequent shocks are delivered. The main aim of the study was to assess the ability of emergency medical teams participating in emergency medicine championships to perform EC. METHODS: The research was a retrospective observational study and was based on an analysis of the evaluation sheets from two tasks simulating the management of a patient with unstable tachycardia conducted during the International Winter Emergency Medicine Championships. Three-person teams consisting of paramedics and representing the Polish emergency services were included in the study. The team representing the championship organiser and the few foreign teams participating in the competition were excluded from the study. RESULTS: The decision to conduct EC was taken by 36 teams (83.72%) in 2015 and 27 teams (87.10%) in 2019. In both editions of the championships, during consecutive shocks, the percentage of actions performed correctly decreased significantly-switching on synchronisation mode in 2015 (94.4%, 83.33%, 72.22%) and in 2019 (100%, 88.89%, 81.48%); correct energies in 2015 (91.67%, 80.56%, 77.78%) and in 2019 (92.59%, 85.19%, 81.48%); shocks in a safe manner in 2015 (94.44%, 94.44%, 91.67%) and in 2019 (100%, 96.30%, 96.30%). CONCLUSIONS: Teams participating in the assessed tasks in a significant majority of cases correctly qualified the patient for EC, and correctly carried out the actions required for this procedure. It is of particular note that with every subsequent shock, the percentage of shocks carried out without the sync mode increased significantly.

Characteristics of Out-of-Hospital Cardiac Arrest Trials Registered in ClinicalTrials.gov.

Background/Objective: Out-of-hospital cardiac arrest (OHCA) poses a substantial public health concern. A collective evaluation of clinical trials is crucial for understanding systemic trends and progress within a specific research area of interest, ultimately shaping future directions. We performed a comprehensive analysis of the characteristics of trials in the adult OHCA population registered on ClinicalTrials.gov. Methods: Aided by medical subject headings (MeSH), we systematically searched the ClinicalTrials.gov database. Trends over time were assessed with the Cochran-Mantel-Haenszel test. The association between publication year and annual number was assessed with the Pearson correlation coefficient. Results: Out of 152 trials spanning the 2003-2023 period, 29.6% were observational and 70.4% were interventional. Compared with the observational trials, interventional trials were more often randomized (RCT) and achieved full publication status in 84% of cases (p = 0.03). The primary focus of interventional trials was "procedures" (43%), "devices" (23%), and "drugs" (21%). Observational studies focused on "biomarkers" (16%) and "diagnostic test" (13%) (p < 0.001). A decrement in the number of interventional trials with a sample size ≥100 patients across three temporal study points was observed. Nevertheless, published studies predominantly had a sample size ≥100 patients (76%), in contrast to unpublished trials (p ≤ 0.001). An increase in the number of interventional studies funded by the "academic/university" sector was also recorded. Conclusions: Clinical trials on OHCA primarily involved interventions aimed at treatment and were more often randomized, single-center, with small (<100) sample sizes, and funded by the "academic/university" sector.

Methods of Using a Manual Defibrillator during Simultaneous Cardiac Arrest in Two Patients-Analysis of the Actions of Emergency Medical Response Teams during the Championships in Emergency Medicine.

Background/Objectives: Conducting advanced resuscitation requires medical personnel to carry out appropriately coordinated actions. Certain difficulties arise when it becomes necessary to conduct cardiopulmonary resuscitation (CPR) on two patients at the same time. The aim of this paper was to assess the actions of teams participating in emergency medicine championships in tasks related to simultaneous cardiac arrests in two patients. Methods: The study was conducted on the basis of an analysis of assessment cards for tasks carried out during the 'International Winter Championships in Emergency Medicine'. Three-person medical response teams (MRTs), with the support of two people, had the task of conducting advanced resuscitation on an adult and child simultaneously. The tasks were prepared and developed by European Resuscitation Council (ERC) instructors. Results: The study showed that teams used four methods of checking heart rhythm and performing defibrillation during CPR-using paddles only, using paddles and self-adhesive electrodes, using paddles and a three-lead ECG and using two pairs of self-adhesive electrodes. Teams performing cardiopulmonary resuscitation using paddles and a three-lead ECG performed significantly more actions incorrectly than other teams-in part due to the fact that they incorrectly interpreted which patient's heart rhythm was displayed on the defibrillator screen. The effectiveness of the remaining methods was similar for most of the actions. The CPR method using two pairs of electrodes enabled personal safety to be maintained to the significantly highest percentage during defibrillation. Conclusions: The study demonstrated that the need to conduct CPR on two patients at the same time, irrespective of the method used, caused MRT members considerable difficulties in correctly conducting some of the actions. The method of assessing heart rhythm using paddles and a three-lead ECG should not be used. The study showed that the optimal method of CPR in use appears to be the method using two pairs of adhesive electrodes-it provided, among other things, the significantly highest percentage of safely conducted defibrillation.

Optimization of Pediatric Medical Emergency Training (PedMET) Program for Pharmacists in the Inpatient Setting.

OBJECTIVE: It is perceived by many pharmacists that inadequate training and the resulting lack of confidence hinder participation in medical emergencies. There is insufficient information detailing training programs for pharmacists responding to pediatric medical emergencies. The primary objective of this study was to compare competency scores pre and post participation in the pediatric medical emergency training (PedMET) program. The secondary objectives included comparing confidence and knowledge for participation in pediatric medical emergencies, knowledge of resources and error prevention tools, description of the median time to prepare medications, and the most common errors that occurred during simulation. METHODS: A comprehensive didactic lecture and simulation-based training were designed and contained pre- and post-competencies to assess pharmacists' knowledge related to pediatric medical emergencies. Self-assessments were included to determine pharmacists' confidence levels in knowledge and preparation of medications. Feedback was solicited from participants to identify areas of improvement for the program. Standards for QUality Improvement Reporting Excellence (SQUIRE) 2.0 was used to report findings. RESULTS: Twenty-nine pharmacists of diverse training (e.g., residency vs nonresidency) and experience levels completed the program between July 2021 and March 2023. Competency scores improved from a median of 86% to 97% (p value < 0.001). Significant improvement was detected in pharmacists' confidence in their ability to prepare complex medications during medical emergencies (p value = 0.001). CONCLUSIONS: Following the implementation of didactic and simulation-based training, pharmacists' knowledge and confidence increased. Departments of pharmacy should consider implementing pharmacist--specific training programs for all pharmacists who respond to pediatric medical emergencies.

Airway management and ventilation techniques in resuscitation during advanced life support: an update.

For many years, ventilation has been an essential part of advanced life support (ALS) in cardiopulmonary resuscitation (CPR). Nevertheless, there is little evidence about the best method of ventilation during resuscitation for both out-of-hospital cardiac arrest (OHCA) and inhospital cardiac arrest (IHCA) patients. Effective ventilation is one of the two main keys to successful resuscitation. In this context, the question always arises as to which airway management, along with which ventilation mode, constitutes the best strategy. Conventional ventilation modes are not designed for cardiac arrest and show important limitations that must be considered when used in CPR. Manual ventilation without the use of an automated transport ventilator (ATV) could be shown to be uncontrolled in applied volumes and pressures and should be avoided. Mechanical ventilation with an ATV is therefore superior to manual ventilation, but both volume- and pressure-controlled ventilation modes are significantly influenced by chest compressions. With the newly designed chest compression synchronized ventilation (CCSV), a special ventilation mode for resuscitation is available. Further research should be conducted to obtain more evidence of the effect of ventilation during CPR on outcomes following OHCA and not only about how to secure the airway for ventilation during CPR.

Cardiac Surgical Unit-Advanced Life Support-certified centers are associated with improved failure to rescue after cardiac arrest: A propensity score-matched analysis.

OBJECTIVE: The impact of Cardiac Surgical Unit-Advanced Life Support (CSU-ALS) training on failure to rescue after cardiac arrest (FTR-CA) is unknown. We hypothesized that institutional CSU-ALS certification would be associated with lower FTR-CA. METHODS: Patients undergoing Society of Thoracic Surgeons index operations from 2020 to 2023 from a regional collaborative were analyzed. Each institution was surveyed regarding its status as a CSU-ALS-certified center. Patients stratified by CSU-ALS certification were 1:1 propensity score matched with subsequent multivariable model reviewing associations with FTR-CA. RESULTS: A total of 12,209 patients were included in the study period across 15 institutions. Eight centers reported CSU-ALS certification. After propensity score matching, 2 patient cohorts were formed (n = 3557). Patients at CSU-ALS centers had greater rates of intensive care unit readmission (3.9% vs 2.3%, P < .01) and total operating room time (340 minutes vs 323 minutes, P < .01). Hospital readmission was less likely in the CSU-ALS centers (9.0% vs 10.1%, P < .01). There was no difference in the rate of postoperative cardiac arrest (1.8% vs 2.2%, P = .24) or operative mortality (2.5% vs 2.9%, P = .30). After risk adjustment, CSU-ALS centers (odds ratio, 0.30; 95% confidence interval, 0.12-0.72, P < .01) and greater-volume centers (odds ratio, 0.15; confidence interval, 0.03-0.74, P = .02) had reduced odds of FTR-CA. CONCLUSIONS: Centers with CSU-ALS certification are associated with a lower risk-adjusted likelihood of FTR-CA. This highlights the importance of well-trained staff and treatment algorithms in the care of patients postcardiac surgery.

Pulmonary vasodilation during cardiopulmonary resuscitation - A randomized, controlled porcine study.

BACKGROUND: During resuscitation pulmonary artery pressure (PAP) increases. This reduces left ventricular filling, leading to decreased blood flow. Inhaled nitric oxide (iNO) produces selective pulmonary vasodilation. We hypothesized that iNO would lower PAP during resuscitation resulting in increased survival. METHODS: 30 pigs (40 kg) were subjected to cardiac arrest for 9.5 min after myocardial ischemia induced by coronary artery occlusion of the left anterior descending artery and ventricular fibrillation. During resuscitation, the pigs were randomized to 40 ppm iNO or placebo. The primary outcome was return of spontaneous circulation (ROSC). Pigs achieving ROSC underwent 4-hours intensive care. RESULTS: The ROSC rate was 9/14 (64%) in the control group and 11/16 (69%) in the iNO group (OR 1.2 95%CI [0.3;5.6], p > 0.99). There was no difference in diastolic aorta pressure/PAP ratio (mean difference -0.99 [95% CI: -2.33-0.36], p = 0.14). Mean pulmonary artery pressure was lower in the iNO group 60 and 120 min after ROSC (mean difference: -12.18 mmHg [95%CI: -16.94; -7.43] p < 0.01 and -5.43 [95%CI: -10.39; -0.46] p = 0.03). Troponin I levels in the iNO group were significantly higher 60 and 120 min after ROSC (mean difference: 266105 ng/l [95%CI: 6356; 525855] p = 0.045 and 420049 ng/l [95%CI: 136779; 703320], p = 0.004). The area at risk of the heart was 33% (SD 1) in controls and 34% (SD 1) in the iNO group. The infarct size divided by the area at risk was 55% (SD 3) in controls and 86% (SD 1) in the iNO group, p = 0.01. CONCLUSION: Application of iNO did not improve the rate of ROSC or hemodynamic function but increased myocardial injury.

Outcomes of Out-of-Hospital Cardiac Arrest Patients Who Received Naloxone in an Emergency Medical Services System With a High Prevalence Of Opioid Overdose.

BACKGROUND: Opioid-associated out-of-hospital cardiac arrest (OA-OHCA) is a subset of cardiac arrests that could benefit from measures outside of standard Advanced Cardiac Life Support (ACLS), such as naloxone. STUDY OBJECTIVES: In this study, we sought to examine whether OHCA patients chosen for naloxone therapy by emergency medical services (EMS) clinicians in a system with high rates of opioid overdose would have increased rates of return of spontaneous circulation (ROSC) and survival to hospital discharge. METHODS: The study took place in an urban EMS system with a high prevalence of opioid overdose. Paramedics could administer naloxone in cardiac arrest in addition to ACLS. It was often administered based on clinical gestalt for suspected OA-OHCA. The outcomes of OHCA patients who received naloxone were compared against those who received usual care in both an adjusted and unadjusted fashion. Lastly, we created a logistic regression model to test for an independent association of naloxone administration on ROSC and survival to hospital discharge. RESULTS: A consecutive sample of 769 OHCA patients was obtained, of which 175 (23%) received naloxone. On average, patients who received naloxone had significantly fewer comorbidities and were younger. There was no difference in ROSC, survival to hospital discharge, or modified Rankin Scores. Using logistic regression modeling, there was no statistically significant effect of naloxone administration on these outcomes. CONCLUSION: OHCA patients who received naloxone, despite being younger and having fewer comorbidities, had similar outcomes compared to those who received usual care. The difference in baseline characteristics suggests that paramedic gestalt reasonably selected for OA-OHCA.

Early intramuscular adrenaline administration is associated with improved survival from out-of-hospital cardiac arrest.

BACKGROUND: Early administration of adrenaline is associated with improved survival after out-of-hospital cardiac arrest (OHCA). Delays in vascular access may impact the timely delivery of adrenaline. Novel methods for administering adrenaline before vascular access may enhance survival. The objective of this study was to determine whether an initial intramuscular (IM) adrenaline dose followed by standard IV/IO adrenaline is associated with improved survival after OHCA. METHODS STUDY DESIGN: We conducted a before-and-after study of the implementation of an early, first-dose IM adrenaline EMS protocol for adult OHCAs. The pre-intervention period took place between January 2010 and October 2019. The post-intervention period was between November 2019 and May 2024. SETTING: Single-center urban, two-tiered EMS agency. PARTICIPANTS: Adult, nontraumatic OHCA meeting criteria for adrenaline use. INTERVENTION: Single dose (5 mg) IM adrenaline. All other care, including subsequent IV or IO adrenaline, followed international guidelines. MAIN OUTCOMES AND MEASURES: The primary outcome was survival to hospital discharge. Secondary outcomes were time from EMS arrival to the first dose of adrenaline, survival to hospital admission, and favorable neurologic function at discharge. RESULTS: Among 1405 OHCAs, 420 (29.9%) received IM adrenaline and 985 (70.1%) received usual care. Fifty-two patients received the first dose of adrenaline through the IV or IO route within the post-intervention period and were included in the standard care group analysis. Age was younger and bystander CPR was higher in the IM adrenaline group. All other characteristics were similar between IM and standard care cohorts. Time to adrenaline administration was faster for the IM cohort [(median 4.3 min (IQR 3.0-6.0) vs. 7.8 min (IQR 5.8-10.4)]. Compared with standard care, IM adrenaline was associated with improved survival to hospital admission (37.1% vs. 31.6%; aOR 1.37, 95% CI 1.06-1.77), hospital survival (11.0% vs 7.0%; aOR 1.73, 95% CI 1.10-2.71) and favorable neurologic status at hospital discharge (9.8% vs 6.2%; aOR 1.72, 95% CI 1.07-2.76). CONCLUSION: In this single-center before-and-after implementation study, an initial IM dose of adrenaline as an adjunct to standard care was associated with improved survival to hospital admission, survival to hospital discharge, and functional survival. A randomized controlled trial is needed to fully assess the potential benefit of IM adrenaline delivery in OHCA.

Cognitive aids used in simulated resuscitation: A systematic review.

Objectives: To compare the effectiveness of cognitive aid use during resuscitation with no use of cognitive aids on cardiopulmonary resuscitation quality and performance. Methods: This systematic review followed the PICOST format. All randomised controlled trials and non-randomised studies evaluating cognitive aid use during (simulated) resuscitation were included in any setting. Unpublished studies were excluded. We did not include studies that reported cognitive aid use during training for resuscitation alone. Medline, Embase and Cochrane databases were searched from inception until July 2019 (updated August 2022, November 2023, and 23 April 2024). We did not search trial registries. Title and abstract screening, full-text screening, data extraction, risk of bias assessment (using RoB2 and ROBINS-I), and certainty of evidence (using GRADE) were performed by two researchers. PRISMA reporting standards were followed, and registration (PROSPERO CRD42020159162, version 19 July 2022) was performed. No funding has been obtained. Results: The literature search identified 5029 citations. After removing 512 duplicates, reviewing the titles and abstracts of the remaining articles yielded 103 articles for full-text review. Hand-searching identified 3 more studies for full-text review. Of these, 29 studies were included in the final analysis. No clinical studies involving patients were identified. The review was limited to indirect evidence from simulation studies only. The results are presented in five different populations: healthcare professionals managing simulated resuscitations in neonates, children, adult advanced life support, and other emergencies; as well as lay providers managing resuscitations. Main outcomes were adherence to protocol or process, adherence to protocol or process assessed by performance score, CPR performance and retention, and feasibility of chatbot guidance. The risk of bias assessment ranged from low to high. Studies in neonatal, paediatric and adult life support delivered by healthcare professionals showed benefits of using cognitive aids, however, some studies evaluating resuscitations by lay providers reported undesirable effects. The performance of a meta-analysis was not possible due to significant methodological heterogeneity. The certainty of evidence was rated as moderate to very low due to serious indirectness, (very) serious risk of bias, serious inconsistency and (very) serious imprecision. Conclusion: Because of the very low certainty evidence from simulation studies, we suggest that cognitive aids should be used by healthcare professionals during resuscitation. In contrast, we do not suggest use of cognitive aids for lay providers, based on low certainty evidence.

Effect of timing of advanced life support on out-of-hospital cardiac arrests at home.

AIM: In cases of out-of-hospital cardiac arrests (OHCA) occurring at home, Japanese emergency medical services personnel decide whether to provide treatment on the scene or during transport based on their judgment. This study aimed to evaluate the association between the timing of advanced life support (ALS) (i.e., endotracheal intubation [ETI] or adrenaline administration) for OHCA at home and prognosis. METHOD: This retrospective cohort study used data from the Japan Utstein Registry and emergency transport data collected from patients who underwent pre-hospital ETI (n = 6806) and received adrenaline (n = 22,636) between 2016 and 2019. The timing of ETI or adrenaline administration was determined as "on the scene" or "in the ambulance." Multiple logistic regression analysis was used to estimate the association among the timing of ALS implementation, pre-hospital return of spontaneous circulation (ROSC), and survival at 1 month. RESULT: ETI on the scene was significantly positively associated with pre-hospital ROSC (adjusted odds ratio [AOR], 1.81; 95% confidence interval [CI], 1.57-2.09) and survival at 1 month (AOR, 1.81; 95% CI, 1.47-2.23). Adrenaline administration on the scene was significantly positively associated with pre-hospital ROSC (AOR, 2.51; 95% CI, 2.33-2.70) and survival at 1 month (AOR, 2.13; 95% CI, 1.89-2.40). CONCLUSION: Our analysis suggests performing ALS on the scene was associated with pre-hospital ROSC and survival at 1 month. Further efforts are needed to increase the rate of ALS implementation on the scene by emergency life-saving technicians.

Effects of gamification in advanced life support training for clinical nurses: A cluster randomized controlled trial.

BACKGROUND: Cardiopulmonary resuscitation training is a mandatory competency, especially for healthcare professionals. However, the spread of COVID-19 caused a sharp decline in the number of participants on advanced life support training, thereby accelerating the diversification of educational methods. Gamification is an increasingly popular method of diversifying instruction, but its effectiveness remains controversial. AIM: To evaluate the effectiveness of gamification learning in advanced life support training. DESIGN: A cluster randomized controlled trial. SETTING: A single advanced life support training center. PARTICIPANTS: Clinical nurses who are currently practicing in a hospital. METHODS: A part of the existing advanced life support course was gamified using Kahoot! platform. Conventional learning and gamified learning were each conducted 11 times, and the level of knowledge after training was assessed. The assessment questions were categorized into advanced life support algorithms, teamwork, and cardiac arrest rhythms. RESULTS: A total of 267 were enrolled in the study, and 148 and 139 learners were assigned to CL and GL, respectively. There was no difference in post-training knowledge related to teamwork, and cardiac arrest rhythms between the conventional learning and gamified learning groups, but knowledge related to the advanced life support algorithm was low in the gamified learning group. CONCLUSIONS: Even if the learners are the same, advanced life support gamification training can lead to negative outcomes depending on the simplicity or goal of the training content. To improve the effectiveness of the training, various methods of gamification training should be applied depending on the goal and content of the training.

Ventilation during cardiopulmonary resuscitation with mechanical chest compressions: How often are two insufflations being given during the 3-second ventilation pauses?

BACKGROUND: Mechanical chest compression devices in 30:2 mode provide 3-second pauses to allow for two insufflations. We aimed to determine how often two insufflations are provided in these ventilation pauses, in order to assess if prehospital providers are able to ventilate out-of-hospital cardiac arrest (OHCA) patients successfully during mechanical chest compressions. METHODS: Data from OHCA cases of the regional ambulance service of Utrecht, The Netherlands, were prospectively collected in the UTrecht studygroup for OPtimal registry of cardIAc arrest database (UTOPIA). Compression pauses and insufflations were visualized on thoracic impedance and waveform capnography signals recorded by manual defibrillators. Ventilation pauses were analyzed for number of insufflations, duration of the subintervals of the ventilation cycles, and ratio of successfully providing two insufflations over the course of the resuscitation. Generalized linear mixed effects models were used to accurately estimate proportions and means. RESULTS: In 250 cases, 8473 ventilation pauses were identified, of which 4305 (51%) included two insufflations. When corrected for non-independence of the data across repeated measures within the same subjects with a mixed effects analysis, two insufflations were successfully provided in 45% of ventilation pauses (95% CI: 40-50%). In 19% (95% CI: 16-22%) none were given. CONCLUSION: Providing two insufflations during pauses in mechanical chest compressions is mostly unsuccessful. We recommend developing strategies to improve giving insufflations when using mechanical chest compression devices. Increasing the pause duration might help to improve insufflation success.

Explorative study on lower inflection point dynamics during cardiopulmonary resuscitation: Potential implications for airway management.

INTRODUCTION: In patients undergoing cardiopulmonary resuscitation (CPR) after an Out-of-Hospital Cardiac Arrest (OHCA), intrathoracic airway closure can impede ventilation, adversely affecting patient outcomes. This explorative study investigates the evolution of intrathoracic airway closure by analyzing the lower inflection point (LIP) during the inspiration phase of CPR, aiming to identify the potential thresholds for alveolar recruitment. METHODS AND MATERIALS: Eleven OHCA patients undergoing CPR with endotracheal intubation and manual bag ventilation were included. Flow and pressure measurements were obtained using Sensirion SFM3200AW and Wika CPT2500 sensors attached to the endotracheal tube, connected to a Surface Go Tablet for data collection. Flow data was analyzed in Microsoft Excel, while pressure data was processed using the Wika USBsoft2500 application. Analysis focused on the inspiration phase of the first 6-8 breaths, with an additional 2 breaths recorded and analyzed at the end of CPR. RESULTS: Across the cohort, the median tidal volume was 870.00 milliliter (mL), average flow was 31.90 standard liters per minute (slm), and average pressure was 17.21 cmH2O. The calculated average LIP was 31.47 cmH2O. Most cases (72.7%) exhibited a negative trajectory in LIP evolution during CPR, with 2 cases (18.2%) showing a positive trajectory and 1 case remaining inconclusive. The average LIP in the first 8 breaths was significantly higher than in the last 2 breaths (p = 0.018). No significant correlation was found between average LIP and return of spontaneous circulation (ROSC), compression depth, frequency, or end-tidal CO2 (EtCO2). However, a significant negative correlation was observed between the average LIP of the last 2 breaths and CPR duration (p = 0.023). VALIDATION: LIP calculation in low-flow ventilations using the novel mathematical method yielded values consistent with those reported in the literature. DISCUSSION/CONCLUSION: These explorative data demonstrate a predominantly negative trajectory in LIP evolution during CPR, suggesting potential challenges in maintaining airway patency. Limitations include a small sample size and sensor recording issues. Further research is warranted to explore the evolution of LIP and its implications for personalized ventilation strategies in CPR.