Intrapulmonary and Intracardiac Shunts in Adult COVID-19 Versus Non-COVID Acute Respiratory Distress Syndrome ICU Patients Using Echocardiography and Contrast Bubble Studies (COVID-Shunt Study): A Prospective, Observational Cohort Study.

OBJECTIVES: Studies have suggested intrapulmonary shunts may contribute to hypoxemia in COVID-19 acute respiratory distress syndrome (ARDS) with worse associated outcomes. We evaluated the presence of right-to-left (R-L) shunts in COVID-19 and non-COVID ARDS patients using a comprehensive hypoxemia workup for shunt etiology and associations with mortality. DESIGN: Prospective, observational cohort study. SETTING: Four tertiary hospitals in Edmonton, Alberta, Canada. PATIENTS: Adult critically ill, mechanically ventilated, ICU patients admitted with COVID-19 or non-COVID (November 16, 2020, to September 1, 2021). INTERVENTIONS: Agitated-saline bubble studies with transthoracic echocardiography/transcranial Doppler ± transesophageal echocardiography assessed for R-L shunts presence. MEASUREMENTS AND MAIN RESULTS: Primary outcomes were shunt frequency and association with hospital mortality. Logistic regression analysis was used for adjustment. The study enrolled 226 patients (182 COVID-19 vs 42 non-COVID). Median age was 58 years (interquartile range [IQR], 47-67 yr) and Acute Physiology and Chronic Health Evaluation II scores of 30 (IQR, 21-36). In COVID-19 patients, the frequency of R-L shunt was 31 of 182 COVID patients (17.0%) versus 10 of 44 non-COVID patients (22.7%), with no difference detected in shunt rates (risk difference [RD], -5.7%; 95% CI, -18.4 to 7.0; p = 0.38). In the COVID-19 group, hospital mortality was higher for those with R-L shunt compared with those without (54.8% vs 35.8%; RD, 19.0%; 95% CI, 0.1-37.9; p = 0.05). This did not persist at 90-day mortality nor after adjustment with regression. CONCLUSIONS: There was no evidence of increased R-L shunt rates in COVID-19 compared with non-COVID controls. R-L shunt was associated with increased in-hospital mortality for COVID-19 patients, but this did not persist at 90-day mortality or after adjusting using logistic regression.

What Are the Care Needs of Families Experiencing Sudden Cardiac Arrest? A Survivor- and Family-Performed Systematic Review, Qualitative Meta-Synthesis, and Clinical Practice Recommendations.

INTRODUCTION: Cardiac arrest care systems are being designed and implemented to address patients', family members', and survivors' care needs. We conducted a systematic review and a meta-synthesis to understand family experiences and care needs during cardiac arrest care to create treatment recommendations. METHODS: We searched eight electronic databases to identify articles. Study findings were extracted, coded and synthesized. Confidence in the quality, coherence, relevance, and adequacy of data underpinning the resulting findings was assessed using GRADE-CERQual methods. RESULTS: In total 4181 studies were screened, and 39 met our inclusion criteria; these studies enrolled 215 survivors and 418 family participants-which includes both co-survivors and bereaved family members. From these studies findings and participant data we identified 5 major analytical themes: (1) When the crisis begins we must respond; (2) Anguish from uncertainty, we need to understand; (3) Partnering in care, we have much to offer; (4) The crisis surrounding the victim, ignore us, the family, no longer; (5) Our family's emergency is not over, now is when we need help the most. Confidence in the evidence statements are provided along with our review findings. DISCUSSION: The family experience of cardiac arrest care is often chaotic, distressing, complex and the aftereffects are long-lasting. Patient and family experiences could be improved for many people. High certainty family care needs identified in this review include rapid recognition and response, improved information sharing, more effective communication, supported presence and participation, or supported absence, and psychological aftercare.

Optic Nerve Sheath Diameter Ultrasound for Raised Intracranial Pressure: A Literature Review and Meta-analysis of its Diagnostic Accuracy.

Optic nerve sheath diameter (ONSD) ultrasound is becoming increasingly more popular for estimating raised intracranial pressure (ICP). We performed a systematic review and analysis of the diagnostic accuracy of ONSD when compared to the standard invasive ICP measurement. METHOD: We performed a systematic search of PUBMED and EMBASE for studies including adult patients with suspected elevated ICP and comparing sonographic ONSD measurement to a standard invasive method. Quality of studies was assessed using the QUADAS-2 tool by two independent authors. We used a bivariate model of random effects to summarize pooled sensitivity, specificity, and diagnostic odds ratio (DOR). Heterogeneity was investigated by meta-regression and sub-group analyses. RESULTS: We included 18 prospective studies (16 studies including 619 patients for primary outcome). Only one study was of low quality, and there was no apparent publication bias. Pooled sensitivity was 0.9 [95% confidence intervals (CI): 0.85-0.94], specificity was 0.85 (95% CI: 0.8-0.89), and DOR was 46.7 (95% CI: 26.2-83.2) with partial evidence of heterogeneity. The Area-Under-the-Curve of the summary Receiver-Operator-Curve was 0.93 (95% CI: 0.91-0.95, P < .05). No covariates were significant in the meta-regression. Subgroup analysis of severe traumatic brain injury and parenchymal ICP found no heterogeneity. ICP and ONSD had a correlation coefficient of 0.7 (95% CI: 0.63-0.76, P < .05). CONCLUSION: ONSD is a useful adjunct in ICP evaluation but is currently not a replacement for invasive methods where they are feasible.

Continuous renal replacement therapy with the addition of CytoSorb cartridge in critically ill patients with COVID-19 plus acute kidney injury: A case-series.

Our aim was to investigate continuous renal replacement therapy (CRRT) with CytoSorb cartridge for patients with life-threatening COVID-19 plus acute kidney injury (AKI), sepsis, acute respiratory distress syndrome (ARDS), and cytokine release syndrome (CRS). Of 492 COVID-19 patients admitted to our intensive care unit (ICU), 50 had AKI necessitating CRRT (10.16%) and were enrolled in the study. Upon ICU admission, all had AKI, ARDS, septic shock, and CRS. In addition to CRRT with CytoSorb, all received ARDS-net ventilation, prone positioning, plus empiric ribavirin, interferon beta-1b, antibiotics, hydrocortisone, and prophylactic anticoagulation. We retrospectively analyzed inflammatory biomarkers, oxygenation, organ function, duration of mechanical ventilation, ICU length-of-stay, and mortality on day-28 post-ICU admission. Patients were 49.64 ± 8.90 years old (78% male) with body mass index of 26.70 ± 2.76 kg/m2 . On ICU admission, mean Acute Physiology and Chronic Health Evaluation (APACHE) II was 22.52 ± 1.1. Sequential Organ Function Assessment (SOFA) score was 9.36 ± 2.068 and the ratio of partial arterial pressure of oxygen to fractional inspired concentration of oxygen (PaO2 /FiO2 ) was 117.46 ± 36.92. Duration of mechanical ventilation was 17.38 ± 7.39 days, ICU length-of-stay was 20.70 ± 8.83 days, and mortality 28 days post-ICU admission was 30%. Nonsurvivors had higher levels of inflammatory biomarkers, and more unresolved shock, ARDS, AKI, and pulmonary emboli (8% vs. 4%, P < .05) compared to survivors. After 2 ± 1 CRRT sessions with CytoSorb, survivors had decreased SOFA scores, lactate dehydrogenase, ferritin, D-dimers, C-reactive protein, and interleukin-6; and increased PaO2 /FiO2 ratios, and lymphocyte counts (all P < .05). Receiver-operator-curve analysis showed that posttherapy values of interleukin-6 (cutoff point >620 pg/mL) predicted in-hospital mortality for critically ill COVID-19 patients (area-under-the-curve: 0.87, 95% CI: 0.81-0.93; P = .001). No side effects of therapy were recorded. In this retrospective case-series, CRRT with the CytoSorb cartridge provided a safe rescue therapy in life-threatening COVID-19 with associated AKI, ARDS, sepsis, and hyperinflammation.

Tracheal Intubation in the Critically Ill. Where We Came from and Where We Should Go.

Tracheal intubation is commonly performed in critically ill patients. Unfortunately, this procedure also carries a high risk of complications; half of critically ill patients with difficult airways experience life-threatening complications. The high complication rates stem from difficulty with laryngoscopy and tube placement, consequences of physiologic derangement, and human factors, including failure to recognize and reluctance to manage the failed airway. The last 10 years have seen a rapid expansion in devices available that help overcome anatomic difficulties with laryngoscopy and provide rescue oxygenation in the setting of failed attempts. Recent research in critically ill patients has highlighted other important considerations for critically ill patients and evaluated interventions to reduce the risks with repeated attempts, desaturation, and cardiovascular collapse during emergency airway management. There are three actions that should be implemented to reduce the risk of danger: 1) preintubation assessment for potential difficulty (e.g., MACOCHA score); 2) preparation and optimization of the patient and team for difficulty-including using a checklist, acquiring necessary equipment, maximizing preoxygenation, and hemodynamic optimization; and 3) recognition and management of failure to restore oxygenation and reduce the risk of cardiopulmonary arrest. This review describes the history of emergency airway management and explores the challenges with modern emergency airway management in critically ill patients. We offer clinically relevant recommendations on the basis of current evidence, guidelines, and expert opinion.

Development of a critical care ultrasound curriculum using a mixed-methods needs assessment and engagement of frontline healthcare professionals.

PURPOSE: Experts recommend that critical care medicine (CCM) practitioners should be adept at critical care ultrasound (CCUS). Published surveys highlight that many institutions have no deliberate strategy, no formalized curriculum, and insufficient engagement of CCM faculty and trainees. Consequently, proficiency is non-uniform. Accordingly, we performed a needs assessment to develop an inter-professional standardized CCUS curriculum as a foundation towards universal basic fluency. METHODS: Mixed-methods study of CCM trainees, attendings, and nurse practitioners working across five academic and community medical-surgical intensive care units in Edmonton, Alberta. We used qualitative focus groups followed by quantitative surveys to explore, refine, and integrate results into a curriculum framework. RESULTS: Focus groups with 19 inter-professional practitioners identified major themes including perceived benefits, learning limitations, priorities, perceived risks, characteristics of effective instruction, ensuring long-term success, and achieving competency. Sub-themes highlighted rapid attrition of skill following one- to two-day workshops, lack of skilled faculty, lack of longitudinal training, and the need for site-based mentorship. Thirty-five practitioners (35/70: 50%) completed the survey. Prior training included workshops (16/35; 46%) and self-teaching (11/35; 31%). Eleven percent (4/35) described concerns about potential errors in CCUS performance. The survey helped to refine resources, content, delivery, and assessment. Integration of qualitative and quantitative findings produced a comprehensive curriculum framework. CONCLUSION: Building on published recommendations, our needs assessment identified additional priorities for a CCUS curriculum framework. Specifically, there is a perceived loss of skills following short workshops and insufficient strategies to sustain learning. Addressing these deficits could narrow the gap between national recommendations and frontline needs.

RéSUMé: OBJECTIF: Les experts recommandent que les intensivistes soient habiles en échographie aux soins intensifs. Les sondages publiés révèlent que de nombreux établissements ne possèdent pas de stratégie réfléchie ni de curriculum formalisé en échographie, tout en souffrant d'un manque d'implication du corps professoral et des résidents. Les aptitudes ne sont donc pas uniformes. C'est pourquoi nous avons réalisé une évaluation des besoins afin de mettre au point un curriculum interprofessionnel standardisé en échographie aux soins intensifs qui servira de fondation vers une maîtrise des aptitudes de bases universelles. MéTHODE: Nous avons réalisé une étude en méthodes mixtes auprès de résidents, de patrons et d'infirmiers et infirmières praticiens en soins intensifs travaillant dans cinq unités de soins intensifs médico-chirurgicaux universitaires et communautaires à Edmonton, en Alberta. Nous avons formé des groupes de réflexion qualitatifs puis avons réalisé des sondages quantitatifs afin d'explorer, d'approfondir et d'intégrer nos résultats dans un cadre de curriculum. RéSULTATS: Des groupes de réflexion composés de 19 praticiens interprofessionnels ont identifié des thèmes majeurs, notamment les avantages perçus, les obstacles à l'apprentissage, les priorités, les risques perçus, les caractéristiques d'un enseignement efficace, l'assurance d'un succès à long terme et l'acquisition des compétences. Les sous-thèmes ont mis en lumière une attrition rapide des compétences après des ateliers d'un ou deux jours, le manque d'enseignants compétents, le manque de formation longitudinale, et le besoin de mentorat sur le lieu de travail. Trente-cinq praticiens (35/70; 50 %) ont répondu au sondage. Les formations antérieures incluaient des ateliers (16/35; 46 %) et de l'auto-apprentissage (11/35; 31 %). Onze pourcent (4/35) des répondants ont fait part d'inquiétudes concernant les erreurs potentielles dans la performance de l'échographie aux soins intensifs. Le sondage a permis de raffiner les ressources, le contenu, la livraison et l'évaluation. L'intégration des résultats qualitatifs et quantitatifs a permis de réaliser un cadre exhaustif de curriculum. CONCLUSION: En nous appuyant sur les recommandations publiées, notre évaluation des besoins a identifié des priorités supplémentaires pour encadrer une formation d'échographie destinée aux soins intensifs. Plus spécifiquement, il existe une perte perçue des compétences à la suite d'ateliers courts et il manque de stratégies pour soutenir l'apprentissage. En palliant ces manques, il pourrait être possible de réduire le fossé entre les recommandations nationales et les besoins en première ligne.

Prospective Longitudinal Evaluation of Point-of-Care Lung Ultrasound in Critically Ill Patients With Severe COVID-19 Pneumonia.

OBJECTIVES: To perform a prospective longitudinal analysis of lung ultrasound findings in critically ill patients with coronavirus disease 2019 (COVID-19). METHODS: Eighty-nine intensive care unit (ICU) patients with confirmed COVID-19 were prospectively enrolled and tracked. Point-of-care ultrasound (POCUS) examinations were performed with phased array, convex, and linear transducers using portable machines. The thorax was scanned in 12 lung areas: anterior, lateral, and posterior (superior/inferior) bilaterally. Lower limbs were scanned for deep venous thrombosis and chest computed tomographic angiography was performed to exclude suspected pulmonary embolism (PE). Follow-up POCUS was performed weekly and before hospital discharge. RESULTS: Patients were predominantly male (84.2%), with a median age of 43 years. The median duration of mechanical ventilation was 17 (interquartile range, 10-22) days; the ICU length of stay was 22 (interquartile range, 20.2-25.2) days; and the 28-day mortality rate was 28.1%. On ICU admission, POCUS detected bilateral irregular pleural lines (78.6%) with accompanying confluent and separate B-lines (100%), variable consolidations (61.7%), and pleural and cardiac effusions (22.4% and 13.4%, respectively). These findings appeared to signify a late stage of COVID-19 pneumonia. Deep venous thrombosis was identified in 16.8% of patients, whereas chest computed tomographic angiography confirmed PE in 24.7% of patients. Five to six weeks after ICU admission, follow-up POCUS examinations detected significantly lower rates (P < .05) of lung abnormalities in survivors. CONCLUSIONS: Point-of-care ultrasound depicted B-lines, pleural line irregularities, and variable consolidations. Lung ultrasound findings were significantly decreased by ICU discharge, suggesting persistent but slow resolution of at least some COVID-19 lung lesions. Although POCUS identified deep venous thrombosis in less than 20% of patients at the bedside, nearly one-fourth of all patients were found to have computed tomography-proven PE.

Residual Lung Injury in Patients Recovering From COVID-19 Critical Illness: A Prospective Longitudinal Point-of-Care Lung Ultrasound Study.

Scarce data exist regarding the natural history of lung lesions detected on ultrasound in those who survive severe COVID-19 pneumonia. OBJECTIVE: We performed a prospective analysis of point-of-care ultrasound (POCUS) findings in critically ill COVID-19 patients during and after hospitalization. METHODS: We enrolled 171 COVID-19 intensive care unit patients. POCUS of the lungs was performed with phased array (2-4 MHz), convex (2-6 MHz) and linear (10-15 MHz) transducers, scanning 12 lung areas. Chest computed tomography angiography was performed to exclude suspected pulmonary embolism. Survivors were clinically and sonographically evaluated during a 4 month period for evidence of residual lung injury. Chest computed tomography angiography and echocardiography were used to exclude pulmonary hypertension (PH) and chest high-resolution-computed-tomography to exclude interstitial lung disease (ILD) in symptomatic survivors. RESULTS: Cox regression analysis showed that lymphocytopenia (hazard ratio [HR]: 0.88, 95% confidence intervals [CI]: 0.68-0.96, p = .048), increased lactate (HR: 1.17, 95% CI: 0.94-1.46, p = 0.049), and D-dimers (HR: 1.21, 95% CI: 1.03-1.44, p = .03) were mortality predictors. Non-survivors had increased incidence of pulmonary abnormalities (B-lines, pleural line irregularities, and consolidations) compared to survivors (p < .05). During follow-up, POCUS with clinical and laboratory parameters integrated in the semi-quantitative Riyadh-Residual-Lung-Injury scale had sensitivity of 0.82 (95% CI: 0.76-0.89) and specificity of 0.91 (95% CI: 0.94-0.95) in predicting ILD. The prevalence of PH and ILD (non-specific-interstitial-pneumonia) was 7% and 11.8%, respectively. CONCLUSION: POCUS showed ability to monitor the evolution of severe COVID-19 pneumonia after hospital discharge, supporting its integration in clinical predictive models of residual lung injury.

Reverse takotsubo cardiomyopathy in fulminant COVID-19 associated with cytokine release syndrome and resolution following therapeutic plasma exchange: a case-report.

BACKGROUND: Fulminant (life-threatening) COVID-19 can be associated with acute respiratory failure (ARF), multi-system organ failure and cytokine release syndrome (CRS). We present a rare case of fulminant COVID-19 associated with reverse-takotsubo-cardiomyopathy (RTCC) that improved with therapeutic plasma exchange (TPE). CASE PRESENTATION: A 40 year old previous healthy male presented in the emergency room with 4 days of dry cough, chest pain, myalgias and fatigue. He progressed to ARF requiring high-flow-nasal-cannula (flow: 60 L/minute, fraction of inspired oxygen: 40%). Real-Time-Polymerase-Chain-Reaction (RT-PCR) assay confirmed COVID-19 and chest X-ray showed interstitial infiltrates. Biochemistry suggested CRS: increased C-reactive protein, lactate dehydrogenase, ferritin and interleukin-6. Renal function was normal but lactate levels were elevated. Electrocardiogram demonstrated non-specific changes and troponin-I levels were slightly elevated. Echocardiography revealed left ventricular (LV) basal and midventricular akinesia with apex sparing (LV ejection fraction: 30%) and depressed cardiac output (2.8 L/min) consistent with a rare variant of stress-related cardiomyopathy: RTCC. His ratio of partial arterial pressure of oxygen to fractional inspired concentration of oxygen was < 120. He was admitted to the intensive care unit (ICU) for mechanical ventilation and vasopressors, plus antivirals (lopinavir/ritonavir), and prophylactic anticoagulation. Infusion of milrinone failed to improve his cardiogenic shock (day-1). Thus, rescue TPE was performed using the Spectra Optia™ Apheresis System equipped with the Depuro D2000 Adsorption Cartridge (Terumo BCT Inc., USA) without protective antibodies. Over 5 days he received daily TPE (each lasting 4 hours). His lactate levels, oxygenation, and LV function normalized and he was weaned off vasopressors. His inflammation markers improved, and he was extubated on day-7. RT-PCR was negative on day-17. He was discharged to home isolation in good condition. CONCLUSION: Stress-cardiomyopathy may complicate the course of fulminant COVID-19 with associated CRS. If inotropic therapy fails, TPE without protective antibodies may help rescue the critically ill patient.

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.

Proximal External Aortic Compression for Life-Threatening Abdominal-Pelvic and Junctional Hemorrhage: An Ultrasonographic Study in Adult Volunteers.

Introduction: Following life-threatening junctional trauma, the goal is to limit blood loss while expediting transfer to operative rescue. Unfortunately, life-threatening abdominal-pelvic or junctional hemorrhage is often not amenable to direct compression and few temporizing strategies are available beyond hemostatic dressings, hypotensive resuscitation, and balanced transfusion. Objectives: In this study, we evaluated proximal external aortic compression to arrest blood flow in healthy adult men. Methods: This was a simulation trial of proximal external aortic compression, for life-threatening abdominal-pelvic and junctional hemorrhage, in a convenience sample of healthy adult male volunteers. The primary end points were cessation of femoral blood flow as assessed by pulse wave Doppler ultrasound at the right femoral artery, caudal to the inguinal ligament. Secondary end points were discomfort and negative sequelae. Results: Aortic blood flow was arrested in 12 volunteers. Median time to blood flow cessation was 12.5 seconds. Median reported discomfort was 5 out of 10. No complications or negative sequelae were reported. Conclusion: This trial suggests that it may be reasonable to attempt temporization of major abdominal-pelvic and junctional hemorrhage using bimanual proximal external aortic compression. In the absence of immediate alternatives for this dangerous and vexing injury pattern, there appear to be few downsides to prehospital proximal external aortic compression while concomitantly expediting definite care.

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.

Bedside Ultrasound to Facilitate Early Diagnosis and Ease of Follow-Up in Neurogenic Heterotopic Ossification: A Pilot Study From the Intensive Care Unit.

OBJECTIVE: To explore the potential role of ultrasound (US) as a bedside tool in intensive care unit patients with presumed neurogenic heterotopic ossification (NHO). SETTING: Tertiary university teaching hospitals. PARTICIPANTS: Critical care patients with acquired brain injury. DESIGN: A multicenter prospective study of critical care patients with possible NHO. MAIN MEASURES: Following a screening clinical examination, the major joints were evaluated with US, serum laboratory work, and x-ray. RESULTS: A total of 310 patients had decreased range of motion by clinical screen and all received US interrogation. Sonographic signs of NHO were identified in 21 of the 310 patients (6.8%), of which 17/21 (81.0%) showed hyperemia; 9/21 (42.8%) showed the reverse zone phenomenon, and 4/21 patients (19.0%) showed the prezone phenomenon. All 21 patients progressed to the zone phenomenon within 15 weeks. Laboratory parameters were not significantly correlated with US (r = 0.11, r = 0.13; P > .05, respectively), whereas x-rays were associated with a mean diagnostic delay of 2 ± 0.5 weeks (P < .05) compared with US. All 21 sonographic NHO patients survived to intensive care unit discharge. Twelve months after admission, 3/21 had died; 6/21 still had abnormalities by x-ray, US, and clinical examination; and 12/21 had resolution by x-ray, US, and clinical examination. CONCLUSION: Our pilot study suggests potential benefits for bedside US in NHO, especially when compared with x-ray or laboratory investigations. These include the possibility of earlier diagnosis, consideration of therapy before ossification, and ease of follow-up. Our study also provides insights into the morphologic, sonographic, radiologic, and clinical course of NHO.

Airway management outside the operating room: how to better prepare.

Airway management outside the operating room is associated with increased risks compared with airway management inside the operating room. Moreover, airway management-whether in the intensive care unit, emergency department, interventional radiology suite, or general wards-often requires mastery of not only the anatomically difficult airway but also the physiologically and situationally difficult airway. The 2015 Difficult Airway Society Guidelines encourage the airway team to "stop and think". This article provides a practical review of how that evidence applies during emergency airway management outside of the operating room. To counter the challenges of airway management outside the operating room, we offer a mnemonic that combines both technical and non-technical insights summarized using the seven letters of the word PREPARE (P: pre-oxygenate/position; R: reset/resist; E: examine/explicit; P: plan A/B; A: adjust/attention; R: remain/review; E: exit/explore). We hope it can unite potentially disparate personnel with a structure that allows them to make acute decisions, coordinate action, and communicate unequivocally. This multidisciplinary publication also hopes to encourage common understanding and language between anesthesiologists and non-anesthesiologists about the perils of airway management outside the operating room and the importance of airway teamwork.

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.

How intravenous nitroglycerine transit time from bag-to-bloodstream can be affected by infusion technique: a simulation study.

OBJECTIVE: To measure the possible delays in intravenous nitroglycerine administration. METHODS: This was a simulation study of sham intravenous nitroglycerine using a standard nitroglycerine titration protocol. Variables studied were (i) common cannulae/needles, (ii) infusion accessories and (iii) presence of a parallel intravenous saline carrier line (or drive line) infusing at 30 mL/h. Outcomes were (i) delay from bag-to-bloodstream arrival and (ii) the dosage showing on the infusion pump when the sham drug first exits the cannula (aka the 'presumed initial dosage'). RESULTS: There was a statistically significant difference in both (i) time-to-bloodstream arrival and (ii) the dosage showing on the infusion pump as the sham first exits the cannula with (i) different cannulae, (ii) different accessories and (iii) presence of a carrier line. The bag-to-bloodstream time varied 10-fold: 197-2062 s. The 'presumed initial dosage' varied sixfold: 5-30 µg/min. Adding the medication to an already flowing carrier line reduced the time for the sham to exit the cannula fourfold: from 2062 to 469 s. CONCLUSIONS: Despite limitations, this study outlines the importance of cannula type, infusion accessories and carrier lines. Larger cannulae and greater priming volumes substantially delay drug delivery, whereas carrier lines/drive lines substantially accelerate drug delivery. Our study also shows how patients could be exposed to clinical delays, as well as incorrect presumptions about drug dosage. Guidelines, and education efforts, should highlight the clinical importance of factors that affect bag-to-bloodstream time.

Temporization of penetrating abdominal-pelvic trauma with manual external aortic compression: a novel case report.

A young civilian man experienced multiple gunshots to the lower abdomen, pelvis, and thigh. These were not amenable to direct compression by a single rescuer. This report outlines the first case in the peer-reviewed literature of manual external aortic compression after severe trauma. This technique successfully temporized external bleeding for more than 10 minutes and restored consciousness to the moribund victim. Subsequently, external bleeding could not be temporized by a second smaller rescuer, or during ambulance transfer. Therefore, we also gained insights about the possible limits of bimanual compression and when alternates, such as pneumatic devices, may be required. Research is needed to test our presumption that successful bimanual compression requires larger-weight rescuers, smaller-weight victims, and a hard surface. It is therefore unclear whether manual external aortic compression is achievable by most rescuers or for most victims. However, it offers an immediate and equipment-free life-sustaining strategy when there are limited alternatives.