Impact of video recordings review with structured debriefings on trauma team performance: a prospective observational cohort study.

PURPOSE: To determine the impact of structured debriefings (SD) with audio/video review of trauma patients' resuscitation events on trauma team (TT) technical and non-technical skills. METHODS: Single-center prospective observational cohort study. The study included all emergency department patients aged 18 years or older who received resuscitation from the TT. Virtual meeting was held with the TT using SD to review one trauma patient resuscitation video. Technical skills improvement was based on adherence to the ATLS protocol and non-technical skills based on T-NOTECHS scale. RESULTS: There was statistically significant improvement in adherence to the ATLS protocol: 73% [55-82%] vs 91% [82-100%] (p < 0.001); and improvement in T-NOTECHS scale: 12 [10-14] vs 16 [14-19] points (p < 0.001). CONCLUSION: In this study, we found that structured debriefings with review of patients' resuscitation video recordings can have a significant positive impact on trauma team performance in the emergency department in both technical and non-technical skills.

Soluble CD146 in the detection and grading of intravascular and tissue congestion in patients with acute dyspnoea: analysis of the prospective observational Lithuanian Echocardiography Study of Dyspnoea in Acute Settings (LEDA) cohort.

OBJECTIVES: To evaluate the potential of soluble cluster of differentiation 146 (sCD146) in the detection and grading of congestion in patients with acute dyspnoea. DESIGN: Subanalysis of the prospective observational Lithuanian Echocardiography Study of Dyspnoea in Acute Settings (LEDA) cohort. SETTING: Two Lithuanian university centres. PARTICIPANTS: Adult patients with acute dyspnoea admitted to the emergency department. METHODS: Congestion was assessed using clinical and sonographic parameters. All patients underwent sCD146 and N-terminal pro-B-type natriuretic peptide (NT-proBNP) testing. RESULTS: The median value of sCD146 concentration in the study cohort (n=437) was 405 (IQR 315-509) ng/mL. sCD146 was higher in patients with peripheral oedema than in those without (median (IQR) 472 (373-535) vs 400 (304-501) ng/mL, p=0.009) and with pulmonary rales than in those without (439 (335-528) vs 394 (296-484) ng/mL, p=0.001). We found a parallel increase of estimated right atrial pressure (eRAP) and sCD146 concentration: sCD146 was 337 (300-425), 404 (290-489) and 477 (363-572) ng/mL in patients with normal, moderately elevated and high eRAP, respectively (p=0.001). In patients with low NT-proBNP, high sCD146 distinguished a subgroup with a higher prevalence of oedema as compared with patients with low levels of both biomarkers (76.0% vs 41.0%, p=0.010). Moreover, high sCD146 indicated a higher prevalence of elevated eRAP, irrespective of NT-proBNP concentration (p<0.05). CONCLUSION: sCD146 concentration reflects the degree of intravascular and tissue congestion assessed by clinical and echocardiographic indices, with this association maintained in patients with low NT-proBNP. Our data support the notion that NT-proBNP might represent heart stretch while sCD146 rather represents peripheral venous congestion.

Impact of the COVID-19 lockdown on trauma team activations in a single major Lithuanian trauma center: A retrospective single-center study.

Background: As a result of the coronavirus disease 2019 (COVID-19) pandemic and national quarantine, different levels of social and movement restrictions, and stay-at-home requests, trauma trends have changed. The aim of the present study was to determine the impact of lockdown on patients treated by the trauma team (TT) at a single major Lithuanian trauma center during the COVID-19 pandemic. Methods: This is a retrospective, descriptive study of adult (≥18 years old) trauma patients (for whom the TT was activated). Consequently, we analyzed the national lockdown periods from 16 March to 15 May 2020 and from 16 December 2020 to 28 February 2021, compared with the corresponding period of the previous year. Results: There was a 10% reduction in TT activations during the national lockdown period. No significant differences were noted in patient demographics. In the COVID-19 cohort, patients had higher Injury Severity Score (14 [IQR 6-21] vs. 9 [IQR 3-18], P = 0.025) and longer time to computed tomography scan (33 [IQR 25-43] vs. 23 [IQR 20-31] min, P < 0.001). Moreover, in the COVID-19 cohort, three times more patients were transferred from the emergency department (ED) straight to the operating room (n = 12 [19%] vs. n = 4 [5.7%], P = 0.018, Cramer's V = 0.21). Conclusion: Patients were more severely injured, and more patients required emergent surgery during the lockdown. In addition, it took longer to transfer patients to the ED and to perform a computed tomography scan.

Biologically Active Adrenomedullin (bio-ADM) is of Potential Value in Identifying Congestion and Selecting Patients for Neurohormonal Blockade in Acute Dyspnea.

PURPOSE: This study was designed to evaluate the role of biologically active adrenomedullin (bio-ADM) in congestion assessment and risk stratification in acute dyspnea. METHODS: This is a sub-analysis of the Lithuanian Echocardiography Study of Dyspnea in Acute Settings. Congestion was assessed by means of clinical (peripheral edema, rales) and sonographic (estimated right atrial pressure) parameters. Ninety-day mortality was chosen for outcome analysis. RESULTS: There were 1188 patients included. Bio-ADM concentration was higher in patients with peripheral edema at admission (48.2 [28.2-92.6] vs 35.4 [20.9-59.2] ng/L, P < .001). There was a stepwise increase in bio-ADM concentration with increasing prevalence of rales: 29.8 [18.8-51.1], 38.5 [27.5-67.1], and 51.1 [33.1-103.2] ng/L in patients with no rales, rales covering less than one-half, and greater than or equal to one-half of the pulmonary area, respectively (P < 0.001). Bio-ADM concentration demonstrated gradual elevation in patients with normal, moderately, and severely increased estimated right atrial pressure: 25.1 [17.6-42.4] ng/L, 36.1 [23.1-50.2], and 47.1 [30.7-86.7] ng/L, respectively (P < .05). Patients with bio-ADM concentration >35.5 ng/L were at more than twofold increased risk of dying (P < .001). Survival in those with high bio-ADM was significantly modified by neurohormonal blockade at admission (P < .05), especially if NT-proBNP levels were lower than the median (P = .002 for interaction). CONCLUSION: Bio-ADM reflects the presence and the degree of pulmonary, peripheral, and intravascular volume overload and is strongly related to 90-day mortality in acute dyspnea. Patients with high bio-ADM levels demonstrated survival benefit from neurohormonal blockade.

Readmission following both cardiac and non-cardiac acute dyspnoea is associated with a striking risk of death.

AIMS: Readmission and mortality are the most common and often combined endpoints in acute heart failure (AHF) trials, but an association between these two outcomes is poorly investigated. The aim of this study was to determine whether unplanned readmission is associated with a greater subsequent risk of death in patients with acute dyspnoea due to cardiac and non-cardiac causes. METHODS AND RESULTS: Derivation cohort (1371 patients from the LEDA study) and validation cohort (1986 patients from the BASEL V study) included acute dyspnoea patients admitted to the emergency department. Cox regression analysis was used to determine the association of 6 month readmission and the risk of 1 year all-cause mortality in AHF and non-AHF patients and those readmitted due to cardiovascular and non-cardiovascular causes. In the derivation cohort, 666 (49%) of patients were readmitted at 6 months and 282 (21%) died within 1 year. Six month readmission was associated with an increased 1 year mortality risk in both the derivation cohort [adjusted hazard ratio (aHR) 3.0 (95% confidence interval, CI 2.2-4.0), P < 0.001] and the validation cohort (aHR 1.8, 95% CI 1.4-2.2, P < 0.001). The significant association was similarly observed in AHF (aHR 3.2, 95% CI 2.1-4.9, P < 0.001) and other causes of acute dyspnoea (aHR 2.9, 95% CI 1.9-4.5, P < 0.001), and it did not depend on the aetiology [aHR 2.2, 95% CI 1.6-3.1 for cardiovascular readmissions; aHR 4.1, 95% CI 2.9-5.7 for non-cardiovascular readmissions (P < 0.001 for both)] or timing of readmission. CONCLUSION​S: Our study demonstrated a long-lasting detrimental association between readmission and death in AHF and non-AHF patients with acute dyspnoea. These patients should be considered 'vulnerable patients' that require personalized follow-up for an extended period.

What happens in the shock room stays in the shock room? A time-based audio/video audit framework for trauma team performance analysis.

INTRODUCTION: A precise tool for analysis of trauma team performance is missing. OBJECTIVES: To create a framework for trauma team performance analysis and feedback. METHODS: An observational study in a level I trauma centre in Lithuania was performed from January 1 2017 to August 31 2017. Audio/video review process was used to evaluate technical and nontechnical performance of the trauma team. RESULTS: In total, 143 trauma team activations were analysed. The mean rate of completion for the primary survey based on Advanced Trauma Life Support principles was 68.5%. Technical steps of patient resuscitation were measured in seconds during first hour of the treatment. The T-NOTECHS scale mean score was 11.99 (SD 2.9). CONCLUSION: During the study period, we were able to measure the time needed for certain steps in trauma patient evaluation and management. Based on this analysis, a performance improvement program will be devised, including the HybridLab medical simulation, audio/video debriefing, and individualised feedback sessions.

Low Temperature and Low UV Indexes Correlated with Peaks of Influenza Virus Activity in Northern Europe during 2010⁻2018.

With the increasing pace of global warming, it is important to understand the role of meteorological factors in influenza virus (IV) epidemics. In this study, we investigated the impact of temperature, UV index, humidity, wind speed, atmospheric pressure, and precipitation on IV activity in Norway, Sweden, Finland, Estonia, Latvia and Lithuania during 2010⁻2018. Both correlation and machine learning analyses revealed that low temperature and UV indexes were the most predictive meteorological factors for IV epidemics in Northern Europe. Our in vitro experiments confirmed that low temperature and UV radiation preserved IV infectivity. Associations between these meteorological factors and IV activity could improve surveillance and promote development of accurate predictive models for future influenza outbreaks in the region.

Evaluation of volume status in a prehospital setting by ultrasonographic measurement of inferior vena cava and aorta diameters.

OBJECTIVES: The aim of this study was to evaluate the utility of ultrasonographic measurement of the diameter of the inferior vena cava (IVCD) and abdominal aorta (AAD) for assessing volume status. MATERIAL AND METHODS: This was a prospective, observational study. A total of 23 volunteers participated in the study. Each participant was selected randomly. All participants completed the 2016 Kaunas Marathon. Participants filed out a brief survey about their fluid intake (in standardised glasses) in the 24 h before the race and during the race. Participants underwent ultrasound measurements 10-40 min before the start of the race and 3-15 min after finishing the race. To visualize respiratory variation, M-mode was used, with the beam crossing the IVCD 2 cm from the right atrium. The AAD was measured 1 cm above the celiac trunk. IVCD in expiration (IVCDexp)/AAD was calculated by dividing the value of IVCDexp by the value of AAD. The findings were compared with difference in body mass index. RESULTS: The mean weight lost after the marathon was 2.93 kg (p < 0.001). Mean IVCD in inspiration (IVCDins) after the run was lower by 0.39 cm (p < 0.001) then before the run. Mean IVCDexp/AAD after the run was 0.24 cm lower than before the run (p = 0.03). Before and after the marathon, there was a statistically significant negative correlation in weight difference, with mean IVCDexp difference (p = 0.047). There was no statistically significant difference in caval index before and after running. CONCLUSION: Ultrasonographic assessment of IVCDexp could be useful in the evaluation of volume status.

How the changes in the system affect trauma care provision: The assessment of and implications for Lithuanian trauma service performance in 2007-2012.

OBJECTIVE: The aim of this study was to identify and assess the effects of changes in the Lithuanian trauma service from 2007 to 2012. We postulate that the implications derived from this study will be of importance to trauma policy planners and makers in Lithuania and throughout other countries of Eastern and Central Europe. MATERIALS AND METHODS: Out of 10,390 trauma admissions to four trauma centers in 2007, 294 patients (2.8%) were randomly selected for the first arm of a representative study sample. Similarly, of 9918 trauma admissions in 2012, 250 (2.5%) were randomly chosen for comparison in the study arm. Only cases with a diagnosis falling into the ICD-10 "S" and "T" codes were included. A survey of whom regarding changes in quality of trauma care from 2007 to 2012 was carried out by emergency medical service (EMS) providers. RESULTS: The Revised Trauma Score (RTS) mean value was 7.45±1.04 for the 2007 year arm; it was 7.53±0.93 for the 2012 year arm (P=0.33). Mean time from the moment of a call from the site of the traumatic event to the patient's arrival at the trauma center did not differ between the arms of the sample: 49.95min in 2007 vs. 51.6min in 2012 (P=0.81). An application of the operational procedures such as a cervical spine protection using a hard collar, oxygen therapy, infusion of intravenous fluids, and pain relief on the trauma scene was more frequent in 2012 than in 2007. Management of trauma patients in the emergency department improved regarding the availability of 24/7 computed tomography scanner facilities and an on-site radiographer. Time to CT-scanning was reduced by 38.8%, and time to decision-making was reduced by 16.5% in 2012. CONCLUSIONS: Changes in operational procedures in the Lithuanian pre-hospital care provision and management of trauma patients in emergency departments of trauma centers improved the efficiency of trauma care delivery over the 2007-2012 period.

Patterns of acute whiplash-associated disorder in the Lithuanian population after road traffic accidents.

OBJECTIVE: To investigate acute whiplash-associated disorder in the Lithuanian population who are unaware of the phenomenon. DESIGN: Controlled cohort study. SUBJECTS/PATIENTS: Seventy-one patients were enrolled from the emergency departments of the Kaunas region of Lithuania following road traffic accidents, examined within 3-14 days after the accident, and compared with 53 matched controls. METHODS: Clinical neurological examination, including range of motion and motion-evoked pain or stiffness in the neck; spontaneous pain and pain pressure threshold. Questionnaires: Quebec Task Force questionnaire (QTFQ); Disability Rating Index (DRI); Cognitive Failures Questionnaire (CFQ); Hospital Anxiety and Depression Scale (HADS) and health perception. RESULTS: Sixty-six of 71 (93%) patients developed acute symptoms. The most frequent symptoms found after road traffic accidents were neck or shoulder pain; reduced or painful neck movements, including decreased range of motion; multiple subjective symptoms according to QTFQ and significantly reduced pain threshold. Perceived health status was decreased and DRI was increased, while HADS showed a significantly higher risk of developing anxiety. Higher grade whiplash-associated disorder was linked with a greater reduction in range of motion and more prominent neck pain. CONCLUSION: Road traffic accidents induce whiplash-associated disorder in patients who seek help, but who are unaware of the condition whiplash-associated disorder. Whiplash-associated disorder should be considered and treated as an entity per se.

Magical manoeuvre: a 5-s instructor's intervention helps lightweight female rescuers achieve the required chest compression depth.

BACKGROUND: Adequate chest compression (CC) depth is crucial for resuscitation outcomes. Lightweight rescuers, particularly women, are often unable to achieve the required 5-6 cm CC depth. This nonrandomized cohort study investigated new strategies to improve CC performance. OBJECTIVE: To evaluate the effects of a 5-s instructor's intervention on the depth of CCs performed by female rescuers during standard video self-instruction basic life support training. METHODS: Data were prospectively collected from January 2011 to January 2012 from 336 female medical and pharmacy students undergoing cardiopulmonary resuscitation (CPR) training at the Lithuanian University of Health Sciences. During the training process, the instructors performed a simple 5-s intervention (Andrew's manoeuvre) with all of the rescuers in the study group. The instructor pushed 10 times on the shoulders of each trainee while she performed CCs to achieve the maximal required compression depth. Immediately after training, the participants were asked to perform a 6-min basic life support test on a manikin that was connected to a PC with Skill Reporter System software; the quality of the participants' CPR skills was then evaluated. RESULTS: The CC depth in the study group increased by 6.4 mm (P<0.001) compared with the control group (52.9 vs. 46.6 mm). A regression analysis showed that Andrew's manoeuvre increased the depth of the CCs among women by 14.87×(1-0.01×weight) mm. CONCLUSION: A simple 5-s instructor's intervention during the CPR training significantly improved the performance of the female rescuers and helped them achieve the CC depth required by 2010 resuscitation guidelines. Andrew's manoeuvre is most effective among the women with the lowest body weight.

Can lightweight rescuers adequately perform CPR according to 2010 resuscitation guideline requirements?

AIM: To evaluate associations between rescuers' anthropometric characteristics and chest compressions (CC) depth according to 2010 resuscitation guidelines. METHODS: 186 medical and pharmacy students, never trained in basic life support (BLS) before, underwent video self-instruction training. The participants were asked to perform a BLS test on a manikin connected to a PC for 6 min immediately after training, and the quality of the cardiopulmonary resuscitation (CPR) skills was evaluated. RESULTS: Women with body weights less than 56 kg were 6.29 times more likely to produce insufficient CCs than women weighing 56-62.7 kg, and 4.72 times more likely to produce insufficient CCs compared with women weighing more than 62.7 kg. CONCLUSIONS: Lightweight rescuers may have difficulty achieving the full compression depth of 5-6 cm required by new resuscitation guidelines. These rescuers require special attention during CPR training, with an emphasis on correct body positioning and use of body weight for CCs.

New insights for adult cardiopulmonary resuscitation. Up-coming resuscitation guidelines 2010.

Despite advances in cardiac arrest care, the overall survival to hospital discharge remains poor. The objective of this paper was to review the innovations in cardiopulmonary resuscitation that could influence survival or change our understanding about cardiopulmonary resuscitation. We have performed a search in the MEDLINE and the Cochrane databases for randomized controlled trials, meta-analyses, expert reviews from December 2005 to March 2010 using the terms cardiac arrest, basic life support, and advanced life support. The lack of randomized trials during the last 5 years remains the main problem for crucial decisions in cardiopulmonary resuscitation. Current trends in cardiopulmonary resuscitation are toward minimizing the interruptions of chest compressions and improving the quality of cardiopulmonary resuscitation. In addition, attention should be paid to all the parts of chain of survival, which remains essential in improving survival rates.