Medical experience as an influencing parameter in emergency medical care for psychiatric emergencies: retrospective analysis of a multicenter survey.

BACKGROUND: Prehospital care of psychiatric patients often relies on the medical experience of prehospital emergency physicians (PHEPs). The psychiatrists (PSs) involved in the further treatment of psychiatric patients also often rely on their experience. Furthermore, the interaction between PHEPs and PSs is characterized by interaction problems and different approaches in the prehospital care of the psychiatric emergency. OBJECTIVES: To analyze the phenomenon of "medical experience" as a cause of possible interaction-related problems and assess its impact on the prehospital decision-making process between prehospital emergency physicians and psychiatrists. METHODS: The retrospective data analysis was conducted between November 2022 and March 2023. Medical experience was defined as follows, based on the demographic information collected in the questionnaires: For PHEPs, the period since obtaining the additional qualification in emergency medicine was defined as a surrogate marker of medical experience: (i) inexperienced: < 1 year, (ii) experienced: 1-5 years, (iii) very experienced: > 5 years. For PSs, age in years was used as a surrogate parameter of medical experience: (i) inexperienced: 25-35 years, (ii) experienced: 35-45 years, (iii) very experienced: > 45 years. RESULTS: Inexperienced PSs most frequently expressed anxiety about the psychiatric emergency referred by a PHEP (27.9%). Experienced PHEPs most frequently reported a lack of qualifications in handling the care of psychiatric emergencies (p = 0.002). Very experienced PHEPs were significantly more likely to have a referral refused by the acute psychiatric hospital if an inexperienced PS was on duty (p = 0.01). Experienced PHEPs apply an intravenous hypnotic significantly more often (almost 15%) than PSs of all experience levels (p = 0.001). In addition, very experienced PHEPs sought prehospital phone contact with acute psychiatry significantly more often (p = 0.01). CONCLUSION: PHEPs should be aware that the PS on duty may be inexperienced and that treating emergency patients may cause him/her anxiety. On the other hand, PHEPs should be receptive to feedback from PS who have identified a qualification deficiency in them. Jointly developed, individualized emergency plans could lead to better prehospital care for psychiatric emergency patients. Further training in the prehospital management of psychiatric disorders is needed to minimize the existing skills gap among PHEPs in the management of psychiatric disorders.

Influence of Ingestion of Game Meat on Blood Concentration of Lead in Southern Germany: A Pilot Study.

Consumption of game meat may exert additional lead exposure with potential health risks. The purpose of the present pilot study was to determine blood lead concentration in game meat and no game meat consumers in southern Germany. Concentration of lead in blood (µg·L- 1) was significantly higher in game meat consumers (n = 190; 21.3 [20.0; 29.7]) compared to study participants consuming no game meat (n = 74; 20.0 [20.0; 20.0], p < 0.0001). In study participants with no game meat consumption, blood lead concentration was significantly higher in those who perform active hunting (80.3 [50.5; 110.0]) as well as active shooting (80.3 [50.5; 110.0]) than in those with no hunting or shooting activities (20.0 [20.0; 20.0], p < 0.01). In conclusion, game meat consumers as well as active hunters and shooters should take in to account their potential for an increased lead exposure and the corresponding health risks.

Emergency medical care of patients with psychiatric disorders - challenges and opportunities: Results of a multicenter survey.

BACKGROUND: Pre-clinical psychiatric emergencies are generally treated by emergency medical staff. The subsequent clinical treatment is often conditioned by interaction problems between emergency medical staff and psychiatric clinical staff. OBJECTIVES: To identify problems affecting interaction between emergency medical and psychiatric care of mentally ill patients and pinpoint aspects of optimized emergency care. METHODS: To shed light on the interaction problems an anonymous, questionnaire-based, nonrepresentative survey of 98 emergency physicians (EM) and 104 psychiatrists (PS) practicing in acute psychiatry was conducted between March 1, 2021 and October 1, 2021. RESULTS: The chi-square test for multiple response sets revealed consistently significant differences (p < 0.001) between EM and PS with respect to the questions analyzed. Approximately 36% of EM reported not to be adequately qualified to handle psychiatric emergencies (p = 0.0001), while around 50% of respondents were neutral in their assessment in how to deal with psychiatric emergencies. 80% of EM reported a negative interaction (rejection of patients) with PS when referring a psychiatric emergency patient to the acute psychiatric unit. The most common reasons for refusal were intoxication (EM: 78.8%, PS: 88.2%), emergency physician therapy (EM: 53.8%, PS: 63.5%), and not resident in the catchment area of the hospital (EM 68.8%, PS: 48.2%). In the casuistry presented, most respondents would choose "talk down" for de-escalation (EM: 92.1%, PS: 91.3%). With respect to drug therapy, benzodiazepine is the drug of choice (EM: 70.4%, PS: 78.8%). More EM would choose an intravenously (i.v.) or a Mucosal Atomization Device (MAD) administration as an alternative to oral medication (i.v.: EM: 38.8%, PS: 3.8%, p = 0.001, MAD: EM: 36.7%, PS: 10.6%, p = 0.006). Significantly more EM would seek phone contact with the acute psychiatric hospital (EM: 84.7%, PS: 52.9%, p = 0.0107). A psychiatric emergency plan was considered useful in this context by more than 90% of respondents. The need for further training for EM with regard to treating psychiatric clinical syndromes was considered important by all respondents. In particular, the topics of "psychogenic seizure," "intoxication," and "legal aspects of psychiatric emergencies" were considered important (Mann-Whitney U test, p < 0.001). CONCLUSION: The interaction-related problems identified in the emergency medical care of pre-clinical psychiatric patients relate to non-modifiable, structural problems, such as insufficient admission capacity and non-existent or inadequate monitoring capabilities in acute psychiatric hospitals. However, factors such as the education and training of EM and communication between EM and PS can be improved. Developing personalized emergency care plans for psychiatric patients could help to optimize their care.

[Impact of the COVID-19 crisis in Spring 2020 on trauma case numbers of an academic teaching hospital in Stuttgart : Trauma during a pandemic]. / Einfluss der COVID-19-Krise im Frühjahr 2020 auf traumatologische Fallzahlen eines akademischen Lehrkrankenhauses in Stuttgart : Trauma während einer Pandemie.

BACKGROUND: To cope with the COVID-19 outbreak in Germany, the government imposed a lockdown, which led to restrictions and lifestyle changes for the population. PURPOSE: This study aimed to evaluate the impact of the lockdown on activities causing trauma and the consultation in emergency rooms. MATERIAL AND METHODS: All consecutive trauma patients consulting the Emergency Department of the Marienhospital Stuttgart (MHS), Germany, during the 6 weeks preceding the lockdown, during and after the lockdown were included. The time and type of consultation, treatment received, Manchester triage score, type of trauma, the anatomical region of the injury as well as demographic data were reported and compared. RESULTS: The study included 551 cases during lockdown, 943 cases before and 783 cases after the lockdown. We observed a reduced caseload during the lockdown of 41.6% compared to before and of 29.7% compared to after (p < 0.001). Patients were on average older in the observation group than in both control groups (before : 51.5 years, lockdown: 56.1 years, after: 51.6 years) (p < 0.001). Injuries to the head and neck were constant (25.0%, 25.4%, 25.5%). We noticed lower limb injuries decreasing (26.1%, 22.3%, 22.7%) and upper limb injuries increasing (25.5%, 31.8%, 30.1%). A decrease in sports injuries (11.1%, 5.1%, 9.1%) and work accidents (16.1%, 10.7%, 12.8%) resulted in more domestic accidents (30.4%, 52.5%, 31.8%). Self-referral decreased (67.7%, 53.2%, 60.3%) while referral via paramedics increased (28.3%, 38.7%, 35.6). Blunt trauma was the most common cause of injury (55.6%, 61.0%, 55.3%). Indications for surgery were higher (16.8%, 21.6%, 14.0%). CONCLUSION: The lockdown and restrictions in personal life and daily routine had an impact on the frequency, etiology and management of trauma patients in Stuttgart.

Periodontal damage after thermal inhalation injury - The impact of high temperature inhalation injury on long term periodontal health.

PURPOSE: Thermal inhalation injury is a common, life-threatening problem in burned patients. Whether or not this single event of damage to the oral integrity causes long term health problems is yet to be examined. MATERIAL AND METHODS: All consecutive burn patients between 2014 and 2017 of Marienhospital Stuttgart (MHS), Germany, with at least 10% of burned skin surface were included and compared. The Periodontal Screening Index as well as Vitamin D levels were examined. Vitamin D has been suspected to contribute to the genesis of periodontitis. Risk factors and subjective oral life quality were prompted. RESULTS: We included a total of 32 patients, 15 of which had an inhalation injury in their medical history. Risk factors were examined via Renatus' questionnaire. While risk factors were equally distributed in both groups we saw a remarkable difference in periodontal integrity, with the Periodontal Screening Index (PSI) per sextant differing drastically (with inhalation injury: 2.40, without inhalation injury: 1.10, p < 0.001). Patients with an inhalation injury had a mean of 5.2 out of 6 possible sextants with a pathologic PSI (with the median being 6/6), while patients without an inhalation injury had a mean of 1.83 out of 6 (median: 1/6), p < 0.001. The oral health impact profile showed a difference as well, albeit without statistical significance (with inhalation injury: median = 11, without: median = 3.5, p = 0.414). A correlation between Serum Vitamin D levels and periodontal integrity could not be seen in this group. CONCLUSION: Inhalation injury is a possible cause for periodontitis and hence impacts the quality of life of burned patients.

Automated mechanical cardiopulmonary resuscitation devices versus manual chest compressions in the treatment of cardiac arrest: protocol of a systematic review and meta-analysis comparing machine to human.

INTRODUCTION: Cardiac arrest is a leading cause of death in industrialised countries. Cardiopulmonary resuscitation (CPR) guidelines follow the principles of closed chest compression as described for the first time in 1960. Mechanical CPR devices are designed to improve chest compression quality, thus considering the improvement of resuscitation outcomes. This protocol outlines a systematic review and meta-analysis methodology to assess trials investigating the therapeutic effect of automated mechanical CPR devices at the rate of return of spontaneous circulation, neurological state and secondary endpoints (including short-term and long-term survival, injuries and surrogate parameters for CPR quality) in comparison with manual chest compressions in adults with cardiac arrest. METHODS AND ANALYSIS: A sensitive search strategy will be employed in established bibliographic databases from inception until the date of search, followed by forward and backward reference searching. We will include randomised and quasi-randomised trials in qualitative analysis thus comparing mechanical to manual CPR. Studies reporting survival outcomes will be included in quantitative analysis. Two reviewers will assess independently publications using a predefined data collection form. Standardised tools will be used for data extraction, risks of bias and quality of evidence. If enough studies are identified for meta-analysis, the measures of association will be calculated by dint of bivariate random-effects models. Statistical heterogeneity will be evaluated by I2-statistics and explored through sensitivity analysis. By comprehensive subgroup analysis we intend to identify subpopulations who may benefit from mechanical or manual CPR techniques. The reporting follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. ETHICS AND DISSEMINATION: No ethical approval will be needed because data from previous studies will be retrieved and analysed. Most resuscitation studies are conducted under an emergency exception for informed consent. This publication contains data deriving from a dissertation project. We will disseminate the results through publication in a peer-reviewed journal and at scientific conferences. PROSPERO REGISTRATION NUMBER: CRD42017051633.

Livedo Racemosa - The Pathophysiology of Decompression-Associated Cutis Marmorata and Right/Left Shunt.

Decompression sickness and arterial gas embolism, collectively known as decompression illness (DCI), are serious medical conditions that can result from compressed gas diving. DCI can present with a wide range of physiologic and neurologic symptoms. In diving medicine, skin manifestations are usually described in general as cutis marmorata (CM). Mainly in the Anglo-American literature the terms cutis marmorata, livedo reticularis (LR), and livedo racemosa (LRC) are used interchangeably but actually describe pathophysiologically different phenomena. CM is a synonym for LR, which is a physiological and benign, livid circular discoloration with a net-like, symmetric, reversible, and uniform pattern. The decompression-associated skin discolorations, however, correspond to the pathological, irregular, broken netlike pattern of LRC. Unlike in diving medicine, in clinical medicine/dermatology the pathology of livedo racemosa is well described as a thrombotic/embolic occlusion of arteries. This concept of arterial occlusion suggests that the decompression-associated livedo racemosa may be also caused by arterial gas embolism. Recent studies have shown a high correlation of cardiac right/left (R/L) shunts with arterial gas embolism and skin bends in divers with unexplained DCI. To further investigate this hypothesis, a retrospective analysis was undertaken in a population of Austrian, Swiss, and German divers. The R/L shunt screening results of 18 divers who suffered from an unexplained decompression illness (DCI) and presented with livedo racemosa were retrospectively analyzed. All of the divers were diagnosed with a R/L shunt, 83% with a cardiac shunt [patent foramen ovale (PFO)/atrium septum defect (ASD)], and 17% with a non-cardiac shunt. We therefore not only confirm this hypothesis but when using appropriate echocardiographic techniques even found a 100% match between skin lesions and R/L shunt. In conclusion, in diving medicine the term cutis marmorata/livedo reticularis is used incorrectly for describing the actual pathology of livedo racemosa. Moreover, this pathology could be a good explanation for the high correlation of livedo racemosa with cardiac and non-cardiac right/left shunts in divers without omission of decompression procedures.

Application of mechanical cardiopulmonary resuscitation devices and their value in out-of-hospital cardiac arrest: A retrospective analysis of the German Resuscitation Registry.

BACKGROUND: Cardiac arrest is an event with a limited prognosis which has not substantially changed since the first description of cardiopulmonary resuscitation (CPR) in 1960. A promising new treatment approach may be mechanical CPR devices (mechanical CPR). METHODS: In a retrospective analysis of the German Resuscitation Registry between 2007-2014, we examined the outcome after using mechanical CPR on return of spontaneous circulation (ROSC) in adults with out-of-hospital cardiac arrest (OHCA). We compared mechanical CPR to manual CPR. According to preclinical risk factors, we calculated the predicted ROSC-after-cardiac-arrest (RACA) score for each group and compared it to the rate of ROSC observed. Using multivariate analysis, we adjusted the influence of the devices' application on ROSC for epidemiological factors and therapeutic measures. RESULTS: We included 19,609 patients in the study. ROSC was achieved in 51.5% of the mechanical CPR group (95%-CI 48.2-54.8%, ROSC expected 42.5%) and in 41.2% in the manual CPR group (95%-CI 40.4-41.9%, ROSC expected 39.2%). After multivariate adjustment, mechanical CPR was found to be an independent predictor of ROSC (OR 1.77; 95%-CI 1.48-2.12). Duration of CPR is a key determinant for achieving ROSC. CONCLUSIONS: Mechanical CPR was associated with an increased rate of ROSC and when adjusted for risk factors appeared advantageous over manual CPR. Mechanical CPR devices may increase survival and should be considered in particular circumstances according to a physicians' decision, especially during prolonged resuscitation.

[Psychiatric Emergencies in the Preclinical Emergency Medicine Service in Ulm, Germany in 2000 and 2010, and Practical Consequences]. / Psychiatrische Notfälle im Notarzt- und Rettungsdienst in Ulm in den Jahren 2000 und 2010 und Konsequenzen für die Praxis.

Background Psychiatric emergencies (PE) in preclinical emergency medical services are about 5 - 10 % of all emergencies and represent often a source of difficulties in handling for the non-psychiatric professional helpers that deal with them. Studies informing about quantitative and qualitative changes of PEs in preclinical emergency medicine in Germany are scarce. Methods Therefore, we conducted a retrospective cross-sectional study of PE in a preclinical emergency medical service based on the protocols of the emergency ambulance of the Section for Emergency Medicine at the University Hospital Ulm comparing the years 2000 and 2010. Results We observed a significant increase of PEs from 8.8 % in the year 2000 (n = 285, from a total of n = 3227) to 10.3 % in 2010 (n = 454, from a total of n = 4425). In both years intoxications were the most common PE [2000: n = 116 (44.4 %); 2010: n = 171 (37.7 %)], followed by suicide-related behavior [2000: n = 59 (22.6 %); 2010: n = 78 (17.2 %)] and acute anxiety disorders [2000: n = 37 (13 %); 2010: n = 105 (23.1 %)]. The mentioned three conditions accounted for about 80 % of all PE. Most frequently PE occurred at the weekend and with the highest density in the evening and at night (18 - 24 h) in both years. Patients with PE were predominantly men, but the rate of women causing PE increased between 2000 and 2010. Discussion/Conclusion This study provides preliminary data on current trends in PEs in preclinical emergency medicine in Germany and has implications for improving the medical care provided.

Effects of a media campaign on resuscitation performance of bystanders: a manikin study.

OBJECTIVE: Cardiac arrest is associated with a poor outcome if cardiopulmonary resuscitation (CPR) is delayed. Nevertheless, CPR performance by laypersons in witnessed cardiac arrest is frequently poor. The present study evaluated the effect of a media campaign on CPR performance. PARTICIPANTS AND METHODS: CPR performance of 1000 individuals who did not have any medical background was evaluated using a resuscitation manikin. The media campaign consisted of flyers, posters, and electronic advertisement. Five hundred individuals were evaluated before the media campaign and 500 individuals after the media campaign. Age and male/female ratio were comparable within each of the groups. Premedia campaign performance was compared with postmedia campaign performance with respect to chest compressions and ventilation metrics. RESULTS: Chest compression depth and total compression work were significantly higher after the media campaign: median depth 51 mm postcampaign versus 45 mm precampaign (P<0.001), median cumulative compression work postcampaign 4176 versus 2462 mm precampaign (P<0.001). Tidal volumes and ventilation work were significantly lower following the media campaign, but did not differ between participants who had acknowledged exposure to the campaign and those who did not. Ventilation performance was generally poor across the two groups both before and after the media campaign. CONCLUSION: A simple and cost-efficient media campaign appears to enhance the performance of chest compressions. Ventilation performance and the rate of CPR performance were not increased by the campaign.

[Case report: Snake bite - an odd case]. / Kasuistik: Notarzteinsatz abseits des Alltags - Biss einer Klapperschlange.

Emergency medical service is called by a 54-year-old man bitten by his rattlesnake. Upon initial survey we find the patient in a cardiopulmonary stable condition. He has bite marks and pain on his rapidly swelling middle finger of his right hand. Our initial treatment is immobilization of the patient. The snake raiser has already called the poison control center in Munich. By the help of this institution we bring him to a hospital having the right antivenom on hand.

[Hyperbaric therapy and diving medicine - diving medicine - present state and prospects]. / Hyperbare Therapie und Tauchmedizin - Tauchmedizin: Status quo und Ausblick.

The diving accident (decompression incident, DCI) occurs in the decompression phase of dives. The DCI can either be caused by an arterial gas embolism (AGE) subsequent to a pulmonary barotrauma or by the formation of inert gas bubbles subsequent to a reduction of ambient pressure during the ascent from depth. In contrast to the traditional assumption that decompression incidents only occur if decompression rules are neglected, recent data indicate that a vast amount of diving accidents occur even though divers adhered to the rules. Hence, there is a large inter- and intraindividual variability in the predisposition for diving accidents. Within the past few years, the molecular understanding of the pathophysiology of diving accidents has improved considerably. It is now well accepted that pro-inflammatory and pro-coagulatory mechanisms play a central role. Moreover, microparticles are increasingly discussed in the pathogenesis of diving accidents. These new molecular findings have not yet resulted in new therapeutic approaches. However, new approaches of preconditioning before the dive have been developed which are intended to reduce the risk of diving accidents. The symptoms of a diving accident show a large variability and range. They reach from pruritus over tension in the female breast, marbled skin and pain in the joints to severe neurological disability like paraplegia or hemiplegia. Furthermore, pulmonary symptoms can be a result of a pulmonary gas embolism and/or a tension pneumothorax. Extreme cases can also manifest as generalized, difficult-to-treat seizures, loss of consciousness or even death. The evidence-based therapy of diving accidents consists of an immediate application of 100% inspiratory O2. This can be performed via a demand valve, face mask with reservoir bag or ventilation bag connected to a reservoir bag. Fluid substitution is performed by i. v. infusion of 500-1000ml/h of cristalloids. If consciousness is not impaired, the diver is positioned in a supine position, in case of impaired or absent consciousness in a lateral recovery position. Especially in severe cases of DCI a fast transfer to a qualified hyperbaric center and the earliest possible hyperbaric O2-therapy is essential.

A novel rescue-tube device for in-water resuscitation.

BACKGROUND: In-water resuscitation (IWR) is recommended in the 2010 guidelines of the European Resuscitation Council. As IWR represents a physical challenge to the rescuer, a novel Rescue Tube device with an integrated "Oxylator" resuscitator might facilitate IWR. The aim of the present study was the assessment of IWR using the novel Rescue Tube device. METHODS: Tidal and minute volumes were recorded using a modified Laerdal Resusci Anne mannequin. Furthermore, rescue time, water aspiration, submersions, and physical exertion were assessed. In this randomized cross-over trial, 17 lifeguards performed four rescue maneuvers over a 100-m distance in open water in random order: no ventilation (NV), mouth-to-mouth ventilation (MMV), Oxylator-aided mask ventilation (OMV), and Oxylator-aided laryngeal tube ventilation (OLTV). RESULTS: OLTV resulted in effective ventilation over the entire rescue distance with the highest mean minute volumes (NV 0, MMV 2.9, OMV 4.1, OLTV 7.6 L · min(-1)). NV was the fastest rescue maneuver while IWR prolonged the rescue maneuver independently of the method of ventilation (mean total rescue time: NV 217, MMV 280, OMV 292, OLTV 290 s). Aspiration of substantial amounts of water occurred only during MMV (mean NV 20, MMV 215, OMV 15, OLTV 6 ml). NV and OLTV were rated as moderately challenging by the lifeguards, whereas MMV and OMV were rated as substantially demanding on a 0-10 visual analog scale (NV 5.3, MMV 7.8, OMV 7.6, OLTV 5.9). DISCUSSION: The device might facilitate IWR by providing effective ventilation with minimal aspiration and by reducing physical effort. Another advantage is the possibility of delivering 100% oxygen.

Helicopter-based in-water resuscitation with chest compressions: a pilot study.

BACKGROUND: Drowning is a relevant worldwide cause of severe disability and death. The delay of ventilations and chest compressions is a crucial problem in drowning victims. Hence, a novel helicopter-based ALS rescue concept with in-water ventilation and chest compressions was evaluated. METHODS: Cardio pulmonary resuscitation (CPR) and vascular access were performed in a self-inflating Heliboat platform in an indoor wave pool using the Fastrach intubating laryngeal mask, the Oxylator resuscitator, Lund University Cardiopulmonary Assist System (LUCAS) chest compression device and EZ-IO intraosseous power drill. The time requirement and physical exertion on a Visual Analogue Scale (VAS) were compared between a procedure without waves and with moderate swell. RESULTS: Measurement of the elapsed time of the various stages of the procedure did not reveal significant differences between calm water and swell: Ventilation was initiated after 02:48 versus 03:02 and chest compression after 04:20 versus 04:18 min; the intraosseous cannulisation was completed after 05:59 versus 06:30 min after a simulated jump off the helicopter. The attachment of the LUCAS to the mannequin and the intraosseous cannulisation was rated significantly more demanding on the VAS during swell conditions. CONCLUSIONS: CPR appears to be possible when performed in a rescue platform with special equipment. The novel helicopter-based strategy appears to enable the rescuers to initiate CPR in an appropriate length of time and with an acceptable amount of physical exertion for the divers. The time for the helicopter to reach the patient will have to be very short to minimise neurological damage in the drowning victim.

Lung function after cold-water dives with a standard scuba regulator or full-face-mask during wintertime.

INTRODUCTION: Full-face-masks (FFM) prevent the diver's face from cold and can support nasal breathing underwater. The aim of the study was to evaluate the effect of the use of FFMs on lung function and wellbeing. METHODS: Twenty-one, healthy, non-asthmatic divers performed two cold-water dives (4°C, 25 min, 10 metres' depth) - one with a FFM and the other with a standard scuba regulator (SSR). Spirometry was performed before and after each dive and well-being and cold sensation were assessed after the dives. RESULTS: Significant decreases in forced vital capacity (FVC), forced expiratory volume in one second (FEV1) and midexpiratory flow at 75% of FVC (MEF75) occurred after both FFM and SSR dives. Changes in FVC and FEV1 did not differ significantly between FFM and SSR dives. However, the mid-expiratory flows measured at 50% and 25% of FVC (MEF50 and MEF25) were significantly lower 10 minutes after the FFM dive compared to 10 minutes after the SSR dive. The wellbeing and cold sensation of the divers were significantly improved with FFM dives compared to SSR dives. CONCLUSIONS: Cold-water dives during wintertime can be associated with airway narrowing. During cold-water dives, the use of a FFM appears to reduce the cold sensation and enhance the well-being of the divers. However, a FFM does not appear to prevent airway narrowing in healthy, non-asthmatic subjects.

Rescue of drowning victims and divers: is mechanical ventilation possible underwater? A pilot study.

INTRODUCTION: In-water resuscitation has recently been proposed in the European resuscitation guidelines. Initiation of mechanical ventilation underwater might be considered when an immediate ascent to the surface is impossible or dangerous. The present study evaluated the feasibility of such ventilation underwater. METHODS: A resuscitation manikin was ventilated using an Interspiro® MK II full-face mask or with an Oxylator® ventilator via a facemask or a laryngeal tube, or with mouth-to-tube inflation. Tidal volumes achieved by the individual methods of ventilation were assessed. The ventilation tests were performed during dives in the wet compartment of a recompression chamber and in a lake. Ventilation was tested at 40, 30, 20, 12, 9 and 6 metres' depth. RESULTS: Ventilation was impossible with the cuffed mask and only sufficient after laryngeal intubation for a small number of breaths. Laryngeal tube ventilation was associated with the aspiration of large amounts of water and the Oxylator failed during the ascent. Efficient ventilation with the MK II full-face mask was also possible only for a short period. An absolutely horizontal position of the manikin was required for successful ventilation, which is likely to be difficult to achieve in open water. Leakage at the sealing lip of the full-face mask and the cuff of the laryngeal tube led to intrusion of water and resulted in subsequent complete failure of ventilation. CONCLUSIONS: The efficacy of underwater ventilation seems to be poor with any of the techniques trialed. Water aspiration frequently makes ventilation impossible and might foster emphysema aquosum-like air trapping and, therefore, increase the risk of pulmonary barotrauma during ascent. Because the limitations of underwater ventilation are substantial even under ideal conditions, it cannot be recommended presently for real diving conditions.

Effectiveness and safety of in-water resuscitation performed by lifeguards and laypersons: a crossover manikin study.

OBJECTIVE: Drowning is associated with a high mortality and morbidity and a common cause of death. In-water resuscitation (IWR) in the case of drowning accidents has been recommended by certain resuscitation guidelines in the last several years. IWR has been discussed controversially in the past, especially with regard to the delay of chest compressions, effectiveness of ventilation, and hazard to the rescuer. The aim of the present study was to assess the effectiveness and safety of IWR. METHODS: In this crossover manikin study, 21 lifeguards and 21 laypersons performed two rescue procedures in an indoor swimming pool over a 50-meter distance: In random order, one rescue procedure was performed with in-water ventilation and one without. Tidal and minute volumes were recorded using a modified Laerdal Resusci Anne (Laerdal Medical, Stavanger, Norway) and total rescue duration, submersions, water aspiration by the victim, and physical effort were assessed. RESULTS: IWR resulted in significant increases in rescue duration (lifeguards: 106 vs. 82 seconds; laypersons: 133 vs. 106 seconds) and submersions (lifeguards: 3 vs. 1; laypersons: 5 vs. 0). Furthermore, water aspiration (lifeguards: 112 vs. 29 mL; laypersons: 160 vs. 56 mL) and physical effort (lifeguards: visual analog scale [VAS] score 7 vs. 5; laypersons: VAS score 8 vs. 6) increased significantly when IWR was performed. Lifeguards achieved significantly better ventilation characteristics and performed both rescue procedures faster and with lower side effects. IWR performed by laypersons was insufficient with regard to both tidal and minute volumes. CONCLUSIONS: In-water resuscitation is associated with a delay of the rescue procedure and a relevant aspiration of water by the victim. IWR appears to be possible when performed over a short distance by well-trained professionals. The training of lifeguards must place particular emphasis on a reduction of submersions and aspiration when IWR is performed. IWR by laypersons is exhausting, time-consuming, and inefficient and should probably not be recommended. Key words: drowning; near-drowning; hypoxia; ventilation, artificial; respiration, artificial; resuscitation, in-water.

Efficacy of ventilation and ventilation adjuncts during in-water-resuscitation--a randomized cross-over trial.

INTRODUCTION: Drowning is a common cause of death in young adults. The 2010 guidelines of the European Resuscitation Council call for in-water-resuscitation (IWR). There has been controversy about IWR amongst emergency and diving physicians for decades. The aim of the present study was assessing the efficacy of IWR. METHODS: In this randomized cross-over trial, nineteen lifeguards performed a rescue manoeuvre over a 100 m distance in open water. All subjects performed the procedure four times in random order: with no ventilation (NV) and transportation only, mouth-to-mouth ventilation (MMV), bag-mask-ventilation (BMV) and laryngeal tube ventilation (LTV). Tidal volumes, ventilation rate and minute-volumes were recorded using a modified Laerdal Resusci Anne manikin. Furthermore, water aspiration and number of submersions of the test mannequin were assessed, as well as the physical effort of the lifeguard rescuers.One lifeguard subject did not complete MMV due to exhaustion and was excluded from analysis. RESULTS: NV was the fastest rescue manoeuvre (advantage ∼40s). MMV and LTV were evaluated as efficient and relatively easy to perform by the lifeguards. While MMV (mean 199 ml) and BMV (mean 481 ml) were associated with a large amount of aspirated water, aspiration was significantly lower in LTV (mean 118 ml). The efficacy of ventilation was consistently good in LTV (Vt=447 ml), continuously poor in BMV (Vt=197) and declined substantially during MMV (Vt=1,019 ml initially and Vt=786 ml at the end). The physical effort of the lifeguards was remarkably higher when performing IWR: 3.7 in NV, 6.7 in MMV, 6.4 in BMV and 4.8 in LTV as measured on the 0-10 visual analogue scale. CONCLUSION: IWR in open water is time consuming and physically demanding. The IWR training of lifeguards should put more emphasis on a reduction of aspiration. The use of ventilation adjuncts like the laryngeal tube might ease IWR, reduce aspiration of water and increase the efficacy of ventilation during IWR.