Empowering the next Generation: An innovative "Kids Save Lives" blended learning programme for schoolchildren training.

INTRODUCTION: Guidelines recommend teaching resuscitation from school age; however, little is known about the best methods to provide it. We devised a blended learning program for primary and secondary students (Kids Save Lives - KSL) consisting of brief lectures, practical training with mannequins, and virtual reality. We aimed to evaluate its impact on students' attitudes towards intervening during cardiac arrest and their knowledge about basic life support. METHODS: This observational, prospective, before-and-after study assessed attitudes and basic life support knowledge in primary and secondary school children exposed to the KSL program. 20 events were conducted in the metropolitan area of Bologna, Italy. A multiple-choice test (before and after the course) explored attitude, knowledge and perceptions of realism, engagement, and agreement with the virtual reality method. RESULTS: A total of 1,179 students (response rate 81.4%) were included in the final analysis, with 12.89% from primary schools, 5.94% from middle schools, and 81.17% from high schools. Students' willingness to intervene during a cardiac arrest rose from 56.9% to 93.1% (p < 0.001) post-course. The course's realism, engagement, and future prospects received positive feedback, with median scores notably higher in primary schools compared to secondary schools. CONCLUSION: The blended learning method improved students' understanding of basic life support techniques and their attitude to act during cardiac arrest situations. The positive reception of the virtual reality component underscores technology's potential to bolster engagement and should be further explored for basic life support teaching in schoolchildren.

Logistic and cognitive-emotional barriers experienced by first responders when alarmed to get dispatched to out-of-hospital cardiac arrest events: a region-wide survey.

Out-of-hospital cardiac arrest (OHCA) is a major public health concern with low survival rates. First responders (FRs) and public access defibrillation (PAD) programs can significantly improve survival, although barriers to response activation persist. The Emilia Romagna region in Italy has introduced a new system, the DAE RespondER App, to improve the efficiency of FR dispatch in response to OHCA. The study aimed to evaluate the association between different logistic factors, FRs' perceptions, and their decision to accept or decline dispatch to an OHCA scene using the DAE RespondER App. A cross-sectional web survey was conducted, querying 14,518 registered FRs using the DAE RespondER app in Emilia Romagna. The survey explored logistic and cognitive-emotional perceptions towards barriers in responding to OHCAs. Statistical analysis was conducted, with responses adjusted using non-response weights. 4,644 responses were obtained (32.0% response rate). Among these, 1,824 (39.3%) had received at least one dispatch request in the past year. Multivariable logistic regression showed that being male, having previous experience with OHCA situations, and having an automated external defibrillator (AED) available at the moment of the call were associated with a higher probability of accepting the dispatch. Regarding FRs' perceptions, logistic obstacles were associated with mission rejection, while higher scores in cognitive-emotional obstacles were associated with acceptance. The study suggests that both logistical and cognitive-emotional factors are associated with FRs' decision to accept a dispatch. Addressing these barriers and further refining the DAE RespondER App can enhance the effectiveness of PAD programs, potentially improving survival rates for OHCA. The insights from this study can guide the development of interventions to improve FR participation and enhance overall OHCA response systems.

Angioedema after rt-PA infusion led to airway emergency: a case report of rescue treatment with fresh frozen plasma

Abstract The authors report the case of a 71-year-old woman presented to the Emergency Department with acute ischemic stroke. She was treated with rt-PA and interventional endovascular revascularization and developed rapidly progressing angioedema that led to emergency intubation. The standard treatment was not very effective and the swelling improved after infusion of fresh frozen plasma. Angioedema after rt-PA infusion could be a life-threatening emergency that requires quick airway management by skilled professionals. As this condition is triggered by several factors, such as unregulated histamine and bradykinin production, the traditional treatment recommended by the guidelines may not be sufficient and the use of FFP can be considered as a safe and valuable aid.

Diagnostic accuracy for hemoperitoneum, influence on prehospital times and time-to-definitive treatment of prehospital FAST: A systematic review and individual participant data meta-analysis.

BACKGROUND: Focused assessment sonography for trauma (FAST) performed in the prehospital setting may improve trauma care by influencing treatment decisions and reducing time to definitive care, but its accuracy and benefits remain uncertain. This systematic review evaluated the diagnostic accuracy of prehospital FAST in detecting hemoperitoneum and its effects on prehospital time and time to definitive diagnosis or treatment. METHODS: We systematically searched PubMed, Embase, and Cochrane library up to November 11th, 2022. Studies investigating prehospital FAST and reporting at least one outcome of interest for this review were considered eligible. The primary outcome was prehospital FAST diagnostic accuracy for hemoperitoneum. A random-effect meta-analysis, including individual patient data, was performed to calculate the pooled outcomes with 95% confidence intervals (CI). Quality of studies was assessed using the QUADAS-2 tool for diagnostic accuracy. RESULTS: We included 21 studies enrolling 5790 patients. The pooled sensitivity and specificity of prehospital FAST for hemoperitoneum were 0.630 (0.454 - 0.777) and 0.970 (0.957-0.979), respectively. Prehospital FAST was performed in a median of 2.72 (2.12 - 3.31) minutes without increasing prehospital times (pooled median difference of 2.44 min [95% CI: -3.93 - 8.81]) compared to standard management. Prehospital FAST findings changed on-scene trauma care in 12-48% of cases, the choice of admitting hospital in 13-71%, the communication with the receiving hospital in 45-52%, and the transfer management in 52-86%. Patients with a positive prehospital FAST achieved definitive diagnosis or treatment more rapidly (severity-adjusted pooled time ratio = 0.63 [95% CI: 0.41 - 0.95]) compared with patients with a negative or not performed prehospital FAST. CONCLUSIONS: Prehospital FAST had a low sensitivity but a very high specificity to identify hemoperitoneum and reduced time-to-diagnostics or interventions, without increasing prehospital times, in patients with a high probability of abdominal bleeding. Its effect on mortality is still under-investigated.

Amplitude Spectrum Area of ventricular fibrillation to guide defibrillation: a small open-label, pseudo-randomized controlled multicenter trial.

BACKGROUND: Ventricular fibrillation (VF) waveform analysis has been proposed as a potential non-invasive guide to optimize timing of defibrillation. METHODS: The AMplitude Spectrum Area (AMSA) trial is an open-label, multicenter randomized controlled study reporting the first in-human use of AMSA analysis in out-of-hospital cardiac arrest (OHCA). The primary efficacy endpoint was the termination of VF for an AMSA ≥ 15.5 mV-Hz. Adult shockable OHCAs randomly received either an AMSA-guided cardiopulmonary resuscitation (CPR) or a standard-CPR. Randomization and allocation to trial group were carried out centrally. In the AMSA-guided CPR, an initial AMSA ≥ 15.5 mV-Hz prompted for immediate defibrillation, while lower values favored chest compression (CC). After completion of the first 2-min CPR cycle, an AMSA < 6.5 mV-Hz deferred defibrillation in favor of an additional 2-min CPR cycle. AMSA was measured and displayed in real-time during CC pauses for ventilation with a modified defibrillator. FINDINGS: The trial was early discontinued for low recruitment due to the COVID-19 pandemics. A total of 31 patients were recruited in 3 Italian cities, 19 in AMSA-CPR and 12 in standard-CPR, and included in the data analysis. No difference in primary outcome was observed between the two groups. Termination of VF occurred in 74% of patients in the AMSA-CPR compared to 75% in the standard CPR (OR 0.93 [95% CI 0.18-4.90]). No adverse events were reported. INTERPRETATION: AMSA was used prospectively in human patients during ongoing CPR. In this small trial, an AMSA-guided defibrillation provided no evidence of an improvement in termination of VF. TRIAL REGISTRATION: NCT03237910. FUNDING: European Commission - Horizon 2020; ZOLL Medical Corp., Chelmsford, USA (unrestricted grant); Italian Ministry of Health - Current research IRCCS.

Factors associated with the arrival of smartphone-activated first responders before the emergency medical services in Out-of-Hospital cardiac arrest dispatch.

BACKGROUND: First responder programs were developed to speed up access to cardiopulmonary resuscitation and defibrillation for out-of-hospital cardiac arrest (OHCA) victims. Little is known about the factors influencing the efficiency of the first responders arriving before the EMS and, therefore, effectively contributing to the chain of survival. OBJECTIVES: The primary objective of this retrospective observational study was to identify the factors associated with first responders' arrival before EMS in the context of a regional first responder program arranged to deliver automated external defibrillators on suspected OHCA scenes. METHODS: Eight hundred ninety-six dispatches where FRs intervened were collected from 2018 to 2022. A robust Poisson regression was performed to estimate the role of the time of day, the immediate availability of a defibrillator, the type of first responder, distances between the responder, the event and the dispatched vehicle, and the nearest available defibrillator on the probability of responder arriving before EMS. Moreover, a geospatial logistic regression model was built. RESULTS: Responders arrived before EMS in 13.4% of dispatches and delivered a shock in 0.9%. The immediate availability of a defibrillator for the responder (OR = 3.24) and special categories such as taxi drivers and police (OR = 1.74) were factors significantly associated with the responder arriving before EMS. Moreover, a geospatial effect suggested that first responder programs may have a greater impact in rural areas. CONCLUSIONS: When dispatched to OHCA scenes, responders already carrying defibrillators could more probably reach the scene before EMS. Special first responder categories are more competitive and should be further investigated.

Angioedema after rt-PA infusion led to airway emergency: a case report of rescue treatment with fresh frozen plasma.

The authors report the case of a 71-year-old woman presented to the Emergency Department with acute ischemic stroke. She was treated with rt-PA and interventional endovascular revascularization and developed rapidly progressing angioedema that led to emergency intubation. The standard treatment was not very effective and the swelling improved after infusion of fresh frozen plasma. Angioedema after rt-PA infusion could be a life-threatening emergency that requires quick airway management by skilled professionals. As this condition is triggered by several factors, such as unregulated histamine and bradykinin production, the traditional treatment recommended by the guidelines may not be sufficient and the use of FFP can be considered as a safe and valuable aid.

Cardiac Arrest in a Young Woman: A Near Miss Diagnosis.

Catecholaminergic polymorphic ventricular tachycardia (CPVT) is a rare channelopathy involving cardiac calcium metabolism that often shows up at an early age with misleading clinical symptoms such as emotion or exercise-related syncope with a normal resting ECG, however, if misdiagnosed, CPVT can lead to cardiac arrest in children or young adults. We describe the case of a 27-year-old woman with several misdiagnosed syncopal episodes leading to out-of-hospital cardiac arrest (OHCA). Her previous medical history, combined with automatic external defibrillator records (AED) and clinical data, strongly suggested the diagnosis of CPVT. Thus beta blocker therapy was immediately started and targeted genetic test undertaken, revealing a previously unreported heterozygous variant in the ryanodine receptor-2 (RYR2) gene.

EISOR Delivery: Regional experience with sharing equipe, equipment & expertise to increase cDCD donor pool in time of pandemic.

Donation after circulatory death (DCD) programs are expanding in Europe, in the attempt to expand donors pool. Even in controlled DCD donors, however, a protracted warm ischemia time occurring in the perimortem period might damage organs, making these unsuitable for transplantation. Implementing a strategy of extracorporeal interval support for organ retrieval (EISOR), a regional reperfusion with normothermic, oxygenated blood provides a physiologic environment allowing extensive assessment of potential grafts, and potentially promotes recovery of native function. Here we report the results of a multi-center retrospective cohort study including 29 Maastricht Category III controlled DCD donors undergoing extracorporeal support in a regional DCD/EISOR Training Center, and in the network of referring In-Training Centers, under the liaison of the regional Transplant Coordination Center during COVID-19 pandemic, between March 2020 and November 2021. The study aims to understand whether a mobile, experienced EISOR team implementing a consistent technique and sharing its equipe, expertise and equipment in a regional network of hospitals, might be effective and efficient in implementing the regional DCD program activity even in a highly stressed healthcare system.

Factors influencing prehospital physicians' decisions to initiate advanced resuscitation for asystolic out-of-hospital cardiac arrest patients.

BACKGROUND: The decision to initiate or continue advanced life support (ALS) in out-of-hospital cardiac arrest (OHCA) could be difficult due to the lack of information and contextual elements, especially in non-shockable rhythms. This study aims to explore factors associated with clinicians' decision to initiate or continue ALS and the conditions associated with higher variability in asystolic patients. METHODS: This retrospective observational study enrolled 2653 asystolic patients on whom either ALS was attempted or not by the emergency medical services (EMS) physician. A multivariable logistic regression analysis was performed to find the factors associated with the decision to access ALS. A subgroup analysis was performed on patients with a predicted probability of ALS between 35% and 65%. The single physician's behaviour was compared to that predicted by the model taking into account the entire agency. RESULTS: Age, location of event, bystander cardiopulmonary resuscitation and EMS-witnessed event were independent factors influencing physicians' choices about ALS. Non-medical OHCA, younger patients, less experienced physicians, presence of breath activity at the emergency call and a longer time for ALS arrival were more frequent among cases with an expected higher variability in behaviours with ALS. Significant variability was detected between physicians. CONCLUSIONS: Significant inter-physician variability in access to ALS could be present within the same EMS, especially among less experienced physicians, non-medical OHCA and in presence of signs of life during emergency call. This arbitrariness has been observed and should be properly addressed by EMS team members as it raises ethical issues regarding the disparity in treatment.

Multicentre observational study on practice of prehospital management of hypotensive trauma patients: the SPITFIRE study protocol.

INTRODUCTION: Major haemorrhage after injury is the leading cause of preventable death for trauma patients. Recent advancements in trauma care suggest damage control resuscitation (DCR) should start in the prehospital phase following major trauma. In Italy, Helicopter Emergency Medical Services (HEMS) assist the most complex injuries and deliver the most advanced interventions including DCR. The effect size of DCR delivered prehospitally on survival remains however unclear. METHODS AND ANALYSIS: This is an investigator-initiated, large, national, prospective, observational cohort study aiming to recruit >500 patients in haemorrhagic shock after major trauma. We aim at describing the current practice of hypotensive trauma management as well as propose the creation of a national registry of patients with haemorrhagic shock. PRIMARY OBJECTIVE: the exploration of the effect size of the variation in clinical practice on the mortality of hypotensive trauma patients. The primary outcome measure will be 24 hours, 7-day and 30-day mortality. Secondary outcomes include: association of prehospital factors and survival from injury to hospital admission, hospital length of stay, prehospital and in-hospital complications, hospital outcomes; use of prehospital ultrasound; association of prehospital factors and volume of first 24-hours blood product administration and evaluation of the prevalence of use, appropriateness, haemodynamic, metabolic and effects on mortality of prehospital blood transfusions. INCLUSION CRITERIA: age >18 years, traumatic injury attended by a HEMS team including a physician, a systolic blood pressure <90 mm Hg or weak/absent radial pulse and a confirmed or clinically likely diagnosis of major haemorrhage. Prehospital and in-hospital variables will be collected to include key times, clinical findings, examinations and interventions. Patients will be followed-up until day 30 from admission. The Glasgow Outcome Scale Extended will be collected at 30 days from admission. ETHICS AND DISSEMINATION: The study has been approved by the Ethics committee 'Comitato Etico di Area Vasta Emilia Centro'. Data will be disseminated to the scientific community by abstracts submitted to international conferences and by original articles submitted to peer-reviewed journals. TRIAL REGISTRATION NUMBER: NCT04760977.

External validation and insights about the calibration of the return of spontaneous circulation after cardiac arrest (RACA) score.

Background: The return of spontaneous circulation (ROSC) after cardiac arrest (RACA) score was developed as a tool to predict ROSC probability (pROSC) based on easily available information and it could be useful to compare the performances of different EMS agencies or the effects of eventual interventions.We performed an external validation of the RACA score in a cohort of out of hospital cardiac arrest (OHCA) patients managed by the EMS of the metropolitan city of Bologna, Italy. Methods: We analyzed data from 2,310 OHCA events prospectively collected between January 2009 and June 2021. Discrimination was assessed with the area under the ROC curve (AUROC), while the calibration belts were used for the comparison of observed versus expected ROSC rates. The AUROCs from our cohort and other validation cohorts were compared using a studentized range test. Results: The AUROC for the study population was 0.691, comparable to that described by previous validation studies. Despite an acceptable overall calibration, we found a poor calibration for asystole and low pROSC ranges in PEA and shockable rhythms. The model showed a good calibration for patients aged over 80, while no differences in performance were found when evaluating events before and after the implementation of 2015 ERC guidelines. Conclusions: Despite AUROC values being similar in different validation studies for RACA score, we suggest separating the different rhythms when assessing ROSC probability with the RACA score, especially for asystole.

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in Non-Traumatic Cardiac Arrest: A Narrative Review of Known and Potential Physiological Effects.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is widely used in acute trauma care worldwide and has recently been proposed as an adjunct to standard treatments during cardiopulmonary resuscitation in patients with non-traumatic cardiac arrest (NTCA). Several case series have been published highlighting promising results, and further trials are starting. REBOA during CPR increases cerebral and coronary perfusion pressure by increasing the afterload of the left ventricle, thus improving the chances of ROSC and decreasing hypoperfusion to the brain. In addition, it may facilitate the termination of malignant arrhythmias by stimulating baroreceptor reflex. Aortic occlusion could mitigate the detrimental neurological effects of adrenaline, not only by increasing cerebral perfusion but also reducing the blood dilution of the drug, allowing the use of lower doses. Finally, the use of a catheter could allow more precise hemodynamic monitoring during CPR and a faster transition to ECPR. In conclusion, REBOA in NTCA is a feasible technique also in the prehospital setting, and its use deserves further studies, especially in terms of survival and good neurological outcome, particularly in resource-limited settings.

Logistic Red Flags in Mass-Casualty Incidents and Disasters: A Problem-Based Approach.

BACKGROUND: Mass-casualty incidents (MCIs) and disasters are characterized by a high heterogeneity of effects and may pose important logistic challenges that could hamper the emergency rescue operations.The main objective of this study was to establish the most frequent logistic challenges (red flags) observed in a series of Italian disasters with a problem-based approach and to verify if the 80-20 rule of the Pareto principle is respected. METHODS: A series of 138 major events from 1944 through 2020 with a Disaster Severity Score (DSS) ≥ four and five or more victims were analyzed for the presence of twelve pre-determined red flags.A Pareto graph was built considering the most frequently observed red flags, and eventual correlations between the number of red flags and the components of the DSS were investigated. RESULTS: Eight out of twelve red flags covered 80% of the events, therefore not respecting the 80-20 rule; the number of red flags showed a low positive correlation with most of the components of the DSS score. The Pareto analysis showed that potential hazards, casualty nest area > 2.5km2, number of victims over 50, evacuation noria over 20km, number of nests > five, need for extrication, complex access to victims, and complex nest development were the most frequently observed red flags. CONCLUSIONS: Logistic problems observed in MCIs and disaster scenarios do not follow the 80-20 Pareto rule; this demands for careful and early evaluation of different logistic red flags to appropriately tailor the rescue response.

[Is it time to implement Cardiac Arrest Centers in Italy? The integrated experience in the decade 2009-2019 between metropolitan area and Maggiore Hospital of Bologna]. / È il momento per implementare i Centri per l'Arresto Cardiaco in Italia? L'esperienza integrata nel decennio 2009-2019 tra area metropolitana ed Ospedale Maggiore di Bologna.

Cardiac arrest (CA) is the third cause of death in Europe. This paper highlights the various treatments for the prevention and early management of CA and provides an overview of available evidence on the CA center concept. The experience of Maggiore Hospital of Bologna, Italy over the last 11 years is also outlined along with the treatments applied to patients with CA and their impact on improving outcomes. The new concept of the "Systems Saving Lives" approach is presented as a potential way for implementing Italian healthcare systems involved in the management of CA patients. Finally, the future perspective of implementation of CA centers in Italy is also described encouraging the healthcare professionals involved in the treatment of CA patients to consider a multidisciplinary approach (including a cardiologist, emergency physician, neurologist, physiatrist, radiologist, and intensivist).

Clinical implications of microvascular CT scan signs in COVID-19 patients requiring invasive mechanical ventilation.

PURPOSE: COVID-19-related acute respiratory distress syndrome (ARDS) is characterized by the presence of signs of microvascular involvement at the CT scan, such as the vascular tree in bud (TIB) and the vascular enlargement pattern (VEP). Recent evidence suggests that TIB could be associated with an increased duration of invasive mechanical ventilation (IMV) and intensive care unit (ICU) stay. The primary objective of this study was to evaluate whether microvascular involvement signs could have a prognostic significance concerning liberation from IMV. MATERIAL AND METHODS: All the COVID-19 patients requiring IMV admitted to 16 Italian ICUs and having a lung CT scan recorded within 3 days from intubation were enrolled in this secondary analysis. Radiologic, clinical and biochemical data were collected. RESULTS: A total of 139 patients affected by COVID-19 related ARDS were enrolled. After grouping based on TIB or VEP detection, we found no differences in terms of duration of IMV and mortality. Extension of VEP and TIB was significantly correlated with ground-glass opacities (GGOs) and crazy paving pattern extension. A parenchymal extent over 50% of GGO and crazy paving pattern was more frequently observed among non-survivors, while a VEP and TIB extent involving 3 or more lobes was significantly more frequent in non-responders to prone positioning. CONCLUSIONS: The presence of early CT scan signs of microvascular involvement in COVID-19 patients does not appear to be associated with differences in duration of IMV and mortality. However, patients with a high extension of VEP and TIB may have a reduced oxygenation response to prone positioning. TRIAL REGISTRATION: NCT04411459.

Mass Gathering Emergency Medicine Organization for the Union of European Football Associations' Under-21 Championship 2019 in Bologna, Italy.

Football events represent a type of Mass Gathering Events (MGE) where crowd behavior, temperature and Heat Index, absence of free water, and alcohol consumption can lead to an increased need for medical assistance in participants. This report describes the environmental issues, organization, and healthcare assistance provided during the four matches of the Union of European Football Associations' (UEFA) Under-21 tournament held in Bologna in June, 2019. The four matches had a total of 72655 spectators; 31 patients required medical assistance with a mean Patient Presentation Rate (PPR) of 0.41; Mean Transport To Hospital Rate (TTHR) of 0.04; with PPR and TTHR comparable with literature findings. Majority of patients suffered from minor injuries and illnesses, and were treated directly in stadium medical sites. Medical assistance involved volunteer rescuers, emergency nurses, and physicians; resources were efficiently allocated and provided effective care to every patient.Climate factors, heat and humidity, the absence of free water, and increased alcohol consumption appear to be associated with increased requests for medical assistance. The retrospective analysis of a wider range of environmental factors, and the historical experience developed during similar MGEs suggest the need for a more comprehensive, improved approach for adequately assessing risk and planning the necessary healthcare resources.

The role of prehospital ultrasound in reducing time to definitive care in abdominal trauma patients with moderate to severe liver and spleen injuries.

BACKGROUND: The role of prehospital focused assessment sonography for trauma (FAST) is still under debate and no definitive recommendations are available in actual guidelines, moreover, the availability of ultrasound machines in emergency medical services (EMS) is still inhomogeneous. On the other hand, time to definitive care is strictly related to survival in bleeding trauma patients. This study aimed at investigating if a positive prehospital FAST in abdominal trauma patients could have a role in reducing door-to-CT scan or door-to-operating room (OR) time. METHODS: This retrospective observational study included all the patients affected by an abdominal trauma with an abdominal abbreviated injury score ≥ 2 and a spleen or liver injury admitted to Maggiore Hospital Carlo Alberto Pizzardi, a level 1 trauma centre between 2014 and 2019. Prehospital and emergency department (ED) clinical and laboratory variables were collected, as well as in-hospital times during the diagnostic and therapeutic pathways of these patients. RESULTS: 199 patients were included in the final analysis. Of these, 44 had a prehospital FAST performed and in 27 of them, peritoneal free fluid was detected in the prehospital setting, while 128 out of 199 patients had a positive ED-FAST. Sensitivity was 62.9% (95% CI: 42.4%-80.6%) and specificity 100% (95% CI: 80.5% - 100%). Patients with a positive prehospital FAST reported a significantly lower door-to-CT or door-to-OR median time (46 vs 69 min, p < 0.001). Prehospital hypotension and Glasgow coma scale, first arterial blood lactate, ISS, age, positive prehospital and ED FAST were inserted in a stepwise selection for a multivariable Cox proportional regression hazards model. Only ISS and prehospital FAST resulted significantly associated with a reduction in the door-to-CT scan or door-to-operating theatre time in the multivariable model. CONCLUSION: Prehospital FAST information of intraperitoneal free fluid could significantly hasten door-to-CT scan or door-to-operating theatre time in abdominal trauma patients if established hospital response protocols are available. LEVEL OF EVIDENCE: III, (Therapeutic / Care Management).