Development and usability testing of a fully immersive VR simulation for REBOA training.

BACKGROUND: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a potentially life-saving procedure for bleeding trauma patients. Being a rare and complex procedure performed in extreme situations, repetitive training of REBOA teams is critical. Evidence-based guidelines on how to train REBOA are missing, although simulation-based training has been shown to be effective but can be costly and complex. We aimed to determine the feasibility and acceptance of REBOA training using a fully immersive virtual reality (VR) REBOA simulation, as well as assess the confidence in conducting the REBOA procedure before and after the training. METHODS: Prospective feasibility pilot study of prehospital emergency physicians and paramedics in Bern, Switzerland, from November 2020 until March 2021. Baseline characteristics of trainees, prior training and experience in REBOA and with VR, variables of media use (usability: system usability scale, immersion/presence: Slater-Usoh-Steed, workload: NASA-TLX, user satisfaction: USEQ) as well as confidence prior and after VR training were accessed. RESULTS: REBOA training in VR was found to be feasible without relevant VR-specific side-effects. Usability (SUS median 77.5, IQR 71.3-85) and sense of presence and immersion (Slater-Usoh-Steed median 4.8, IQR 3.8-5.5) were good, the workload without under-nor overstraining (NASA-TLX median 39, IQR 32.8-50.2) and user satisfaction high (USEQ median 26, IQR 23-29). Confidence of trainees in conducting REBOA increased significantly after training (p < 0.001). CONCLUSIONS: Procedural training of the REBOA procedure in immersive virtual reality is possible with a good acceptance and high usability. REBOA VR training can be an important part of a training curriculum, with the virtual reality-specific advantages of a time- and instructor-independent learning.

Virtual Reality for Pain Relief in the Emergency Room (VIPER) - a prospective, interventional feasibility study.

BACKGROUND: Pain is one of the most common, yet challenging problems leading to emergency department (ED) presentation, despite the availability of a wide range of pharmacological therapies. Virtual reality (VR) simulations are well studied in a wide variety of clinical settings, including acute and chronic pain management, as well as anxiety disorders. However, studies in the busy environment of an adult ED are scarce. The aim of this study is to explore the feasibility and effectiveness of a VR simulation for pain and anxiety control in a convenience sample of adult ED patients presenting with traumatic and non-traumatic pain triaged 2-5 (i.e., urgent to non-urgent) with a pain rating of ≥ 3 on a numeric rating scale (NRS 0-10). METHODS: Prospective within-subject, repeated measures interventional feasibility pilot study at a Swiss University ED. The intervention consisted of a virtual reality simulation in addition to usual care. Pain and anxiety levels were measured using a verbally administered numeric rating scale (NRS) before and after the intervention. Information on patient experience was collected using established rating scales. RESULTS: Fifty-two patients were enrolled. The most common pain localisations were extremities (n = 15, 28.8%) and abdomen (n = 12, 23.1%). About one third of patients presented with trauma-associated pain (n = 16, 30.8%). Duration of pain was mainly acute (< 24 h) (n = 16, 30.8%) or subacute (> 24 h) (n = 32, 61.5%). The majority of patients were triage category 3, i.e. semi-urgent (n = 48, 92.3%). Significant reduction in pain (NRS median pre-VR simulation 4.5 (IQR 3-7) vs. median post-VR simulation 3 (IQR 2-5), p < 0.001), and anxiety levels (NRS median pre-VR simulation 4 (IQR 2-5) vs. median post-VR simulation 2 (IQR 0-3), p < 0.001) was achieved, yielding moderate to large effect sizes (Cohen's d estimate for pain reduction = 0.59 (95% CI 0.19-0.98), for anxiety level on NRS = 0.75 (95% CI 0.34-1.15). With medium immersion and good tolerability of the VR simulation, user satisfaction was high. CONCLUSIONS: Virtual reality analgesia for pain and anxiety reduction in the busy setting of an ED is feasible, effective, with high user satisfaction. Further randomized controlled studies are needed to better characterize its impact on pain perception and resource utilization.

[Dizziness and vertigo in a tertiary ENT emergency department]. / Schwindelerkrankungen in einem tertiären HNO-Notfallzentrum.

BACKGROUND: Although vestibular symptoms are amongst the most frequent reasons for seeking emergency medical help, many patients remain undiagnosed. OBJECTIVE: In this cross-sectional study, we investigated the spectrum of vertigo and dizziness in a tertiary ear, nose, and throat (ENT) emergency department (ED). Furthermore, we investigated the attendant symptoms, clinical signs, and the diagnostic tests performed. METHODS: We screened all ED reports from 01/2013 to 12/2013 for adult patients with vestibular symptoms referred to the ENT department. RESULTS: In total, we found 2596 cases with reported vestibular symptoms in the ED as a main or accompanying complaint. Of these, 286 were referred to the ENT specialist directly (n = 98) or via other major medical specialties (n = 188). Benign paroxysmal positional vertigo (BPPV) was the most frequent diagnosis in our study (n = 46, 16.1%), followed by vestibular neuritis (n = 44, 15.4%), otitis media (n = 20, 7%), and 9 patients (3.1%) had an ischemic stroke or a transient ischemic attack. In 70 (24.5%) cases, dizziness was not further specified. CONCLUSION: BPPV is the most frequent diagnosis seen in the ED; however, physicians need to document nystagmus more precisely and perform diagnostic tests systematically, in order to make an accurate diagnosis. To avoid misdiagnoses, ED physicians and ENT specialists should be able to recognize central signs in patients with an acute vestibular syndrome. Every fourth patient does not receive a definitive diagnosis. Diagnostic ED workup for patients with dizziness needs further improvement.

Epistaxis in anticoagulated patients: Fewer hospital admissions and shorter hospital stays on rivaroxaban compared to phenprocoumon.

OBJECTIVES: Treatment of epistaxis in patients on anticoagulants is challenging and associated with higher admission rates and longer hospital stays compared with patients without anticoagulation. However, there is little information about epistaxis in patients taking new direct oral anticoagulants such as rivaroxaban compared with patients on traditional vitamin K antagonists such as phenprocoumon. DESIGN: Retrospective cohort study. SETTING: The study was conducted at the emergency department of the University Hospital Inselspital, Bern, Switzerland. PARTICIPANTS: All admissions to the emergency department of the University Hospital Inselspital, Bern, Switzerland from 1st July 2012 to 30th June 2016 with non-traumatic epistaxis on anticoagulant therapy with phenprocoumon or rivaroxaban were included. MAIN OUTCOME MEASURES: We compared clinical outcome parameters (admission rates, length of hospital stay and mortality) for both anticoagulant groups. RESULTS: We included 440 patients with epistaxis, 123 (28%) on rivaroxaban and 317 (72%) on phenprocoumon. Fewer hospital admissions and shorter hospital stays were found in patients under rivaroxaban (12 (10.4%) vs 57 (18.0%) patients, P=.033; 0.7±2.2 vs 1.5±3.7 days, P=.011) compared with phenprocoumon. Anterior epistaxis was more common in the rivaroxaban group in contrast to posterior epistaxis in patients on phenprocoumon (74 (60.2%) vs 139 (43.8%) patients, P=.002; 7 (5.7%) vs 39 (12.3%) patients, P=.042). CONCLUSIONS: Our data suggests that epistaxis on direct oral anticoagulation with rivaroxaban is associated with shorter hospital stays and fewer hospital admissions than epistaxis on vitamin K antagonist phenprocoumon.