Multiprofessional perinatal care in a pregnant patient with acute respiratory distress syndrome due to COVID-19.

BACKGROUND: The coronavirus disease (COVID-19) pandemic has caused ongoing challenges in health services worldwide. Despite the growing body of literature on COVID-19, reports on perinatal care in COVID-19 cases are limited. CASE PRESENTATION: We describe a case of severe acute respiratory distress syndrome (ARDS) in a 36-year-old G5/P2 pregnant woman with morbid obesity, confirmed severe acute respiratory syndrome coronavirus 2 infection, and fulminant respiratory failure. At 28+ 1 gestational weeks, the patient delivered an uninfected newborn. Using ImmunoCAP ISAC® technology, we found no immunoglobulin (Ig) M antibodies, suggesting that no mother-to-child viral transmission occurred during pregnancy or delivery. The maternal respiratory state improved rapidly after delivery; both maternal and neonatal outcomes were encouraging given the early gestational age and fulminant course of respiratory failure in our patient. CONCLUSIONS: The management of ARDS in pregnant women with COVID-19 is complex and requires an individualized, multidisciplinary approach, while considering maternal and fetal outcomes.

Impact of a virtual reality-based simulation training for shoulder dystocia on human and technical skills among caregivers: a randomized-controlled trial.

This study analyzed the adherence to the modified Advanced Life Support in Obstetrics (ALSO) algorithm (HELP-RER) for handling shoulder dystocia (SD) using a virtual reality (VR) training modality. Secondary outcomes were improvements in the post-training diagnosis-to-delivery time, human skills factors (HuFSHI), and perceived task-load index (TLX). Prospective, case-control, single-blind, 1:1 randomized crossover study. Participants were shown a 360° VR video of SD management. The control group was briefed theoretically. Both groups underwent HuFSHI and HELP-RER score assessments at baseline and after the manikin-based training. The TLX questionnaire was then administered. After a washout phase of 12 weeks, we performed a crossover, and groups were switched. There were similar outcomes between groups during the first training session. However, after crossover, the control group yielded significantly higher HELP-RER scores [7 vs. 6.5; (p = 0.01)], with lower diagnosis-to-delivery-time [85.5 vs. 99 s; (p = 0.02)], and TLX scores [57 vs. 68; (p = 0.04)]. In the multivariable linear regression analysis, VR training was independently associated with improved HELP-RER scores (p = 0.003). The HuFSHI scores were comparable between groups. Our data demonstrated the feasibility of a VR simulation training of SD management for caregivers. Considering the drawbacks of common high-fidelity trainings, VR-based simulations offer new perspectives.

ST-T segment changes in prehospital emergency physicians in the field: a prospective observational trial.

AIMS: Due to time-critical decision-making, physical strain and the uncontrolled environment, prehospital emergency management is frequently associated with high levels of stress in medical personnel. Stress has been known to cause ischemia like changes in electrocardiograms (ECGs), including arrhythmias and deviations in ST-T segments. There is a lack of knowledge regarding the occurrence of changes in ST-T segments in prehospital emergency physicians. We hypothesized that ST-T segment deviations occur in prehospital emergency physicians in the field. METHODS: In this prospective observational trial, ST-T segments of emergency physicians were recorded using 12-lead Holter ECGs. The primary outcome parameter was defined as the incidence of ST-T segment changes greater than 0.1 mV in two corresponding leads for more than 30 s per 100 rescue missions. The secondary outcomes included T-wave inversions and ST-segment changes shorter than 30 s or smaller than 0.1 mV. Surrogate parameters of stress were measured using the NASA-Task Load Index and cognitive appraisal, and their correlation with ST-T segment changes were also assessed. RESULTS: Data from 20 physicians in 36 shifts (18 days, 18 nights) including 208 missions were analysed. Seventy percent of previously healthy emergency physicians had at least one ECG abnormality; the mean duration of these changes was 30 s. Significantly more missions with ECG changes were found during night than day shifts (39 vs. 17%, p < 0.001). Forty-nine ECG changes occurred between missions. No ST-T segment changes > 30 s and > 0.1 mV were found. Two ST-T segment changes < 30 s or < 0.1 mV (each during missions) and 122 episodes of T-wave inversions (74 during missions) were identified. ECG changes were found to be associated with alarms when asleep and NASA task load index. CONCLUSION: ECG changes are frequent and occur in most healthy prehospital emergency physicians. Even when occurring for less than 30 s, such changes are important signs for high levels of stress. The long-term impact of these changes needs further investigation. Trial registration The trial was registered at ClinicalTrials.gov (NCT04003883) on 1.7.2019:  https://clinicaltrials.gov/ct2/show/NCT04003883?term=emergency+physician&rank=2.

Biomarkers for differentiation of coronavirus disease 2019 or extracorporeal membrane oxygenation related inflammation and bacterial/fungal infections in critically ill patients: A prospective observational study.

Secondary infections in coronavirus disease 2019 (COVID-19) patients are difficult to distinguish from inflammation associated with COVID-19 and/or extracorporeal membrane oxygenation (ECMO). Therefore, highly specific and sensitive biomarkers are needed to identify patients in whom antimicrobial therapy can be safely withheld. In this prospective monocentric study, 66 COVID-19 patients admitted to the intensive care unit (ICU) for ECMO evaluation were included. A total of 46 (70%) patients with secondary infections were identified by using broad microbiological and virological panels and standardized diagnostic criteria. Various laboratory parameters including C-reactive protein (CRP), interleukin (IL)-6, procalcitonin (PCT), and IL-10 were determined at time of study inclusion. The best test performance for differentiating bacterial/fungal secondary infections and COVID-19 and/or ECMO associated inflammation was achieved by IL-10 (ROC-AUC 0.84) and a multivariant step-wise regression model including CRP, IL-6, PCT, and IL-10 (ROC-AUC 0.93). Data obtained in the present study highlights the use of IL-10 to differentiate secondary bacterial/fungal infections from COVID-19 and/or ECMO associated inflammation in severely ill COVID-19 patients.

Cardiopulmonary resuscitation and the 2005 universal algorithm: has the quality of CPR improved?

BACKGROUND AND AIM: Chest compressions are crucial in cardiopulmonary resuscitation (CPR), although the optimal number, rate and sequence are unknown. The 2005 CPR guidelines of the European Resuscitation Council (ERC) brought major changes to the basic life support algorithm. One of the major aims of the ERC was to decrease hands-off time in order to improve perfusion of the coronary vessels and the brain. Using a manikin model of basic life support in simulated cardiac arrest, we compared hands-off time and total number of chest compressions according to the guidelines of 2000 and those of 2005. METHODS: A total of 50 volunteers performed CPR according to the guidelines of 2000 (Group 2000) and 2005 (Group 2005) in a randomized unblinded cross-over study. Volunteers received 10 min of standardized teaching and 10 min of training, including corrective feedback, for each set of guidelines before performing 5 min of basic life support on a manikin. We compared hands-off time as the primary outcome parameter and the total number of chest compressions as the secondary outcome parameter. RESULTS: Fifty volunteers were enrolled in the study, one individual dropped out after randomization. In Group 2005, hands-off time was significantly lower (mean 107 +/- 19 [SD] s vs. 139 +/- 15 s in Group 2000 (P < 0.0001) and the total number of chest compressions was significantly higher (347 +/- 64 compressions vs. 233 +/- 51 compressions; P < 0.0001). CONCLUSION: In this manikin setting, both hands-off time and the total number of chest compressions improved with basic life support performed according to the ERC guidelines of 2005.

Results from Austria's nationwide public access defibrillation (ANPAD) programme collected over 2 years.

AIM OF THE STUDY: To analyse 2 years of experience after introducing automated external defibrillators (AED) all over Austria. MATERIALS AND METHODS: This observational study evaluated the number of privately purchased devices and the rate of local bystander-triggered AED deployments from November 2002 to December 2004. As outcome measurements, the hospital discharge rate and neurological condition were recorded. Arrival times of the emergency medical service (EMS) on scene and the time intervals until shock decisions were made were calculated. Shock decisions were verified according to ECG downloads. Results were compared with historical data if applicable. RESULTS: During the study period, 1865 devices were installed. Seventy-three AED deployments were recorded. Eleven cases were excluded from the study because bystanders were part of the local EMS. Seventeen out of the remaining 62 (27%) compared to a historical 27 out of 623 (4.3%) individuals were discharged alive from hospital. Fourteen out of 26 (54%) patients who were found with a shockable rhythm survived to hospital discharge. Fifteen of our patients survived in good neurological condition (CPC I and II), two suffered from severe neurological deficit (CPC III and IV) and 45 people died. The median "call-to-AED advice interval" was 3.5 min (IQR 2-6 min; N=24). In two cases, the AED made inappropriate decisions because of artefacts. CONCLUSIONS: Compared to historical data, short 'intervals to shock' delivery and the frequent start of basic life support resulted in an increased hospital discharge rate in good neurological condition. Despite the relatively high number of installed devices, the number of patients reached remained small.

Anaesthesia for brachytherapy.

PURPOSE OF REVIEW: The demand for anaesthesia in brachytherapy is increasing. Patients often present with high-risk factors and multiple comorbidities. To achieve a stable position of the implants, immobility is often mandatory. Duration of brachytherapy varies greatly and may exceed the duration of single-shot regional anaesthesia. Transportation of anaesthetized patients is a typical challenge. This review gives information about anaesthesia techniques in brachytherapy on the basis of the literature and the authors' experiences. RECENT FINDINGS: The choice of anaesthesia technique depends on the body region, the type of brachytherapy and the local infrastructure. Topical or local anaesthesia is used by radiotherapists. For brachytherapy of the lower body, regional anaesthesia provides effective and safe conditions. Catheter techniques are used for longer procedures and for high-risk patients, allowing excellent ongoing epidural patient-controlled analgesia. General anaesthesia is safely utilized for brachytherapy of the upper body or as an alternative to regional techniques. However, the effort under the typical conditions of the brachytherapy setting may be higher. Sedation is regarded as an alternative to general anaesthesia in less painful and short procedures. SUMMARY: In conclusion, anaesthesiologists play a key role in the ongoing challenge to provide safe and pain-free conditions for an optimum brachytherapy treatment effect.

Reaching the public via a multi media campaign as a first step to nationwide public access defibrillation.

Public access defibrillation (PAD) is a promising strategy to fight sudden cardiac death. The Austrian Red Cross provided automated external defibrillators (AEDs) and basic life support (BLS) training as an "all inclusive package" combined with on site consultation and maintenance with annual retraining as a part of a nationwide PAD programme. A multi media campaign was started to promote the package and to increase awareness about sudden cardiac death. Data about the campaign, its recognition by the public in Austria and the number of packages were recorded. Sixty-eight percent of the Austrian public above the age of 15 years were able to recall the multi media campaign. Comparing the periods before and after the campaign, the number of website hits climbed significantly from 2,931 hits/month (1,866-6,168) to 4,812 hits/month (3,432-13,434) (p=0.0276). The number of AED services implemented before the campaign increased significantly (p=0.0026) in the time after the campaign. Therefore, we conclude that a multi media campaign is useful to stimulate public discussion and it encourages companies to buy "all inclusive packages" containing AEDs, BLS training, on site consultation and maintenance. These measures represent a possible first step in introducing PAD but it seems that they have to be continued on a constant basis.

Automated external defibrillators do not recommend false positive shocks under the influence of electromagnetic fields present at public locations.

Electromagnetic fields (EMF) reduce the signal quality of electrocardiograms and may lead to the misinterpretation by automated external defibrillators (AED). We designed this investigation as a prospective study, with a randomized sequence of AED applications on healthy volunteers. We chose busy public places where public access defibrillation was possible as test locations. Strong EMF were sought and found at train stations next to accelerating and decelerating trains. The primary outcome variable was the absolute number of shocks advised in the presence of sinus rhythm by five commonly used AED in Austria. For data analysis, the statistician was blinded in regard to the AED models tested. Data analysis was based on a per protocol evaluation. Of 390 tests run, 0 cases of false positive results occurred (95% CI: 0-0.77). AED can be regarded as safe, even with the interference of EMF present at train stations.

Hands-off time during insertion of six airway devices during cardiopulmonary resuscitation: a randomised manikin trial.

INTRODUCTION: Cardiopulmonary resuscitation (CPR) guidelines recommend limiting interruptions of chest compressions because prolonged hands-off (i.e., non-compression) time compromises tissue perfusion. 2010 European Resuscitation Council guidelines suggest that chest compressions should be paused less than 10 s during airway device insertion. METHODS: With approval of the local ethics committee of the Medical University of Vienna and written informed consent, we recruited 40 voluntary emergency medical technicians, none of whom had advanced airway management experience. After a standardised audio-visual lecture and practical demonstration, technicians performed airway management with each six airway devices (endotracheal tube, Combitube, EasyTube, laryngeal tube, Laryngeal Mask Airway, and I-Gel) during on-going chest compressions in a randomised sequence on a Resusci Anne Advanced Simulator. Data were analysed using a mixed-effects model accounting for the repeated measurements and pair-wise comparisons among the airway devices. RESULTS: The hands-off time associated with airway management using an endotracheal tube (including all intubation attempts) was 48 s (95% confidence interval: 43-53). The hands-off time for airway management using a laryngeal tube was 8.4 (3.4-16.4) s, Combitube 10.0 (4.9-15.1) s, EasyTube 11.4 (6.4-16.4) s, LMA 13.3 (8.2-18.3) s and for I-Gel 15.9 (10.8-20.9) s. Hands-off time was significantly longer with the conventional endotracheal tube than with any of the other airway systems. Only a third of the technicians successfully inserted an endotracheal tube whereas all of them successfully positioned each supraglottic device. CONCLUSION: Supraglottic devices appear to be a reasonable emergency airway management strategy, even for inexperienced personnel.

Performance and skill retention of intubation by paramedics using seven different airway devices--a manikin study.

INTRODUCTION: Endotracheal intubation (ETI) is the most widespread method for emergency airway management. Several studies reported that ETI requires considerable skill and experience and if performed incorrectly, may result in serious adverse events. Unrecognized tube misplacement or oesophageal intubation is associated with high prehospital morbidity. This study investigates the usability of supraglottic airway devices compared to ETI and the skill retention of 41 previously inexperienced paramedics following training using a manikin model. METHODS: 41 paramedics participated in this study. None had prior experience in airway management, apart from bag-valve ventilation. After a standardised audio-visual lecture lasting 45min, the paramedics participated in a practical demonstration using the advanced patient simulator SimMan(®) (Laerdal Medical, Stavanger, Norway). Afterwards, paramedics were instructed to perform airway-management using seven different techniques to secure the airway (ETI, Laryngeal mask unique [LMA], Proseal, Laryngeal tube disposable [LT-D(®)], I-Gel(®), Combitube(®), and EasyTube(®)) following a randomized sequence. Participants underwent reassessment after 3 months without any further training or practice in airway-management. RESULTS: During the initial training session, ETI was successfully performed in 78% of cases, while 3 months later the success rate was 58%. For the supraglottic airway devices, five out of six were successfully used by all paramedics at both time points, the exception being Proseal(®). Our data show successful skill retention (success rate: 100%) after 3 months for five out of six supraglottic airway devices. Time to ventilation (T3) was significantly less for LMA, LT-D(®) and I-Gel(®) at all time points compared to ETI. CONCLUSION: ETI performed by inexperienced paramedics is associated with a low success rate. In contrast, supraglottic airway devices like LMA, LT-D(®), I-Gel(®), Combitube(®) and EasyTube(®) are fast, safe and easy-to-use. Within the limitations of a manikin-study, this study suggests that inexperienced medical staff might benefit from using supraglottic airway devices for emergency airway management.

Influence of electromagnetic fields on function of automated external defibrillators.

OBJECTIVES: In this study, the authors tested whether electromagnetic interference (EMI) is able to impair correct electrocardiogram analysis and produce false-positive shock advice from automated external defibrillators (AEDs) when the true rhythm is sinus. METHODS: Nineteen healthy subjects were used to test five AEDs available on the Austrian market in a prospective, open, and sequence-randomized study. The primary outcome variable was the absolute number of shocks advised in the presence of EMI. The secondary outcome was the number of impaired analyses caused by incorrectly detected patient movements or electrode failure. RESULTS: Of 760 tests run, 18 (2.37%) cases of false-positive results occurred, and two of five AEDs recommended shocks in the presence of sinus rhythm. Of 760 tests run, no electrode failures occurred. There were 27 occurrences (3.55%) of motion detected by an AED in the presence of strong electromagnetic fields. CONCLUSIONS: AED models differ in their response to EMI; it may be useful to consider specific safety requirements for areas with such fields present. Working personnel and emergency medical services staff should be informed about potential risks and the possible need for patient evacuation before AEDs are attached and shock recommendations are followed.