Signa Vitae

Journal for Intensive Care and Emergency Medicine

Can tablets be used as a simulator for automated external defibrillation during cardiopulmonary resuscitation courses?


Background. A novel, tablet-based automated external defibrillator (AED) simulator has been developed to facilitate AED training.

Objective. To evaluate if the tablet AED simulator (an AED simulator based on mobile technology (M-AED)) can be successfully used during cardiopulmonary resuscitation (CPR) courses. To test medical and dental students’ CPR attitudes, knowledge and skills, and evaluate the impact of a one day CPR course.

Methods. One hundred and twenty-four medical and dental students of University of Zagreb participated in a basic life support and automated external defibrillator (BLS/AED) course. All students filled out demographic, CPR attitudes and knowledge questionnaires before and after the course. Half of the students practised AED skills during the course on a conventional AED trainer (C-AED), and half on M-AED. All underwent assessment of CPR skills after the course with C-AED. Those that used M-AED during training, rated its use.

Results. All students successfully completed the assessment of skills after the course, with no significant difference in the number of those who had to be retested between C-AED and M-AED. A significant improvement in CPR attitudes and knowledge was noted after the course among all students, with no difference between C-AED and M-AED groups. M-AED as an AED trainer was highly rated.

Conclusions. Tablet based AED simulators can be effectively utilized during BLS/AED courses as a substitute for conventional AED trainers.

Key words: defibrillators, computer simulation, mobile applications, cardiopulmonary resuscitation, European Resuscitation Council Guidelines

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Comparison of sevoflurane and propofol anaesthetic regimes in respect to the release of troponin I and cystatin C in off-pump myocardial revascularisation: a randomised controlled trial


Objective. Sevoflurane has been used in cardiac surgery because of its protective effects on the myocardium from ischaemic injury. We wanted to test the hypothesis that sevoflurane has beneficial effects on the heart and kidneys in comparison to propofol.

Methods. We conducted a randomised controlled study, with balanced randomization blocked by sex. The participants were 62 patients undergoing off-pump myocardial revascularization (44 men and 18 women), who did not have a myocardial infarction less than 24 hours before the start of the operation and who had normal serum values of troponin I preoperatively. The surgery and the measurements were conducted according to the same protocol for both groups. Propofol was used for the induction of anaesthesia in both groups; anaesthesia was continued with either propofol or sevoflurane. Troponin I and cystatin C plasma concentrations were determined in eight consecutive blood samples, starting before induction of anaesthesia and ending 48 hours after admission to the intensive care unit (ICU). The data were log-transformed and analysed using analysis of variance.

Results. We observed a clear and highly statistically significant effect of time for troponin I (p<0.001) without statistically significant differences between the groups (either main or interaction effects). For the majority of patients, the measurements rose quickly upon reperfusion and reached a peak 12 hours after admission to the ICU, descending approximately back to the reperfusion level 48 hours after admission to the ICU. Similar inferences were reached for cystatin C, for which the time-course was approximately bath-shaped.

Conclusion. We observed no clear superiority of either sevoflurane or propofol anaesthetic regime in off-pump myocardial revascularisation.

Key words: anaesthetic regime, cardioprotection, kidney function, heart surgery

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The effect of posture modification during continuous one-handed chest compression: A pilot study using in-hospital pediatric cardiac arrest simulation


Background. We modified the posture of the one-handed chest compression (MOHCC) as follows: first, the axis of the rescuer’s compression hand was adjusted to the lower half of the patient’s sternum; second, the opposite hand was wrapped around the elbow joint of the rescuer’s compression arm. This study evaluated the effect of the MOHCC on the mean chest compression depth (MCD) over time.

Methods. Thirty medical doctors conducted 2 min of continuous MOHCC without ventilation using the in-hospital pediatric arrest model (70-cm-high bed, 25-cm-high stepstool, a pediatric manikin and a cardiopulmonary resuscitation (CPR) meter). The MCD and mean chest compression rate (MCR) were measured at 30 s intervals using the Q-CPR review software.

Results. The MCD changed significantly over time (0–30 s, 41.9–44.7 mm; 30–60 s, 40.4–43.6 mm; 60–90 s, 39.2–42.8 mm; 90–120 s, 38.6–42.3 mm; [95% CI], P=0.002). However, it did not decrease significantly between 60–90 s and 90–120 s (P=0.173). The total decrease in MCD was 2.9 mm over a 2 min period. The MCR did not change significantly over time (0–30 s, 108.6–118.9 /min; 30–60 s, 107.9–119.1 /min; 60–90 s, 107.7–119.3 /min; 90–120 s, 107.4–119.0 /min; P=0.800).

Conclusions. Although the MCD changed significantly over a 2 min period, it did not decrease significantly after 90 s during performance of MOHCC. The MOHCC might be considered when the one-handed chest compression (OHCC) is selected as a chest compression method for cardiac arrest in small children.

Key words: cardiopulmonary resuscitation, cardiac arrest, child, fatigue

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Effects of bed height on the performance of endotracheal intubation and bag mask ventilation


Objectives. This study was performed to evaluate whether different bed heights affect the performance of airway procedures.

Methods. Thirty three medical doctors performed endotracheal intubation (EI) and bag mask ventilation (BMV) using three different bed heights; knee height, mid-thigh height, and anterior superior iliac spine (ASIS) height. For EI, performance was assessed based on intubation time, intubation success, and damage to teeth. For BMV, performance was assessed based on tidal volume, ventilation rate, peak pressure, minute ventilation, and airway opening. In addition, three numeric rating scales (NRS; 1 to 10) were used to assess the level of difficulty for each procedure and the doctors’ self-confidence. NRS scoring was based on posture (comfortable to uncomfortable), handling (easy to hard), and visual field (good to bad).

Results. No significant differences in performance were observed for EI or BMV at the three different bed heights. However, all of the NRS scores were significantly different among the different bed heights (P<0.001), and were poorest for the knee height beds: knee height (EI: posture 5.8~7.3, handling 4.3~5.7, visual field 3.9~5.5; BMV: posture 7.1~8.0, handling 5.9~7.2, 95% CI), mid-thigh height (EI: posture 2.9~4.0, handling 2.9~4.0, visual field 2.7~3.8; BMV: posture 2.4~3.2, handling 2.3~3.5) and ASIS height (EI: posture 2.2~3.5, handling 2.6~3.8, visual field 2.1~3.4; BMV: posture 2.9~4.4, handling 4.7~6.1).

Conclusions. Although the participants reported that the knee height beds were the least comfortable, hardest to handle, and made seeing the vocal cord difficult, these caveats did not affect their performance during airway procedures.

Key words: endotracheal intubation, positive pressure ventilation, bed, cardiopulmonary resuscitation

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Improving Emergency Department Capacity Efficiency


Objective. The demand for emergency services has risen dramatically around the world. Many Emergency Departments (EDs) have signs of low capacity efficiency (which we define as the rate at which a production facility with limited resources can convert input into output); insufficient resources (staffing, equipment, facilities), inefficient ways to use them, or both. Our purpose was to investigate how to improve ED capacity efficiency through layout planning and present some novel ideas of ED bottlenecks.

Methods. We adopted an industrial engineering perspective to one Finnish ED as a case example. In contrary to a simple case report we used more generalizable methods and demand-supply chain analysis to improve capacity efficiency.

Results. This study resulted in concrete and generalizable improvements of capacity efficiency concerning both ED premises and staffing. The former includes designing patient locations, organizing beds, improving space usage and optimizing an ED layout. The latter identified the demand for different specialties and optimal allocation of nursing staff.

Conclusion. We present a rather unique combination of ways to enhance ED functionality by using methods of industrial engineering.

Key words: capacity efficiency, emergency department, operations management, healthcare

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