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Signa Vitae

Journal of Intensive Care and Emergency Medicine

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Football referees as first responders in cardiac arrest. Assessment of a Basic Life Support training program.


Aim. To assess football referees´ cardiopulmonary resuscitation (CPR) skills and automated external defibrillator (AED) use in a simulated sport incident scenario, after a brief training program.

Material and Methods. Quasi-experimental study with 35 amateur league football referees. A test – retest of related samples was carried out after the training program. Theoretical and hands-on session lasted 30 minutes, with 1/10 instructor/participant ratio. CPR skills were measured using Wireless Skill Report software and AED use by means of a specific check list.

Results. A third of sample knew what an AED is but only 8% knew how to use it. After training, all participants achieved 70% or higher CPR quality scores and were able to use AED properly (54.2% without any incidence). Mean time to discharge was shorter for participants who accomplished the quality goal (p=0.022).

Conclusions. After a very brief and simple training program, football referees were able to perform a potentially effective CPR and use an AED correctly in a simulated scenario. Basic life support training should be implemented in football referees´ formative curriculum.

Key words: automated external defibrillator, referees, cardiac arrest, cardiopulmonary resuscitation, basic life support, training, sport, football

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Outcomes of very low birth weight infants born by vaginal delivery versus cesarean section


The optimal mode of delivery for very low birth weight (VLBW) infants remains controversial. Despite lacking evidence of benefits regarding neonatal outcomes, cesarean section delivery is becoming more prevalent, particularly in early gestational ages. In our retrospective, multicentr study data were collected for very low birth weight infants born in two Croatian perinatal regions in a 3 – year period (2014. – 2016.). The final cohort consisted of 255 very low birth weight infants. The rate of delivery via cesarean section was 74.1% (189/255) and is one of the highest reported in the literature so far. Infants born vaginally were born at an lower gestational age, had lower 1- and 5-minute Apgar scores, lower birth weights, and prognosis as expressed by higher Clinical risk index for babies (CRIB) scores and were more often born following chorioamnionitis and had higher mortality rate until 7 days of hospitalization. Univariate logistic regression analysis showed that cesarean section reduced the risk of death before 7 days of life (OR 0.34 95% CI 0.182-0.667). This significance was lost after multivariate analysis. In infants surviving after 7 days of hospitalization, rates of short-term neonatal morbidity (severe intracranial hemorrhage, cystic periventricular leukomalacia (cPVL), late-onset sepsis, necrotizing enterocolitis, kidney injury and retinopathy of prematurity requiring interventions) were not significant when comparing infants born vaginally and those born following cesarean section.

Key words: cesarean section, very low birth weight infants, vaginal delivery

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Prenatal echocardiography – the impact on neonatal management


Congenital heart disease (CHD) results in neonatal morbidity and mortality. Prenatal diagnosis allows preparing an appropriate perinatal and postnatal care. Babies born in low-risk level sites with unexpected CHD may have poorer outcomes. The purpose of this study was to compare results of foetal echocardiography to postnatal findings and assess the impact of antenatal suspicions of CHD on postnatal management. Medical records of mother-infant pairs with CHD admitted to the Neonatal Intensive Care Unit (NICU) of the Medical University of Gdansk from 01.01. to 31.12.2013 were reviewed. We analysed if the defect was detected pre- or postnatally, and if the diagnosis was made by the obstetrician from low-risk level sites (level I) or from a tertiary care centre (level II sonography). The overall incidence of CHD was 68 (3,4%). Critical congenital heart defects (CCHD) were found in 24 neonates (1,2%), 21 were diagnosed prenatally, 3 were transferred from 1st level units.

Correlation between prenatal diagnosis made at our centre and postnatal findings was achieved in 47,7%. Accuracy in all prenatal and postnatal findings for both I and II sonography levels was 35,2%. There were major differences in the disproportion of the great vessels and postnatal confirmation of coarctation of the aorta (CoAo) (7,1%). We obtained a high accuracy of prenatal and postnatal findings in detection of lesions such as Tetralogy of Fallot (ToF), transposition of the great arteries (TGA), DORV (double outlet right ventricle) and Critical Pulmonary Stenosis, which require an outflow tract view (92,9% of cases). Conclusions: We confirmed increasing diagnostic rates when the diagnostics is performed at a tertiary care centre. These results are in agreement with literature stating that prenatal detection of CoAo is still challenging.

Despite the high rates of misdiagnosis, majority of infants benefited from prenatally diagnosed CCHD.

Key words: critical congenital heart disease, foetal, neonatal echocardiography, prenatal diagnosis.

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I-gel as a first-line airway device in the emergency room for patients with out-of-hospital cardiac arrest


Aim. The optimal method for advanced airway management during cardiac arrest remains controversial. Most patients with out-of-hospital cardiac arrest (OHCA) in Korea are managed with a bag-valve mask by paramedics, while physicians perform advanced airway management in emergency departments (ED). Endotracheal intubation (ETI) has a risk of failure at the first attempt. By contrast, I-gel, a supraglottic airway device, is easier to insert than an endotracheal tube and shows a higher first-attempt success rate than ETI in out-of-hospital settings by paramedics in the United States. We reviewed the use of ETI and I-gel by ED physicians to assess the first attempt success rate in a hospital setting.

Methods. We conducted a retrospective chart review of patients with non-traumatic OHCA who were managed with either ETI using a Macintosh laryngoscope, or I-gel in the ED of Korean hospital from January 2012 to January 2014.

Results. Of 322 adult patients with non-traumatic OHCA, 160 received I-gel and 162 received ETI. The first-attempt success rate was higher in the I-gel group (96.9%) than in the ETI group (84.6%, p < 0.001). The time from arrival to obtaining advanced airway management was shorter in the I-gel group than in the ETI group.

Conclusions. I-gel showed a better first-attempt success rate and shorter insertion time compared with ETI when performed by physicians in a hospital setting.

Key words: airway management, laryngeal mask, out-of-hospital cardiac arrest, resuscitation

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The additional ımpact of simulation based medical training to traditional medical training alone in advanced cardiac life support: a scenario based evaluation


Objectives. The principal aim of medical education is to provide medical student with the fundamental knowledge and required skills that can be specifically used in real-life conditions such as high-quality cardiopulmonary resuscitation (CPR). Traditional medical training (TMT) is an effective method in Advanced cardiac life support (ACLS) training. Simulation-based medical training (SBMT), with the advancements in technology, is a relatively new, but a preferred ACLS training method since it implements a safe educational environment. We planned a scenario-based study to evaluate the additional impact of SBMT to TMT alone in ACLS training.

Methods. This before-after type, comparative, cohort study was performed in a simulation center. One hundred thirty-six 6th grade medical students who took ACLS training with TMT on their emergency medicine clerkship were enrolled in 34 teams. All students managed a specific ACLS scenario before and after SBMT with a high-fidelity manikin. All data regarding chest compression, airway management, defibrillation and drug administration were recorded by the sensors of the high-fidelity manikin.

Results. Median age was 23 and 51.5% were male. After SBMT, we found significant increases in the successful CPR cycle rate and successful scenario completion rate (60.3%; 61.8%, respectively). Median time to chest compression (Tcc) and defibrillation (Tdef) were significantly decreased after SBMT (1 sec., 1 sec., respectively). For the adequacy of chest compressions, compression depth, recoil, and frequency are all significantly increased after SBMT, 7.0 mm, 6.0 mm and 8.5/min, respectively.

Conclusion. SBMT in combination with TMT is a promising ACLS training method when compared to TMT alone.

Key words: simulation-based medical training, traditional medical training, high-fidelity manikin, CPR, ACLS

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