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Background: Intraoperative neuromonitoring (IONM) is widely used for elective resection of eloquently located brain tumors to increase safety and extent of resection. Owing to the need for specially trained personnel for IONM and the sophisticated, time-consuming technical setup, standard IONM is usually not suitable for emergency situations. We report the use of a device that can be operated by the neurosurgeon autonomously for monopolar brain mapping in 2 emergency cases., Methods: Both patients were initially scheduled for elective neurosurgery under IONM. Acute neurological deterioration in both cases led to emergency surgery. For monopolar cortical/subcortical stimulation, a standard monopolar probe was connected to a new device enabling electromyography real-time tracking of 8 muscles. Preoperative application of subdermal electromyography needles and intraoperative handling of the device were performed by the neurosurgeons independently., Results: Cortical mapping of the motor cortex was performed in both patients with a threshold of 4 mA in case 1 and 14 mA in case 2. Gross total resection with residual tumor volume of <2 mL in case 1 and subtotal resection with residual tumor volume of 4.2 mL in case 2 were achieved under use of the new device without any new neurological deficit. Grade IV glioblastoma was diagnosed in both patients., Conclusions: We demonstrate the feasibility of monopolar stimulation in 2 patients undergoing emergency neurosurgery using a device autonomously operated by the surgeon. Owing to fast setup and nondemanding handling, monopolar stimulation could be used during emergency neurosurgery to extend resection with preservation of neurological function in both cases., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Patients with chronic kidney disease (CKD) who require urgent initiation of dialysis but without having a permanent dialysis access have traditionally commenced haemodialysis (HD) using a central venous catheter (CVC). However, several studies have reported that urgent initiation of peritoneal dialysis (PD) is a viable alternative option for such patients., Objectives: This review aimed to examine the benefits and harms of urgent-start PD compared to HD initiated using a CVC in adults and children with CKD requiring long-term kidney replacement therapy., Search Methods: We searched the Cochrane Kidney and Transplant Register of Studies up to 25 May 2020 for randomised controlled trials through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. For non-randomised controlled trials, MEDLINE (OVID) (1946 to 11 February 2020) and EMBASE (OVID) (1980 to 11 February 2020) were searched., Selection Criteria: All randomised controlled trials (RCTs), quasi-RCTs and non-RCTs comparing urgent-start PD to HD initiated using a CVC., Data Collection and Analysis: Two authors extracted data and assessed the quality of studies independently. Additional information was obtained from the primary investigators. The estimates of effect were analysed using random-effects model and results were presented as risk ratios (RR) with 95% confidence intervals (CI). The GRADE framework was used to make judgments regarding certainty of the evidence for each outcome., Main Results: Overall, seven observational studies (991 participants) were included: three prospective cohort studies and four retrospective cohort studies. All the outcomes except one (bacteraemia) were graded as very low certainty of evidence given that all included studies were observational studies and few events resulting in imprecision, and inconsistent findings. Urgent-start PD may reduce the incidence of catheter-related bacteraemia compared with HD initiated with a CVC (2 studies, 301 participants: RR 0.13, 95% CI 0.04 to 0.41; I 2 = 0%; low certainty evidence), which translated into 131 fewer bacteraemia episodes per 1000 (95% CI 89 to 145 fewer). Urgent-start PD has uncertain effects on peritonitis risk (2 studies, 301 participants: RR 1.78, 95% CI 0.23 to 13.62; I 2 = 0%; very low certainty evidence), exit-site/tunnel infection (1 study, 419 participants: RR 3.99, 95% CI 1.2 to 12.05; very low certainty evidence), exit-site bleeding (1 study, 178 participants: RR 0.12, 95% CI 0.01 to 2.33; very low certainty evidence), catheter malfunction (2 studies; 597 participants: RR 0.26, 95% CI: 0.07 to 0.91; I 2 = 66%; very low certainty evidence), catheter re-adjustment (2 studies, 225 participants: RR: 0.13; 95% CI 0.00 to 18.61; I 2 = 92%; very low certainty evidence), technique survival (1 study, 123 participants: RR: 1.18, 95% CI 0.87 to 1.61; very low certainty evidence), or patient survival (5 studies, 820 participants; RR 0.68, 95% CI 0.44 to 1.07; I 2 = 0%; very low certainty evidence) compared with HD initiated using a CVC. Two studies using different methods of measurements for hospitalisation reported that hospitalisation was similar although one study reported higher hospitalisation rates in HD initiated using a catheter compared with urgent-start PD., Authors' Conclusions: Compared with HD initiated using a CVC, urgent-start PD may reduce the risk of bacteraemia and had uncertain effects on other complications of dialysis and technique and patient survival. In summary, there are very few studies directly comparing the outcomes of urgent-start PD and HD initiated using a CVC for patients with CKD who need to commence dialysis urgently. This evidence gap needs to be addressed in future studies., (Copyright © 2021 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.)

Thoracic aortic diseases, including disease of the descending thoracic aorta (DTA), are significant causes of death in the United States. Open repair of the DTA is a physiologically impactful operation with relatively high rates of mortality, paraplegia, and renal failure. Thoracic endovascular aortic repair (TEVAR) has revolutionized treatment of the DTA and has largely supplanted open repair because of lower morbidity and mortality. These Society for Vascular Surgery Practice Guidelines are applicable to the use of TEVAR for descending thoracic aortic aneurysm (TAA) as well as for other rarer pathologic processes of the DTA. Management of aortic dissections and traumatic injuries will be discussed in separate Society for Vascular Surgery documents. In general, there is a lack of high-quality evidence across all TAA diseases, highlighting the need for better comparative effectiveness research. Yet, large single-center experiences, administrative databases, and meta-analyses have consistently reported beneficial effects of TEVAR over open repair, especially in the setting of rupture. Many of the strongest recommendations from this guideline focus on imaging before, during, or after TEVAR and include the following: In patients considered at high risk for symptomatic TAA or acute aortic syndrome, we recommend urgent imaging, usually computed tomography angiography (CTA) because of its speed and ease of use for preoperative planning. Level of recommendation: Grade 1 (Strong), Quality of Evidence: B (Moderate). If TEVAR is being considered, we recommend fine-cut (≤0.25 mm) CTA of the entire aorta as well as of the iliac and femoral arteries. CTA of the head and neck is also needed to determine the anatomy of the vertebral arteries. Level of recommendation: Grade 1 (Strong), Quality of Evidence: A (High). We recommend routine use of three-dimensional centerline reconstruction software for accurate case planning and execution in TEVAR. Level of recommendation: Grade 1 (Strong), Quality of Evidence: B (Moderate). We recommend contrast-enhanced computed tomography scanning at 1 month and 12 months after TEVAR and then yearly for life, with consideration of more frequent imaging if an endoleak or other abnormality of concern is detected at 1 month. Level of recommendation: Grade 1 (Strong), Quality of Evidence: B (Moderate). Finally, based on our review, in patients who could undergo either technique (within the criteria of the device's instructions for use), we recommend TEVAR as the preferred approach to treat elective DTA aneurysms, given its reduced morbidity and length of stay as well as short-term mortality. Level of recommendation: Grade 1 (Strong), Quality of Evidence: A (High). Given the benefits of TEVAR, treatment using a minimally invasive approach is largely based on anatomic eligibility rather than on patient-specific factors, as is the case in open TAA repair. Thus, for isolated lesions of the DTA, TEVAR should be the primary method of repair in both the elective and emergent setting based on improved short-term and midterm mortality as well as decreased morbidity., (Copyright © 2020 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background : Uncontrolled bleeding is the leading cause of preventable death from trauma. The Stop the Bleed (STB) initiative provides basic education about bleeding to potential immediate responders. The present study aimed to assess the perceptions of self-efficacy and school preparedness related to responding to a life-threatening bleeding emergency in school personnel at an urban high school. Methods : High school personnel from an urban high school ( N = 156) completed a 1-hour STB course that included a didactic and hands-on component. Participants rated their agreement with statements about self-efficacy and school preparedness on a 5-point Likert-type scale, responded to items regarding how school personnel could be better prepared for life-threatening emergencies, and had the option to provide written responses pre- and post-course. Findings : Independent samples t tests revealed that perceptions of self-efficacy and school preparedness increased after the course ( p < .001). Before the course, 87% of participants felt they needed training, 80% felt the school needed clearer procedures, and 74% felt the school required more equipment for a life-threatening bleeding incident compared with 63%, 69%, and 78% post-course, respectively. Thematic analysis of written responses revealed that participants desired higher frequencies of STB training, more equipment, clearer school procedures, and realistic training scenarios with students. Conclusions/Application to Practice : The STB course increased both perceptions of self-efficacy and school preparedness in a sample of high school personnel. Qualitative analyses provided insight to personnel's opinion of STB's effectiveness and what is necessary to maintain or follow through with this knowledge after completion of the course.

Implementation and staff perceptions of usability and feasibility.

Competing Interests: Competing interests: None declared.

This study investigated the efficiency of a portable nitric oxide (NO) inhalation device through optimizing its design and structure. The portable rescue device could be used in clinical applications in outbreaks of viral pneumonia such as SARS. To reduce energy consumption for battery-powered portable usage, NO micro-channel plasma reactions induced by a continuous discharge arc were employed. A single-use airway tube could be combined with an intubation tube in clinical applications. In the experiment, a switching transistor controlled high frequency DC (12.5 kHz) was used to create a continuous discharge arc between two stainless steel electrodes (1-mm separation) after high-voltage breakthrough. A rotate instrument was employed to change the direction angle between the airflow and discharge arc, tube filled with Calcium hydroxide connected with gas outlet for reducing NO2, gas flow rate and input voltage were evaluated separately with concentration of NO and NO2/NO ratio. Results showed that a 2 L/min air flow direction from the cathode to the anode of electrodes (direction angle was zero) under 4 V input voltages produced 32.5±3.8 ppm NO, and the NO2/NO ratio reduced to less than 10%, stable output of nitric oxide might be convenient and effective for NO inhalation therapy. Modularization of the design produced a portable NO inhalation device that has potential for use in clinical applications as it is low cost, easy to disinfect, consumes low levels of energy and is ready to use., Competing Interests: The authors have declared that no competing interests exist.

Competing Interests: Declaration of Competing Interest All authors declared that there is no conflict of interest.

In the obese, the evidence for the choice of the optimal emergency front-of-neck access technique is very limited and conflicting. We compared cannula and scalpel-bougie emergency front-of-neck access techniques in an anaesthetised porcine model with thick pretracheal tissue. Cannula and scalpel-bougie cricothyroidotomy techniques were performed in 11 and 12 anaesthetised pigs, respectively. Following successful tracheal access, oxygenation was commenced and continued for 5 min using Rapid-O2 device for cannula and circle breathing system for scalpel-bougie study groups. The primary outcome was a successful rescue oxygenation determined by maintenance of arterial oxygen saturation >90% 5 min after the beginning of oxygenation. Secondary outcomes included success rate of airway device placement, time to successful airway device placement, and trauma to the neck and airway. The success rate of rescue oxygenation was 18% after cannula, and 83% after scalpel-bougie technique (P = 0.003). The success rate of airway device placement was 73% with cannula and 92% with scalpel-bougie technique (P = 0.317). Median (inter-quartile-range) times to successful airway device placement were 108 (30-256) and 90 (63-188) seconds (P = 0.762) for cannula and scalpel-bougie emergency front-of-neck access, respectively. Proportion of animals with iatrogenic trauma additional to the procedure itself was 27% for cannula and 75% for scalpel-bougie technique (P = 0.039). Thus, in the porcine model of obesity, the scalpel-bougie technique was more successful in establishing and maintaining rescue oxygenation than cannula-based technique; however, it was associated with a higher risk of severe trauma., Competing Interests: The authors have declared that no competing interests exist.

There are several situations such as medical emergencies and incidents involving mass casualties where drugs and antidotes have to be administered immediately along with other first aid at the site of the event. Self-administration by the affected person or by a companion is required as a life-saving measure. Autoinjector devices (AIDs) are useful for the rapid administration of drugs and antidotes and they can also be used by those who have not been medically trained. This makes them very convenient for emergency and mass casualty management. An AID has a drug cartridge with an embedded needle for subcutaneous or intramuscular injection, which is usually painless. The drugs are delivered slowly by the AID across a large area in the muscle, which increases the absorption and the drug effects are equal to that of intravenous administration. A variety of AIDs are available, such as atropine and pralidoxime for nerve agent poisoning, epinephrine for anaphylactic shock and allergy, diazepam for seizures, sumatriptan for migraine, amikacin for antibacterial treatment, buprenorphine for pain relief and monoclonal antibodies for a variety of diseases. This review describes the published peer-reviewed literature identified by online searches of journal databases.

It is crucial that all children are provided with high-quality and safe health care. Pediatric inpatient needs are unique in regard to policies, equipment, facilities, and personnel. The intent of this clinical report is to provide recommendations for the resources necessary to provide high-quality and safe pediatric inpatient medical care., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The author has indicated she has no potential conflicts of interest to disclose., (Copyright © 2020 by the American Academy of Pediatrics.)

Importance: More than 500 000 laypeople in the United States have been trained in hemorrhage control, including tourniquet application, under the Stop the Bleed campaign. However, it is unclear whether after hemorrhage control training participants become proficient in a specific type of tourniquet or can also use other tourniquets effectively., Objective: To assess whether participants completing the American College of Surgeons Bleeding Control Basic (B-Con) training with Combat Application Tourniquets (CATs) can effectively apply bleeding control principles using other tourniquet types (commercial and improvised)., Design, Setting, and Participants: This nonblinded, crossover, sequential randomized clinical trial with internal control assessed a volunteer sample of laypeople who attended a B-Con course at Gillette Stadium and the Longwood Medical Area in Boston, Massachusetts, for correct application of each of 5 different tourniquet types immediately after B-Con training from April 4, 2018, to October 9, 2018. The order of application varied for each participant using randomly generated permutated blocks., Interventions: Full B-Con course, including cognitive and skill sessions, that taught bleeding care, wound pressure and packing, and CAT application., Main Outcomes and Measures: Correct tourniquet application (applied pressure of ≥250 mm Hg with a 2-minute time cap) in a simulated scenario for 3 commercial tourniquets (Special Operation Forces Tactical Tourniquet, Stretch-Wrap-and-Tuck Tourniquet, and Rapid Application Tourniquet System) and improvised tourniquet compared with correct CAT application as an internal control using 4 pairwise Bonferroni-corrected comparisons with the McNemar test., Results: A total of 102 participants (50 [49.0%] male; median [interquartile range] age, 37.5 [27.0-53.0] years) were included in the study. Participants correctly applied the CAT at a significantly higher rate (92.2%) than all other commercial tourniquet types (Special Operation Forces Tactical Tourniquet, 68.6%; Stretch-Wrap-and-Tuck Tourniquet, 11.8%; Rapid Application Tourniquet System, 11.8%) and the improvised tourniquet (32.4%) (P < .001 for each pairwise comparison). When comparing tourniquets applied correctly, all tourniquet types had higher estimated blood loss, had longer application time, and applied less pressure than the CAT., Conclusions and Relevance: The B-Con principles for correct CAT application are not fully translatable to other commercial or improvised tourniquet types. This study demonstrates a disconnect between the B-Con course and tourniquet designs available for bystander first aid, potentially stemming from the lack of consensus guidelines. These results suggest that current B-Con trainees may not be prepared to care for bleeding patients as tourniquet design evolves., Trial Registration: ClinicalTrials.gov identifier: NCT03538379.

Background: Obstructive colorectal cancer (OCC) is always accompanied by severe complications, and the optimal strategy for patients with OCC remains undetermined. Different from emergency surgery (ES), self-expandable metal stents (SEMS) as a bridge to surgery (BTS), could increase the likelihood of primary anastomosis. However, the stent failure and related complications might give rise to a high recurrence rate. Few studies have focused on the indications for either method, and the relationship between preoperative inflammation indexes and the prognosis of OCC is still underestimated., Aim: To explore the indications for ES and BTS in OCCs based on preoperative inflammation indexes., Methods: One hundred and twenty-eight patients who underwent ES or BTS from 2008 to 2015 were enrolled. Receiver operating characteristic (ROC) curve analysis was used to define the optimal preoperative inflammation index and its cutoff point. Kaplan-Meier analyses and Cox proportional hazards models were applied to assess the association between the preoperative inflammation indexes and the survival outcomes [overall survival (OS) and disease-free survival (DFS)]. Stratification analysis was performed to identify the subgroups that would benefit from ES or BTS., Results: OS and DFS were comparable between the ES and BTS groups ( P > 0.05). ROC curve analysis showed derived neutrophil-to-lymphocyte ratio (dNLR) as the optimal biomarker for the prediction of DFS in ES ( P < 0.05). Lymphocyte-to-monocyte ratio (LMR) was recommended for BTS with regard to OS and DFS ( P < 0.05). dNLR was related to stoma construction ( P = 0.001), pneumonia ( P = 0.054), and DFS ( P = 0.009) in ES. LMR was closely related to lymph node invasion (LVI) ( P = 0.009), OS ( P = 0.020), and DFS ( P = 0.046) in the BTS group. dNLR was an independent risk factor for ES in both OS ( P = 0.032) and DFS ( P = 0.016). LMR affected OS ( P = 0.053) and DFS ( P = 0.052) in the BTS group. LMR could differentiate the OS between the ES and BTS groups ( P < 0.05)., Conclusion: Preoperative dNLR and LMR could predict OS and DFS in patients undergoing ES and BTS, respectively. For OCC, as the potential benefit group, patients with a low LMR might be preferred for BTS via SEMS insertion., Competing Interests: Conflict-of-interest statement: All authors read and approved the final manuscript and declared no conflicts of interest.

Massive transfusion therapy in severe paediatric trauma is a challenge. When this occurs in a rural setting, the potential delays in accessing medical services can lead to worse coagulopathy on presentation. We report successful treatment of a child post-traumatic lower limb amputation where treatment was only initiated 3 hours postinjury due to difficulties in access/retrieval. Rotational thromboelastometry (ROTEM)-guided, goal-directed haemostatic therapy perioperatively utilising a blood product ratio of 2:2:1 units of red blood cell:free frozen plasma:platelet reverted his coagulopathy. This report aims to raise awareness of the utility of ROTEM in paediatric trauma., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Indication: In-hospital patients with limited mobility are extremely vulnerable in cases of emergency or fire. In the past, several large fires in multi-story hospitals have resulted in deaths., Methods: For this reason, we have developed an evacuation mattress that incorporates the functions of an evacuation towel with the comfort of a normal mattress. The retention and fixation belts are protected and hidden by the washable mattress cover and can be reached by zippers in case of emergency. One person can pull the patient from the bed, along the hallway, and through the stairwell without injury. The entire mattress costs approximately 80 - 90 € more than a normal mattress. In the meantime, all beds of our six hospital group have been equipped with these mattresses., Conclusion: Rapid rescue can thus be facilitated with a complete system., Competing Interests: Die Autoren geben an, dass kein Interessenkonflikt besteht., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: Junctional hemorrhage surpassed extremity hemorrhage as the leading cause of preventable death after the resurgence of limb tourniquets during the recent conflicts in Afghanistan and Iraq. Junctional tourniquets (JTQs) were developed in response to this injury pattern. Published data for JTQ efficacy are limited and do not incorporate nonmedical, military first responders. We compared the time for effective placement and scores for device satisfaction between two different JTQs, stratified by combat lifesaver (CLS) and combat medics., Methods: We performed a prospective, randomized, crossover trial utilizing the SAM® Medical Junctional Tourniquet (SJT) and Junctional Emergency Treatment Tool (JETT™). Investigators simple randomized CLS and combat medics to SJT or JETT for their first JTQ application on mannequins with penetrating inguinal injuries. Then, participants immediately placed the other JTQ on another casualty with the same injury. The primary outcome measured was time of successful application. Success was defined as proper JTQ placement and a pressure reading of at least 180 mmHg. We compared outcomes between CLS and combat medics. Unsuccessful JTQ applications were excluded from the comparative analysis., Results: From June 2015 to August 2015, a total of 227 personnel (133 CLS and 94 combat medics) at Fort Hood, Texas, USA volunteered to participate in the study. Twenty-eight percent (38 of 133) of CLS and 40% (38 of 94) of combat medics placed both JTQs successfully, for a total of 152 applications (76 SJTs and 76 JETTs). We found a significant difference between applications of the JETT between the CLS and combat medics (92.0 ± 37.7 s versus 70.5 ± 20.5 s, P = 0.004). No other subgroup analyses, whether by device or user, demonstrated a significant difference in application time. Both groups preferred the SJT over the JETT. CLS disagreed with combat medics that the JETT could be easily applied by one person (median 3.0 [2.0, 4.0] versus median 4.0 [3.0, 5.0]; P = 0.006)., Conclusion: Overall, success rates for both the SJT and JETT were low. Improved training is needed to increase successful application of junctional tourniquets before widespread implementation. Combat lifesavers and combat medics prefer the SJT over the JETT.

Competing Interests: Disclosure The authors report no conflicts of interest in this work.

Study Objective: Nonrebreather masks and bag-valve masks are used for preoxygenation before emergency intubation. Flush rate oxygen delivered with a nonrebreather mask is noninferior to bag-valve mask oxygen at 15 L/min. We seek to compare the nonrebreather mask with flush rate oxygen to a bag-valve mask with flush rate oxygen (with and without inspiratory assistance) and determine whether the efficacy of bag-valve mask with flush rate oxygen is compromised by a simulated mask leak., Methods: We conducted 2 prospective studies in healthy, adult volunteers. All devices in both studies used flush rate oxygen, achieved by rotating the flowmeter dial counterclockwise until it could not be rotated farther, which delivered oxygen at 40 to 60 L/min. Study 1 compared preoxygenation with nonrebreather mask to bag-valve mask (modified with a one-way exhalation port) with and without a simulated mask leak. Study 2 compared nonrebreather mask to bag-valve mask with inspiratory assistance. The primary outcome was FeO 2 . For each comparison, we prespecified a noninferiority margin of FeO 2 for the nonrebreather mask (compared with the bag-valve mask, bag-valve mask with mask leak, and bag-valve mask with assistance) of 10%., Results: Thirty subjects were enrolled in study 1 and 27 subjects were enrolled in study 2. For study 1, mean FeO 2 values for nonrebreather mask, bag-valve mask, and bag-valve mask with leak were 81% (95% confidence interval [CI] 78% to 83%), 76% (95% CI 71% to 81%), and 30% (95% CI 26% to 35%), respectively. FeO 2 for the nonrebreather mask was noninferior to the bag-valve mask at flush rate (difference 5%; 95% CI -1% to 10%). FeO 2 was higher for the nonrebreather mask compared with the bag-valve mask with a simulated mask leak (difference 51%; 95% CI 46% to 55%). For study 2, mean FeO 2 values for nonrebreather mask and bag-valve mask with assistance were 83% (95% CI 80% to 86%) and 77% (95% CI 73% to 80%), respectively. FeO 2 for the nonrebreather mask was noninferior to the bag-valve mask with assistance at flush rate (difference 6%; 95% CI 3% to 10%)., Conclusion: With flush rate oxygen, the nonrebreather mask is noninferior to the bag-valve mask, with and without inspiratory assistance. Bag-valve mask performed poorly with a mask leak, even with flush rate oxygen. Flush rate oxygen with a nonrebreather mask is a reasonable default preoxygenation method in spontaneously breathing patients with no underlying respiratory pathology., (Copyright © 2017 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Purpose: The purpose of this study was to evaluate the dental student's ability to locate medical emergency equipment/items at the University of Michigan School of Dentistry clinic., Methods: A total of 138 second-year dental students (traditional group) participated in this study as part of a simulation-based medical emergencies rotation course held during the winter term of 2014 and 2015. Without prior training, students were tested on their ability to locate nine predetermined items on the clinic floor using a self-reported checklist. Six months later, a convenience sample of 18 students (novel group) from the same cohort were later trained on their location and retested individually., Results: Of the 138 students tested, only 10.14% students could locate seven of the nine items when compared to 100% in the novel group. Only 5.07% of students in the traditional group could locate all items initially, compared with 72.22% students in the novel group., Conclusion: Whilst our students have lecture-based knowledge about medical emergencies, the results of our study identified a gap of knowledge of emergency equipment/item location amongst students. Therefore, an intervention performed with a similar group of second-year dental students supported that proper training may be used to achieve retention of knowledge. Based on our "novel group" results, we have incorporated targeted training in the dental curriculum that leads to students being better prepared in locating emergency equipment/items. This study suggests that other populations, such as faculty or staff, may also benefit from hands-on training., (© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Objective: To evaluate the contents of parent-created emergency tracheostomy kits and identify deficiencies., Methods: This was an observational study. Data on emergency tracheostomy kits were abstracted for 30 consecutive children who had a tracheostomy tube in situ during an outpatient clinic visit with the Division of Respiratory Medicine and/or the Department of Otolaryngology-Head and Neck Surgery at the Hospital for Sick Children between February 1 and October 30, 2016. A checklist of 12 essential items based on expert consensus was used to evaluate each tracheostomy kit., Results: Emergency tracheostomy kits from all children were missing at least one item from the 12-item checklist. Nineteen (63%) kits had three or more critical items missing. All kits had the same size tracheotomy tube. Twenty-two (73%) kits did not have a half size smaller tracheostomy tube. Fifteen (50%) were missing a manual resuscitation bag and four (13.3%) were missing a suction machine. Children who had tracheostomy tube in situ for ≥4 years were more likely to have ≥3 missing items in their kit (43.4%) compared to those who had tracheostomy tube for <4 years (20%), (χ2 (1) = 9.85, P = 0.0017)., Conclusion: Maintenance of a fully stocked emergency tracheostomy kit can save a child's life. It is incumbent upon healthcare providers to ensure ongoing reassessment of knowledge and skills required to care for a child with a tracheostomy tube and to regularly review the components of a child's emergency tracheostomy kit., (© 2017 Wiley Periodicals, Inc.)

Background: Although endovascular approaches for acute ischemic stroke have been developed, the appropriate selection and sequence of device application or other treatments is unclear. If information about the clot quality can be obtained before the selection of devices, fast recanalization with a suitable device and strategy can be achieved. We studied the relationship between clot quality and the configuration of a microguidewire during endovascular thrombectomy., Methods: This prospective single-center study included all patients who were admitted for acute ischemic stroke between October 2015 and June 2017 and underwent emergency endovascular thrombectomy. We used a modified pigtail-shaped microguidewire to penetrate clots. The configurations under radiograph were distinguished into 2 types and assessed according to collected clot appearance and quality., Results: A total of 54 patients underwent acute endovascular thrombectomy. When the tip of the microguidewire became stuck against a clot during penetration, the clot was solid and hard, with statistical significance (P = 0.013)., Conclusions: Our results showed that we can select a suitable device and strategy for fast recanalization according to information about clot quality obtained using the modified pigtail-shaped microguidewire., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: To study the application timing and effect of intra-aortic balloon pump (IABP) in the emergency PCI treatment of patients with combined acute myocardial infarction (AMI) and cardiogenic shock (CS)., Patients and Methods: 84 cases of patients with combined AMI and CS under PCI in emergency treatment were randomly divided into the control group (n=42) and observational group (n=42). The control group underwent IABP again, after the invalidation of internal medicine drug treatment, while the observational group underwent IABP before the operation. We compared the effects of treatment., Results: After the intervention, the averages of arterial pressure and urine volume were increased in both groups than before (p <0.05). The average of heart rate was decreased, and the improvement in the observational group was more significant (p <0.05). However, the mortality rate in the observational group during the perioperative period was decreased than the control group as well as, the success rate of off-respirator was significant (p <0.05). The comparison of IABP complication occurrence rate as well as the survival rate after 1-year follow-up between both groups was not significantly different. Additionally, whereas the NYHA grouping in two groups was gradually improved, the difference was not statistically significant between both groups. However, in the observational group, the LVEF after one-month follow-up was significantly higher than in the control group (p <0.05), but not when comparing 1-year. VEDd at each time point in two groups were also similar., Conclusions: The early IABP can improve hemodynamics of patients with combined AMI and CS under emergency PCI. It can reduce perioperative mortality rate, improve the success rate of off-respirator, but cannot increase IABP complication incidence rate while having little influence on the long-term survival rate and cardiac function indicator.

Emergency airway management in children is generally considered to be challenging, and endotracheal intubation requires a high level of personal skills and experience. Immobilization of the cervical spine is indicated in all patients with the risk of any cervical spine injury but significantly aggravates endotracheal intubation. The best airway device in this setting has not been established yet, although the use of videolaryngoscopes is generally promising. Seventy-five moderately experienced paramedics of the Emergency Medical Service of Poland performed endotracheal intubations in a pediatric manikin in three airway scenarios: (A) normal airway, (B) manual in-line cervical immobilization, and (C) cervical immobilization using a Patriot cervical extrication collar and using two airway techniques: (1) McGrath videolaryngoscope and (2) Macintosh blade in a randomized sequence. First-attempt intubation success rate, time to intubation, glottis visualization, and subjective ease of intubation were investigated in this study. Intubation of difficult airways, including manual in-line and cervical collar immobilization, using the McGrath was significantly faster, with a higher first-attempt intubation success rate, better glottic visualization, and ease of intubation, compared to Macintosh-guided intubation. In the normal airway, both airway techniques performed equal., Conclusion: Our manikin study indicates that the McGrath may be a reasonable first intubation technique option for endotracheal intubation in difficult pediatric emergencies. Further clinical studies are therefore indicated. What is known : • Airway management in pediatrics is challenging and requires a high level of skills and experience. Cervical immobilization is indicated in all patients with any risk of cervical spine injury, but it significantly aggravates endotracheal intubation in these patients. Videolaryngoscopes have been reported to ease intubation and provide better airway visualization in the regular clinical setting. What is new: • The McGrath is an easy-to-use and clinically often used videolaryngoscope, but it has never been investigated in pediatrics with an immobilized cervical spine. In the normal airway, the McGrath provided better airway visualization compared to Macintosh laryngoscopy. However, better visualization did not lead to decreased time to intubation and a higher success rate of the first intubation attempt. In difficult airways, the McGrath provided better airway visualization and this led to faster intubation, a higher first-attempt intubation success rate, and better ease of intubation compared to Macintosh-guided intubation.

Background: Surfing is an increasingly popular activity and surfing-related injuries have increased accordingly. However, to the best of our knowledge, there are no reports of penetrating upper airway injuries in surfers. We present a "cannot ventilate, cannot intubate" situation following penetrating neck injury by a surfboard fin., Case Presentation: A previously healthy 29-year-old Japanese man was swept off his board by a large wave and his left mandible, tongue root, and right epipharynx were penetrated by the surfboard fin. He presented with severe hypovolemic shock because of copious bleeding from his mouth. Direct laryngoscopy failed, as did manual ventilation, because of the exacerbated upper airway bleeding and distorted upper airway anatomy. Open cricothyrotomy was immediately performed, followed by surgical exploration, which revealed extensive ablation of his tongue root and laceration of his lingual artery. After definitive hemostasis and intensive care, he returned home with no sequelae., Conclusions: The long, semi-sharp surfboard fin created both extensive crushing upper airway lesions and a sharp vascular injury, resulting in a difficult airway. This case illustrates that surfing injuries can prompt a life-threatening airway emergency and serves as a caution for both surfers and health care professionals.

In community-based care, the teams must adapt to the environment and perform a number of technical procedures. Foldable medical equipment has been developed and patented, enabling the care provision to approach hospital standards and improving working conditions in this context., (Copyright © 2017 Elsevier Masson SAS. All rights reserved.)

Objective: To assess the implementation and effects of the strategy, introduced in June 2011, of making obstetric kits readily available in health facilities in the Adamaoua region of Cameroon., Methods: We conducted a quasi-experimental study using an interrupted time series to assess the effects of the strategy, and a case study to evaluate its implementation. The reviewed data were gathered from 13 health facilities over a period from January 2008 to December 2014. Qualitative data were collected from in-depth interviews., Results: The provision of obstetric kits was effective in the intervention health facilities, although some challenges existed and included lack of staff motivation and rampant illegal practices. The number of deliveries and cesareans increased., Conclusion: There is a need to rethink this strategy, given its gaps and shortcomings., (Copyright © 2016. Published by Elsevier Ireland Ltd.)

Background: Emergency surgery for colon cancer, as a result of obstruction, has been vitiated by a high frequency of complications and poor survival. The concept of "bridge to surgery" includes either placement of self-expanding metallic stents (SEMS) or diverting stoma of an obstructing tumour and subsequent planned resection. The aim of this study was to compare acute resection with stoma or stent and later resection regarding surgical and oncological outcomes and total hospital stay., Methods: This is a retrospective cohort study. All 2424 patients diagnosed with colorectal cancer during 1997-2013 were reviewed. All whom underwent acute surgery with curative intention for left-sided malignant obstruction were included in the study., Results: One hundred patients fulfilled the inclusion criteria. Among them, 57 patients were treated with acute resection and 43 with planned resection after either acute diverting colostomy (n = 23) or stent placement (n = 20). The number of harvested lymph nodes in the resected specimen was higher in the planned resection group compared with acute resection group (21 vs. 8.7; p = 0.001). Fewer patients were treated with adjuvant chemotherapy in the acute resection group than in the stoma group (14 % (8/57 patients) vs. 43 %, (10/23 patients; p = 0.024)). Patients operated with acute resection had a higher 30-day mortality rate and were more frequently left with a permanent stoma., Conclusions: Decompression of emergency obstructive left colon cancer with stent or stoma and subsequent curative resection appears safer and results in a higher yield of lymph node harvest, and fewer patients are left with a permanent stoma.

Objectives: To assess the performance of two pediatric length-based tapes (Broselow and Handtevy) in predicting actual weights of US children., Methods: In this descriptive study, weights and lengths of children (newborn through 13 years of age) were extracted from the 2009-2010 National Health and Nutrition Examination Survey (NHANES). Using the measured length ranges for each tape and the NHANES-extracted length data, every case from the study sample was coded into Broselow and Handtevy zones. Mean weights were calculated for each zone and compared to the predicted Broselow and Handtevy weights using measures of bias, precision, and accuracy. A sub-sample was examined that excluded cases with body mass index (BMI)≥95th percentile. Weights of children longer than each tape also were examined., Results: A total of 3,018 cases from the NHANES database met criteria. Although both tapes underestimated children's weight, the Broselow tape outperformed the Handtevy tape across most length ranges in measures of bias, precision, and accuracy of predicted weights relative to actual weights. Accuracy was higher in the Broselow tape for shorter children and in the Handtevy tape for taller children. Among the sub-sample with cases of BMI≥95th percentile removed, performance of the Handtevy tape improved, yet the Broselow tape still performed better. When assessing the weights of children who were longer than either tape, the actual mean weights did not approximate adult weights; although, those exceeding the Handtevy tape were closer., Conclusions: For pediatric weight estimation, the Broselow tape performed better overall than the Handtevy tape and more closely approximated actual weight. Lowe CG , Campwala RT , Ziv N , Wang VJ . The Broselow and Handtevy resuscitation tapes: a comparison of the performance of pediatric weight prediction. Prehosp Disaster Med. 2016;31(4):364-375.

Study Objective: Although preoxygenation for emergency airway management is usually performed with nonrebreather face masks or bag-valve-mask devices, some clinicians also deliver supplemental high-flow oxygen by nasal cannula. We aim to measure the efficacy of supplemental nasal cannula oxygen delivery to conventional bag-valve-mask and nonrebreather face mask preoxygenation both with and without a simulated face mask leak., Methods: We conducted a randomized crossover trial using healthy volunteers. We randomized subjects to preoxygenation with bag-valve-mask or nonrebreather face mask. In random sequence, subjects underwent 3-minute trials of preoxygenation with oxygen through mask alone at 15 L/min, oxygen through mask at 15 L/min with standardized leak, oxygen through mask at 15 L/min+oxygen through nasal cannula at 10 L/min, and oxygen through mask at 15 L/min+oxygen through nasal cannula at 10 L/min with standardized leak. The primary outcome was single-breath exhalation end-tidal oxygen (eto2). We compared eto2 between preoxygenation modalities, using nonparametric techniques., Results: We enrolled 60 subjects (30 nonrebreather face mask and 30 bag-valve-mask). In scenarios without a mask leak, eto2 was similar between bag-valve-mask and bag-valve-mask+nasal cannula (mean 79% versus 75%; difference -3%; 95% confidence interval [CI] -8% to 1%). In bag-valve-mask scenarios with a mask leak, eto2 was higher for bag-valve-mask+nasal cannula than bag-valve-mask alone (mean 66% versus 41%; difference 25%; 95% CI 21% to 29%). eto2 was higher for nonrebreather face mask+nasal cannula than nonrebreather face mask (mean 67% versus 52%; difference 15%; 95% CI 12% to 18%). In nonrebreather face mask scenarios with a mask leak, eto2 was higher for nonrebreather face mask+nasal cannula than nonrebreather face mask (mean 65% versus 48%; difference 17%; 95% CI 13% to 20%)., Conclusion: Although not aiding bag-valve-mask preoxygenation with a good mask seal, supplemental nasal cannula oxygen improved preoxygenation efficacy in the presence of a bag-valve-mask mask leak. Supplemental nasal cannula oxygen improved nonrebreather face mask preoxygenation both with and without a mask leak. Supplemental nasal cannula oxygen may be helpful for preoxygenation before emergency airway management., (Copyright © 2015 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Background: Growing research suggests that a large number of peripheral intravenous catheters (PIVCs) inserted in the Emergency Department (ED) are unused. The aim of this study was to assess the proportion of unused ED inserted PIVCs in a before-and-after interventional study. Additional aims were to ascertain indications for PIVC insertion in the ED and to increase the appropriateness of PIVC insertion., Method: A prospective interventional study was conducted. Data were collected on 150 cases in the pre- and a further 150 cases in the post-intervention phase. During the intervention phase strategies were implemented to increase appropriate PIVC insertion in the ED. Interventions included introduction of insertion and removal stickers, new venepuncture devices, changing the intravenous (IV) trolley layout, and an educational campaign., Results: Results from this study demonstrate that the number of PIVCs used (50 vs. 28) remained unchanged, however the number of PIVC insertions initiated by nursing staff reduced significantly (p=0.049). With regard to the indication for PIVC insertion, the implementation of the interventions was associated with significantly fewer PIVCs being inserted for routine blood collection (p=0.006) and for PIVCs inserted for a potential need of medication and intravenous fluid administration (p=0.03). There was a significant reduction in the number of PIVCs inserted following the intervention (74 vs. 50: p=0.005)., Conclusion: This study demonstrated a high proportion of unused PIVCs in the ED. A composite intervention strategy was developed and significantly reduced the "just-in-case" PIVCs inserted., (Copyright © 2016 College of Emergency Nursing Australasia. Published by Elsevier Ltd. All rights reserved.)

Background: Hypothermia is an independent predictor of increased morbidity and mortality in patients with trauma. Several strategies and products have been developed to minimise patients' heat loss in the prehospital arena, but there is little evidence to inform the clinician concerning their effectiveness., Methods: We used a human torso model consisting of two 5.5-litre fluid bags to simultaneously compare four passive (space blanket, bubble wrap, Blizzard blanket, ambulance blanket) and one active (Ready-Heat II blanket) temperature preservation products. A torso model without any temperature preservation device provided a control. For each test, the torso models were warmed to 37°C and left outdoors. Core temperatures were recorded every 10 min for 1 h in total; tests were repeated 10 times., Results: A significant difference in temperature was detected among groups at 30 and 60 min (F (1.29, 10.30)=103.58, p<0.001 and F (1.64, 14.78)=163.28, p<0.001, respectively). Mean temperature reductions (95% CI) after 1 h of environmental exposure were the following: 11.6 (10.3 to 12.9) °C in control group, 4.5 (3.9 to 5.1) °C in space blanket group, 3.6 (3 to 4.3) °C in bubble-wrap group, 2.1 (1.7 to 2.5) °C in Blizzard blanket group, 6.1 (5.8 to 6.5) °C in ambulance blanket group and 1.1 (0.7 to 1.6) °C in Ready-Heat II blanket group., Conclusions: In this study, using a torso model based on two 5 L dialysate bags we found the Ready-Heat II heating blanket and Blizzard blanket were associated with lower rates of heat loss after 60 min environmental exposure than the other devices tested., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Background: Personal alarms support independent living and have the potential to reduce serious consequences after a fall or during a medical emergency. While some Australian states have government funded personal alarm programs, others do not; but user-pays services are available. Although several studies have examined the profiles of alarm users, little is known about the risk profile of non-users. Specifically, whether there are "at risk" individuals who are unable, or choose not to purchase a service, who experience a home-based emergency in which an alarm could have mitigated an adverse outcome. This study aimed to describe the 'risk profile' of purchasers and non-purchasers of alarms; explore the reasons behind the decision to purchase or not to purchase and identify how often emergency assistance was needed and why., Methods: Purchasers and non-purchasers were followed for one year in this prospective cohort study. Demographic, decision-making and risk factor data were collected at an initial face-to-face interview, while information about emergencies was collected by monthly calls., Results: One hundred and fifty-seven purchasers and sixty-five non-purchasers completed the study. The risk profiles between the groups were similar in terms of gender, living arrangements, fall history and medical conditions. Purchasers (Mean = 82.6 years) were significantly older than non-purchasers (Mean = 79.3 years), (t(220) = -3.38, p = 0.000) and more functionally dependent on the IADL (z = -2.57, p = 0.010) and ADL (z = -2.45 p = 0.014) function scores. Non-purchasers (Mean = 8.04, SD = 3.57) were more socially isolated with significantly fewer family networks than purchasers (Mean = 9.46, SD = 3.25) (t(220) = -2.86, p = 0.005). Both groups experienced similarly high numbers of emergencies, 38.2 % of purchasers and 41.5 % of non-purchasers had at least one emergency where an alarm could have assisted. Main reasons for non-purchase were: cost (77 %), limited alarm range (51 %), no need (39 %) and lack of suitable contacts (30 %)., Conclusion: There are older individuals who are at high risk of an emergency who are choosing, often for financial and lack of family support reasons, not to purchase a personal alarm service. Greater availability of government funded subsidy schemes would enable these individuals to access a service. Increasing the range over which alarms work could increase their appeal to a broader range of older persons living in the community. Future research should consider how strategies that improve social isolation from family and challenge clients' beliefs about their own health and independence can support increased access to personal alarm services.

Background: As the overwhelming surgical burden of injury and disease steadily increases, disproportionately affecting low- and middle-income countries, adequate surgical and trauma care systems are essential. Yet, little is known about the emergency and essential surgical care (EESC) capacity of facilities in many African countries. The objective of this study was to assess the EESC capacity in different types of hospitals across Cameroon., Methods: This cross-sectional survey used the WHO Tool for Situational Analysis to Assess EESC, investigating four key areas: infrastructure, human resources, interventions, and equipment and supplies. Twelve hospitals were surveyed between August and September 2009. Facilities were conveniently sampled based on proximity to road traffic and sociodemographic composition of population served in four regions of Cameroon. To complete the survey, investigators interviewed heads of facilities, medical advisors, and nursing officers and consulted hospital records and statistics at each facility., Results: Seven district hospitals, two regional hospitals, two general hospitals, and one missionary hospital completed the survey. Infrastructure for EESC was generally inadequate with the largest gaps in availability of oxygen concentrator supply, an on-site blood bank, and pain relief management guidelines. Human resources were scarce with a combined total of six qualified surgeons, seven qualified obstetrician/gynecologists, and no anesthesiologists at district, regional, and missionary hospitals. Of 35 surgical interventions, 16 were provided by all hospitals. District hospitals reported referring patients for 22 interventions. Only nine of the 67 pieces of equipment were available at all hospitals for all patients all of the time., Conclusions: Severe shortages highlighted by this survey demonstrate the significant gaps in capacity of hospitals to deliver EESC and effectively address the increasing surgical burden of disease and injury in Cameroon. This data provides a foundation for evidence-based decision-making surrounding appropriate allocation and provision of resources for adequate EESC in the country.