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Heliyon Apr 2024Confirming proper placement of an endotracheal tube (ETT) is important, as accidental misplacements may occur and lead to critical injuries, potentially leading to...
BACKGROUND
Confirming proper placement of an endotracheal tube (ETT) is important, as accidental misplacements may occur and lead to critical injuries, potentially leading to adverse outcomes. Multiple methods are available for determining the correct ETT placement in prehospital care.
OBJECTIVE
To assess the accuracy and reliability of the different methods used to confirm endotracheal intubation in prehospital settings.
METHODS
A comprehensive literature search was performed in the MEDLINE, EMBASE, Scopus, and Web of Science databases for studies that were published between 1-June-1992 and 12-June-2022 using a combination of predetermined search terms. Studies that met the inclusion criteria were included and assessed for risk of bias using "Risk of Bias in Non-randomized Studies of Intervention" tool.
RESULTS
Of the 1016 identified studies, nine met the inclusion criteria. Capnography and point-of-care ultrasound showed high sensitivity and specificity rates when applied to confirm ETT placement in prehospital care. Other methods including capnometry, colorimetric detectors, ODDs, and auscultation showed varied sensitivity and specificity. Patient comorbidities and device failure contributed to decreased accuracy rates in prehospital care. Capnography was less reliable in distinguishing between endotracheal intubation and right main stem intubation, which is known as a complication in out-of-hospital endotracheal intubation. Point-of-care ultrasound was more accurate and reliable in detecting oesophageal and endobronchial misplacements. ETCO monitors, i.e., capnometry and colorimetric detectors, were less reliable in patients with low perfusion states.
CONCLUSION
This systematic review showed that there is no single method with 100% accuracy in confirming the correct ETT placement and detecting the occurrence of accidental oesophageal or endobronchial misplacements in prehospital care. Further studies with a larger sample size are needed to assess the accuracy of multiple confirmatory methods in prehospital settings.
PubMed: 38586363
DOI: 10.1016/j.heliyon.2024.e28479 -
Prehospital Emergency Care Jul 2023Helicopter EMS (HEMS) is a well-established mode of rapid transportation for patients with need for time-sensitive interventions, especially in patients with significant...
BACKGROUND AND AIM
Helicopter EMS (HEMS) is a well-established mode of rapid transportation for patients with need for time-sensitive interventions, especially in patients with significant traumatic injuries. Traditionally in the setting of trauma, HEMS is often considered appropriate when used for patients with "severe" injury as defined by Injury Severity Score (ISS) >15. This may be overly conservative, and patients with a lower ISS may benefit from HEMS-associated speed or care quality. Our objective was to perform a meta-analysis of trauma HEMS transports to evaluate for possible mortality benefit in injured cases defined by an ISS score >8, lower than the customary ISS cutoff of >15.
METHODS
A broad search of the literature was performed including PubMed, EMBASE, SCOPUS, Cochrane Central Register of Controlled Trials, and Google Scholar from the years 1970 to 2022. The gray literature and reference lists of included publications were also examined. We included studies with the outcome of mortality in HEMS vs control in trauma transports from scene of injury for patients (adult or pediatric) with ISS > 8.
RESULTS
Nine eligible studies were used in the final analysis: six in the primary analysis and three in sensitivity analysis due to patient overlap. All studies reported statistically significant survival benefit in HEMS compared to control group. The minimum survival odds ratio (OR) benefit observed was OR 1.15 (95% CI 1.06-1.25) and maximum was OR 2.04 (95% CI 1.18-3.57). Risk of bias tool (ROBINS-I) application yielded moderate to low risk of bias, mainly due to the observational nature of the studies included.
CONCLUSIONS
There was a statistically significant survival benefit in patients with ISS > 8 when HEMS was used over traditional ground ambulance transportation, although novel and more inclusive trauma triage criteria may be more appropriate in the future to guide HEMS utilization decision-making. Restricting HEMS to trauma patients with ISS >15 likely misses survival benefit that could be afforded to the subset of trauma patients with serious injury.
PubMed: 37406174
DOI: 10.1080/10903127.2023.2232453 -
British Paramedic Journal Dec 2023The current Joint Royal Colleges Ambulance Liaison Committee guidelines in the United Kingdom provide clear national guidance for low-voltage electrical injury patients....
INTRODUCTION
The current Joint Royal Colleges Ambulance Liaison Committee guidelines in the United Kingdom provide clear national guidance for low-voltage electrical injury patients. While patients can be considered safe to discharge with an apparently 'normal' initial electrocardiogram (ECG), some evidence questions the safety profile of these patients with a risk of a 'delayed arrhythmia'. This review aims to examine this as well as identifying the frequency and common arrhythmias that require patients to be conveyed to hospital for further monitoring post electrical injury. It will also aim to improve the understanding of potentially clinically significant arrhythmias that may require clinical intervention or even admission within an in-hospital environment.
METHODS
A systematic review using three electronic databases (CINAHL, MEDLINE, AMED) was conducted in January 2022. A preferred reporting items for systematic reviews and meta-analyses (PRISMA) approach was used to identify relevant studies with a suitable quality to support a critical review of the topic. A modified Critical Appraisal Skills Programme quality assessment checklist was used across suitable studies and a descriptive statistics approach was adopted to present the findings.
RESULTS
Seven studies, largely retrospective reviews, met the inclusion criteria. The findings showed 26% of patients had an arrhythmia on initial presentation (n = 364/1234) with incidences of sinus tachycardia, sinus bradycardia and premature ventricular contractions. However, making definitive statements is challenging due to the lack of access to individual patients' past ECGs. Within these arrhythmias' ST segment changes, atrial fibrillation and long QT syndrome could be considered potentially significant, however associated prognosis with these and electrical injuries is unknown. Only six (0.5%) patients required treatment by drug therapy, and a further three died from associated complications. Most patients with a normal ECG were discharged immediately with only a limited follow-up. No presentation of a 'delayed arrhythmia' was identified throughout the studies.
CONCLUSION
The data for low-voltage electrical injuries are limited, but the potential arrhythmias for this patient group seldom require intervention. The entity of the 'delayed arrhythmia' may not be a reason to admit or monitor patients for prolonged periods. Further studies should consider the safety profile of discharging a patient with a normal ECG.
PubMed: 38046790
DOI: 10.29045/14784726.2023.12.8.3.27 -
Journal of Athletic Training Dec 2023Exercise-associated dehydration is a common problem, especially at sporting events. Although there are recommendations to drink a certain volume per kg body mass lost...
OBJECTIVE
Exercise-associated dehydration is a common problem, especially at sporting events. Although there are recommendations to drink a certain volume per kg body mass lost after exercise, there is no clear guidance about the type of rehydration beverage. The aim of this systematic review is to assess the effectiveness of carbohydrate-electrolyte solutions as a rehydration solution for exercise-associated dehydration.
DATA SOURCES
Medline (via the PubMed interface), Embase and the Cochrane Library were searched for relevant studies. The search is up to date until June 2022.
STUDY SELECTION
Controlled trials involving adults and children were included if dehydration was the result of physical exercise and if drinking carbohydrate-electrolyte solutions, of any percentage carbohydrate, was compared with drinking water. All languages were included as long as an English abstract was available.
DATA EXTRACTION
Data on study design, study population, interventions, outcome measures and study limitations were extracted from each included article. Certainty was assessed using GRADE.
DATA SYNTHESIS
Out of 3485 screened articles, 19 studies were included that assessed carbohydrate-electrolyte solutions (0% - 9% carbohydrate) compared with water. Although there is variability amongst the identified studies, drinking 0-3.9% and, especially, 4-9% carbohydrate-electrolyte (CE) solution may be effective for rehydration.
CONCLUSIONS
A potential beneficial effect of drinking CE drinks compared with water was seen for many of the reviewed outcomes. Commercial CE drinks (ideally 4-9% CE drinks or alternatively 0-3.9% CE drinks) could be suggested for rehydration in persons with exercise associated dehydration when whole foods are not available.
PubMed: 38116803
DOI: 10.4085/1062-6050-0682.22 -
PloS One 2024In adult major trauma patients admission hypocalcaemia occurs in approximately half of cases and is associated with increased mortality. However, data amongst paediatric... (Meta-Analysis)
Meta-Analysis
OBJECTIVES
In adult major trauma patients admission hypocalcaemia occurs in approximately half of cases and is associated with increased mortality. However, data amongst paediatric patients are limited. The objectives of this review were to determine the incidence of admission ionised hypocalcaemia in paediatric major trauma patients and to explore whether hypocalcaemia is associated with adverse outcomes.
METHODS
A systematic review was conducted following PRISMA guidelines. All studies including major trauma patients <18 years old, with an ionised calcium concentration obtained in the Emergency Department (ED) prior to the receipt of blood products in the ED were included. The primary outcome was incidence of ionised hypocalcaemia. Random-effects Sidik-Jonkman modelling was executed for meta-analysis of mortality and pH difference between hypo- and normocalcaemia, Odds ratio (OR) was the reporting metric for mortality. The reporting metric for the continuous variable of pH difference was Glass' D (a standardized difference). Results are reported with 95% confidence intervals (CIs) and significance was defined as p <0.05.
RESULTS
Three retrospective cohort studies were included. Admission ionised hypocalcaemia definitions ranged from <1.00 mmol/l to <1.16 mmol/l with an overall incidence of 112/710 (15.8%). For mortality, modelling with low heterogeneity (I2 39%, Cochrane's Q p = 0.294) identified a non-significant (p = 0.122) estimate of hypocalcaemia increasing mortality (pooled OR 2.26, 95% CI 0.80-6.39). For the pH difference, meta-analysis supported generation of a pooled effect estimate (I2 57%, Cochrane's Q p = 0.100). The effect estimate of the mean pH difference was not significantly different from null (p = 0.657), with the estimated pH slightly lower in hypocalcaemia (Glass D standardized mean difference -0.08, 95% CI -0.43 to 0.27).
CONCLUSION
Admission ionised hypocalcaemia was present in at least one in six paediatric major trauma patients. Ionised hypocalcaemia was not identified to have a statistically significant association with mortality or pH difference.
Topics: Hypocalcemia; Humans; Incidence; Child; Wounds and Injuries; Calcium; Adolescent; Retrospective Studies; Patient Admission
PubMed: 38805515
DOI: 10.1371/journal.pone.0303109 -
Journal of Telemedicine and Telecare Jan 2024Telemedicine can alleviate the problems faced in rural settings in providing access to specialist stroke care. The evidence of the cost-effectiveness of this model of...
INTRODUCTION
Telemedicine can alleviate the problems faced in rural settings in providing access to specialist stroke care. The evidence of the cost-effectiveness of this model of care outside high-income countries is limited. This study aimed to conduct: (a) a systematic review of economic evaluations of telestroke and (b) a cost-utility analysis of telestroke, using China as a case study.
METHODS
We systematically searched Embase, Medline Complete and Cochrane databases. Inclusion criteria: full economic evaluations of telemedicine/telestroke networks examining the use of thrombolysis in patients with acute ischaemic stroke, published in English. A cost-utility analysis was undertaken using a Markov model incorporating a decision tree to simulate the delivery of telestroke for acute ischaemic stroke in rural China, compared to no telestroke from a societal and healthcare perspective. One-way deterministic sensitivity analyses and probabilistic sensitivity analyses were performed to test the robustness of results.
RESULTS
Of 559 publications found, eight met the eligibility criteria and were included in the systematic review (two cost-effectiveness analyses and six cost-utility analyses, all performed in high-income countries). Telestroke was a cost-saving/cost-effective intervention in five out of the eight studies. In our modelled analysis for rural China, telestroke was the dominant strategy, with estimated cost savings of Chinese yuan 4,328 (US$627) and additional 0.0925 quality-adjusted life years per patient. Sensitivity analyses confirmed the base case results.
DISCUSSION
Consistent with published economic evaluations of telestroke in other jurisdictions, telestroke represents a cost-effective solution to enhance stroke care in rural China.
Topics: Humans; Stroke; Cost-Benefit Analysis; Brain Ischemia; Developing Countries; Ischemic Stroke
PubMed: 34292801
DOI: 10.1177/1357633X211032407 -
Diabetes/metabolism Research and Reviews Jul 2024Fluid resuscitation during diabetic ketoacidosis (DKA) is most frequently performed with 0.9% saline despite its high chloride and sodium concentration. Balanced... (Meta-Analysis)
Meta-Analysis
Fluid resuscitation with balanced electrolyte solutions results in faster resolution of diabetic ketoacidosis than with 0.9% saline in adults - A systematic review and meta-analysis.
Fluid resuscitation during diabetic ketoacidosis (DKA) is most frequently performed with 0.9% saline despite its high chloride and sodium concentration. Balanced Electrolyte Solutions (BES) may prove a more physiological alternative, but convincing evidence is missing. We aimed to compare the efficacy of 0.9% saline to BES in DKA management. MEDLINE, Cochrane Library, and Embase databases were searched for relevant studies using predefined keywords (from inception to 27 November 2021). Relevant studies were those in which 0.9% saline (Saline-group) was compared to BES (BES-group) in adults admitted with DKA. Two reviewers independently extracted data and assessed the risk of bias. The primary outcome was time to DKA resolution (defined by each study individually), while the main secondary outcomes were changes in laboratory values, duration of insulin infusion, and mortality. We included seven randomized controlled trials and three observational studies with 1006 participants. The primary outcome was reported for 316 patients, and we found that BES resolves DKA faster than 0.9% saline with a mean difference (MD) of -5.36 [95% CI: -10.46, -0.26] hours. Post-resuscitation chloride (MD: -4.26 [-6.97, -1.54] mmoL/L) and sodium (MD: -1.38 [-2.14, -0.62] mmoL/L) levels were significantly lower. In contrast, levels of post-resuscitation bicarbonate (MD: 1.82 [0.75, 2.89] mmoL/L) were significantly elevated in the BES-group compared to the Saline-group. There was no statistically significant difference between the groups regarding the duration of parenteral insulin administration (MD: 0.16 [-3.03, 3.35] hours) or mortality (OR: -0.67 [0.12, 3.68]). Studies showed some concern or a high risk of bias, and the level of evidence for most outcomes was low. This meta-analysis indicates that the use of BES resolves DKA faster than 0.9% saline. Therefore, DKA guidelines should consider BES instead of 0.9% saline as the first choice during fluid resuscitation.
Topics: Adult; Humans; Diabetic Ketoacidosis; Electrolytes; Fluid Therapy; Prognosis; Resuscitation; Saline Solution
PubMed: 38925619
DOI: 10.1002/dmrr.3831