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The Western Journal of Emergency... Sep 2016Leadership skills are described by the American College of Surgeons' Advanced Trauma Life Support (ATLS) course as necessary to provide care for patients during... (Review)
Review
INTRODUCTION
Leadership skills are described by the American College of Surgeons' Advanced Trauma Life Support (ATLS) course as necessary to provide care for patients during resuscitations. However, leadership is a complex concept, and the tools used to assess the quality of leadership are poorly described, inadequately validated, and infrequently used. Despite its importance, dedicated leadership education is rarely part of physician training programs. The goals of this investigation were the following: 1. Describe how leadership and leadership style affect patient care; 2. Describe how effective leadership is measured; and 3. Describe how to train future physician leaders.
METHODS
We searched the PubMed database using the keywords "leadership" and then either "trauma" or "resuscitation" as title search terms, and an expert in emergency medicine and trauma then identified prospective observational and randomized controlled studies measuring leadership and teamwork quality. Study results were categorized as follows: 1) how leadership affects patient care; 2) which tools are available to measure leadership; and 3) methods to train physicians to become better leaders.
RESULTS
We included 16 relevant studies in this review. Overall, these studies showed that strong leadership improves processes of care in trauma resuscitation including speed and completion of the primary and secondary surveys. The optimal style and structure of leadership are influenced by patient characteristics and team composition. Directive leadership is most effective when Injury Severity Score (ISS) is high or teams are inexperienced, while empowering leadership is most effective when ISS is low or teams more experienced. Many scales were employed to measure leadership. The Leader Behavior Description Questionnaire (LBDQ) was the only scale used in more than one study. Seven studies described methods for training leaders. Leadership training programs included didactic teaching followed by simulations. Although programs differed in length, intensity, and training level of participants, all programs demonstrated improved team performance.
CONCLUSION
Despite the relative paucity of literature on leadership in resuscitations, this review found leadership improves processes of care in trauma and can be enhanced through dedicated training. Future research is needed to validate leadership assessment scales, develop optimal training mechanisms, and demonstrate leadership's effect on patient-level outcome.
Topics: Clinical Competence; Cooperative Behavior; Health Personnel; Humans; Leadership; Quality of Health Care; Resuscitation; Surveys and Questionnaires; Wounds and Injuries
PubMed: 27625718
DOI: 10.5811/westjem.2016.7.29812 -
Critical Care (London, England) Aug 2018After cardiac arrest a combination of basic and advanced airway and ventilation techniques are used during cardiopulmonary resuscitation (CPR) and after a return of... (Review)
Review
After cardiac arrest a combination of basic and advanced airway and ventilation techniques are used during cardiopulmonary resuscitation (CPR) and after a return of spontaneous circulation (ROSC). The optimal combination of airway techniques, oxygenation and ventilation is uncertain. Current guidelines are based predominantly on evidence from observational studies and expert consensus; recent and ongoing randomised controlled trials should provide further information. This narrative review describes the current evidence, including the relative roles of basic and advanced (supraglottic airways and tracheal intubation) airways, oxygenation and ventilation targets during CPR and after ROSC in adults. Current evidence supports a stepwise approach to airway management based on patient factors, rescuer skills and the stage of resuscitation. During CPR, rescuers should provide the maximum feasible inspired oxygen and use waveform capnography once an advanced airway is in place. After ROSC, rescuers should titrate inspired oxygen and ventilation to achieve normal oxygen and carbon dioxide targets.
Topics: Airway Management; Cardiopulmonary Resuscitation; Heart Arrest; Humans; Respiration, Artificial; Resuscitation
PubMed: 30111343
DOI: 10.1186/s13054-018-2121-y -
Journal of the American College of... Jun 2011Despite substantial efforts to make cardiopulmonary resuscitation (CPR) algorithms known to healthcare workers, the outcome of CPR has remained poor during the past... (Review)
Review
Despite substantial efforts to make cardiopulmonary resuscitation (CPR) algorithms known to healthcare workers, the outcome of CPR has remained poor during the past decades. Resuscitation teams often deviate from algorithms of CPR. Emerging evidence suggests that in addition to technical skills of individual rescuers, human factors such as teamwork and leadership affect adherence to algorithms and hence the outcome of CPR. This review describes the state of the science linking team interactions to the performance of CPR. Because logistical barriers make controlled measurement of team interaction in the earliest moments of real-life resuscitations challenging, our review focuses mainly on high-fidelity human simulator studies. This technique allows in-depth investigation of complex human interactions using precise and reproducible methods. It also removes variability in the clinical parameters of resuscitation, thus letting researchers study human factors and team interactions without confounding by clinical variability from resuscitation to resuscitation. Research has shown that a prolonged process of team building and poor leadership behavior are associated with significant shortcomings in CPR. Teamwork and leadership training have been shown to improve subsequent team performance during resuscitation and have recently been included in guidelines for advanced life support courses. We propose that further studies on the effects of team interactions on performance of complex medical emergency interventions such as resuscitation are needed. Future efforts to better understand the influence of team factors (e.g., team member status, team hierarchy, handling of human errors), individual factors (e.g., sex differences, perceived stress), and external factors (e.g., equipment, algorithms, institutional characteristics) on team performance in resuscitation situations are critical to improve CPR performance and medical outcomes of patients.
Topics: Cardiopulmonary Resuscitation; Clinical Competence; Communication; Female; Humans; Interprofessional Relations; Leadership; Patient Care Team; Prognosis; Switzerland; Total Quality Management; Treatment Outcome
PubMed: 21658557
DOI: 10.1016/j.jacc.2011.03.017 -
Colombia Medica (Cali, Colombia) Dec 2020Damage Control Resuscitation (DCR) seeks to combat metabolic decompensation of the severely injured trauma patient by battling on three major fronts: Permissive... (Review)
Review
Damage Control Resuscitation (DCR) seeks to combat metabolic decompensation of the severely injured trauma patient by battling on three major fronts: Permissive Hypotension, Hemostatic Resuscitation, and Damage Control Surgery (DCS). The aim of this article is to perform a review of the history of DCR/DCS and to propose a new paradigm that has emerged from the recent advancements in endovascular technology: The Resuscitative Balloon Occlusion of the Aorta (REBOA). Thanks to the advances in technology, a bridge has been created between Pre-hospital Management and the Control of Bleeding described in Stage I of DCS which is the inclusion and placement of a REBOA. We have been able to show that REBOA is not only a tool that aids in the control of hemorrhage, it is also a vital tool in the hemodynamic resuscitation of a severely injured blunt and/or penetrating trauma patient. That is why we propose a new paradigm "The Fourth Pillar": Permissive Hypotension, Hemostatic Resuscitation, Damage Control Surgery and REBOA.
Topics: Aorta; Balloon Occlusion; Endovascular Procedures; Humans; Hypotension, Controlled; Injury Severity Score; Resuscitation; Wounds and Injuries
PubMed: 33795897
DOI: 10.25100/cm.v51i4.4353 -
The Western Journal of Emergency... Mar 2019Emergency physicians (EP) frequently resuscitate and manage critically ill patients. Resuscitation of the crashing obese patient presents a unique challenge for even the... (Review)
Review
Emergency physicians (EP) frequently resuscitate and manage critically ill patients. Resuscitation of the crashing obese patient presents a unique challenge for even the most skilled physician. Changes in anatomy, metabolic demand, cardiopulmonary reserve, ventilation, circulation, and pharmacokinetics require special consideration. This article focuses on critical components in the resuscitation of the crashing obese patient in the emergency department, namely intubation, mechanical ventilation, circulatory resuscitation, and pharmacotherapy. To minimize morbidity and mortality, it is imperative that the EP be familiar with the pearls and pitfalls discussed within this article.
Topics: Anti-Infective Agents; Anticoagulants; Cardiopulmonary Resuscitation; Cardiovascular Agents; Cardiovascular System; Critical Illness; Disease Management; Drug Dosage Calculations; Emergency Service, Hospital; Emergency Treatment; Humans; Hypnotics and Sedatives; Obesity; Out-of-Hospital Cardiac Arrest; Patient Positioning; Respiration, Artificial; Resuscitation
PubMed: 30881553
DOI: 10.5811/westjem.2018.12.41085 -
Chirurgia (Bucharest, Romania : 1990) 2017Damage control surgery is a combination of temporizing surgical interventions to arrest hemorrhage and control infectious source, with goal directed resuscitation to... (Review)
Review
Damage control surgery is a combination of temporizing surgical interventions to arrest hemorrhage and control infectious source, with goal directed resuscitation to restore normal physiology. The convention of damage control surgery largely arose following the discovery of the lethal triad of hypothermia, acidosis, and coagulopathy, with the goal of Damage Control Surgery (DCS) is to avoid the initiation of this "bloody vicious cycle" or to reverse its progression. While hypothermia and acidosis are generally corrected with resuscitation, coagulopathy remains a challenging aspect of DCS, and is exacerbated by excessive crystalloid administration. This chapter focuses on resuscitative principles in the four settings of trauma care: the prehospital setting, emergency department, operating room, and intensive care unit including historical perspectives, resuscitative methods, controversies, and future directions. Each setting provides unique challenges with specific goals of care.
Topics: Acidosis; Blood Coagulation Disorders; Hemorrhage; Humans; Hypothermia; Practice Guidelines as Topic; Resuscitation; Shock, Hemorrhagic
PubMed: 29088551
DOI: 10.21614/chirurgia.112.5.514 -
JAMA Surgery Feb 2023Aortic occlusion (AO) is a lifesaving therapy for the treatment of severe traumatic hemorrhagic shock; however, there remains controversy whether AO should be...
IMPORTANCE
Aortic occlusion (AO) is a lifesaving therapy for the treatment of severe traumatic hemorrhagic shock; however, there remains controversy whether AO should be accomplished via resuscitative thoracotomy (RT) or via endovascular balloon occlusion of the aorta (REBOA) in zone 1.
OBJECTIVE
To compare outcomes of AO via RT vs REBOA zone 1.
DESIGN, SETTING, AND PARTICIPANTS
This was a comparative effectiveness research study using a multicenter registry of postinjury AO from October 2013 to September 2021. AO via REBOA zone 1 (above celiac artery) was compared with RT performed in the emergency department of facilities experienced in both procedures and documented in the prospective multicenter Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery (AORTA) registry. Propensity score matching (PSM) with exact institution matching was used, in addition to subgroup multivariate analysis to control for confounders. The study setting included the ED, where AO via RT or REBOA was performed, and participants were adult trauma patients 16 years or older.
EXPOSURES
AO via REBOA zone 1 vs RT.
MAIN OUTCOMES AND MEASURES
The primary outcome was survival. Secondary outcomes were ventilation-free days (VFDs), intensive care unit (ICU)-free days, discharge Glasgow Coma Scale score, and Glasgow Outcome Score (GOS).
RESULTS
A total of 991 patients (median [IQR] age, 32 [25-48] years; 808 male individuals [81.9%]) with a median (IQR) Injury Severity Score of 29 (18-50) were included. Of the total participants, 306 (30.9%) had AO via REBOA zone 1, and 685 (69.1%) had AO via RT. PSM selected 112 comparable patients (56 pairs). REBOA zone 1 was associated with a statistically significant lower mortality compared with RT (78.6% [44] vs 92.9% [52]; P = .03). There were no significant differences in VFD greater than 0 (REBOA, 18.5% [10] vs RT, 7.1% [4]; P = .07), ICU-free days greater than 0 (REBOA, 18.2% [10] vs RT, 7.1% [4]; P = .08), or discharge GOS of 5 or more (REBOA, 7.5% [4] vs RT, 3.6% [2]; P = .38). Multivariate analysis confirmed the survival benefit of REBOA zone 1 after adjustment for significant confounders (relative risk [RR], 1.25; 95% CI, 1.15-1.36). In all subgroup analyses (cardiopulmonary resuscitation on arrival, traumatic brain injury, chest injury, pelvic injury, blunt/penetrating mechanism, systolic blood pressure ≤60 mm Hg on AO initiation), REBOA zone 1 offered an either similar or superior survival.
CONCLUSIONS AND RELEVANCE
Results of this comparative effectiveness research suggest that REBOA zone 1 provided better or similar survival than RT for patients requiring AO postinjury. These findings provide the ethically necessary equipoise between these therapeutic approaches to allow the planning of a randomized controlled trial to establish the safety and effectiveness of REBOA zone 1 for AO in trauma resuscitation.
Topics: Adult; Humans; Male; Shock, Hemorrhagic; Prospective Studies; Thoracotomy; Empiricism; Aorta; Resuscitation; Cardiopulmonary Resuscitation; Injury Severity Score; Aortic Diseases; Balloon Occlusion
PubMed: 36542395
DOI: 10.1001/jamasurg.2022.6393 -
American Family Physician Apr 2011Appropriate resuscitation must be available for each of the more than 4 million infants born annually in the United States. Ninety percent of infants transition safely,... (Review)
Review
Appropriate resuscitation must be available for each of the more than 4 million infants born annually in the United States. Ninety percent of infants transition safely, and it is up to the physician to assess risk factors, identify the nearly 10 percent of infants who need resuscitation, and respond appropriately. A team or persons trained in neonatal resuscitation should be promptly available to provide resuscitation. The Neonatal Resuscitation Program, which was initiated in 1987 to identify infants at risk of needing resuscitation and provide high-quality resuscitation, underwent major updates in 2006 and 2010. Among the most important changes are to not intervene with endotracheal suctioning in vigorous infants born through meconium-stained amniotic fluid (although endotracheal suctioning may be appropriate in nonvigorous infants); to provide positive pressure ventilation with one of three devices when necessary; to begin resuscitation of term infants using room air or blended oxygen; and to have a pulse oximeter readily available in the delivery room. The updated guidelines also provide indications for chest compressions and for the use of intravenous epinephrine, which is the preferred route of administration, and recommend not to use sodium bicarbonate or naloxone during resuscitation. Other recommendations include confirming endotracheal tube placement using an exhaled carbon dioxide detector; using less than 100 percent oxygen and adequate thermal support to resuscitate preterm infants; and using therapeutic hypothermia for infants born at 36 weeks' gestation or later with moderate to severe hypoxic-ischemic encephalopathy.
Topics: Adrenergic Agonists; Animals; Canada; Continuous Positive Airway Pressure; Epinephrine; Evidence-Based Medicine; Humans; Hypothermia, Induced; Hypoxia-Ischemia, Brain; Infant, Newborn; Infant, Premature; Patient Care Team; Positive-Pressure Respiration; Practice Guidelines as Topic; Premature Birth; Randomized Controlled Trials as Topic; Resuscitation; Resuscitation Orders; United States
PubMed: 21524031
DOI: No ID Found -
Clinical Microbiology Reviews Dec 2021Cardiopulmonary resuscitation (CPR) is an emergency lifesaving endeavor, performed in either the hospital or outpatient settings, that significantly improves outcomes... (Review)
Review
Cardiopulmonary resuscitation (CPR) is an emergency lifesaving endeavor, performed in either the hospital or outpatient settings, that significantly improves outcomes and survival rates when performed in a timely fashion. As with any other medical procedure, CPR can bear potential risks not only for the patient but also for the rescuer. Among those risks, transmission of an infectious agent has been one of the most compelling triggers of reluctance to perform CPR among providers. The concern for transmission of an infection from the resuscitated subject may impede prompt initiation and implementation of CPR, compromising survival rates and neurological outcomes of the patients. Infections during CPR can be potentially acquired through airborne, droplet, contact, or hematogenous transmission. However, only a few cases of infection transmission have been actually reported globally. In this review, we present the available epidemiological findings on transmission of different pathogens during CPR and data on reluctance of health care workers to perform CPR. We also outline the levels of personal protective equipment and other protective measures according to potential infectious hazards that providers are potentially exposed to during CPR and summarize current guidelines on protection of CPR providers from international societies and stakeholders.
Topics: Cardiopulmonary Resuscitation; Humans
PubMed: 34319149
DOI: 10.1128/CMR.00018-21 -
Anaesthesiology Intensive Therapy 2015While organ hypoperfusion caused by inadequate resuscitation has become rare in clinical practice due to the better understanding of burn shock pathophysiology, there is... (Review)
Review
An overview on fluid resuscitation and resuscitation endpoints in burns: Past, present and future. Part 2 - avoiding complications by using the right endpoints with a new personalized protocolized approach.
While organ hypoperfusion caused by inadequate resuscitation has become rare in clinical practice due to the better understanding of burn shock pathophysiology, there is growing concern that increased morbidity and mortality related to over-resuscitation induced by late 20th century resuscitation strategies based on urine output, is occurring more frequently in burn care. In order to reduce complications related to this concept of "fluid creep", such as respiratory failure and compartment syndromes, efforts should be made to resuscitate with the least amount of fluid to provide adequate organ perfusion. In this second part of a concise review, the different targets and endpoints used to guide fluid resuscitation are discussed. Special reference is made to the role of intra-abdominal hypertension in burn care and adjunctive treatments modulating the inflammatory response. Finally, as urine output has been recognized as a poor resuscitation target, a new personalized stepwise resuscitation protocol is suggested which includes targets and endpoints that can be obtained with modern, less invasive hemodynamic monitoring devices like transpulmonary thermodilution.
Topics: Burns; Central Venous Pressure; Endpoint Determination; Fluid Therapy; Humans; Intra-Abdominal Hypertension; Precision Medicine; Resuscitation; Urination
PubMed: 26480868
DOI: 10.5603/AIT.a2015.0064