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Research Review

CPR Instructions for Cell Phones
Merchant RM, Abella BS, Abotsi EJ, et al. Cell phone cardiopulmonary resuscitation: Audio instruction when needed by lay rescuers: a randomized, controlled trial. Ann Emerg Med. 2010;55:538–543.

With all the applications available for cellular devices, who would’ve thought of having pre-recorded CPR instructions available on your phone? These authors randomly assigned trained and untrained lay volunteers to perform CPR on a manikin for three minutes. Both groups performed CPR with and without the assistance of the recorded message.

The authors found that when the participants were coached by the recorded message, they had a better compression rate, compression depth and hand placement independent of whether they’d received previous training. Participants coached by the audio recording also had fewer pauses in their CPR cycles. This application makes you wonder what others will be made available to improve bystander response to emergencies.

Evidence-Based Pediatric Trauma Protocols
Shah MI. Prehospital management of pediatric trauma. Clin Pediatr Emerg Med. 2010;11:10–17.

I’ve written at length in the past about the need to base out-of-hospital treatment protocols on scientific evidence. The author of this study addresses seven controversial areas of pediatric trauma care and discusses the lack of scientific evidence for many of the actions we take in caring for this patient population.

Examples of the issues include IV and IO access and infusion. The author discusses the lack of scientific evidence supporting placing an IV in a pediatric patient. Airway management is another controversial topic presented. The author evaluates the research surrounding time requirements for rapid sequence intubation (RSI) and non-RSI intubations in pediatrics, noting that increased prehospital time has a direct relationship with poorer outcomes.

Other topics in this study include triage and transport, C-spine immobilization, traumatic brain injury, and pain assessment and management.

Caring for children in the prehospital environment may not be a daily event for you, but wouldn’t it be nice to know that the care you provided was supported by scientific research? This might be a good article for your next journal club.

Intubation experience & Patient Outcome
Wang HE, Balasubramani GK, Cook LJ, et al. Out-of-hospital endotracheal intubation experience and patient outcome. Ann Emerg Med. 2010;55:527–537.

It would seem as if the conclusion could easily be predicted from the title of this article; however, you’d be only half right if you said more experience equals better outcomes for all types of intubations. This study compares the outcomes of patients who underwent endotracheal (ET) intubation with the skill level of the provider and found that more experience was important only for survival of cardiac arrest or medical non-arrest patients. Provider experience didn’t correlate with better survival for traumatic non-arrest patients.

This is an interesting finding. The authors don’t attempt to provide a reason for the conclusion, which opens the door for others to examine it further.

What makes it more important to be highly experienced for cardiac arrest intubation than others? Are traumatic non-arrest patients easier to intubate? This certainly could provide the fuel for some thought-provoking discussions.

Airway Management
Kobayashi M, Fujiwara A, Morita H, et al. Verification of airway management during cardiac arrest: A manikin-based observational study. Am J Emerg Med. 2010;28:499–504.

Establishing a definitive airway has always been a routine part of CPR. However, like many things in EMS, there’s no evidence that the number of patients surviving to hospital discharge is improved as a result of intubation. Since the American Heart Association’s advanced cardiac life support (ACLS) guidelines were issued in 2005, the emphasis has been on not interrupting chest compressions to establish an ET airway.

But if more consistent, uninterrupted chest compressions are the norm, then why hasn’t patient survival improved? These authors evaluate various time intervals of resuscitation in an effort to determine whether other interruptions play a part in poor outcomes.

At a simulated cardiac arrest station at a widely attended conference, the authors videotaped participants in an effort to establish this intubation time line. What they found was that chest compressions aren’t significantly interrupted to place an advanced airway. However, ventilation is significantly interrupted for ET placement.

The ACLS guidelines state that an intubation should take no longer than 30 seconds. But how is intubation defined? These authors conclude that intubation has four distinct stages: final ventilation, insertion of the laryngoscope, removal of the laryngoscope and restart of ventilation.

These stages are the same whether the intubation is successful or unsuccessful. The authors found that this sequence takes longer than 30 seconds in most patients.

Outcomes from cardiac arrest are very poor. We owe it to our patients to determine other areas where we can improve their chance of survival. Next time you have an intubation skills practice, evaluate the amount of time between ventilations. If you can’t make the 30-second mark, you should consider a different airway device. JEMS

This article originally appeared in August 2010 JEMS as “Research Review.”
 



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