Can intubation be improved with endotracheal tubes marked with a color scale? Randomized controlled study.

Objective: To assess if a color scale in the endotracheal tube (ETT) helps operators to correctly select the size and depth of placement of the ETT and decrease the time required, compared with the usual numeric ETT scale, in a mannequin model. Design/Methods: The study was conducted in 8 centers. Each size of the ETT was identified with different color by size. All experimental ETT had two painted zones: the mouthpiece and an area of 1 cm marked with the same color (to identify where the ETT should be taped above the lip). The operators were trained as part of the protocol using a video. Four clinical scenarios requiring endotracheal intubation were designed and randomly assigned. Each operator had to select the size and depth of ETT based on the BW, and then had to perform 4 intubation procedures. Results: 108 operators performed 432 intubations. No difference were found in the correct placement and selection of the ETT. Median time (in seconds) required for intubation using numeric vs. experimental tube was: for ETT Ø 2.5, 11.5 vs. 8 (p<0.001), ETTØ3,12 vs. 10 (p<0.001), ETT Ø 3.5, 15.5 vs.12 (p 0.003), ETT Ø4 12 vs.11 (p 0.019). Conclusions: No significant difference was observed in the selection and correct placement of the ETT. However, the intubation time was significantly shorter using the experimental ETT. This device could improve the effectiveness of intubation by reducing the time needed to properly place the ETT at mid trachea.

Comparison of different mechanical chest compression devices in the alpine rescue setting: a randomized triple crossover experiment

Background Cardiopulmonary resuscitation in mountain environment is challenging. Continuous chest compressions during transport or hoist rescue are almost impossible without mechanical chest compression devices. Current evidence is predominantly based on studies conducted by urbane ambulance service. Therefore, we aimed to investigate the feasibility of continuous mechanical chest compression during alpine terrestrial transport using three different devices. Methods Randomized triple crossover prospective study in an alpine environment. Nineteen teams of the Austrian Mountain Rescue Service trained according to current ERC guidelines performed three runs each of a standardised alpine rescue-scenario, using three different devices for mechanical chest compression. Quality of CPR, hands-off-time and displacement of devices were measured. Results The primary outcome of performed work (defined as number of chest compressions x compression depth) was 66,062 mm (2832) with Corpuls CPR, 65,877 mm (6163) with Physio-Control LUCAS 3 and 40,177 mm (4396) with Schiller Easy Pulse. The difference both between LUCAS 3 and Easy Pulse (Δ 25,700; 95% confidence interval 21,118 – 30,282) and between Corpuls CPR and Easy Pulse (Δ 25,885; 23,590 – 28,181) was significant. No relevant differences were found regarding secondary outcomes. Conclusion Mechanical chest compression devices provide a viable option in the alpine setting. For two out of three devices (Corpuls CPR and LUCAS 3) we found adequate quality of CPR. Those devices also maintained a correct placement of the piston even during challenging terrestrial transport. Adequate hands-off-times and correct placement could be achieved even by less trained personnel.

Nasogastric tube in critical care setting: combining ETCO2 and pH measuring to confirm correct placement

Introduction: nasogastric tube (NGT) placement is a common procedure performed in critical care setting. Chest X-Ray is the diagnostic gold-standard to confirm correct placement, with the downsides of both the need for critical care patients' mobilization and intrinsic actinic risk. Other potential methods to confirm NGT placement have shown lower accuracy compared to chest X-ray; ETCO2 and pH analysis have singularly yet investigated as an alternative to the gold standard. Aim of this study was to determine thresholds in combine measurements of ETCO2 and pH values, at which correct NGT positioning can be confirmed with the highest accuracy. Material & Methods: a prospective, multicenter, observational trial; a continuous cohort of eligible patients was allocated to two arms, to identify clear cut-off threshold able to detect correct NGT tip positioning with the maximal accuracy. Patients underwent general anesthesia and orotracheal intubation; in the first group difference between tracheal and esophageal ETCO2 values were assessed. In the second group difference between esophageal and gastric pH values were determined. Results: from November 2020 to March 2021, 85 consecutive patients were enrolled: 40 in the ETCO2 group and 45 in the pH group. The ETCO2 ROC analysis for predicting NGT tracheal misplacement demonstrate an optimal ETCO2 cutoff value of 25.5 mmHg, where both sensitivity than specificity reach 1.0 (AUC 1.0, p < 0.001). The pH ROC analysis for predicting NGT correct gastric placement demonstrated the optimal pH cutoff value at 4.25, with a mild diagnostic accuracy (AUC 0.79, p < 0.001). Discussion: A device capable of combining the presence of a negative marker with a positive marker could be accurate enough in identifying the correct NGTs positioning. Further studies are required to validate the reproducibility of these results by a specific device, whose accuracy also ought to be compared with standard chest X-ray.

Uncommon Iatrogenic Devices Seen on Chest Radiographs

Chest radiograph (CXR) is the most common imaging performed for both inpatients and outpatients. With advances in medicine and technology, newer devices/prosthesis are being used in the treatment of cardiothoracic conditions. Some of these are common while others are seen only in a handful of cases, especially in patients being treated or referred from tertiary care centers. It is important to know about these devices, their functionality, and radiographic appearances. Many of these devices also help us in understanding the clinical condition of the patient, as some are only used in unstable patients. Newer methods of life support are now available in intensive care units and these also can be seen on CXRs. In this review, we present various iatrogenic devices that we come across on a CXR and highlight important features to determine their correct placement and potential complications. The review looks at cardiac temporary and permanent pacing devices, cardiac interventional devices used to treat congenital heart disease, newer cardiac monitoring devices, and unusual surgical devices that one may come across on a CXR. We also suggest a stepwise algorithm to assess these devices on a CXR.

Accuracy of ECG chest electrode placements by paramedics: an observational study

Background: The use of the 12-lead electrocardiogram (ECG) is common in sophisticated pre-hospital emergency medical services but its value depends upon accurate placement of the ECG electrodes. Several studies have shown widespread variation in the placement of chest electrodes by other health professionals but no studies have addressed the accuracy of paramedics. The main objective of this study was to ascertain the accuracy of the chest lead placements by registered paramedics.Methods: Registered paramedics who attended the Emergency Services Show in Birmingham in September 2018 were invited to participate in this observational study. Participants were asked to place the chest electrodes on a male model in accordance with their current practice. Correct positioning was determined against the Society for Cardiological Science and Technology’s 2017 clinical guidelines for recording a standard 12-lead ECG, with a tolerance of 19 mm being deemed acceptable based upon previous studies.Results: Fifty-two eligible participants completed the study. Measurement of electrode placement in the vertical and horizontal planes showed a high level of inaccuracy, with 3/52 (5.8%) participants able to accurately place all chest electrodes. In leads V1‐V3, the majority of incorrect placements were related to vertical displacement, with most participants able to identify the correct horizontal position. In V4, the tendency was to place the electrode too low and to the left of the pre-determined position, while V5 tended to be below the expected positioning but in the correct horizontal alignment. There was a less defined pattern of error in V6, although vertical displacement was more likely than horizontal displacement.Conclusions: Our study identified a high level of variation in the placement of chest ECG electrodes, which could alter the morphology of the ECG. Correct placement of V1 improved placement of other electrodes. Improved initial and refresher training should focus on identification of landmarks and correct placement of V1.

Patients with osteoarthritis of the knee: management in the outpatient setting

The article discusses the treatment of osteoarthritis. To prevent serious structural and functional changes, it is extremely important to start therapy in the early stages of the disease. Symptomatic slow-acting drugs for the treatment of osteoarthritis (SYSADOA) are an important class in the pharmacological arsenal of OA treatment. The results of the use of this group of drugs in numerous clinical studies have demonstrated good effectiveness in the long-term achievement of the goal. The SYSADOA class (chondroprotectors) includes many different drugs, including glucosamine, chondroitin, diacerein, and soy unsaponifiable avocado substances. Particular attention is paid to the injectable forms of chondroprotective drugs, data from experimental and clinical studies confirming their effectiveness. The authors discuss the issue of intra-articular administration of drugs for knee osteoarthritis and the choice of optimal access. Intra-articular drug delivery has a number of advantages over systemic delivery, including increased local bioavailability, reduced systemic exposure, fewer side effects, and reduced cost. To minimize side effects, it is important to determine the injection site and to have some preparation in the correct placement of the needle during these procedures. To improve the accuracy of intraarticular injections, various imaging methods can be used, but ultrasound of the musculoskeletal system is the most practical. The article presents the data of personal experience of choosing access under the control of ultrasound. Taking into account the anatomy of the knee joint, performing an intra-articular injection from the inside into the upper inversion is the most affordable and optimal. The article presents the data of a clinical example of the introduction of chondroprotectors through the selected access.