Point-of-Care Ultrasound Use by EMS Providers in Out-of-Hospital Cardiac Arrest

Aim: Paramedics received training in point-of-care ultrasound (POCUS) to assess for cardiac contractility during management of medical out-of-hospital cardiac arrest (OHCA). The primary outcome was the percentage of adequate POCUS video acquisition and accurate video interpretation during OHCA resuscitations. Secondary outcomes included POCUS impact on patient management and resuscitation protocol adherence. Methods: A prospective, observational cohort study of paramedics was performed following a four-hour training session, which included a didactic lecture and hands-on POCUS instruction. The Prehospital Echocardiogram in Cardiac Arrest (PECA) protocol was developed and integrated into the resuscitation algorithm for medical non-shockable OHCA. The ultrasound (US) images were reviewed by a single POCUS expert investigator to determine the adequacy of the POCUS video acquisition and accuracy of the video interpretation. Change in patient management and resuscitation protocol adherence data, including end-tidal carbon dioxide (EtCO2) monitoring following advanced airway placement, adrenaline administration, and compression pauses under ten seconds, were queried from the prehospital electronic health record (EHR). Results: Captured images were deemed adequate in 42/49 (85.7%) scans and paramedic interpretation of sonography was accurate in 43/49 (87.7%) scans. The POCUS results altered patient management in 14/49 (28.6%) cases. Paramedics adhered to EtCO2 monitoring in 36/36 (100.0%) patients with an advanced airway, adrenaline administration for 38/38 (100.0%) patients, and compression pauses under ten seconds for 36/38 (94.7%) patients. Conclusion: Paramedics were able to accurately obtain and interpret cardiac POCUS videos during medical OHCA while adhering to a resuscitation protocol. These findings suggest that POCUS can be effectively integrated into paramedic protocols for medical OHCA.

Effects of xylazine and adrenaline combinations: Preliminary clinical application for non-surgical protocols of nephrosplenic entrapment in horses

Background and Aim: The medical treatment of horses with nephrosplenic entrapment (NSE) of the large colon through administrating phenylephrine and rolling during general anesthesia was effective and less expensive than surgical treatment. However, the selection of drugs for non-surgical treatment of NSE is not a usual method for clinical practice. This study aimed to identify the effects of combined drugs on the cardiac and splenic response in horses and provide information on the NSE of the large colon for clinical application. Materials and Methods: Six healthy Thai native crossbred horses were enrolled in this study. Horses received two protocols with a withdrawal period of 14 days: Group 1 received xylazine (0.5 mg/kg IV) and adrenaline (1 mcg/kg IV), and Group 2 received xylazine (0.5 mg/kg IV) and adrenaline (3 mcg/kg IV). Heart rate (HR), HR variability (HRV), heart dimensions, and the splenic response of six horses were measured before the sedation, 30 and 60 min later, and 65, 70, 75, 80, 90, and 100 min after adrenaline administration. Doppler was used to obtain systolic blood pressure. Results: The HRV low-frequency and high-frequency power ratios decreased after using xylazine. Hypertension was observed after adrenaline administration. In this study, there were only minimal differences in the HR and respiratory rate between groups. However, overall cardiac and splenic parameters were statistically higher in Group 2. Conclusion: This study suggested that xylazine and three micrograms of adrenaline preserved the cardiac autonomic activity balance and were safe to use non-surgical applicability in horses.

A Novel Approach for More Effective Emergency Equipment Storage: The Task-Based Package-Organized Neonatal Emergency Backpack

Objectives: To evaluate a new task-based package-organized (TPO) neonatal emergency backpack and to compare it to the classical (ABC- and material-based) backpack.Methods: Simulation-based assessment of time to retrieve equipment for three different tasks [intraosseous access (IO), intubation and adrenaline administration] using the TPO and the classical emergency backpack was compared.Results: Equipment retrieval times for the three tasks were assessed for 24 nurses (12 intermediate care, 12 intensive care) and were significantly faster in the TPO than in the classical backpack (IO 33 vs. 75 s, p < 0.001; intubation 53 vs. 70 s, p = 0,001; adrenaline 22 vs. 45 s, p < 0.001). The number of missing items was significantly lower using the TPO backpack for IO and adrenaline retrieval (IO 0,9 vs. 2,3 items, p < 00001, adrenaline 0.04 vs. 1, p < 0.001) but not for intubation equipment (0.9 vs. 1, not significant). The subjective rating of overall clearness was significantly higher for the TPO compared with the classical backpack (5,9 vs. 3,5, p < 0.001).Conclusion: Task-based package organization of neonatal emergency backpacks is feasible and might be superior to ABC-/material-oriented storage.

Paradoxical refractory hypotension following adrenaline administration in a patient taking clozapine

Clozapine is a potent antipsychotic commonly used for refractory schizophrenia. Adverse effects are well recognised including constipation, intestinal obstruction, agranulocytosis and cardiomyopathy. We present a case of paradoxical refractory hypotension following epinephrine administration in a patient taking clozapine. A psychiatric inpatient who had been taking clozapine for many years developed paralytic ileus and obstruction requiring surgical intervention. Following initiation of epinephrine administration intraoperatively he developed refractory hypotension which improved only when epinephrine was weaned off. This effect is likely due to uninterrupted β2-agonist activity in the presence of clozapine-induced α-blockade. Clinicians need to have greater awareness of this serious interaction and avoid the use of epinephrine in patients taking clozapine.

Evaluation of anaphylaxis recurrence and adrenaline autoinjector use in childhood

Introduction: Limited data are available on recurrent anaphylaxis in childhood. Delayed adrenaline administration is the major cause of deaths due to anaphylaxis. As well as prescribing the adrenaline autoinjector (AAI), it is important to make sure that the patient carries the device at all times and uses it correctly for the appropriate indication. Objective: The aim of our study was to evaluate the recurrence of anaphylaxis and AAI use in childhood. Methods: Pediatric patients who were evaluated for anaphylaxis and prescribed AAI between January 2015 and December 2018, in the pediatric allergy and immunology clinic of our hospital were screened retrospectively. A telephone-based survey was conducted with the parents of the patients to investigate the recurrence of anaphylaxis in patients and the use of AAI by their parents for the management of anaphylaxis. Results: A total of 148 patients (64.9% boys) were prescribed an AAI for anaphylaxis. The telephone survey could be conducted with 111 parents (75%) with an AAI prescription. Of these patients, 23.4% (n = 26) of the parents reported that their children experienced recurrent episodes of anaphylaxis. In the recurrent anaphylaxis cases, the triggers were foods in 77%, venoms in 11.5%, drugs in 3.8%, and idiopathic anaphylaxis in 7.7% of the patients. AAI use at the time of anaphylaxis was reported by 42.3% of the parents. The reasons cited by the parents for not using AAI during an episode of anaphylaxis included the preference to have adrenaline administered at a health care facility because of its proximity (60%), fear of using the device (13.3%), hesitation (6.7%), not having the device with them (13.3%), and unavailability of the device (6.7%). Conclusion: Educating the patients and families about the importance of using AAI is crucial, and training on how to use the device should be repeated at each clinic visit and every opportunity.

Improving medical workforce knowledge of adrenaline (epinephrine) administration in treatment of anaphylaxis in adults

Aim: To compare results of repeated surveys (2010, 2015 and 2017) regarding the knowledge of the medical workforce potentially involved in adrenaline administration for the emergency treatment of anaphylaxis in adults Methods: Convenience samples of medical (and advanced nursing) staff were surveyed on three separate occasions (2010, 2015 and 2017). Several educational methods were used to increase awareness of the specific administration of adrenaline. Results: Overall, knowledge of the medical workforce regarding correct first dose adrenaline administration improved from 15% in 2010 to 49% in 2015 and finally 63% in 2017. Conclusion: This survey comparison shows knowledge of the medical workforce regarding adrenaline administration for treatment of anaphylaxis in adults can be significantly improved by employing a variety of educational methods.

Food-induced anaphylaxis in children – state of art

Food-induced anaphylaxis is the most frequent type of anaphylaxis and the most common cause of fatal acute hypersensitivity reactions in children. It typically occurs after accidental food exposure, after inhalation of food allergen, cutaneous contact and controlled oral food challenge. There is no consensus on a universal clinical definition of anaphylaxis or a uniform symptoms severity score. Recent advances in molecular allergology allow, in many cases, the detailed identification of the allergenic molecule responsible for anaphylaxis. Along with the development of precision medicine, new phenotypes and endotypes of anaphylaxis are being defined. The anaphylaxis course is entirely unpredictable, and even initially mild symptoms may herald a potentially fatal reaction. At the same time, a significant proportion of immediate food hypersensitivity episodes are mild and known as systemic allergic reactions. The occurrence and severity of clinical course of food-induced anaphylaxis are influenced by factors related directly to the child, coexisting diseases, the type and the nature of the allergen, or the presence of cofactors. The unpredictable course of anaphylaxis justifies immediate treatment based on rapid intramuscular administration of adrenaline, regardless of severity. Delayed adrenaline administration is associated with higher incidence of severe course and death. Appropriate and prompt treatment of anaphylaxis is even more critical during the COVID-19 pandemic due to difficult access to medical facilities, hence current treatment plans for food-induced anaphylaxis emphasise the need to administer adrenaline immediately after the onset of the first, even mild, but rapidly progressive symptoms and recommend that the patient have at least two adrenaline autoinjectors.

OP7 Did west midlands ambulance service paramedics’ usage of adrenaline change after the publication of the paramedic2 results, but prior to any guideline change? A service evaluation

BackgroundThis project evaluated whether practice change occurred amongst Paramedics directly after the publication of the PARAMEDIC2 trial, regarding adrenaline administration during out-of-hospital cardiac arrest (OHCA) without a change in guidelines. When Paramedics are exposed to a seminal publication there is anecdotal concern their autonomous practice changes, based on comprehension of findings ahead of potential guideline changes, however little evidence appraises whether this really occurs.MethodsA service evaluation to determine any variation in adrenaline administration during OHCA, before and after publication of the PARAMEDIC2 trial.WMAS electronic patient record data that has been collected for use within OHCA ambulance quality indicators was used to evaluate practice variation.Proportion of adult patients receiving adrenaline, number of administrations and time to first administration from EMS arrival (or arrest if EMS witnessed) are reported.This evaluation assesses from the day after recruitment ended on 18th October 2017 until the trial results publication on 19th July 2018, and the same timeframe (273 days) post-publication.ResultsProportion receiving adrenalinePre-publication: 88.7% of 3026 casesPost-publication: 88.0% of 2682 casesMean number of adrenaline administrationsPre-publication: 4Post-publication: 4Mean time to adrenalinePre-publication: 30:02 minutesPost-publication: 30:11 minutesConclusionsIn both datasets, average time to first adrenaline administration and number of administrations were found to be similar. This suggests Paramedic practice adheres to current guidelines when a highly anticipated article is published, however this may vary by intervention so further work is recommended. Limitations of retrospective observational evaluations include uncontrolled treatment variables; however randomised controlled trials cannot assess standard practice. Individuals need continued awareness for implications of changing practice following a trial publication, as patient safety could be breached whilst the wider medical community are scrutinising the trial results. This demonstrates how routine data can be used to evaluate practice and changes within it.