Research round-up – 14 June

Research round-up – 14 June
Research round-up – 14 June

Research published in this week includes studies on cardiac arrest management; using end-tidal carbon dioxide to predict ROSC; predicting survival from drowning; advice on cardiovascular implanted electronic devices in people towards the end of life; analgesia for sciatica; use of tourniquets; recognition of stroke; remote ischaemic conditioning in patients with STEMI; use of logbooks for clinical training and a series of articles on neonate assessment and common medical conditions.

Cardiac arrest management

This study identified that team-focused CPR, witnessed arrest, initial shockable rhythm and in-hospital hypothermia were associated with good neurologic outcome while use of a mechanical CPR device, CPR feedback device and endotracheal intubation were associated with less likelihood for a good neurologic outcome.

Comparison of team-focused CPR vs standard CPR in resuscitation from out-of-hospital cardiac arrest: Results from a statewide quality improvement initiative

Resuscitation. Available online 27 April 2016.

Background: Team-focused CPR (TFCPR) is a choreographed approach to cardiopulmonary resuscitation (CPR) with emphasis on minimally interrupted high-quality chest compressions, early defibrillation, and discourages endotracheal intubation and encourages use of the bag-valve-mask (BVM) and/or blind-insertion airway device (BIAD) with a ventilation rate of 8–10 breaths/min to minimise hyperventilation. Widespread incorporation of TFCPR in North Carolina (NC) EMS agencies began in 2011, yet its impact on outcomes is unknown.

Objectives: To determine whether TFCPR improves survival with good neurological outcome in out-of-hospital cardiac arrest (OHCA) patients compared to standard CPR.

Methods: This retrospective cohort analysis of NC EMS agencies reporting data to the Cardiac Arrest Registry for Enhanced Survival (CARES) database from January 2010 to June 2014 included adult, non-traumatic OHCA with presumed cardiac etiology where EMS performed CPR or patient received defibrillation. Exclusions were arrest terminated per EMS policy or DNR. EMS agencies self-reported the TFCPR implementation dates. Patients were categorised as receiving either TFCPR or standard CPR. The primary outcome was good neurologic outcome at time of hospital discharge defined as Pittsburgh Cerebral Performance Category (CPC) 1–2.

Results: Of 14,994 OHCAs, 14,129 patients were included for analysis with a mean age 65 (IQR 50–81) years, 61% male, 7.3% with good neurologic outcome, 24.3% with shockable initial rhythm, and 71.5% receiving TFCPR. Of the 3427 (24.3%) with an initial shockable rhythm, 739 (71.9%) had a good neurological outcome. Good neurologic outcome was higher with TFCPR [836 (8.3%)] vs. standard CPR [193 (4.8%)]. Logistic regression controlling for demographic and arrest characteristics revealed TFCPR (OR 1.5), witnessed arrest (OR 4.3), initial shockable rhythm (OR 7.1), and in-hospital hypothermia were associated with good neurologic outcome. Mechanical CPR device (OR 0.68), CPR feedback device (OR 0.47), and endotracheal intubation (OR 0.44) were associated with less likelihood for a good neurologic outcome.

Conclusion: In our statewide OHCA cohort, TFCPR was associated with improved survival with good neurological outcome.

To be implemented effectively, team-focussed CPR, or often termed the pit-crew approach, requires a well developed education system. Examples of implementing team-focused CPR and improving cardiac arrest survival rates can be found at:

End-tidal carbon dioxide indicates ROSC

This cross-sectional design study examined patients suffering a non-traumatic cardiac arrest brought into two regional hospitals and identified that a sudden rise in EtCOwas associated with ROSC. While use of EtCO2 has been used as a predictor of death (the US ACLS 2015 guideline states that after 20 minutes of cardiopulmonary resuscitation (CPR) EtCO is an important early prognosticator and, according to the European Resuscitation Council (ERC) resuscitation guideline 2015, EtCO2 should be part of a multi-modal approach to decision-making for ending resuscitative efforts) it can also be used to identify ROSC.

Abrupt rise of end tidal carbon dioxide level was a specific but non-sensitive marker of return of spontaneous circulation in patient with out-of-hospital cardiac arrest

Resuscitation. July 2016, Vol.104:53–58.

Objective: To evaluate the diagnostic accuracy of an abrupt and sustained increase in end-tidal carbon dioxide (ETCO2) to indicate return of spontaneous circulation (ROSC) during resuscitation of patient with out-of-hospital cardiac arrest.

Methods: Patients with age ≥18 years old, suffered non-traumatic out-of-hospital cardiac arrest with active resuscitation and endotracheal intubation performed in emergency department, were included. ETCOvalue was charted throughout resuscitation. Time of ROSC was remarked. ETCOlevels before and after ROSC were compared. Diagnostic accuracy of ETCOrise ≥10 mmHg, ETCO2 rise ≥20 mmHg, and ETCOrise to the level ≥40 mmHg were evaluated for indicating ROSC.

Results: ETCOlevel immediately after ROSC was higher as compared to the value before return of circulation (median ETCOwas 32 mmHg and 41 mmHg respectively). With ETCOrise ≥10 mmHg, the sensitivity was low (33%, 95% CI 22–47%), while specificity was 97%. Positive and negative predictive values were 83% and 74% respectively. The diagnostic accuracy was higher in cardiac arrest with presumed non-cardiac etiology (sensitivity 45%, specificity 100%) as compared to those with cardiac etiology (sensitivity 18%, specificity 97%).

Conclusions: The feature of an abrupt rise of ETCOwas a specific but non-sensitive marker of ROSC in patient with out-of-hospital cardiac arrest.

Further information on using capnography in out-of-hospital care can be found at:

Predicting survival from drowning

This review and meta-analysis identified that submersion durations of less than 5 minutes were associated with favourable outcomes, while those greater than 25 minutes were invariably fatal.

Predicting outcome of drowning at the scene: A systematic review and meta-analyses

Resuscitation. July 2016, Vol.104:63–75.

Objective: To identify factors available to rescuers at the scene of a drowning that predict favourable outcomes.

Method: PubMed, Embase and Cochrane Library were searched (1979–2015) without restrictions on age, language or location and references lists of included articles. Cohort and case–control studies reporting submersion duration, age, water temperature, salinity, emergency services response time and survival and/or neurological outcomes were eligible. Two reviewers independently screened articles for inclusion, extracted data, and assessed quality using GRADE. Variables for all factors, including time and temperature intervals, were categorised using those used in the articles. Random effects meta-analyses, study heterogeneity and publication bias were evaluated.

Results: Twenty-four cohort studies met the inclusion criteria. The strongest predictor was submersion duration. Meta-analysis showed that favourable outcome was associated with shorter compared to longer submersion durations in all time cutoffs evaluated: ≤5–6 min: risk ratio [RR] = 2.90; ≤10–11 min: RR = 5.11; ≤15–25 min: RR = 26.92. Favourable outcomes were seen with shorter EMS response times (RR = 2.84) and salt water versus fresh water (RR = 1.16). No difference in outcome was seen with victim’s age, water temperatures, or witnessed versus unwitnessed drownings.

Conclusions: Increasing submersion duration was associated with worse outcomes. Submersion durations <5 min were associated with favourable outcomes, while those >25 min were invariably fatal. This information may be useful to rescuers and EMS systems deciding when to perform a rescue versus a body recovery.

Cardiovascular implanted device guidance

Cardiovascular implanted electronic devices (CIEDs) include permanent pacemakers and implantable cardioverter defibrillators (ICDs). They provide effective treatment for many people by reducing symptoms and/or by preventing sudden cardiac death. This open access guidance includes advice deactivating devices and managing devices during a cardiac arrest.

Cardiovascular implanted electronic devices in people towards the end of life, during cardiopulmonary resuscitation and after death: guidance from the Resuscitation Council (UK), British Cardiovascular Society and National Council for Palliative Care

Heart 2016;102:A1-A17

The Resuscitation Council (UK), the British Cardiovascular Society (including the British Heart Rhythm Society and the British Society for Heart Failure) and the National Council for Palliative Care recognise the importance of providing clear and consistent guidance on management of cardiovascular implanted electronic devices (CIEDs) towards the end of life, during cardiorespiratory arrest and after death.

This document has been developed to provide guidance for the full range of healthcare professionals who may encounter people with CIEDs in the situations described and for healthcare managers and commissioners. The authors recognise that some patients and people close to patients may also wish to refer to this document. It is intended as an initial step to help to ensure that people who have CIEDs, or are considering implantation of one, receive explanation of and understand the practical implications and decisions that this entails; to promote a good standard of care and service provision for people in the UK with CIEDs in the circumstances described; to offer relevant ethical and legal guidance on this topic; to offer guidance on the delivery of services in relation to deactivation of CIEDs where appropriate; to offer guidance on whether any special measures are needed when a person with a CIED receives cardiopulmonary resuscitation; and to offer guidance on the actions needed when a person with a CIED dies.

Analgesia for sciatica 

While most cases of sciatica resolve by themselves within six weeks to three months, the acute pain or loss of power sometimes result in calls to either ambulance services or urgent care centres. This study, while perhaps not surprisingly, found that Morphine and acetaminophen are both effective for treating sciatica at 30 minutes, but morphine is superior to paracetamol.

Comparison of Intravenous Morphine Versus Paracetamol in Sciatica: A Randomised Placebo Controlled Trial

Academic Emergency Medicine. Volume 23, Issue 6, pages 674–678, June 2016

Objective: The objective was to compare intravenous morphine and intravenous acetaminophen (paracetamol) for pain treatment in patients presenting to the emergency department with sciatica.

Methods: Patients, between the ages of 21 and 65 years, suffering from pain in the sciatic nerve distribution and a positive straight leg-raise test composed the study population. Study patients were assigned to one of three intravenous interventions: morphine (0.1 mg/kg), acetaminophen (1 g), or placebo. Physicians, nurses, and patients were blinded to the study drug. Changes in pain intensity were measured at 15 and 30 minutes using a visual analog scale. Rescue drug (fentanyl) use and adverse effects were also recorded.

Results: Three-hundred patients were randomised. The median change in pain intensity between treatment arms at 30 minutes were as follows: morphine versus acetaminophen 25 mm, morphine versus placebo 41 mm and acetaminophen versus placebo 16 mm. Eighty percent of the patients in the placebo group, 18% of the patients in the acetaminophen group and 6% of those in the morphine group required a rescue drug. Adverse effects were similar between the morphine and acetaminophen groups.

Conclusion: Morphine and acetaminophen are both effective for treating sciatica at 30 minutes. However, morphine is superior to acetaminophen.

Use of tourniquets 

Tourniquets use in Australia can be considered as a first aider skill – the Australian Resuscitation Council’s  Principles for the control of bleeding for first aiders guideline advise that should be used for life threatening bleeding from a limb that cannot be controlled by direct pressure. This US review suggested that tourniquets can be used appropriately in the non-military environment for patients with major limb trauma that occur via blunt and penetrating mechanisms.

Safety and Appropriateness of Tourniquets in 105 Civilians

Prehospital Emergency Care. Published online 31 May 2016.

The United States military considers tourniquets to be effective for controlling bleeding from major limb trauma. The purpose of this study was to assess whether tourniquets are safely applied to the appropriate civilian patient with major limb trauma of any etiology.

Methods: Following IRB approval, patients arriving to a level-1 trauma centre between October 2008 and May 2013 with a prehospital (PH) or emergency department (ED) tourniquet were reviewed. Cases were assigned the following designations: absolute indication (operation within 2 hours for limb injury, vascular injury requiring repair/ligation, or traumatic amputation); relative indication (major musculoskeletal/soft-tissue injury requiring operation 2–8 hours after arrival, documented large blood loss); and non-indicated. Patients with absolute or relative indications for tourniquet placement were defined as indicated, while the remaining were designated as non-indicated. Complications potentially associated with tourniquets, including amputation, acute renal failure, compartment syndrome, nerve palsies, and venous thromboembolic events, were adjudicated by orthopaedic, hand or trauma surgical staff. Univariate analysis was performed to compare patients with indicated versus non-indicated tourniquet placement.

Results: A total of 105 patients received a tourniquet for injuries sustained via sharp objects, i.e., glass or knives (32%), motor vehicle collisions (30%), or other mechanisms (38%). A total of 94 patients (90%) had indicated tourniquet placement; 41 (44%) of which had a vascular injury. Demographics, mechanism, transport, and vitals were similar between patients that had indicated or non-indicated tourniquet placement. 48% of the indicated tourniquets placed PH were removed in the ED, compared to 100% of the non-indicated tourniquets. The amputation rate was 32% among patients with indicated tourniquet placement (vs. 0%). Acute renal failure (3.2 vs. 0%), compartment syndrome (2.1 vs. 0%), nerve palsies (5.3 vs. 0%), and venous thromboembolic events (9.1 vs. 8.5%) and were similar in patients that had indicated compared to non-indicated tourniquet placement. After adjudication, no complication was a result of tourniquet use.

Conclusion: The current study suggests that PH and ED tourniquets are used safely and appropriately in civilians with major limb trauma that occur via blunt and penetrating mechanisms.

Tourniquet use is only one element of haemorrhage control, bleeding should be effectively managed using a stepwise approach, for example by using a major haemorrhage algorithm to identify the most suitable means. The UK South Western Ambulance Service’s Major haemorrhage control guideline contains one example of a clinical decision-making algorithm to manage serious bleeding.

Stroke identification 

Despite well established guidelines, not all people with stroke receive appropriate treatment and there is variation in the type of care received1. This US study looked at patients presenting at the Hospital of the University of Pennsylvania and identified that patients identified as having a stroke by EMS saw a doctor sooner, received a CT scan quicker and more likely to receive thrombolytic therapy.

Recognition of Stroke by EMS is Associated with Improvement in Emergency Department Quality Measures

Prehospital Emergency Care. Published online: 31 May 2016

Objective: Hospital arrival via Emergency Medical Services (EMS) and EMS pre-notification are associated with faster evaluation and treatment of stroke. The authors sought to determine the impact of diagnostic accuracy by pre-hospital providers on emergency department quality measures.

Methods: A retrospective study was performed of patients presenting via EMS between September 2009 and December 2012 with a discharge diagnosis of transient ischemic attack (TIA), ischemic stroke (IS), or intracerebral hemorrhage (ICH). Hospital and EMS databases were used to determine EMS impression, pre-hospital and in-hospital time intervals, EMS pre-notification, NIH stroke scale (NIHSS), symptom duration, and thrombolysis rate.

Results: 399 cases were identified: 14.5% TIA, 67.2% IS, and 18.3% ICH. EMS providers correctly recognised 57.6% of cases. Compared to cases missed by EMS, correctly recognised cases had longer median on-scene time (17 vs. 15 min, p = 0.01) but shorter transport times (12 vs. 15 min, p = 0.001). Cases correctly recognised by EMS were associated with shorter door-to-physician time (4 vs. 11 min) and shorter door-to-CT time (23 vs. 48 min). These findings were independent of age, NIHSS, symptom duration, and EMS pre-notification. Patients with ischemic stroke correctly recognised by EMS were more likely to receive thrombolytic therapy, independent of age, NIHSS, symptom duration both with and without pre-notification.

Conclusion: Recognition of stroke by EMS providers was independently associated with faster door-to-physician time, faster door-to-CT time, and greater odds of receiving thrombolysis. Quality initiatives to improve EMS recognition of stroke have the potential to improve hospital-based quality of stroke care.

Considering stroke patients in Australia, Aboriginal and Torres Strait Islander peoples have twice the rate of hospitalisation for stroke and are 1.6 times more likely to die from stroke than non-Indigenous Australians. In addition, people living in remote and very remote areas have 1.4 times the rate of stroke compared with people living in major cities, and people from the lowest socio-economic group have 1.3 times the rate of stroke than people from the highest socio-economic group2.

The Australian Commission on Safety and Quality in Healthcare has published numerous resources to assist organisations meeting its 2015 Acute Stroke Clinical Care Standard and delivering appropriate care to people with an acute stroke. For out-of-hospital practitioners this involves assessing all people with suspected stroke using a validated screening tool (FAST, ROSIER or MASS) to guide diagnosis of stroke and timely transportation to an appropriate centre which offers re-perfusion therapy and multidisciplinary stroke care in a stroke unit.

1. Australian Commission on Safety and Quality in Healthcare (2015). Acute Stroke Clinical Care Standard

2. Australian Institute of Health and Welfare (2013). Stroke and its management in Australia: an update. Canberra: AIHW.

Neonate evaluation and management

While this series of articles addresses some of the challenges that can surround the newborn presenting to the emergency department (ED), such as the birth and death of an infant in the emergency department and how to transport an infant, other articles, such as approaches to the assessment of ‘fussy babies,’ and ways to evaluate and treat common neonatal illnesses, can also be considered beneficial for practitioners required to assess neonates outside the hospital environment.

Normal Infant or Sick Newborn: The Challenge of Evaluating an Infant in the Emergency Department

Clinical Pediatric Emergency Medicine: Jun-2016 (Volume 17, Issue 2)

There are about 3,900,000 babies born in the United States every year. The vast majority of babies will require no medical care or intervention, but all of them will be thoroughly evaluated before discharge from the newborn nursery. About 10% of infants require limited help in the delivery room, with only 1% requiring significant support. Just after delivery, most infants quickly transition to routine post-delivery care which consists of being dried, warmed, and placed with the infant’s mother. The next 48 hours consists of learning to feed, bonding with his or her new family, and monitoring expected weight loss. Before discharge, infants undergo a battery of screening tests to identify those infants with an underlying abnormality. Those screening tests include total bilirubin, hearing evaluation, metabolic testing, and pulse oximeter screening for congenital heart disease. Former preterm infants will also receive a car seat test and may have had a head ultrasound. Despite the extensive post-delivery evaluation of all newborns, a small number of infants will return to the emergency department for additional workup. These recently normal but now sick infants can be hard to evaluate for a variety of reasons.

While the vast majority of infants in the first 30 days of life will appear well, subtle presentations of disease can be a challenge in treating the newborn. One method to combat this difficulty is developing a strong sense of normal vs abnormal, however, this may not be sufficient – because most infants will end up being normal, there is a temptation is to treat all infants as well. Considering the reverse approach, where practitioners consider each infant as ill can be more useful – with a careful questioning approach for each infant used to identify the patient as well.

Respiratory Distress in the Newborn: An Approach for the Emergency Care Provider

Clinical Pediatric Emergency Medicine: Jun-2016 (Volume 17, Issue 2)

The emergency care provider has a crucial role in the evaluation and management of respiratory distress in the newborn and can see infants presenting at time of birth to many months old. Respiratory distress in the newborn is important to recognise as it can present anywhere along a spectrum of severity from tachypnoea to respiratory failure. In addition, it may represent a primary respiratory disease or be the harbinger of a systemic illness or problem in another organ system. Timely assessment, recognition of signs of newborn respiratory distress, and proper newborn airway management and assisted ventilation are the key initial steps in treatment. Once the infant is stabilised, being familiar with the normal newborn physical examination and vital sign parameters as well as the pertinent historical questions to ask can help rule in or out different causes of respiratory distress and help guide definitive treatment.

Newborns with respiratory distress can present with a wide range of symptoms that can overlap with those seen in a variety of diseases. It is essential to first stabilise the infant and then initiate further evaluation, including a thorough history and examination, to assist in the development of a differential diagnoses. Important diagnoses to consider include transient tachypnoea, respiratory distress syndrome, infection, meconium aspiration syndrome, pneumothorax, Congenital diaphragmatic hernia, persistent pulmonary hypertension, congenital heart disease, Tracheal tracheal oesophageal fistula and oesophageal atresi, upper airway disorder, and interstitial lung disease.

Emesis in the Neonate: Recommendations for Initial Management

Clinical Pediatric Emergency Medicine: Jun-2016 (Volume 17, Issue 2)

The symptom of emesis in the neonate is common and caused by a myriad of clinical states, some pathologic and some benign. There are many clinical data points that steer the astute clinician toward certain diagnoses and away from others. The focus of this article is to provide a framework for evaluating a neonate that presents to an emergency department with emesis. After reading this article, the emergency department clinician will have a better understanding of the clinical presentation and evaluation of surgical and nonsurgical etiologies of emesis in the neonate.

While notable features of concern in the history and physical examination include bilious emesis, weight loss, lethargy, an obtunded infant, shock, dehydration and an acute abdomen, it can still be the challenging for any practitioner to determine the actual etiology.

Neonatal Sepsis

Clinical Pediatric Emergency Medicine: Jun-2016 (Volume 17, Issue 2)

Sepsis is a significant cause of morbidity and mortality for neonates and infants. Neonates are at increased risk for sepsis due to their immature immune system. Bacterial, viral, and fungal organisms may cause sepsis in the young patient. Identifying septic neonates upon presentation to their primary care physician or the emergency department remains a challenge given the nonspecific manifestations of illness. Suspicion for sepsis should prompt evaluation to identify a source to tailor treatment appropriately. Timely diagnosis and management of neonatal sepsis, especially for those in septic shock, will lead to improved outcomes. The following article presents an overview of the most common organisms causing disease, clinical presentation, evaluation, and management for the neonate or infant presenting with suspected sepsis.

Neonatal sepsis is a significant cause of morbidity and mortality not only during initial hospitalisation but also after discharge. Identifying septic neonates who present to their primary care physician, ambulance service or the emergency department often remains a challenge given the nonspecific manifestations of illness. Suspicion for sepsis should prompt evaluation to identify a source to tailor treatment appropriately.

The Decompensated Neonate in the First Week of Life

Clinical Pediatric Emergency Medicine: Jun-2016 (Volume 17, Issue 2)

The first week of life can be a critical period in which previously subclinical disorders may manifest, causing significant illness. Newborn infants also have different baseline vitals and laboratory parameters, which complicate the initial evaluation of infants. Rapid identification of sick neonates, stabilisation, and directed evaluation are keys to minimising long-term morbidity and mortality. This review targets 5 conditions that present in the first week of life: neonatal sepsis, critical congenital heart disease, inborn errors of metabolism, congenital adrenal hyperplasia, and haemorrhagic disease of the newborn. The primary focus is on key findings, initial evaluation, and immediate treatment in the emergency department where these infants often present after discharge from the newborn nursery.

The critically ill neonate presents a challenge to caregivers and should be managed rapidly and methodically. The review discusses the diagnosis and initial management of these life-threatening neonatal conditions, but primary focus should be placed on ensuring the neonate’s stability – ensuring a patent airway, adequate ventilation and oxygenation, and sufficient circulatory perfusion is the priority.

Sick or Fussy? Normal and Abnormal Findings in the First Week of Life

Clinical Pediatric Emergency Medicine: Jun-2016 (Volume 17, Issue 2)

“Neonates are not just small children.” Health care providers in the emergency department should recognize presenting signs and symptoms of neonatal clinical problems in order to differentiate “sick” from merely “fussy” newborns. In this review, common neonatal presenting complaints will be discussed with the goal of recognizing normal and abnormal findings in the first 28 days of life. Topics will include respiratory distress, cyanosis, sepsis, meningitis, neonatal seizures, and feeding difficulties in the newborn.

Considering crying for 2 hours a day is usual for neonates, being presented with a crying baby is not rare for health practitioners. Ensure that the baby is being appropriately fed, changed, soothed and not shaken.  Sources of crying not to miss in the neonatal period include the following
sepsis/meningitis; hair tourniquet; corneal abrasion or anomalous origin of the left coronary artery from the pulmonary artery.

Interhospital Transport of the Neonatal Patient

Clinical Pediatric Emergency Medicine: Jun-2016 (Volume 17, Issue 2)

Regionalised perinatal care has improved neonatal outcomes, but the transport of critically ill neonates from non-tertiary centres continues to be affected by the type of care provided during pre-transport stabilisation and transport itself. Although the use of highly trained personnel during transports has reduced adverse events, there are still opportunities to standardise care and improve patient outcomes, particularly through improvements in key areas identified by quality and patient safety drivers. An important goal of transport care is to be an effective bridge to the type of intensive care provided by the receiving units. Delivering the ultimate patient experience with consideration to family-centred care and community relations is discussed as a way to improve the inter-hospital transport process.

Overall, the transport of critically ill infants to centres that can offer appropriate intensive care has resulted in improved neonatal outcomes and the standardisation of care continues to be a priority with new quality initiatives aimed at improving patient safety. Training and education for improved pre-transport stabilisation as part of a greater transport process is also essential.

Clinical training and logbooks

The use of logbooks has numerous benefits in paramedic education but some studies have shown that logbooks do not necessarily improve clinical training or are not used for learning. This open access report suggests how the use of logbooks can be improved in the clinical education process.

Twelve tips for successfully implementing logbooks in clinical training

Medical Teacher 2016: Volume 38, Issue 6

Background: Logbooks are widely used to set learning outcomes and to structure and standardise teaching in clinical settings. Experience shows that logbooks are not always optimally employed in clinical training. In this article, we have summarised our own experiences as well as results of studies into twelve tips on how to successfully implement logbooks into clinical settings.
Methods: The authors conducted a workshop concerning the importance of logbook training to exchange experiences in teaching practice, organisation, didactic knowledge and a literature research to compare our own experiences and add additional aspects.
Results: Tips include the process of developing the logbook itself, the change-management process, conditions of training and the integration of logbooks into the curriculum.
Conclusions: Logbooks can be a valuable tool for training in clinical settings, especially when multiple sites are involved, when you take our tips into consideration.

In contrast to portfolios, which focus on students’ documentation and self-reflection of their learning activities, logbooks set clear learning objectives and help to structure the learning process in clinical settings and to ease communication between trainee and clinical teacher. To implement logbooks in clinical training successfully, logbooks have to be an integrated part of the curriculum and the daily routine. Continuous measures of quality management are necessary. Then logbooks are a valuable tool for training in clinical settings, especially when multiple sites are involved.

Delays in patients with STEMI

Remote ischemic conditioning (RIC) is a therapeutic strategy for protecting organs or tissue against the detrimental effects of acute ischemia-reperfusion injury (IRI). It describes an endogenous phenomenon in which the application of one or more brief cycles of non-lethal ischemia and reperfusion to an organ or tissue protects a remote organ or tissue from a sustained episode of lethal IRI. In this study the authors identified that RIC could benefit patients with a STEMI who would take over 2 hours to receive primary percutaneous coronary intervention.

Remote ischaemic conditioning and healthcare system delay in patients with ST-segment elevation myocardial infarction

Heart. 2016 Jul 1;102(13):1023-8

The authors investigated influence of remote ischaemic conditioning (RIC) on the detrimental effect of healthcare system delay on myocardial salvage in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (pPCI).

Methods: A post-hoc analysis of a randomised controlled trial in patients with STEMI randomised to treatment with pPCI or RIC+pPCI. RIC was performed as four cycles of intermittent 5 min upper arm ischaemia and reperfusion. Healthcare system delay was defined as time from emergency medical service call to pPCI-wire. Myocardial salvage index (MSI) was assessed by single photon emission computerised tomography.

Results: Data for healthcare system delay and MSI were available for 129 patients. MSI was negatively associated with healthcare system delay in patients treated with pPCI alone (−0.003 decrease in MSI/min of healthcare system delay) but not in patients treated with RIC+pPCI (−0.0002 decrease in MSI/min of healthcare system delay). In patients with healthcare system delay ≤120 min, RIC+pPCI did not affect median MSI compared with pPCI alone. However, in patients with healthcare system delay >120 min, RIC+pPCI increased median MSI compared with pPCI alone (0.74 vs 0.42). Adjusting for potential confounders did not affect the results.

Conclusions: RIC as adjunctive to pPCI attenuated the detrimental effect of healthcare system delay on myocardial salvage in patients with STEMI, suggesting that the cardioprotective effect of RIC increases with the duration of ischaemia.

The ability to induce RIC using a standard blood pressure cuff placed on the upper or lower limb has facilitated its translation into the clinical setting. RIC is simple to apply, non-invasive and virtually cost-free, and a single RIC stimulus offers multi-organ protection, lending itself to a variety of clinical settings in which there is organ or tissue acute IRI1.

Back in 2007, it was demonstrated that three 5 min cuff inflations and deflations of a cuff placed on the upper arm to 200 mmHg, administered prior to cardiac surgery, reduced peri-operative myocardial injury (43% less troponin T release) in adult patients undergoing elective CABG surgery2.

1. Lim, S. Y., & Hausenloy, D. J. (2012). Remote Ischemic Conditioning: From Bench to Bedside. Frontiers in Physiology, 3, 27.

2. Hausenloy DJ, Mwamure PK, Venugopal V, Harris J, Barnard M, Grundy E, Ashley E, Vichare S, Di Salvo C, Kolvekar S, Hayward M, Keogh B, MacAllister RJ, Yellon DM (2007). Effect of remote ischaemic preconditioning on myocardial injury in patients undergoing coronary artery bypass graft surgery: a randomised controlled trial. Lancet. Aug 18; 370(9587):575-9.