Correspondence / American Journal of Emergency Medicine 35 (2017) 1759-1783 1773

Table 3

Outcomes pre- versus post-intervention

Abbreviations: IQR = interquartile range, HLOS = hospital length of stay, ILOS = intensive care length of stay.

Table 4

Patient outcomes based on compliance with three-hour sepsis bundle

Abbreviations: IQR = interquartile range, HLOS = hospital length of stay, ILOS = intensive care length of stay.

resuscitate this patient population out fear of precipitating pulmonary edema. Despite improving bundle compliance with our intervention, we observed no differences in morbidity or mortality in the pre- versus post-intervention group. The pre- and post-intervention groups were well matched in terms of demographics and severity of illness. Howev- er, the post-intervention group was more likely to receive ineffective Empiric antibiotics in the ED, which may have negated some of the ben- eficial effect of earlier administration of antibiotics on mortality in this group. We observed a lower mortality (24%) in the bundle compliant group when compared to the non-compliant group (31%), although this finding did not reach statistical significance. We suspect that our relatively small sample size may have, in part, accounted for the lack of statistical difference in mortality between groups.

In conclusion, a process of Audit and feedback improved compliance with the three-hour sepsis bundle in patients admitted from the ED to the ICU. The improvement in compliance was primarily related to the lactate metric. The observed improvement in three-hour bundle com- pliance was not associated with a statistically significant reduction in sepsis-related morbidity or mortality.

Joanne Wozniak

Yuxiu Lei James Dargin*

Lahey Hospital & Medical Center, Tufts University School of Medicine, 41

Mall Road, Burlington, MA 01805, United States

*Corresponding author.

E-mail address: [email protected] (J. Wozniak)

http://dx.doi.org/10.1016/j.ajem.2017.05.018

References

1. Levy MM, Dellinger RP, Townsend SR. The Surviving sepsis campaign: results of an in- ternational guidelines-based performance improvement targeting severe sepsis. Crit Care Med 2010;38:367-74.
2. Ferrer R, Artigas A, Levy MM, et al. Improvement in process of care and outcome after a multicenter severe sepsis educational program in Spain. JAMA 2008;299:2294.
3. Castellano-Ortega A, Suberviola B, Garcia-Astudillo LA, et al. Impact of the surviving sepsis campaign protocols on hospital length of stay and mortality in septic shock pa- tients: results of a 3-year follow-up quasi-experimental study. Crit Care Med 2010; 38:1036.
4. Leisman DE, Doerfler ME, Ward MF, et al. Survival benefit and cost saving from com- pliance with a simplified 3-hour sepsis bundle in a series of prospective, multisite, ob- servational cohorts. Crit Care Med 2017;45:395-406.
5. Rhodes A, Phillips G, Beale R, et al. The surviving sepsis campaign bundles and out- come: results from the international multicentre prevalence study on sepsis (the IM- PreSS study). Intensive Care Med 2015;41:1620-8.
6. Dellinger RP, Levy MM, Rhodes A, Annane D, et al. surviving sepsis campaign: interna- tional guidelines for the management of severe sepsis and septic shock, 2012. Crit Care Med 2013;41:580-637.
7. Damiani E, Donati A, Serafini G, et al. Effect of performance improvement programs on compliance with Sepsis bundles and mortality: a systematic review and meta- analysis of observational studies. PLoS One 2015;10:e0125827.
8. Ivers N, Jamtyedt G, Flottorp S, et al. Audit and feedback: effects on professional prac- tice and Healthcare outcomes. Cochrane Database Syst Rev 2012;13:CD000259.

   Chest compressions in infants

   

   Sir,

   Cardiopulmonary resuscitation on infants and children is associated with extreme emotions and stress among members of resuscitation team. For most healthcare professionals in the pre-hospital care system, in- fant sudden cardiac arrest is a rare incident. Detailed knowledge of the guidelines and regular training is essential to ensure a high quality of re- suscitation. Only proper chest compressions are able to provide adequate high coronary perfusion pressure and consequently maintain oxygenation of the cardiomyocytes and provide them with an energy reserve [1]. It is easy to make a mistake even in such simple operations as chest compres- sions while working under stress conditions [2]. Professional medical teams have equipment for Mechanical chest compression. It has been esti- mated that the use of these devices in children also significantly improves chest Compression quality parameters such as rate, depth, correct recoil. It also allows to minimize unnecessary interruptions [1]. The key to improve survival is resuscitation provided by bystanders, and services such as fire brigade or water rescue. In addition, before ambulance arrival, a medical dispatcher instructs witnesses on how to perform resuscitation. First peo- ple at the scene are often parents of the injured infant who are unable to carry out complicated procedures. The first-aid rescue techniques must therefore be simple and at the same time highly effective so that even those without appropriate medical training could provide high quality chest compressions. In the present day, first aid training is widely available to the public. Also a large part of citizens declare their willingness to pro- vide first aid in cases of sudden cardiac arrest [3]. Nonetheless, the out- come of pediatric out-of-hospital sudden cardiac arrest remains unsatisfactory. That is why it is important to look for new techniques that would make it even easier to provide good resuscitation.

   Semerka et al. [4,5], published results of their studies that present the in-

   teresting alternative to previously used techniques of chest compressions in infants. The presented method is based on compressions with two thumbs, arranged at an angle of 90 degrees perpendicular to the chest surface, while the other fingers are folded in the fist [4,5,6]. The results of the study com- paring the previously known infant CC techniques indicate that the new technique is superior to those previously known. The results that have been presented by the authors suggest that by using this innovative tech- nique, both systolic, diastolic and mean arterial blood pressure as well as mean, compression depth and chest recoil were significantly better than other methods [6,7]. Thanks to these achievements, infant CPR quality pa- rameters may be elevated and consequently infant survival may increase.

   1774 Correspondence / American Journal of Emergency Medicine 35 (2017) 1759-1783

   We see the need for further analyzes to answer the question wheth- er the new technique allows for the maintenance of adequate coronary perfusion pressure. We believe further studies by Semerka et al.¹ will improve survival among infants-victims of sudden cardiac arrest.

   Tomasz Klosiewicz* Agata Dabrowska Adrian Maciejewski

   Department of Rescue and Disaster Medicine, Poznan University of Medical

   Sciences, Poland Polish Society of Medical Simulation, Poland

   *Corresponding author at: Department of Rescue and Disaster Medicine, Poznan University of Medical Sciences, 79 Dabrowskiego Str, 60-529

   Poznan, Poland.

   E-mail address: [email protected] (T. Klosiewicz)

   Radoslaw Zalewski

   Department of Rescue and Disaster Medicine, Poznan University of Medical

   Sciences, Poland

   http://dx.doi.org/10.1016/j.ajem.2017.05.020

   ¹ Smereka J, Szarpak L, Rodriguez-Nunez A, Ladny JR, Leung S, Ruetzler K. A randomized comparison of three chest compression techniques and associated hemodynamic effect during infant CPR: a randomized manikin study. Am J Emerg Med. 2017;35:1420-5.

   References

   Szarpak L, Truszewski Z, Smereka J, Czyzewski L. Does the use of a chest compression system in children improve the effectiveness of chest compressions? A randomised crossover simulation pilot study. Kardiol Pol 2016;74(12):1499-504. http://dx.doi. org/10.5603/KP.a2016.0107.

9. Bjorshol CA, Myklebust H, Nilsen KL, Hoff T, Bjorkli C, Illguth E, et al. Effect of socioemotional stress on the Quality of cardiopulmonary resuscitation during ad- vanced life support in a randomized manikin study. Crit Care Med 2011;39(2): 300-4. http://dx.doi.org/10.1097/CCM.0b013e3181ffe100.
10. Kozlowski Dariusz, Klosiewicz Tomasz, Kowalczyk Adam, Kowalczyk Anna Krystyna,

    Kozluk Edward, Dudziak Maria, et al. The knowledge of public access to defibrillation in selected cities in Poland. Arch Med Sci 2013;9(1):27-33. http://dx.doi.org/10.5114/ aoms.2013.33345.

    Smereka J, Szarpak L, Rodriguez-Nunez A, Ladny JR, Leung S, Ruetzler K. A randomized comparison of three chest compression techniques and associated hemodynamic ef- fect during infant CPR: A randomized manikin study. Am J Emerg Med 2017;35(10): 1420-5.

11. Smereka J, Szarpak L, Smereka A, Leung S, Ruetzler K. Evaluation of new two-thumb

    chest compression technique for infant CPR performed by novice physicians. A ran- domized, crossover, manikin trial. Am J Emerg Med 2017;35(4):604-9.

    Smereka J, Kasinski M, Smereka A, Ladny JR, Szarpak L. The quality of a newly devel-

    oped infant chest compression method applied by paramedics: a randomized cross- over manikin trial. Kardiol Pol 2017 Feb 2. http://dx.doi.org/10.5603/KP.a2017.0015 [Epub ahead of print].

    Kozlowski D, Klosiewicz T, Kowalczyk A, Kowalczyk AK, Kozluk E, Dudziak M, et al. The knowledge of public access to defibrillation in selected cities in Poland. Arch Med Sci 2013 Feb 21;9(1):27-33. http://dx.doi.org/10.5114/aoms.2013.33345.

    First aid protocols for lifeguards. What

    

    should equipment be there in a portable emergency bag??

    To the Editor,

    Lifeguards use to provide protection at aquatic areas, but they do not only have to intervene when a person is in a hazardous situation in

    ? Conflict of interest: None.

    water. For example, on a beach, lifeguard must also provide assistance to people in distress on the sand or adjacent areas.

    In the last few years, an increasing number of investigations with lifeguards were carried out in order to obtain evidence-based guide- lines for their activities. The most of them are focused in water res- cue under the justification that drowning is one of the leading causes of unintentional injury death worldwide. However, lots of lifeguard interventions are performed out of the water; in this sense, Moran and Webber have studied the nature of non-drowning injuries at beaches in New Zealand, and they have reported that almost one third of injuries were attributed to land-based walking/ running activity [1].

    Regardless if intervention is in the water or on the sand, lifeguards should move the equipment necessary from where they are (usually a watch facility) to where the emergency is occurring. As protocols and rescue guidelines in lifeguarding have been established based on com- mon experience and experts’ opinion [2], there is no consensus and no universally accepted protocol that define the concrete equipment which should be contained in a portable emergency bag (PEB) for lifeguarding intervention.

    Such guide would contribute to follow the international guidelines for First Aid (FA), reduce intervention time, increase the likelihood of surviv- al of the patient and/or improve the outcome. Bearing in mind that a life- guard could be forced to run long distances, we consider that the equipment must be strictly limited to the most useful and necessary.

    After reviewing the current international guidelines for FA, what should be the reference in this field, we propose to include in a PEB the items shown in Table 1.

    Briefly and below we explain the rationale for the equipment selected:

    Airway: Oropharyngeal airway helps to maintain the airway opened [3]. The European Resuscitation Council Guidelines for Resuscitation (2015) recommend, “Do not try an attempt to re- move the foam as it will keep coming. Continue rescue breaths/ ventilations until an ALS provider arrives and is able to intubate de victim. […] If this prevents ventilation completely, turn the vic- tim on their side and remove the regurgitated material using di- rected suction if possible” [4]. We added the suction equipment because lifeguards could find a no-drowning victim with fluid/ foreign bodies in the mouth. Equipment for neck immobilization was not added because this can be done by careful manual stabiliza- tion [5] in less time [6]. In addition, evidences about the usefulness of cervical collar are limited and the application of a cervical collar by a first aid provider is not recommended currently [7,8].

    Breathing: Oxygen is recommended during cardiopulmonary resus- citation (CPR) and first aid in case of near-drowning. It should be connected to bag-mask or pocket mask to increase the oxygen con- centration and also to a face-mask in case of spontaneous breathing after near-drowning.

    Circulation: Generally, lifeguards must follow the basic life support protocol starting CPR when patient does not breathe without checking pulse. When a victim is rescued from the water, lifeguards do not know either if patient suffered a cardiac arrest while swim- ming or arrest was product of a drowning (respiratory) event. This is why Automated external defibrillator application is also rec- ommended in drowning victims. On the other hand, the ideal proce- dure for Bleeding control by FA providers is not clear [9]. International guidelines recommend for FA providers to apply direct pressure firstly. Hemostatic dressings may be considered when di- rect pressure is not effective, the wound is in a position where direct pressure is not possible or a tourniquet cannot be applied. Although training is necessary for a safe and correct application, tourniquet is