Pre- and apnoeic high-flow oxygenation for rapid sequence intubation in the emergency department (the Pre-AeRATE trial): A multicentre randomised controlled trial

INTRODUCTION@#Evidence regarding the efficacy of high-flow nasal cannula (HFNC) oxygenation for preoxygenation and apnoeic oxygenation is conflicting. Our objective is to evaluate whether HFNC oxygenation for preoxygenation and apnoeic oxygenation maintains higher oxygen saturation (SpO2) during rapid sequence intubation (RSI) in ED patients compared to usual care.@*METHODS@#This was a multicentre, open-label, randomised controlled trial in adult ED patients requiring RSI. Patients were randomly assigned 1:1 to either intervention (HFNC oxygenation at 60L/min) group or control (non-rebreather mask for preoxygenation and nasal prongs of at least 15L/min oxygen flow for apnoeic oxygenation) group. Primary outcome was lowest SpO2 during the first intubation attempt. Secondary outcomes included incidence of SpO2 falling below 90% and safe apnoea time.@*RESULTS@#One hundred and ninety patients were included, with 97 in the intervention and 93 in the control group. Median lowest SpO2 during the first intubation attempt was 100% in both groups. Incidence of SpO2 falling below 90% was lower in the intervention group (15.5%) compared to the control group (22.6%) (adjusted relative risk=0.68, 95% confidence interval [CI] 0.37-1.25). Post hoc quantile regression analysis showed that the first quartile of lowest SpO2 during the first intubation attempt was greater by 5.46% (95% CI 1.48-9.45%, P=0.007) in the intervention group.@*CONCLUSION@#Use of HFNC for preoxygenation and apnoeic oxygenation, when compared to usual care, did not improve lowest SpO2 during the first intubation attempt but may prolong safe apnoea time.

Health-seeking behaviour of foreign workers in Singapore: Insights from emergency department visits

INTRODUCTION@#Foreign workers (FWs) on work permit face unique health challenges and potential barriers to healthcare. We aimed to examine the epidemiology, attendance patterns, disposition, and adherence to follow-up, by FWs on work permit to two emergency departments (EDs) in Singapore.@*METHODS@#In this retrospective observational study, we included consecutive FWs on work permit who registered at the EDs of two public restructured hospitals from 1 May 2016 to 31 October 2016. Data obtained from electronic medical records included patient demographics, triage acuity, disposition, ED diagnoses and bill information.@*RESULTS@#There were 6,429 individual FWs on work permit who contributed to 7,157 ED visits over the 6-month study period, with male predominance (72.7%, 4672/6429), and median age of 31 (interquartile range 26 to 38) years. A high proportion of these FWs were triaged to low-acuity status compared to the general ED population (66.9% versus 45.9%, @*CONCLUSION@#In Singapore, the EDs of public restructured hospitals provide healthcare safety nets to FWs on work permit. These workers made more low-acuity visits compared to the general population during the study period and may face potential barriers to admission and follow-up.

Virtual reality mobile application to improve videoscopic airway training: A randomised trial

INTRODUCTION@#Flexible bronchoscopic intubation (FBI) is an important technique in managing an anticipated difficult airway, yet it is rarely performed and has a steep learning curve. We aim to evaluate if the integration of virtual reality gaming application into routine FBI training for emergency department doctors would be more effective than traditional teaching methods.@*METHODS@#We conducted a randomised controlled trial to compare self-directed learning using the mobile application, Airway Ex* in the intervention group versus the control group without use of the mobile application. All participants underwent conventional didactic teaching and low-fidelity simulation with trainer's demonstration and hands-on practice on a manikin for FBI. Participants randomised to the intervention arm received an additional 30 minutes of self-directed learning using Airway Ex, preloaded on electronic devices while the control arm did not. The primary outcome was time taken to successful intubation.@*RESULTS@#Forty-five physicians (20 junior and 25 senior physicians) were enrolled, with male predominance (57.8%, 26/45). There was no difference in time taken to successful intubation (median 48 seconds [interquartile range, IQR 41-69] versus 44 seconds [IQR 37-60], P=0.23) between the control and intervention groups, respectively. However, the intervention group received better ratings (median 4 [IQR 4-5]) for the quality of scope manipulation skills compared to control (median 4 [IQR 3-4], adjusted P=0.03). This difference remains significant among junior physicians in stratified analysis.@*CONCLUSION@#Incorporating virtual reality with traditional teaching methods allows learners to be trained on FBI safely without compromising patient care. Junior physicians appear to benefit more compared to senior physicians.

Emergency airway management in a Singapore centre: A registry study

INTRODUCTION@#Intubations in the emergency department (ED) are often performed immediately without the benefit of pre-selection or the ability to defer. Multicentre observational data provide a framework for understanding emergency airway management but regional practice variation may exist. We aim to describe the intubation indications, prevalence of difficult airway features, peri-intubation adverse events and intubator characteristics in the ED of the National University Hospital, Singapore.@*METHODS@#We conducted a prospective observational study over a period of 31 months from 1 March 2016 to 28 September 2018. Information regarding each intubation attempt, such as indications for intubation, airway assessment, intubation techniques used, peri-intubation adverse events, and clinical outcomes, was collected and described.@*RESULTS@#There were 669 patients, with male predominance (67.3%, 450/669) and mean age of 60.9 years (standard deviation [SD] 18.1). Of these, 25.6% were obese or grossly obese and majority were intubated due to medical indications (84.8%, 567/669). Emergency physicians' initial impression of difficult airway correlated with a higher grade of glottis view on laryngoscopy. First-pass intubation success rate was 86.5%, with hypoxia (11.2%, 75/669) and hypotension (3.7%, 25/669) reported as the two most common adverse events. Majority was rapid sequence intubation (67.3%, 450/669) and the device used was most frequently a video laryngoscope (75.6%, 506/669). More than half of the intubations were performed by postgraduate clinicians in year 5 and above, clinical fellows or attending physicians.@*CONCLUSION@#In our centre, the majority of emergency intubations were performed for medical indications by senior doctors utilising rapid sequence intubation and video laryngoscopy with good ffirst-attempt success.

Comparison of Reusable Models in Pericardiocentesis Simulation Training

INTRODUCTION@#Pericardiocentesis is a potentially life-saving procedure. We compared two low-cost models-an agar-based model and a novel model, Centesys-in terms of ultrasound image quality and realism, effectiveness of the model, and learners' confidence and satisfaction after training.@*METHODS@#In this pilot randomised 2x2 crossover trial stratified by physician seniority, participants were assigned to undergo pericardiocentesis training either with the agar-based or Centesys model first, followed by the other model. Participants were asked to rate their confidence in performing ultrasound-guided pericardiocentesis, clarity and realism of cardiac structures on ultrasound imaging, and satisfaction on a 7-point Likert scale before and after training with each model.@*RESULTS@#Twenty participants with median postgraduate year of 4 (interquartile range [IQR] 3.75-6) years were recruited. Pre-training, participants rated themselves a median score of 2.5 (IQR 2-4) for level of confidence in performing pericardiocentesis, which improved to 5 (IQR 4-6) post-training with Centesys (@*CONCLUSION@#Centesys achieved greater learner satisfaction as compared to the agar-based model, and was an effective tool for teaching ultrasound-guided pericardiocentesis and drain insertion.

Road Crashes in Older Persons and the Use of Comorbidity Polypharmacy Score in an Asian Population

<p><b>INTRODUCTION</b>Age-related physiological changes predispose older road users to higher mortality from traffic crashes. We aimed to describe the injury epidemiology of these patients, and explore the association between the comorbidity polypharmacy score (CPS) and outcomes.</p><p><b>MATERIALS AND METHODS</b>This retrospective study utilised data from the Trauma Registry in the National University Hospital, Singapore, between January 2011 and December 2014. Patients involved in traffic crashes aged 45 years and above with injury severity scores (ISS) of 9 and higher were included.</p><p><b>RESULTS</b>There were 432 patients; median age was 58 (interquartile range, 51 to 65.5) years with predominance of male patients (82.2%) and Chinese ethnicity (66%). Overall mortality was 9.95%, with lower odds associated with higher Glasgow Coma Scale (odds ratio [OR] 0.73; 95% confidence interval [CI], 0.65 to 0.81,<0.001), higher diastolic blood pressure (OR 0.98; 95% CI, 0.97 to 1.00,= 0.031), and lower ISS of 9 to 15 (OR 0.10; 95% CI, 0.02 to 0.43,= 0.002). The need for blood products was associated with higher mortality (OR 7.62; 95% CI, 2.67 to 21.7,<0.001). CPS did not predict mortality. Independent predictors of discharge venue included length of stay, tier of injury and CPS group. Moderate CPS was statistically significant for nursing home placement (OR 10.7; 95% CI, 2.33 to 49.6,= 0.002) but not for rehabilitation facility.</p><p><b>CONCLUSION</b>CPS score is useful in predicting discharge to a nursing home facility for older patients with traffic crashes. Further larger studies involving other trauma types in the Asian population are needed to evaluate its utility.</p>

Reversible Causes in Cardiovascular Collapse at the Emergency Department Using Ultrasonography (REVIVE-US)

<p><b>INTRODUCTION</b>Ultrasonographic evaluation of patients in cardiac arrest is currently not protocolised in the advanced cardiac life support (ACLS) algorithm. Potentially reversible causes may be identified using bedside ultrasonography that is ubiquitous in most emergency departments (EDs). This study aimed to evaluate the incidence of sonographically detectable reversible causes of cardiac arrest by incorporating an ultrasonography protocol into the ACLS algorithm. Secondary objectives include rates of survival to hospital admission, hospital discharge, and 30-day mortality.</p><p><b>MATERIALS AND METHODS</b>We conducted a prospective study using bedside ultrasonography to evaluate for potentially reversible causes in patients with cardiac arrest at the ED of National University Hospital, Singapore, regardless of the initial electrocardiogram rhythm. A standardised ultrasonography protocol was performed during the 10-second pulse check window.</p><p><b>RESULTS</b>Between June 2015 and April 2016, 104 patients were recruited, corresponding to 65% of all out-of-hospital cardiac arrest patients conveyed to the ED. Median age was 71 years (interquartile range, 55 to 80) and 71 (68.3%) patients were male. The most common rhythm on arrival was asystole (45.2%). Four (3.8%) patients had ultrasonographic findings suggestive of massive pulmonary embolism while 1 received intravenous thrombolysis and survived until discharge. Pericardial effusion without tamponade was detected in 4 (3.8%) patients and 6 (5.8%) patients had intra-abdominal free fluid. Twenty (19.2%) patients survived until admission, 2 of whom (1.9%) survived to discharge and beyond 30 days.</p><p><b>CONCLUSION</b>Bedside ultrasonography can be safely incorporated into the ACLS protocol. Detection of any reversible causes may alter management and improve survival in selected patients.</p>

Acute Wound and Management

Acute wounds are a common presenting complaint of patients in the primary care setting. These can result from a variety of mechanisms ranging from lacerations and abrasions to stings, bites or burns. The management of acute wounds involves a proper evaluation with history, physical examination, and adequate management with local wound care, and consideration for the need for specialist review or systemic treatment. The general principles of wound management and special wounds like bite wounds and stings will be discussed.

Not all unexplained hypoxia is pulmonary embolism

Acute myocardial infarction is one of the conditions frequently managed in the emergency department. There are many complications associated with right ventricular infarction, and the incidence of right ventricular infarction associated with inferior myocardial infarction is as high as 51% based on electrocardiographic findings. We herein report the case of a 45-year-old Chinese man with inferior myocardial infarction complicated by right ventricular failure. He had hypoxaemia refractory to supplemental oxygen due to an acute right-to-left shunting through a patent foramen ovale (PFO). He underwent coronary angioplasty and closure of the PFO. It is crucial for the attending physician to consider the presence of a right-to-left shunt when there is persistent uncorrectable hypoxaemia despite maximal oxygen supplementation in the setting of right ventricular infarction, as there are clinical implications and certain clinical managing principles that should be applied.