Evaluation of endotracheal intubations in the emergency department of a tertiary care facility.

OBJECTIVE: In this study, we aimed to evaluate the performance of emergency department intubations for 1 year. METHODS: This was a retrospective analysis of prospectively collected data. The collected variables were patient demographics, indication for intubation, preintubation hemodynamics, preoxygenation methods, medications used for premedication, induction and paralysis, type of laryngoscope used, Cormack-Lehane (C-L) grades, number of intubation attempts, and peri-intubation adverse events. RESULTS: A total of 194 patients were included. The median age of the population was 66.5 years (53.75-79); 61.9% of the patients were male. The majority of the patients were intubated due to medical conditions. The main indication for endotracheal intubation was respiratory failure in 38.6% of the patients. Preoxygenation before intubation was performed in 87.2% of the patients. Fifty-eight percent of the population were hemodynamically stable before the intubation. Fentanyl was the agent used for premedication, induction agents of choice were ketamine and midazolam, and rocuronium was the neuromuscular blocking agent. The C-L grades 1 and 2 were detected in 87.6% of the patients. The first-pass success rate was 72.8%. The peri-intubation adverse events were mainly hypotension and desaturation observed in 82 (42%) patients. The patients with higher C-L grades needed more intubation attempts (P < 0.001). Peri-intubation adverse events were associated with the increased number of intubation attempts (P < 0.001). CONCLUSION: This and similar studies or an airway registry on a national level may help improve the quality of service given and delineate the deficiencies of the airway-related procedures in the emergency department.

The value of doppler ultrasound in predicting arterial injuries of the penetrating forearm trauma.

OBJECTIVE: The aim of this study was to determine the diagnostic value of Doppler ultrasound (DU) in predicting arterial injuries following the penetrating trauma of the forearm, by comparing preoperative diagnosis made by DU and that made by physical examination (PE) with the intraoperative diagnosis. METHODS: In this retrospective study, 48 patients (44 men, 3 women; mean age = 30 ± 12.5 years) who underwent surgical treatment due to a suspected arterial injury following a penetrating trauma in the forearm from 2016 to 2018 were included. The DU examination was frequently done before an orthopedic examination. In the orthopedic PE, the knowledge as to whether an arterial injury occurred or (if present) which artery was injured was noted. Preoperative diagnoses by PE and DU were first compared with each other, and then with the intraoperative diagnoses. The specificity, sensitivity, negative and positive predictive values were calculated. RESULTS: While the DU findings from 24 patients (50%) matched their intraoperative results, the result from the remaining 24 patients (50%) did not. Nine (18.75%) were considered false-positive and 15 (31.25%) were false-negative. Whereas the PE findings from 30 patients (62.5%) matched their intraoperative results, the remaining 18 patients (37.5%) did not. Six (12.5%) were considered false-positive and 12 (25%) were false- negative. No significant difference was found between the diagnoses of DU and PE, and there was good agreement between the DU and PE findings (P = 0,065, κ = 0,504). While the DU findings were significantly different from the intraoperative findings (P = 0.004), the PE findings were not significantly different from the intraoperative findings (P = 0.302). Sensitivities of DU and PE were both 75% for the diagnosis of radial artery injury as well as 63.3% and 70% for the ulnar artery injury, respectively. Specificities of DU and PE were 83.3% and 91.66% for the diagnosis of radial artery injury as well as 77.77% and 72.22% for the ulnar artery injury, respectively. CONCLUSION: The PE seems more sensitive and useful than the DU in predicting arterial injuries following the penetrating trauma of the forearm. LEVEL OF EVIDENCE: Level IV.

Effect of smartphone applications on cardiopulmonary resuscitation quality metrics in a mannequin study: A randomized trial.

OBJECTIVE: The aim of this randomized, cross-over trial is to reveal the effect of smartphone cardio-pulmonary resuscitation (CPR) feedback applications (App) on a group of lay rescuers' chest compression-only CPR quality metrics. Quality metrics is measured initially and after 3 months. METHODS: A floor-based Resusci Anne mannequin (Laerdal Medical, Stavanger, Norway) was used. Three scenarios (CPR with device App-on [scenario-a], CPR with device App-off [scenario-b], and hands-only CPR [scenario-c]) were randomly allocated to all participants. All the participants performed 2 min of hands only-CPR for each scenario. Data of mean chest compression rate, mean chest compression depth, and recoil were recorded and compared for each scenario. RESULTS: One hundred and thirty-seven first-year students from the Vocational School of Health Services in Turkey participated in this study to mimic lay rescuers. Difference in the initial mean rate of chest compressions was statistically significant when CPR was performed with device App-on (scenario-a) compared to scenarios b and c (P < 0.001, P < 0.001). Furthermore, difference in the mean chest compression rate at the 3rd month was statistically significant among the scenarios when CPR was performed with device App-on (scenario-a) (P = 0.002, P = 0.001). The difference in initial and 3rd month mean compression depth and the percentage of recoil was not statistically significant among the scenarios. CONCLUSION: This study shows that the mean chest compression rate and percentage of compressions with adequate rate improved with smartphone App-on, and these results were persistent up to 3 months.

Vibrio albensis: An unusual urinary tract infection in a healthy male.

Infections with non-O1 non-O139 Vibro cholerae strains have been reported to affect different extra intestinal sites including the urinary tract infection. We report the first case of UTI due to Vibrio albensis in an immunocompetent patient from Lebanon, where the organism was also recovered from water at his home.

Non-invasive ventilation in the ED: Whom, When, How?

As emergency physicians, we encounter patients suffering from either hypoxemic and/or hypercarbic respiratory problems on a daily basis. A stepwise approach to solving this problem seems logical from an emergency medicine perspective. Current literature supports the notion that NIV decreases endotracheal intubation rates and, mortality in select patient populations. The key to the success of NIV is patient cooperation and support for the care givers. In this narrative review, non-invasive ventilation (NIV) is discussed in terms of modes of delivery, interface and patient selection, as well as practical considerations.

Comparison of the C-MAC video laryngoscope to the Macintosh laryngoscope for intubation of blunt trauma patients in the ED.

OBJECTIVES: We aimed to compare the performance of the C-MAC video laryngoscope (C-MAC) to the Macintosh laryngoscope for intubation of blunt trauma patients in the ED. MATERIAL AND METHODS: This was a prospective randomized study. The primary outcome measure is overall successful intubation. Secondary outcome measures are first attempt successful intubation, Cormack-Lehane (CL) grade, and indicators of the reasons for unsuccessful intubation at the first attempt with each device. Adult patients who suffered from blunt trauma and required intubation were randomized to video laryngoscopy with C-MAC device or direct laryngoscopy (DL). RESULTS: During a 17-month period, a total of 150 trauma intubations were performed using a C-MAC and DL. Baseline characteristics of patients were similar between the C-MAC and DL group. Overall success for the C-MAC was 69/75 (92%, 95% CI 0.83 to 0.96) while for the DL it was 72/75 (96%, 95% CI 0.88 to 0.98). First attempt success for the C-MAC was 47/75 (62.7%, 95% CI 0.51 to 0.72) while for the DL it was 44/75 patients (58.7%, 95% CI 0.47 to 0.69). The mean time to achieve successful intubation was 33.4 ± 2.5 s for the C-MAC versus 42.4 ± 5.1 s for the DL (p = 0.93). There was a statistically significant difference between the DL and C-MAC in terms of visualizing the glottic opening and esophageal intubation in favor of the C-MAC (p = 0.002 and p = 0.013 respectively). DISCUSSION AND CONCLUSION: The overall success rates were similar. The C-MAC demonstrated improved glottic view and decrease in esophageal intubation rate.

Comparison of the C-MAC Videolaryngoscope and Rigid Fiberscope with Direct Laryngoscopy in Easy and Difficult Airway Scenarios: A Manikin Study.

BACKGROUND: Intubation is a fundamental skill in maintaining adequate oxygenation and ventilation of seriously ill patients. OBJECTIVES: To compare the C-MAC video laryngoscope and Bonfils intubation fiberscope with direct laryngoscopy in simulated easy and difficult airway scenarios. METHODS: This was a prospective, randomized-controlled cross-sectional study. Thirty emergency medicine residents attempted to intubate a manikin using four progressively more difficult airway settings (normal airway [scenario 1], cervical spine immobilization [scenario 2], cervical spine immobilization + tongue swelling scenario [scenario 3], and cervical spine immobilization + tongue swelling + limited jaw opening scenario [scenario 4]) with both the C-MAC video laryngoscope and the Bonfils intubation fiberscope and direct laryngoscope. RESULTS: In the first and the second scenarios, there were no statistically significant differences between the airway devices in terms of the duration of endotracheal intubation, the viewing duration of the glottic opening, and endotracheal tube insertion time. There was no statistically significant difference between the laryngoscopes in terms of the duration of endotracheal intubation and endotracheal tube insertion time in the third scenario. The overall success rates and the viewing duration of the glottic opening were shorter with the C-MAC and Bonfils in scenarios 3 and 4. Furthermore, the duration of intubation was better with Bonfils in scenario 4. The severity of dental trauma was lowest with the Bonfils in all scenarios. The device difficulty score was greatest with the Macintosh blade, except in the normal airway scenario. The most preferred airway device was the C-MAC. CONCLUSION: The Bonfils and C-MAC enabled better visualization of the glottic opening when compared with the Macintosh laryngoscope.

Comparison of ultrasonography and surface landmarks in detecting the localization for cricothyroidotomy.

OBJECTIVE: The aim of the study was to compare ultrasonography (US) and surface landmark techniques for detecting the cricothyroid membrane (CTM) to perform a cricothyroidotomy on healthy volunteers. METHODS: In this prospective observational study, 5 operators and 24 models were included. The borders of the CTM were marked with an invisible pen. The operators were asked to point the CTM either with the palpation method or the US-guided fashion. RESULTS: The CTM was detected accurately in 80 (66.7%) attempts with palpation and 83 (69.2%) attempts with US. There was no statistically significant difference in the accuracy of detection of the CTM with palpation and US. The mean time for detecting the CTM with palpation was 8.25 ± 4.8 seconds (95% confidence interval, 7.3-9.1). The mean time for detecting CTM with US was 17 ± 9.2 seconds (95% confidence interval, 15.3-18.7). The duration for detecting the localization of the CTM was longer with US. CONCLUSION: According to the results of this study, the accuracy of US and palpation was similar in detecting the localization of the CTM. However, the duration for detecting the CTM was longer with US when compared with the palpation technique.

The Factors Influencing Relapse in Patients Presenting to the Emergency Department with COPD Exacerbation.

OBJECTIVES: Chronic Obstructive Pulmonary Disease (COPD) is associated with high mortality and morbidity and is projected to be the third most common cause of death worldwide by 2020. For a variety of reasons, there is a drive to manage a greater number of individuals as outpatients. Preventing readmissions can reduce associated morbidity and subsequent healthcare costs. METHODS: The aim of the present study was to determine the factors affecting the relapse of COPD exacerbated patients in the emergency department (ED). This study combines data from two prospective cohort studies. Patients included in the study were above 18 years of age, had a previous diagnosis of COPD, and presented to the ED for the treatment of acute exacerbation. All the information relevant to the study was collected during the patient's visit to the ED. Relapse was defined as an unscheduled visit to an ED or primary physician within 2 weeks of initial ED visit for worsening COPD symptoms. Telephone follow-up was done on all patients at the end of 2 weeks. RESULTS: The cohort consists of 196 patients. Relapse rate in this study was 27%. Mean respiratory rate, exacerbations in previous year, home nebulizator therapy, home oxygen therapy, admission to intensive care or hospital ward due to COPD exacerbation, previous intubation and abnormal chest x-ray were associated with increased re-visit in univariate analysis. However, after multivariate analysis, exacerbations in previous year (OR: 1.08, 95%CI: 1.01-1.15) and abnormal chest X-ray (OR: 2.5, 95%CI: 1.10-6.11) were still significant. CONCLUSIONS: In conclusion, the number of ED visits previous year and abnormal chest x-ray can predict the revisit of a COPD exacerbated patient within 14 days of an ED visit.

The role of nitric oxide in predicting revisit of patients with exacerbated chronic obstructive pulmonary disease.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is associated with high mortality and morbidity. OBJECTIVE: The aim of the present study was to determine the role of nitric oxide (NO) and other possible factors in predicting the revisit of patients with COPD exacerbation to the emergency department (ED). METHODS: This is a prospective cohort study on patients with exacerbated COPD in the ED setting. Bedside nasal NO values were measured with a hand-held analyzer device. Revisit to the ED has been defined as any unscheduled visit to an ED or to primary physician's office within 2 weeks of the initial ED visit for worsening COPD symptoms. A follow-up survey via telephone was conducted on all patients at the end of 2 weeks. RESULTS: The data from 64 patients who visited the ED once was compared to 28 revisits. Total of 92 patients were analyzed and variables were compared. The rate of revisits to the ED was 30%. Nasal NO measurement could not predict the revisits of patients with COPD exacerbation to the ED. The mean respiratory rate, exacerbations in previous year, home nebulizer therapy, prescribed antibiotic at discharge, home oxygen therapy, and abnormal chest x-ray studies were associated with increased rate of revisits to ED in univariate analysis. After multivariate analysis, only the mean respiratory rate at presentation and the prescribed antibiotic at discharge were significant determinants. CONCLUSIONS: There was no statistically significant difference measured in NO level at presentation or before discharge between the groups. The mean respiratory rate at presentation and the prescribed antibiotic at discharge may predict the return of a COPD-exacerbated patient within 14 days to ED.

Contribution of verbal suggestion to the therapeutic efficacy of an analgesic agent for acute primary headache.

OBJECTIVE: The therapeutic response of a patient cannot purely be explained by the method of therapy or the efficacy of a drug. Clinician-patient interaction, psychosocial factors, patients' expectations, hopes, beliefs and fears are all related to the healing outcome. Malleability and suggestibility are also important in the placebo or nocebo effect. The purpose of this study was to evaluate whether adding brief verbal suggestions for pain relief could change the magnitude of an analgesic's efficacy. METHODS: This prospective study was performed in the emergency department of a university hospital. Patients who were ordered analgesia with diclofenac sodium for primary headache were divided into three groups. All groups were informed that they would be administered a pain killer by intramuscular injection. The second and third groups were given positive and reduced treatment expectations about the therapeutic efficacy, respectively. Patients were asked to rate their pain on a VAS at 0 and 45 minutes and if they needed any additional analgesic 45 minutes after the injection. RESULTS: A total of 153 patients were included in the study. The paired univariate analyses showed significant differences for all groups between 0- and 45-minute VAS scores. However, there was no difference between the three groups according to the differences in VAS scores between 45 and 0 minutes and according to the administration of an additional drug. CONCLUSION: Simple verbal suggestions did not alter the efficacy of an analgesic agent for headache in an emergency setting. The contributions of suggestibility, desire and expectation in acute primary headache patients should be further investigated.

Traumatic pseudoaneurysm and arteriovenous fistula detected by bedside ultrasound.

BACKGROUND: The case of late presentation of a pseudoaneurysm and an arteriovenous fistula (AVF) of the common femoral artery and vein secondary to penetrating trauma is reported. Traumatic AVF and pseudoaneurysm may be present within a variety of clinical conditions, which sometimes makes it difficult to detect them clinically. Undiagnosed AVF can lead to clinical manifestations mostly secondary to increased output generated by the fistula. CASE REPORT: A 31-year-old man presented to the Emergency Department (ED) for wound care follow-up. A week before, he had suffered a stab wound to the medial thigh and the primary suture was performed in our ED. During his first visit to our ED, the vascular examination revealed palpable dorsalis pedis and tibialis posterior pulses. The formal Doppler ultrasound was negative. During his second presentation, however, the physical examination was remarkable for a palpable thrill and continuous bruit in the left mid-thigh region. Also, an ultrasound with a 7.5-MHz linear probe demonstrated a pseudoaneurysm and an AVF between the femoral artery and vein. CONCLUSION: The mechanism of the injury, wound location and tract, and physical findings after a penetrating thigh trauma can help to predict femoral artery injury. Also, occult injuries to the medial thigh after penetrating trauma may be easily overlooked on the physical examination. Furthermore, bedside ultrasound performed by an emergency physician may be helpful in diagnosing occult vascular injuries.

Upper cervical spine movement during intubation with different airway devices.

UNLABELLED: Prevention of secondary neurologic injury is critical during the airway management of a trauma patient. Trauma patients are assumed to have an unstable cervical spine (C-spine) until proven otherwise: orotracheal intubation during airway management may result in a certain amount of C-spine movement. This study, therefore, aimed to compare C-spine movement within different advanced airway devices (Macintosh blade, McCoy Blade, LMA, I-LMA, and Combitube) during airway management. MATERIALS AND METHODS: A total of 3 fresh frozen cadavers were used. The cadavers were consecutively intubated by 4 different postgraduate year residents with LMA4, I-LMA5, Combitube (37F), Macintosh 3, and McCoy blades. The cinefluoroscopic view of the entire intubation process was recorded, and vertebral body angles were calculated. RESULTS: At the C0C1 level, compared with the McCoy laryngoscope (median, 7°), the LMA (median, 2.5°) and the Combitube (median, 1.5°) caused less extension of the cervical vertebra. In addition, the Combitube (median, -1°) and the I-LMA (median, -2°) caused less extension of the C2C3 region when compared with the Macintosh laryngoscope (median, 3°). There was no significant difference between groups at the C1C2, C3C4, and C4C5 segments. CONCLUSION: Supraglottic devices used during airway management cause C-spine movement less or equal to conventional laryngoscopes. Furthermore, because of ease of training and blind insertion, supraglottic devices can be safely used with trauma patients when C-spine integrity is a concern.

ETCO2: a predictive tool for excluding metabolic disturbances in nonintubated patients.

OBJECTIVES: The purpose of this study is to examine the relation between end-tidal carbon dioxide (ETCO2) measurement and bicarbonate (HCO3) level reflecting the patient's metabolic status. METHOD: This prospective cross-sectional study has been carried out during a 3-month period in a tertiary care university hospital's emergency department (ED). During the study period, every spontaneously ventilating ED patient requiring arterial blood gas analysis for any medical indication, regardless of presenting symptoms, had a simultaneous ETCO2 measurement using a Medlab Cap 10 side stream capnograph. The demographics and clinical outcomes of the patients were recorded. RESULTS: Of 399 eligible patients, 240 with possible metabolic disturbance were enrolled into the study. There was a statistically significant correlation between the value of ETCO2 and HCO3 levels (r = 0.506). The mean ET(CO)2 level was statistically significantly lower in patients who died (26.5 ± 7.2, 95% confidence interval [CI], 24.2-28.6, vs 30 ± 7.5, 95% CI, 29-31; P = .007) and who had low bicarbonate levels (25.7 ± 6.7, 95% CI, 24.3-27.1, vs 31.6 ± 7.1, 95% CI, 30.4-32.8; P = .000). The value of ET(CO)2 measurement to detect low bicarbonate level was found to be significant. The area under the receiver operating characteristic curve was 0.734, the (+) likelihood ratio for ETCO2 less than or equal to 25 was 2.7, and the (-) likelihood ratio for ETCO2 greater than or equal to 36 was 0.05. CONCLUSION: ETCO2 values correlate moderately with HCO3 levels and thus might predict mortality and metabolic acidosis. Therefore, side stream capnograph can be used as a noninvasive diagnostic tool for ruling out suspected severe metabolic disturbance in the ED.