A randomized controlled trial comparing minichest tube and needle aspiration in outpatient management of primary spontaneous pneumothorax.

OBJECTIVES: The aim of this study was to compare outcomes and complications associated with needle aspiration (NA) and minichest tube (MCT) insertion with Heimlich valve attachment in the treatment of primary spontaneous pneumothorax at an emergency department (ED). METHODS: Patients presenting with primary spontaneous pneumothorax were randomized to NA or MCT. They had repeat chest x-rays immediately after the procedure and 6 hours later. Patients who underwent NA were discharged if repeat x-rays showed less than 10% pneumothorax. Those who had MCT were discharged if repeat x-rays did not show worsening of pneumothorax. They were reviewed at the outpatient clinic within 3 days. The primary outcomes of interest were failure rate and admission rate. The secondary outcomes were complication rate, pain and satisfaction scores, length of hospital stay, and rate of full recovery during outpatient follow-up. RESULTS: There were 48 patients whose mean age was 25 years. We found no difference in failure rate between the groups, except that there were more MCT (24%) than NA patients (4%) with complete expansion at first review (difference, -0.20; 95% confidence interval, -0.38 to -0.01). Thirty-five percent of NA group and 20% of MCT group needed another procedure at the ED. Fifty-two percent of NA patients and 28% of MCT patients were admitted from the ED to the inpatient ward. Nine percent and 12%, respectively, of patients who had NA and MCT were admitted from the review clinic. Both groups of patients had equivalent pain scores, satisfaction scores, and complication rates. CONCLUSION: Both MCT and NA allowed safe management of primary spontaneous pneumothorax in the outpatient setting.

Using demand analysis and system status management for predicting ED attendances and rostering.

INTRODUCTION: It has been observed that emergency department (ED) attendances are not random events but rather have definite time patterns and trends that can be observed historically. OBJECTIVES: To describe the time demand patterns at the ED and apply systems status management to tailor ED manpower demand. METHODS: Observational study of all patients presenting to the ED at the Singapore General Hospital during a 3-year period was conducted. We also conducted a time series analysis to determine time norms regarding physician activity for various severities of patients. RESULTS: The yearly ED attendances increased from 113387 (2004) to 120764 (2005) and to 125773 (2006). There was a progressive increase in severity of cases, with priority 1 (most severe) increasing from 6.7% (2004) to 9.1% (2006) and priority 2 from 33.7% (2004) to 35.1% (2006). We noticed a definite time demand pattern, with seasonal peaks in June, weekly peaks on Mondays, and daily peaks at 11 to 12 am. These patterns were consistent during the period of the study. We designed a demand-based rostering tool that matched doctor-unit-hours to patient arrivals and severity. We also noted seasonal peaks corresponding to public holidays. CONCLUSION: We found definite and consistent patterns of patient demand and designed a rostering tool to match ED manpower demand.

The effect of severe acute respiratory syndrome (SARS) on emergency airway management.

From early March 2003 to late May 2003, severe acute respiratory syndrome (SARS) was detected in Singapore. The increase in workload and new infection control procedures were thought to affect resuscitation and airway management. Our aim was to study the effects of wearing of personal protective equipment (PPE) and powered air-purifying respirator (PAPR) and the restriction in the number of resuscitation personnel on airway management during the SARS crisis. Data was collected prospectively through an ongoing emergency airway registry. The data was divided into three periods: (1) before PPE was instituted from 1 November 2002 to 31 March 2003; (2) during SARS (when PPE use was mandatory) from 1 April to 31 July 2003; (3) post-SARs (when PPE use was non-mandatory but encouraged) from 1 August to 31 March 2004. There was no change in patient demographics during the three periods. There were significant increases in the proportion of resuscitation cases and airway interventions during the SARS period compared to the pre-SARS period. The resident medical officer intubation rate decreased from 45.1% pre-SARS to 35.2% during SARS and 17.7% post-SARS. The complication rates were 10.5%, 9.9% and 9.4% in periods 1-3, respectively. Restriction in the number of healthcare staff attending to each patient may have influenced the department's decision to allow only the most confident or experienced personnel to manage the airway. The exposure of junior medical officers in emergency airway management during SARS and the immediate post-SARS period was decreased. This trend should be monitored further and intervention may be necessary should it continue to decline.

Emergency airway management--experience of a tertiary hospital in South-East Asia.

OBJECTIVE: To study the indications and diagnoses of patients requiring emergency airway management and to evaluate the adequacy of airway management skills of emergency physicians. METHODS: Prospective observational study of all patients requiring advanced airway management from 1 November 1998 to 31 October 2002. RESULTS: There were 1068 cases, 710 (66.5%) were men. The median age was 63 years. The most common diagnoses requiring tracheal intubation were cardiopulmonary arrest (37.7%), congestive heart failure (20.8%) and head injury (8.3%). The main indications were apnoea (42.5%), hypoxia (21.3%) and prophylactic airway protection (17.6%). Orotracheal intubation with no medication was most common (51.5%) followed by rapid sequence induction (RSI) (28.4%) and orotracheal intubation with sedation only (19.6%). The overall success rate for orotracheal intubation was 99.6%. The cricothyrotomy rate was 0.2%. Hypotension (4.2%), multiple intubation attempts (1.9%) and oesophageal intubation (1.5%) were the three most common peri-intubation complications. There was no statistical difference in the occurrence of hypotension between the use of midazolam and etomidate for sedation or induction prior to intubation. Six hundred and forty-six (60.5%) patients survived the immediate post-resuscitation period. No patient died from failure to secure the airway. CONCLUSION: Airway management and rapid sequence induction for intubation can be safely performed by emergency physicians.