Engagement of the Median Glossoepiglottic Fold and Laryngeal View During Emergency Department Intubation.

STUDY OBJECTIVE: When using a standard geometry laryngoscope, experts recommend engaging the hyoepiglottic ligament-a ligament deep to the vallecula not visible to the intubator. The median glossoepiglottic fold (hereafter termed midline vallecular fold) is a superficial mucosal structure, visible to the intubator, that lies in the midline of the vallecula. We aimed to determine whether engaging the midline vallecular fold with a standard geometry blade tip during orotracheal intubation improved laryngeal visualization. METHODS: We reviewed laryngoscopic videos from intubations by emergency physicians using standard geometry video laryngoscopes over a 2-year period. Two reviewers watched each video and recorded whether the blade tip engaged the midline vallecular fold (obscured the fold with the blade tip) and the best modified Cormack-Lehane grade and percent of glottic opening obtained. We compared laryngeal views in the presence and absence of fold engagement. RESULTS: We analyzed 183 discrete laryngoscopic episodes, including 113 instances in which the midline vallecular fold was engaged and 70 instances in which the fold was not engaged. The proportion with a Cormack-Lehane grade 1 or 2a was higher with fold engagement (96%) than without (87%) (absolute difference 9% [95% confidence interval (CI) 1 to 18%]). Ordinal logistic regression demonstrated that midline vallecular fold engagement was associated with a more favorable Cormack-Lehane grade (odds ratio 2.1 [95% CI 1.1 to 4.2]). The median percent of glottic opening score was 95% (interquartile range 90 to 100%) with fold engagement and 95% (65 to 100%) without engagement (median difference 0% [95% CI 0 to 5%]). CONCLUSION: Engaging the midline vallecular fold with the laryngoscope blade tip during orotracheal intubation when using a standard geometry blade was associated with improved laryngeal visualization.

Human Errors and Adverse Hemodynamic Events Related to "Push Dose Pressors" in the Emergency Department.

BACKGROUND: Though the use of small bolus doses of vasopressors, termed "push dose pressors," has become common in emergency medicine, data examining this practice are scant. Push dose pressors frequently involve bedside dilution, which may result in errors and adverse events. The objective of this study was to assess for instances of human error and adverse hemodynamic events during push dose pressor use in the emergency department. METHODS: This was a structured chart and video review of all patients age ≥ 16 years undergoing resuscitation and receiving push dose pressors from a single center from January 2010 to November 2017. Push dose pressors were defined as intended intravenous boluses of phenylephrine (any dose) or epinephrine (≤ 100 mcg). RESULTS: A total of 249 patients were analyzed. Median age was 60 years (range, 16-97), 58% were male, 49% survived to discharge. Median initial epinephrine dose was 20 mcg (n = 139, IQR 10-100, range 1-100); median phenylephrine dose was 100 mcg (n = 110, IQR 100-100, range 25-10,000). Adverse hemodynamic events occurred in 98 patients (39%); 30 in the phenylephrine group (27%; 95% CI, 19-36%), and 68 in the epinephrine group (50%; 95% CI, 41-58%). Human errors were observed in 47 patients (19%), including 7 patients (3%) experiencing dosing errors (all overdoses; range, 2.5- to 100-fold) and 43 patients (17%) with a documentation error. Only one dosing error occurred when a pharmacist was present. CONCLUSIONS: Human errors and adverse hemodynamic events were common with the use of push dose pressors in the emergency department. Adverse hemodynamic events were more common than in previous studies. Future research should determine if push dose pressors improve outcomes and if so, how to safely implement them into practice.

Applicant Reactions to the AAMC Standardized Video Interview During the 2018 Application Cycle.

PURPOSE: This study examined applicant reactions to the Association of American Medical Colleges Standardized Video Interview (SVI) during its first year of operational use in emergency medicine (EM) residency program selection to identify strategies to improve applicants' SVI experience and attitudes. METHOD: Individuals who self-classified as EM applicants applying in the Electronic Residency Application Service 2018 cycle and who completed the SVI in summer 2017 were invited to participate in 2 surveys. Survey 1, which focused on procedural issues, was administered immediately after SVI completion. Survey 2, which focused on applicants' SVI experience, was administered in fall 2017, after SVI scores were released. RESULTS: The response rates for surveys 1 and 2 were 82.3% (2,906/3,532) and 58.7% (2,074/3,532), respectively. Applicant reactions varied by aspect of the SVI studied and their SVI total scores. Most applicants were satisfied with most procedural aspects of the SVI, but most applicants were not satisfied with the SVI overall or with their total SVI scores. About 20% to 30% of applicants had neutral opinions about most aspects of the SVI. Negative reactions to the SVI were stronger for applicants who scored lower on the SVI. CONCLUSIONS: Applicants had generally negative reactions to the SVI. Most were skeptical of its ability to assess the target competencies and its potential to add value to the selection process. Applicant acceptance and appreciation of the SVI will be critical to the SVI's acceptance by the graduate medical education community.