Ideal Cricoid Pressure Is Biomechanically Impossible During Laryngoscopy.

OBJECTIVE: This study was a prospective, randomized controlled trial of rapid sequence intubation (RSI) with cricoid pressure (CP) within the emergency department (ED). The primary aim of the study was to examine the link between ideal CP and the incidence of aspiration. METHOD: Patients > 18 years of age undergoing RSI in the ED of two hospitals in New South Wales, Australia, were randomly assigned to receive measured CP using weighing scales to target the ideal CP range (3.060-4.075 kg) or control CP where the weighing scales were used, but the CP operator was blinded to the amount of CP applied during the RSI. A data logger recorded all CP delivered during each RSI. Immediately after intubation, tracheal and esophageal samples were taken and underwent pepsin analysis. RESULTS: Fifty-four RSIs were analyzed (25 measured/29 control). Macroscopic contamination of the larynx at RSI was observed in 14 patients (26%). During induction (0-50 seconds), both groups delivered in-range CP. During intubation (51-223 seconds), laryngoscopy was associated with a reduction in mean CP below 3.060 kg in both groups. When compared, there was no statistically significant difference between the groups. For 11 patients, pepsin was detected in the oropharyngeal sample, while three were positive for tracheal pepsin. Seven patients (four control/three measured) were treated for clinical aspiration during hospitalization. As a result of the finding that neither group could maintain ideal range CP during laryngoscopy, the trial was abandoned. CONCLUSION: Laryngoscopy provides a counter force to CP, which is negated to facilitate tracheal intubation. The concept that a static 3.060 to 4.075 kg CP could be maintained during laryngoscopy and intubation was rejected by our study. Whether a lower CP range could prevent aspiration during RSI was not explored by this study.

Effectiveness of cricoid pressure in preventing gastric aspiration during rapid sequence intubation in the emergency department: study protocol for a randomised controlled trial.

BACKGROUND: Cricoid pressure is considered to be the gold standard means of preventing aspiration of gastric content during Rapid Sequence Intubation (RSI). Its effectiveness has only been demonstrated in cadaveric studies and case reports. No randomised controlled trials comparing the incidence of gastric aspiration following emergent RSI, with or without cricoid pressure, have been performed. If improperly applied, cricoid pressure increases risk to the patient. The clinical significance of aspiration in the emergency department is unknown. This randomised controlled trial aims to; 1. Compare the application of the 'ideal" amount of force (30 - 40 newtons) to standard, unmeasured cricoid pressure and 2. Determine the incidence of clinically defined aspiration syndromes following RSI using a fibrinogen degradation assay previously described. METHODS/DESIGN: 212 patients requiring emergency intubation will be randomly allocated to either control (unmeasured cricoid pressure) or intervention groups (30 - 40 newtons cricoid pressure). The primary outcome is the rate of aspiration of gastric contents (determined by pepsin detection in the oropharyngeal/tracheal aspirates or treatment for aspiration pneumonitis up to 28 days post-intubation). Secondary outcomes are; correlation between aspiration and lowest pre-intubation Glasgow Coma Score, the relationship between detection of pepsin in trachea and development of aspiration syndromes, complications associated with intubation and grade of the view on direct largyngoscopy. DISCUSSION: The benefits and risks of cricoid pressure application will be scrutinised by comparison of the incidence of aspiration and difficult or failed intubations in each group. The role of cricoid pressure in RSI in the emergency department and the use of a pepsin detection as a predictor of clinical aspiration will be evaluated. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12611000587909.

Could we care for Amillia in rural Australia?

Extremely premature and very low birth weight infants have multiple, costly and complex health and developmental issues. After the neonatal period, the best chance for these children to avoid extreme disability and dependence, and thereby reach their potential, is with timely and intensive early intervention by appropriate allied health services, such as speech, occupational and physiotherapy. However, currently in rural Australia, such children are further disadvantaged by their relative lack of access to appropriate types and levels of services, compared with their urban counterparts.

Evidence-based implementation of adult asthma guidelines in the emergency department: a controlled trial.

OBJECTIVE: To determine if an evidence-based implementation (EBI) strategy could lead to the successful implementation of guidelines for the management of adult asthma in a large rural ED. METHODS: This was a pre- and post-intervention trial, comparing data for seven clinical indicators from a study hospital and a control hospital. Retrospective pre-intervention audits were conducted at the study hospital for 3 months (1 April-30 June 2004) and the control hospital for 4 months (1 March-30 June 2004). The effect of an EBI to implement established guidelines for the management of asthma at the study hospital was compared with the effect of a mail-out of guideline booklets and wall charts to the control hospital. Post-intervention audits were then performed at both hospitals. Sustainability of the EBI was gauged by 12 month follow-up data at the study hospital. RESULTS: There were 55 presentations of adult asthma at the study hospital in the pre-intervention phase and 67 post-intervention. The corresponding numbers for the control hospital were 51 and 42, respectively. Following the EBI there were significant improvements at the study hospital for the documentation of severity (27-99%, P < 0.01), use of spirometry (38-84%, P < 0.01), medication delivery via spacer device (0-26%, P < 0.01), use of systemic steroids (66-84%P < 0.05), use of written short-term asthma plans (14-82%, P < 0.01), reduction of ipratropium use in mild asthma (43-16%, P < 0.05) and reduction in antibiotic use in afebrile asthmatics (37-6%, P < 0.01). For the control hospital there was a significant increase in spirometry use from 2% to 40% (P < 0.01). For seven clinical indicators combined, compliance with the guideline increased from 38% to 79.1% (P < 0.01) at the study hospital, whereas there was no change at the control hospital, 44.3% to 43% (P = 0.75) There were 68 presentations at 12 month follow up at the study hospital and compliance with the seven clinical indicators was 78.2%. CONCLUSION: An EBI significantly improved compliance at the study hospital with no improvement noted in the control hospital. These improvements were maintained at 12 month follow up. An EBI can lead to significant improvements in the management of asthma at a large rural referral hospital ED and might have implications for hospitals with similar roles and profiles.

Duodenal perforation: an interesting case report.

We describe a young child presenting with vomiting and altered neurological status. An incidental finding of pneumoperitoneum on abdominal X-ray led to laparotomy and the discovery of a duodenal perforation. We describe the difficulties in making the diagnosis of duodenal perforation in children and some of the factors that led to the delay in diagnosis in this case.

Inpatient mortality as related to triage category in three New South Wales regional base hospitals.

OBJECTIVE: To establish the incidence of death after admission via the ED for each of the five categories of the Australasian Triage Scale in three New South Wales base hospitals, and to compare this with published data from an adult tertiary referral hospital in Victoria. To examine the causes of death in each category. METHODS: Information was collected from databases established as part of quality assurance projects at three New South Wales rural base hospitals from 1 January 2000 to 31 December 2000. RESULTS: Overall mortality rates per ED presentation and per ED admission were significantly lower than for similar data from an adult tertiary referral hospital. There were significant differences in mortality per ED presentation for categories 2, 3 and 4 and significant differences in mortality per admission for Australasian Triage Scale categories 2 and 3. The commonest causes of death were acute cardiac/respiratory and malignancy related conditions. Triage category 3 had both the highest number of total admissions and the highest number of deaths post admission. This finding differs from published data from an adult tertiary referral hospital where category 4 represented the largest number of admissions and of in-hospital deaths following admission. CONCLUSION: This study has established the mortality rates per ED presentation and admission for each of the five categories of the Australasian Triage Scale in three New South Wales rural base hospitals. Significant differences were found between these rates and the published rates for an adult tertiary referral hospital.