Rapid Extrication versus the Kendrick Extrication Device (KED): Comparison of Techniques Used After Motor Vehicle Collisions.

INTRODUCTION: The goal of this study was to compare application of the Kendrick Extrication Device (KED) versus rapid extrication (RE) by emergency medical service personnel. Our primary endpoints were movement of head, time to extrication and patient comfort by a visual analogue scale. METHODS: We used 23 subjects in two scenarios for this study. The emergency medical services (EMS) providers were composed of one basic emergency medical technician (EMT), one advanced EMT. Each subject underwent two scenarios, one using RE and the other using extrication involving a commercial KED. RESULTS: Time was significantly shorter using rapid extraction for all patients. Angles of head turning were all significantly larger when using RE. Weight marginally modified the effect of KED versus RE on the "angle to right after patient moved to backboard (p= 0.029) and on subjective movement on patient questionnaire (p=0.011). No statistical differences were noted on patient discomfort or pain. CONCLUSION: This is a small experiment that showed decreased patient neck movement using a KED versus RE but resulted in increased patient movement in obese patients. Further studies are needed to determine if the KED improves any meaningful patient outcomes in the era of increased evidence-based medicine in emergency medical services.

Intravenous lidocaine for the emergency department treatment of acute radicular low back pain, a randomized controlled trial.

BACKGROUND: Acute radicular back pain is a frequent complaint of patients presenting to the Emergency Department. STUDY OBJECTIVE: Determine the efficacy of intravenous lidocaine when compared to ketorolac for the treatment of acute radicular low back pain. METHODS: Randomized double-blind study of 41 patients aged 18-55 years presenting with acute radicular low back pain. Patients were randomized to receive either 100 mg lidocaine or 30 mg ketorolac intravenously over 2 min. A 100-mm visual analog scale (VAS) was used to assess pain at Time 0 (baseline), and 20, 40, and 60 minutes. Changes in [median] VAS scores were compared over time (within groups) by the signed-rank test and between groups by the rank-sum test. A 5-point Pain Relief Scale (PRS) was administered at the conclusion of the study (60 min) and again at 1 week by telephone follow-up; [median] scores were compared between groups by rank-sum. RESULTS: Forty-four patients were recruited; 41 completed the study (21 lidocaine, 20 ketorolac). Initial VAS scores were not significantly different between the lidocaine and ketorolac groups (83; 95% confidence interval [CI] 74-98 vs. 79; 95% CI 64-94; p = 0.278). Median VAS scores from baseline to 60 min significantly declined in both groups (lidocaine [8; 95% CI 0-23; p = 0.003]; ketorolac [14; 95% CI 0-28; p = 0.007]), with no significant difference in the degree of reduction between groups (p = 0.835). Rescue medication was required by 67% receiving lidocaine, compared to 50% receiving ketorolac. No significant change in PRS between groups was found at the conclusion or at the follow-up. CONCLUSION: Intravenous lidocaine failed to clinically alleviate the pain associated with acute radicular low back pain.

Bedside method to estimate actual body weight in the Emergency Department.

BACKGROUND: Actual body weight (ABW) is important for accurate drug dosing in emergency settings. Oftentimes, patients are unable to stand to be weighed accurately or clearly state their most recent weight. OBJECTIVE: Develop a bedside method to estimate ABW using simple anthropometric measurements. METHODS: Prospective, blinded, cross-sectional convenience sampling of adult Emergency Department (ED) patients. A multiple linear regression equation from Derivation Phase (n = 208: 121 males, 87 females) found abdominal and thigh circumferences (AC and TC) had the best fit and an inter-rater correlation of 0.99 and 0.96, respectively: Male ABW (kg) = -47.8 + 0.78 ∗ (AC) + 1.06 ∗ (TC); Female ABW = -40.2 + 0.47 ∗ (AC) + 1.30 ∗ (TC). RESULTS: Derivation phase: Number of patients (%) with a body weight estimation (BWE) > 10 kg from ABW for males/females were: 7 (6%)/1 (1%) for Patients, 46 (38%)/28 (32%) for Doctors, 38 (31%)/24 (27%) for Nurses, 75 (62%)/43 (49%) for 70 kg/60 kg convention, and 14 (12%)/8 (9%) using the anthropometric regression model. For validation phase (55 males, 44 females): Gold standard ABW mean (SD) male/female = 83.6 kg (14.3)/71.5 kg (18.9) vs. anthropometric regression model = 86.3 kg (14.7)/73.3 kg (15.1). R(2) = 0.89, p < 0.001. The number (%) for males/females with a BWE > 10 kg using the anthropometric regression model = 8 (15%)/11 (27%). CONCLUSIONS: For male patients, a regression model using supine thigh and abdominal circumference measurements seems to provide a useful and more accurate alternative to physician, nurse, or standard 70-kg male conventional estimates, but was less accurate for use in female patients.

Bedside estimation of patient height for calculating ideal body weight in the emergency department.

BACKGROUND: Ideal body weight (IBW), which can be calculated using the variables of true height and sex, is important for drug dosing and ventilator settings. True height often cannot be measured in the emergency department (ED). OBJECTIVES: Determine the most accurate method to estimate IBW using true height-based IBW that uses true height estimated by providers or patients compared to true height estimated by a regression formula using measured tibial length, and compare all to the conventional 70 kg male/60 kg female standard IBW. METHODS: Prospective, observational, double-blind, convenience sampling of stable adult patients in a tertiary care ED from September 2004 to April 2006. Derivation set (215 patients) had blinded provider and patient true height estimates and tibial length measurements compared to gold-standard standing true height. A validation set (102 patients) then compared the accuracy of IBW using true height calculated from the regression formula vs. IBW using gold-standard true height. Regression formula for men tibial length-IBW (kg) = 25.83 + 1.11 × tibial length; for women tibial length-IBW = 7.90 + 1.20 × tibial length; R(2) = 0.89, p < 0.001. Inter-rater correlation of tibial length was 0.94. RESULTS: Derivation set: percent within 5 kg of true height-based IBW for men/women = PATIENT: 91.1%:/85.7%; Physician: 66.1%/45.1%; Nurse: 65.7%/ 47.3%; tibial length: 66.1%/63.7%; and 70 kg male/60 kg female standard 46%/75%. Validation set: tibial length-IBW estimates were within 5 kg of true height-ideal body weight in only 56.2% of men and 42.2% of women. CONCLUSIONS: PATIENT-reported height is the best bedside method to estimate true height to calculate ideal body weight. Physician and nurse estimates of true height are substantially less accurate, as is true height obtained from a regression formula that uses measured tibial length. All methods were more accurate than using the conventional 70 kg male/60 kg female IBW standard.

Disposable stainless steel vs plastic laryngoscope blades among paramedics.

BACKGROUND: Several studies have been published in the literature about intubation methods, but little is available on intubation equipment used in this setting. This is the first prehospital comparison of disposable plastic vs disposable stainless steel laryngoscope blades used by paramedics. STUDY OBJECTIVE: The objective of this study was to compare prehospital intubation success rates on first attempt and overall number of attempts to obtain intubations using disposable plastic laryngoscopes blades vs disposable stainless steel laryngoscope blades. METHODS: A retrospective prehospital cohort study was conducted during two 3-year periods. Two-way contingency table and χ(2) test were conducted to determine if there was a difference between the 2 types of blades. A proportional odds model with calculated 95% confidence interval (CI) and odd ratios were then calculated. RESULTS: A total of 2472 paramedic intubations were recorded over the 6-year period. The stainless steel single-use blades had a first attempt success rate of 88.9% vs 78.5% with plastic blades (P = .01; odds ratio, 1.94; 95% CI, 1.17-3.41). The stainless steel single-use laryngoscope blade had a lower number of attempts to successful intubation than the plastic blade (88.8% vs 74.3%, respectively) (P < .01; odds ratio, 1.64; 95% CI, 1.34-2.00). CONCLUSIONS: In the prehospital setting, stainless steel disposable blades were superior to plastic disposable blades in first attempt and overall number of attempts to intubation. Until further research is done, we recommend use of stainless steel blades for intubations in the prehospital setting by paramedics.

Naloxone in cardiac arrest with suspected opioid overdoses.

INTRODUCTION: Naloxone's use in cardiac arrest has been of recent interest, stimulated by conflicting results in both human case reports and animal studies demonstrating antiarrhythmic and positive ionotropic effects. We hypothesized that naloxone administration during cardiac arrest, in suspected opioid overdosed patients, is associated with a change in cardiac rhythm. METHODS: From a database of 32,544 advanced life support (ALS) emergency medical dispatches between January 2003 and December 2007, a retrospective chart review was completed of patients receiving naloxone in cardiac arrest. Forty-two patients in non-traumatic cardiac arrest were identified. Each patient received naloxone because of suspicion by a paramedic of acute opioid use. RESULTS: Fifteen of the 36 (42%) (95% confidence interval [CI]: 26-58) patients in cardiac arrest who received naloxone in the pre-hospital setting had an improvement in electrocardiogram (EKG) rhythm. Of the participants who responded to naloxone, 47% (95% CI: 21-72) (19% [95% CI: 7-32] of all study subjects) demonstrated EKG rhythm changes immediately following the administration of naloxone. DISCUSSION: Although we cannot support the routine use of naloxone during cardiac arrest, we recommend its administration with any suspicion of opioid use. Due to low rates of return of spontaneous circulation and survival during cardiac arrest, any potential intervention leading to rhythm improvement is a reasonable treatment modality.

A pilot study of mechanical stimulation and cardiac dysrhythmias in a porcine model of induced hypothermia.

BACKGROUND: Hypothermia is a frequent complication of cold weather exposure and/or wilderness injuries. Anecdotal reports have postulated that patients suffering from acute hypothermia are at significantly increased risk of developing lethal cardiac dysrhythmias secondary to the physical stimulation from moving and transporting patients. OBJECTIVE: To develop a model to attempt to determine if rough handling and sudden movement can induce lethal cardiac dysrhythmias in a controlled animal study of mild to severe hypothermia. METHODS: Ten anesthetized swine had continuous cardiac and invasive blood pressure (BP) monitoring. Core body temperature (CBT) was measured with an esophageal probe. Animals were secured to a backboard in a supine position for the duration of the study and their CBT was serially lowered by external cooling measures. At preset intervals (every 3 degrees C lowered from the baseline CBT of 38 degrees C), the animals were lifted via the backboard and rolled 90 degrees to the left and held for 5 seconds and then rolled to the right and held for 5 seconds. After rolling, the swine were lifted via the backboard 6 inches off the surgical table and dropped back onto the table, and after 15 seconds this was repeated at 12 inches. If no signs of dysrhythmia were noted, external cooling was continued. Data were analyzed by tests of proportion on mortality associated with hypothermia and mechanical stimulation. To determine whether hypothermia and mechanical stimulation were independent effects, a one-sided McNemar's test of matched pairs was employed. RESULTS: No animal developed a dysrhythmia at a CBT > 25 degrees C with or without stimulation. Fifty percent of the animals developed fatal dysrhythmias (3 ventricular fibrillation, 2 asystole) with no stimulation but at CBT