RESUMO
BACKGROUND: Fentanyl is often administered during rapid sequence induction of anesthesia (RSI) in the emergency department (ED) to ameliorate the hypertensive response that may occur. Due to its more rapid onset, the use of alfentanil may be more consistent with both the onset time of the sedative and the commencement of laryngoscopy. As such, we compared the effect of alfentanil and fentanyl on post-induction hemodynamic changes when administered as part of a standardized induction regimen including ketamine and rocuronium in ED RSI. METHODS: This was a double-blind pilot randomized controlled trial of adult patients requiring RSI in the ED of three urban Australian hospitals. Patients were randomized to receive either alfentanil or fentanyl in addition to ketamine and rocuronium for RSI. Non-invasive blood pressure and heart rate were measured immediately before and at two, four, and six minutes after induction. The primary outcome was the occurrence of at least one post-induction systolic blood pressure outside the pre-specified range of 100-160mmHg (with adjustment for patients with baseline hypertension). Secondary outcomes included hypertension, hypotension, hypoxia, first-pass intubation success, 30-day mortality, and the pattern of hemodynamic changes. RESULTS: A total of 61 patients were included in the final analysis (31 in the alfentanil group and 30 in the fentanyl group). The primary outcome was met in 58% of the alfentanil group and 50% of the fentanyl group (difference 8%, 95% confidence interval: -17% to 33%). The 30-day mortality rate, first-pass success rate, and incidences of hypertension, hypotension, and hypoxia were similar between the groups. There were no significant differences in systolic blood pressure or heart rate between the groups at any of the measured time-points. CONCLUSION: Alfentanil and fentanyl produced comparable post-induction hemodynamic changes when used as adjuncts to ketamine in ED RSI. Future studies could consider comparing different dosages of these opioids.
RESUMO
OBJECTIVE: To describe the clinical and transport characteristics of patients diagnosed with a suspected traumatic pneumothorax and managed conservatively by prehospital medical teams including secondary deterioration during transfer and the subsequent rate of in-hospital tube thoracostomy. METHODS: Retrospective observational study of all adult trauma patients diagnosed with a suspected pneumothorax on ultrasound and managed conservatively by their treating prehospital medical team between 2018 and 2020. Descriptive analysis was performed comparing patients who did and did not receive in-hospital tube thoracostomy. RESULTS: In total, 181 patients were diagnosed with suspected traumatic pneumothoraces on prehospital ultrasound of which 75 (41.4%) were managed conservatively by their treating medical team whilst 106 (58.6%) underwent pleural decompression. There were no recorded cases of emergent pleural decompression required in transit. Of the 75 conservatively managed patients, 42 (56%) had an intercostal catheter (ICC) placed within four hours of hospital arrival and another nine (17.6%) had an ICC placed between four- and 24-hours post-hospital arrival. There was no significant difference in prehospital clinical characteristics between patients who did and did not receive an in-hospital ICC. The detection of a pneumothorax on the initial chest x-ray and larger pneumothorax volume visualised on computed tomography imaging were significantly more common in patients receiving in-hospital ICCs. Aviation factors including flight altitude and duration of flight were not associated with subsequent in-hospital tube thoracostomy. CONCLUSION: Prehospital medical teams can safely identify patients who have a traumatic pneumothorax and can be transported to hospital without pleural decompression. Patient characteristics at the time of hospital arrival combined with the size of pneumothorax identified on imaging appear most likely to influence subsequent urgent in-hospital tube thoracostomy placement.
