Emergency Department Management of Out-of-Hospital Laryngeal Tubes.

STUDY OBJECTIVE: Laryngeal tubes are commonly used by emergency medical services (EMS) personnel for out-of-hospital advanced airway management. The emergency department (ED) management of EMS-placed laryngeal tubes is unknown. We seek to describe ED airway management techniques, success, and complications of patients receiving EMS laryngeal tubes. METHODS: Using a keyword text search of ED notes, we identified patients who arrived at our ED with a laryngeal tube from 2010 through 2017. We performed structured chart and video reviews for all eligible patients. In our ED, emergency physicians perform all airway management, and there is no protocol dictating airway management for patients arriving with a laryngeal tube. Using descriptive methods, we report the techniques, success, and complications of ED airway management. RESULTS: We analyzed data on 647 patients receiving out-of-hospital laryngeal tubes, including 472 (73%) with cardiac arrest from medical causes, 75 (21%) with cardiac arrest from trauma, and 100 (15%) with other conditions. For 580 patients (89%), emergency physicians exchanged the laryngeal tube for a definitive airway in the ED. Of the 67 patients not intubated in the ED, 66 died in the ED without further airway management. Of the 580 patients intubated in the ED, orotracheal intubation was the first method attempted for 578 (>99%) and was successful on the first attempt for 515 of 578 (89%). Macintosh video laryngoscopy (88% of initial attempts) and a bougie (68% of initial attempts) were commonly used adjuncts. For 345 of 578 patients (60%), the laryngeal tube was removed before intubation attempts. For 112 of 578 patients (19%), the first intubation attempt occurred with the deflated laryngeal tube left in place. Three patients (<1%) required a surgical airway. CONCLUSION: In this cohort, emergency physicians successfully exchanged an out-of-hospital laryngeal tube for an endotracheal tube, using commonly available airway management techniques. ED clinicians should be familiar with techniques for exchanging out-of-hospital extraglottic airways for an endotracheal tube.

Rescue Sedation When Treating Acute Agitation in the Emergency Department With Intramuscular Antipsychotics.

BACKGROUND: Rapid treatment of agitation in the emergency department (ED) is critical to avoid injury to patients and providers. Treatment with intramuscular antipsychotics is often utilized, but there is a paucity of comparative effectiveness evidence available. OBJECTIVE: The purpose of this investigation was to compare the effectiveness of droperidol, olanzapine, and haloperidol for treating agitation in the ED. METHODS: This was a retrospective observational study of adult patients who received intramuscular medication to treat agitation. Patients were classified based on the initial antipsychotic they received. The primary effectiveness outcome was the rate of additional sedation administered (rescue medication) within 1 h. Secondary outcomes included rescue sedation for the entire encounter and adverse events. RESULTS: There were 15,918 patients included (median age 37 years, 75% male). Rescue rates at 1 h were: 547/4947 for droperidol (11%, 95% confidence interval [CI] 10-12%), 988/8825 olanzapine (11%, 95% CI 10-12%), and 390/2146 for haloperidol (18%, 95% CI 17-20%). Rescue rates for the entire ED encounter were: 832/4947 for droperidol (17%, 95% CI 16-18%), 1665/8825 for olanzapine (19%, 95% CI 18-20%), and 560/2146 for haloperidol (26%, 95% CI 24-28%). Adverse events were uncommon: intubation (49, 0.3%), akathisia (7, 0.04%), dystonia (5, 0.03%), respiratory arrest (1, 0.006%), and torsades de pointes (0), with no significant differences between drugs. CONCLUSIONS: Olanzapine and droperidol lead to lower rates of rescue sedation at 1 h and overall, compared with haloperidol. There were no significant differences in major adverse events.

The Effect of a Clinical Decision Support for Pending Laboratory Results at Emergency Department Discharge.

BACKGROUND: Health care systems often implement changes within the electronic health record (EHR) to improve patient safety and reduce medical errors. OBJECTIVE: To compare the proportion of emergency department (ED) encounters with laboratory tests resulting subsequent to patient discharge before and after a clinical decision support was implemented. METHODS: In 2015, our institution added an EHR dialogue when placing ED discharge orders, requiring providers to declare whether all laboratory results had been reviewed. To determine the effectiveness of this initiative, we searched the EHR to identify the proportion of ED encounters with laboratory tests resulting after discharge in pre- (January to June 2015) and post-intervention (January to June 2016) periods. RESULTS: There were 67,287 discharged patients during the study periods. In the pre- and post-intervention periods, respectively, 6.9% (95% confidence interval [CI] 6.7-7.2%) and 7.9% (95% CI 7.6-8.2%) of encounters had laboratory tests resulting after discharge, with an absolute difference of 0.9% (95% CI 0.5-1.3%). Of these patients with laboratory tests resulting after ED discharge, in 92% the provider inaccurately marked "yes" or "not applicable" to the EHR dialogue prompt. CONCLUSIONS: This workflow intervention was associated with an increase in the proportion of laboratory tests resulting after ED discharge; inaccurate answers to the EHR dialogue were pervasive. EHR workflow interventions do not always accomplish their intended goals, and their implementation should be considered thoughtfully.

Development of the Intestinal RNA Virus Community of Healthy Broiler Chickens.

Several RNA viruses such as astrovirus, rotavirus, reovirus and parvovirus have been detected in both healthy and diseased commercial poultry flocks. The aim of this study was to characterize (a) the development of the RNA viral community in the small intestines of healthy broiler chickens from hatch through 6 weeks of age (market age) and (b) the contribution of the breeder source vs. bird age in development of the community structure. Intestinal tissue samples were harvested from breeders and their progeny, processed for viral RNA extraction and sequenced using Illumina Hiseq sequencing technology resulting in 100 bp PE reads. The results from this study indicated that the breeder source influenced the RNA viral community only at hatch but later environment i.e. bird age had the more significant effect. The most abundant RNA viral family detected at 2, 4 and 6 weeks of age was Astroviridae, which decreased in abundance with age while the abundance of Picornaviridae increased with age.

Development and application of quantitative real-time PCR for the rapid detection of hemorrhagic enteritis virus in tissue samples.

Hemorrhagic enteritis virus (HEV) is a type II avian adenovirus that causes intestinal hemorrhages accompanied with immunosuppression in 4-to-12-wk-old turkeys. In the present study, a hexon gene-based, quantitative real-time PCR with TaqMan probe was developed and applied to tissue samples from poultry farms to detect and quantify HEV genome copy numbers. The method was confirmed to be rapid, specific, and sensitive for the detection of HEV. This method is an excellent research and diagnostic tool that can be used to study pathogenesis and to gain insights into different phases of infection on poultry farms and for high-throughput epidemiologic investigations.