Initial Experience of Emergency Physicians Using the Intubating Laryngeal Mask Airway: A Case Series

OBJECTIVE: Although the intubating laryngeal mask airway (ILMA) is widely available, its use by emergency physicians (EPs) has not been reported. The authors report the initial experience of EPs using the ILMA. A review of their experience and the relevant anesthesia literature provides a basis for EPs to use the ILMA more confidently and effectively. METHODS: Between January 2000 and January 2001, the ILMA was used on a convenience sample of emergency department (ED) patients undergoing "routine" intubations, and "rescue" situations, after failed rapid-sequence intubation (RSI). Patients were identified from the ED resuscitation case database. Chart review and intubating physician interviews focused on success of the device, complications encountered, and "pearls" of the device's use as perceived by the intubating physician. RESULTS: Ventilation with the appropriate-size ILMA occurred in less than 15 seconds in all "routine" intubations; tracheal intubation was subsequently accomplished in less than 1 minute. Eight of nine "routine" patients had blind tracheal intubation through the ILMA. One patient required fiberoptic bronchoscopy to guide the endotracheal tube into the trachea. Of the "rescue" intubations, all patients (n = 7) were successfully ventilated and five were successfully intubated using the ILMA. CONCLUSIONS: In this case series, the ILMA was easy to use in acute resuscitations, and proved to be invaluable in cases of failed RSI.     

Trauma Patients Can Be Safely Extubated in the Emergency Department

Background: Many trauma patients are intubated for conditions that fully resolve during their emergency department (ED) stay. Often, these patients remain intubated until after they leave the ED. Objective: The objective of this study was to examine the prognosis of patients extubated in the ED. Methods: Data from the records of adult trauma patients who were intubated and then extubated in the ED at a single trauma referral center were prospectively collected for a quality initiative. Two trained abstractors retrospectively recorded these data as well as additional information from the trauma registry and patient charts. The primary outcome was the need for unplanned reintubation during hospitalization. Additional outcomes were disposition and complications from the extubation. Results: There were 50 eligible patients identified and included in the study. Reasons for the intubation included combative behavior or decreased mental status before computed axial tomography (CT) scan in 24 patients (48%), sedation before the performance of a painful procedure in 18 patients (36%), and seizures before CT scan in 3 patients (6%). None of the patients (0%; 95% confidence interval 0–6%) required unplanned reintubation. Eight (16%) of the patients were able to be discharged from the ED before admission. Conclusions: Although our findings must be verified in larger, controlled studies, it may be safe to extubate patients in the ED, if the condition necessitating intubation has fully resolved. This practice may reduce admission rates and limit the need for intensive care unit beds for the patients who are admitted.     

小儿心肺复苏后脑血流监测的临床研究

目的探讨心肺复苏后患儿脑血流变化特点及与预后的关系。方法经颅多普勒超声动态监测心肺复苏后的患儿45例,以左侧大脑中动脉和颈内动脉颅外段为靶血管,观察频谱形态和血流速度,同时做Glasgow昏迷评分。根据经颅多普勒超声频谱形态将患儿分为低灌流组、高灌流组和大致正常组。结果低灌流组和高灌流组最高G1asgow评分明显低于大致正常组(P<0.01);而因深昏迷放弃治疗和死亡数明显高于大致正常组(P<0.01)。低灌流组随病程进展脑血流无明显改善;高灌流组2例随病情加重转变为低灌流型:存活患儿随病情好转经颅多普勒超声频谱逐渐趋于正常。结论经颅多普勒超声监测心肺复苏后患儿脑血流变化有助于了解脑灌流状况,评估预后,并指导临床治疗。     

Care of the Intubated Emergency Department Patient

Background: Emergency physicians perform tracheal intubation and initiate mechanical ventilation for critically ill patients on a daily basis. With the current national challenges of intensive care unit bed availability, intubated patients now often remain in the emergency department (ED) for exceedingly long periods of time. As a result, care of the intubated patient falls to the emergency physician (EP). Given the potential for significant morbidity and mortality, it is crucial for the EP to possess the most current, up-to-date information pertaining to the care of intubated patients. Discussion: This article discusses critical aspects in the ED management of intubated and mechanically ventilated patients. Specifically, emphasis is placed on providing adequate sedation and analgesia, limiting the use of neuromuscular blocking agents, correctly setting and adjusting the mechanical ventilator, utilizing appropriate monitoring modalities, and providing key supportive measures. Despite these measures, inevitably, some patients deteriorate while receiving mechanical ventilation. The article concludes with a discussion outlining a step-wise approach to evaluating the intubated patient who develops respiratory distress or circulatory compromise. With this information, the EP can more effectively care for ventilated patients while minimizing morbidity, and ultimately, improving outcome. Conclusion: Essential components of the care of intubated ED patients includes administering adequate sedative and analgesic medications, using lung-protective ventilator settings with attention to minimizing ventilator-induced lung injury, elevating the head of the bed in the absence of contraindications, early placement of an orogastric tube, and providing prophylaxis for stress-related mucosal injury and deep venous thrombosis when indicated.     

A comparison of transcranial doppler ultrasound (TCD) and radioactive microspheres in determining cerebral perfusion in normal and low flow states

We have previously utilized the technique of transcranial Doppler (TCD) ultrasound to determine cerebral perfusion in patients undergoing cardiopulmonary resuscitation (CPR). In order to assess if TCD can reliably measure alterations in cerebral perfusion under conditions of normal and low cardiac outputs, we compared TCD measured blood flow velocities in the middle cerebral artery (MCA) of six piglets with radioactive microsphere determinations of total cerebral perfusion at baseline normal sinus rhythm (NSR), during CPR, and following return of spontaneous circulation (ROSC). Peak systolic and mean blood flow velocities were compared to the microsphere perfusion results on 15 different occasions; six during NSR, five during CPR, and four following ROSC. Although qualitative alterations in TCD measurements reflected changes in microsphere perfusion, we could not find a statistically significant correlation between either peak systolic or mean MCA blood flow velocities and microsphere perfusion measurements either overall or in any subgroup. The possible reasons which may explain the findings are discussed.     

Impact of Emergency Medicine Faculty and an Airway Protocol on Airway Management

OBJECTIVE: To determine the impact of emergency medicine (EM) faculty presence and an airway management protocol on success rates of tracheal intubation in the emergency department (ED). METHODS: A retrospective observational study of prospectively collected data on rates of successful intubations between June 1997 and December 2001 in the ED of a large urban teaching hospital. The authors compared success rates of the first attempt at intubation and times to intubation prior to and after EM faculty presence and the institution of an airway management protocol. RESULTS: Prior to EM faculty presence and the airway management protocol, tracheal intubation was achieved on the first attempt 46% of the time; more than six attempts were required 2.9% of the time. The mean time to intubation was 9.2 minutes (+/-13.2 SD). Following EM faculty presence and the airway protocol, the success rate on the first attempt was 62%, more than six attempts were required 1.1% of the time, and the mean time to intubation was 4.6 minutes (+/-6.2 SD). CONCLUSIONS: First-attempt intubation success rates and decreased mean time to successful intubation improved following EM faculty presence and the introduction of an airway management protocol.     

Use of Emergency Department Transcranial Doppler Assessment of Reperfusion After Intravenous tPA for Ischemic Stroke

Background: Thrombolysis with intravenous recombinant tissue plasminogen activator (IV-tPA) has been associated with significant improvements in clinical outcomes when initiated within 3 h of symptom onset. Although adjunctive therapies for acute stroke have been developed, challenges remain in identifying appropriate patients and therapeutic end-point measurements. Objective: To describe the use of transcranial Doppler (TCD) monitoring in the Emergency Department (ED) to guide the decision for advanced reperfusion strategies after failure of IV-tPA. Case Report: A 75-year-old man presented to the ED within 50 min after the acute onset of right-sided hemiparesis and aphasia. After administration of IV-tPA, there was no immediate improvement in neurological symptoms. TCD performed in the ED demonstrated persistent left middle cerebral artery (MCA) occlusion. Based on this information, the patient received intra-arterial tPA followed by mechanical thrombectomy of the MCA occlusion, resulting in clinical improvement of the patient's right hemiparesis and aphasia. Conclusion: TCD is a feasible assessment tool for use in the ED to aid in diagnosis and to guide treatment decisions in patients with acute ischemic stroke, including those not responding to IV-tPA therapy.     

Cardiac Rupture

Background

Cardiac rupture is an unusual cause of chest pain and sudden cardiovascular collapse. This diagnosis may be easily forgotten while managing a patient in extremis in the initial minutes of evaluation and resuscitation in the emergency department (ED).

Objectives

To report the benefit of immediate bedside cardiac ultrasonography in the diagnosis of cardiac rupture and its influence on emergent intervention in the ED.

Case Report

The initial electrocardiogram, performed within 5 min of arrival, of a 65-year old man who presented with 20 min duration of chest pain, showed a biphasic T wave in V1 and inverted T wave in V2, without ST-segment elevation myocardial infarction. Fifteen minutes later, he lost consciousness and was pulseless without a shockable rhythm on the monitor. Chest compressions were started and the patient was intubated. Echocardiography was performed at the bedside by the emergency physician. Cardiac contractility was grossly decreased in both ventricles and a large amount of pericardial fluid was seen. Two attempts at ultrasound-guided pericardiocentesis yielded only a few milliliters of blood. Interruptions in chest compressions were minimized during pericardiocentesis. Before transport of the patient to the operating room for definitive repair, asystole occurred. On the subsequent echocardiogram, heart contractions were absent and a hematoma was seen in the pericardial space. Resuscitation efforts were stopped. An autopsy was not performed per family request.

Conclusions

Typical ultrasonographic findings of cardiac rupture were present in this patient, who presented in extremis with chest pain. Early bedside echocardiography can be helpful in directing the initial care of critically ill patients.     

经颅多普勒超声在老年人椎动脉型颈椎病的诊断及治疗中的价值

目的 探讨经颅多普勒超声（TCD）对老年人椎动脉型颈椎病的诊断及疗效评定价值。方法 按临床诊断标准收集椎动脉型颈椎病患者36例,平均年龄53.6岁,对照组为年龄相近的健康人28例。采用MT－1000型彩色经颅多普勒超声仪于治疗前后对基底动脉（BA）、椎动脉（VA）、大脑后动脉（PCA）、大脑前动脉（ACA）和大脑中动脉（MCA）的血流峰速度（Vp）、血流平均速度（Vm）及血流频谱图像进行检测分析。结果 疾病组椎基底动脉（VBA）流速明显低于对照组（P＜0.05）。疾病组TCD异常率为80.6％（29例／36例）,以VBA流速降低为主要特点。治疗后椎基底动脉系统血流速度明显改善（P＜0.05）。结论 TCD可作为老年人椎动脉型颈椎病患者诊断及疗效评定的参考依据。     

颅脑损伤昏迷病人院前救护程序改进的效果观察

目的探讨改良颅脑损伤昏迷病人院前急救护理程序的效果。方法按颅脑损伤昏迷病人救护车出诊先后顺序编号,单号为观察组60例,双号为对照组59例。观察组实施改良的救护程序：第1步先进行快速护理诊断,根据GCS昏迷评分标准确定昏迷等级;第2步保持呼吸道和静脉通道有效开放;第3步测定瞳孔、脉搏、血压、呼吸、血氧饱和度,为进一步采取急救措施提供依据;第4步,应对措施处于预启动状态,包括心肺复苏、抗休克、伤口处理、头部CT检查和术前准备,形成院前救护-CT室一手术室的绿色通道。对照组实施常规急救护理流程。比较两组接到“120”呼救电话至气管插管、头部CT检查、入手术室时间,两组术后3d内意识进展情况、并发症发生率和死亡率。结果与对照组比较,观察组接到呼救电话至入手术室时间、至头部CT检查时间、至气管插管／气管切开时间均较对照组提前（P〈0．05）;术后3d内意识好转、意识恢复率提高（P〈0．05或P〈0．01）,2周内并发症的发生率和死亡率明显降低（P〈0．05或P〈0．01）。结论改良院前救护程序能有效缩短颅脑损伤昏迷病人的院前急救时间,是减少并发症及死亡率的有效急救护理措施。     

A prospective study of tracheal intubation in an emergency department in Hong Kong.

Emergency department (ED) doctors often intubate patients, however no data was available in Hong Kong on this aspect. Our study was to assess the competency of ED doctors in intubating critical patients in a typical ED in Hong Kong. Between March and August 1999, in an urban hospital with an emergency physician training programme, all doctors, after performing any tracheal intubation, were required to fill in a pro forma designed for the study. Data collected included the training status of the intubator, the number of intubation attempts, intubation methods and complications. A total of 214 ED patients required advanced airway management including 87 (41%) patients in cardiopulmonary arrest; 207 (97%) of them were successfully intubated by ED doctors (76 by specialists, 61 by trainees, 70 by residents) and 90% were successful in the first attempt. The remaining seven patients' airway control was eventually managed by anaesthetists who successfully intubated six patients and performed cricothyrotomy for one patient. Rapid sequence intubation was performed in 70 (33%) patients by ED doctors and specialists. There were 30 (14%) patients successfully intubated using sedative agents alone. Twenty-two (10%) patients were found to have a total of 32 complications including 13 patients with oesophageal intubation, seven with soft tissue damage, four with desaturation, three with bronchial intubation, three with hypotension, one with dental trauma, one with dysrhythmia. The majority of ED intubations for critically ill patients were performed by ED doctors with high success rate and few major complications.     

经颅多普勒超声对椎-基底动脉供血不足的诊断及评定价值

为探讨经颅多普勒超声对椎－基底动脉供血不足患者的诊断及评定价值,按临床诊断标准收集椎－基底动脉供血不足患者８０例,对照组为年龄相近的健康人５１例,采用ＭＴ－１０００型彩色经颅多普勒超声仪对基底动脉、椎动脉、大脑后动脉、大脑前动脉和大脑中动脉的血流速度、搏动指数及血流频谱图像进行检测分析。结果：疾病组椎－基底动脉流速明显低于对照组（Ｐ〈０．００１）,且搏动指数值增高（Ｐ〈０．０５）。疾病组经颅多普勒     

急诊内科危重病人气管插管时机与方法的探讨

目的:总结急诊内科病人气管插管的特点,分析其治疗效果,并探讨其插管时机、方法与转归。方法:根据病人在急诊科治疗情况,将病人分成三组。第Ⅰ组23例,系到医院前已临床死亡;第Ⅱ组30例,经抢救无效在急诊科死亡;第Ⅲ组30例,经抢救病人在急诊科存活,后转入病房或急诊留观。结果:第Ⅰ组病人经口气管插管,抢救平均30分钟,无一例心跳呼吸恢复;第Ⅱ组虽经急诊CPR,但呼吸功能不能恢复正常,或因其原发病未能控制,最终在急诊科死亡;第Ⅲ组病人经口插管13例,经鼻插管17例,6例病人在急诊留观治疗后出院,12例病人经ICU或病房住院治疗后基本痊愈出院,另12例最终死亡。结论:急诊科所遇垂危病人,多数需气管插管者是由内科医师首诊实施。正确的插管方法和较高的成功率是直接影响病人转归的重要因素。     

Emergency Evaluation of Patients Presenting with Acute Scrotum Using Bedside Ultrasonography

Acute scrotal pain is not a rare emergency department (ED) complaint. Traditional reliance on medical history and physical examination can be precarious as signs and symptoms can overlap in various etiologies of acute scrotal pain. OBJECTIVE: To determine the accuracy with which emergency physicians (EPs) using bedside ultrasonography are able to evaluate patients presenting to the ED with acute scrotal pain. METHODS: The study was performed at an urban community hospital ED with a residency program and an annual census of 70,000. A retrospective chart review identified 36 patients who presented with complaints of acute scrotal pain and were evaluated by EPs using bedside ultrasound. A 5.0- or 7.5-MHz linear-array transducer with color and power Doppler capability was used to scan the scrotum. Patients were seen between July 1998 and September 1999. Diagnoses were verified by radiology or surgery. Sensitivity and specificity with 95% confidence intervals were calculated. RESULTS: The EP ultrasound examinations agreed with confirmatory studies for 35 of 36 patients, resulting in a sensitivity of 95% (95% CI = 0.78 to 0.99) and a specificity of 94% (95% CI = 0.72 to 0.99). Diagnoses included three testicular torsions, six cases of epididymitis, four cases of orchitis, one testicular fracture, three hernias, three hydroceles, and 15 normal examinations. One case of epididymitis was misdiagnosed as an epididymal mass. CONCLUSIONS: This study suggests that EPs using bedside ultrasonography are able to accurately diagnose patients presenting with acute scrotal pain. In addition, they appear able to differentiate between surgical emergencies, such as testicular torsion, and other etiologies.     

Transvaginal Ultrasonography by Emergency Physicians Decreases Patient Time in the Emergency Department

Abstract. Objectives : An important argument for emergency physician use of ultrasonography is that it results in more rapid patient disposition, but there are few articles to support this position. This study sought to demonstrate a significant decrease in the time spent in the ED when emergency physicians performed transvaginal ultrasonography (TVUS), as compared with when TVUS was performed by consultants, in the evaluation of first-trimester pelvic pain or vaginal bleeding. Methods : A retrospective analysis was conducted of the time spent in the ED (time placed in gynecologic examination room to time released from ED) by patients with first-trimester pelvic pain or vaginal bleeding necessitating further evaluation with TVUS. TVUS was performed in the ED by obstetrics/gynecology (ob/gyn) residents who were consulted to the ED from January 11, 1996, to March 31, 1996, and by emergency physicians from April 17, 1996, to July 7, 1996. Results : Emergency physicians evaluated 46 patients by TVUS, with a mean time of 164.70 minutes (SEM ± 13.29). Ob/gyn consultants evaluated 38 patients by TVUS, with a mean time of 234.79 minutes (SEM ± 12.74). This was a significant difference at the level of p < 0.0003 (Student's t-test). There were no known missed ectopic pregnancies as ascertained by 100% patient follow-up. There was no significant difference between the groups in the percentage of ectopic pregnancies (Fisher's exact test). The number of patients in the emergency physician group requiring subsequent consultation was reduced by 85%. Conclusions : This study demonstrates a more rapid ED transit time when TVUS was performed at the bedside by emergency physicians as compared with when pelvic ultrasonography required consultation. Additionally, fewer calls to consultants were required.     

Emergency Tracheal Intubation in an Ankylosing Spondylitis Patient in a Sitting Position Using an Airway Scope Combined with Face-to-Face and Digital Intubation

Background

Emergency intubation in a patient with advanced ankylosing spondylitis (AS) who presents with severe thoracic kyphosis deformity, rigid cervical flexion deformity of the neck, and an inability to achieve the supine position is particularly challenging to emergency physicians.

Rapid Emergency Medicine Score Can Predict Long-term Mortality in Nonsurgical Emergency Department Patients

OBJECTIVES: To examine the Rapid Emergency Medicine Score (REMS) as a predictor of long-term (4.7 years) mortality in the nonsurgical emergency department (ED). METHODS: This was a prospective cohort study. A total of 12,006 nonsurgical patients consecutively presenting to an adult ED at a 1,200-bed university hospital during a period of one year were enrolled. REMS (including blood pressure, respiratory rate, pulse rate, Glasgow Coma Scale score, peripheral oxygen saturation, and patient age) was calculated for all patients admitted to the ED. The statistical associations between REMS and long-term mortality were examined. RESULTS: REMS could predict mortality over 4.7 years (hazard ratio, 1.26; p < 0.0001). Similar results were obtained in the major patient groups (chest pain, stroke, coma, dyspnea, and diabetes). CONCLUSIONS: REMS was a powerful predictor of long-term mortality in patients attending the ED for a wide range of common nonsurgical disorders.     

Lack of a Hyperkalemic Response in Emergency Department Patients Receiving Succinylcholine

Objective: To determine whether serum potassium (K) levels increase significantly following succinylcholine (SCh)-assisted intubation in ED patients.
Methods: A prospective. noncontrolled, consecutive case series design was used to evaluate the change in serum K levels in ED patients who received SCh for emergency intubation. The study was performed at an academic medical center staffed by board-certified emergency physicians. The subjects were 100 consecutive prescreened ED patients with various diagnoses who received SCh for intubation. The eligible subjects had serum K levels determined prior to and 5 minutes after administration of a 1.0–1.5-mg/kg IV dose of SCh. Serum K levels were measured by the ionselective electrode assay method.
Results: The mean change in serum K levels was -0.04 mmol/L (95% CI -0.14 to 0.06). The maximum increase was 1.10 mmol/L. The serum K level rose in 46 cases, decreased in 46 cases, and was unchanged in eight cases. No instance of SCh-induced cardiac arrest was identified.
Conclusion: Changes in serum K levels following SCh administration in prescreened ED patients were minimal. A hyperkalemic response is uncommon in ED patients who undergo SCh-assisted intubation.     

Live Conjoined Twins: A Rare First Trimester Diagnosis during Emergency Department Sonography

Background: The evaluation of vaginal bleeding and pelvic pain in the first trimester of pregnancy is an important component of emergency physician training. The increased use of bedside sonography by emergency physicians in the evaluation of these patients requires knowledge about the normal anatomy, variants, abnormal findings and their appearance on sonography. Objectives: To highlight the importance of a thorough pelvic and abdominal sonographic examination during a routine evaluation in the emergency department (ED). Case Report: We present the case of a patient found to have conjoined twins diagnosed by ED sonography. Conclusion: A discussion of the diagnosis, the findings on bedside sonogram and management options are presented.