Brandy Snowden

A Comparison of GlideScope Video Laryngoscopy Versus Direct Laryngoscopy Intubation in the Emergency Department

OBJECTIVES The first-attempt success rate of intubation was compared using GlideScope video laryngoscopy and direct laryngoscopy in an emergency department (ED). METHODS A prospective observational study was conducted of adult patients undergoing intubation in the ED of a Level 1 trauma center with an emergency medicine residency program. Patients were consecutively enrolled between August 2006 and February 2008. Data collected included indication for intubation, patient characteristics, device used, initial oxygen saturation, and resident postgraduate year. The primary outcome measure was success with first attempt. Secondary outcome measures included time to successful intubation, intubation failure, and lowest oxygen saturation levels. An attempt was defined as the introduction of the laryngoscope into the mouth. Failure was defined as an esophageal intubation, changing to a different device or physician, or inability to place the endotracheal tube after three attempts. RESULTS A total of 280 patients were enrolled, of whom video laryngoscopy was used for the initial intubation attempt in 63 (22%) and direct laryngoscopy was used in 217 (78%). Reasons for intubation included altered mental status (64%), respiratory distress (47%), facial trauma (9%), and immobilization for imaging (9%). Overall, 233 (83%) intubations were successful on the first attempt, 26 (9%) failures occurred, and one patient received a cricothyrotomy. The first-attempt success rate was 51 of 63 (81%, 95% confidence interval [CI] = 70% to 89%) for video laryngoscopy versus 182 of 217 (84%, 95% CI = 79% to 88%) for direct laryngoscopy (p = 0.59). Median time to successful intubation was 42 seconds (range, 13 to 350 seconds) for video laryngoscopy versus 30 seconds (range, 11 to 600 seconds) for direct laryngoscopy (p < 0.01). CONCLUSIONS Rates of successful intubation on first attempt were not significantly different between video and direct laryngoscopy. However, intubation using video laryngoscopy required significantly more time to complete.

Single-Dose Etomidate for Intubation in the Trauma Patient

BACKGROUND Concerns over adrenal suppression caused by a single dose of etomidate for intubation led to limiting its use in trauma patients in 2006. OBJECTIVE The purpose of this study was to compare mortality, hypotension, and intensive care unit (ICU) and hospital length of stay (LOS) for trauma patients requiring intubation during periods of liberal vs. limited etomidate use. METHODS A retrospective review of trauma patients requiring emergent intubation who presented between August 2004 and December 2008, before and after we decided to limit the use of etomidate. Data were collected on patient demographics, induction agents used, episodes of hypotension in the first 24h, ICU and total hospital LOS, and survival. RESULTS Of 1325 trauma patients intubated in the Emergency Department during the study period, 443 occurred during the 23 months before July 2006 (liberal etomidate use) and 882 in the 30 months after July 2006 (limited etomidate use). During the liberal use period, 258/443 (58%) were intubated using etomidate, compared to 205/882 (23%, p<0.0001) during the period of limited use. We found no significant differences in mortality (30% vs. 29%, p=0.70), mean ICU days (8.2 vs. 8.8, p=0.356), or mean hospital LOS (13.8 vs. 14.4 days, p=0.55). Episodes of hypotension were more common in the limited etomidate use group (45% vs. 33%, p<0.0001). CONCLUSIONS A significant reduction in the use of etomidate in trauma patients was not associated with differences in mortality, ICU days, or hospital LOS, but was associated with an increase in episodes of hypotension within 24h of presentation.

Lightning Safety Awareness of Visitors in Three California National Parks

OBJECTIVE To assess the level of lightning safety awareness among visitors at 3 national parks in the Sierra Nevada Mountains of California. METHODS A 12-question, short answer convenience sample survey was administered to participants 18 years of age and over concerning popular trails and points of interest with known lightning activity. There were 6 identifying questions and 5 knowledge-based questions pertaining to lightning that were scored on a binary value of 0 or 1 for a total of 10 points for the survey instrument. Volunteers in Fresno, California, were used as a control group. Participants were categorized as Sequoia and Kings Canyon National Park (SEKI), frontcountry (FC), or backcountry (BC); Yosemite National Park (YNP) FC or BC; and Fresno. Analysis of variance (ANOVA) was used to test for differences between groups. RESULTS 467 surveys were included for analysis: 77 in Fresno, 192 in SEKI, and 198 in YNP. National park participants demonstrated greater familiarity with lightning safety than individuals from the metropolitan community (YNP 5.84 and SEKI 5.65 vs Fresno 5.14, P = .0032). There were also differences noted between the BC and FC subgroups (YNP FC 6.07 vs YNP BC 5.62, P = .02; YNP FC 6.07 vs SEKI FC 5.58, P = .02). Overall results showed that participants had certain basic lightning knowledge but lacked familiarity with other key lightning safety recommendations. CONCLUSIONS While there are statistically significant differences in lightning safety awareness between national parks and metropolitan participants, the clinical impact of these findings are debatable. This study provides a starting point for providing educational outreach to visitors in these national parks.

Urinalysis is an inadequate screen for rhabdomyolysis

STUDY OBJECTIVES Hematuria by urine dipstick with absent red blood cells (RBCs) on microscopy is indicative of rhabdomyolysis. We determined the sensitivity of this classic urinalysis (UA) finding in the diagnosis of rhabdomyolysis. METHODS We conducted a retrospective electronic medical record review of patients with a primary or secondary diagnosis of rhabdomyolysis with a creatine phosphokinase (CPK) greater than 1000 IU/L and a UA within the first 24 hours. Data were collected using a standardized data form, and a blinded panel of 3 emergency medicine physicians reviewed selected cases. Sensitivity and 95% confidence intervals (CIs) were calculated for detection of rhabdomyolysis by UA. RESULTS During the study period, 1796 patients were diagnosed with rhabdomyolysis, of whom 228 met inclusion criteria. The mean peak CPK was 27509 IU/L. One hundred ninety-five (86%) had a urine dip-positive for blood. However, only 94 patients (41%) had a positive urine dip and negative microscopic hematuria, resulting in a sensitivity of 41% (95% CI, 35%-47%). In a subset of 66 patients (29%) with more severe rhabdomyolysis (initial CPK, ≥10000 IU/L; mean CPK, 53365 IU/L), UA had a sensitivity of 55% (95% CI, 43%-67%). Broadening the definition of negative microscopy from 0 to 3 RBCs to less than 10 RBCs only increased the sensitivity to 79% (95% CI, 73%-83%). CONCLUSIONS The combination of a positive urine dip for blood and negative microscopy is an insensitive test for rhabdomyolysis, and the absence of this finding should not be used to exclude the diagnosis.