David Plummer

Model Curriculum for Physician Training in Emergency Ultrasonography

A model curriculum for the implementation and training of physicians in emergency medicine ultrasonography is described. Widespread use of limited bedside ultrasonography by emergency physicians will improve diagnostic accuracy and efficiency, increase the quality of care, and prove to be a cost-effective technique for the practice of emergency medicine.

Fiberoptic intubation in the emergency department

Fiberoptic-aided endotracheal intubation has been shown to be effective in difficult intubation secondary to anatomic abnormalities and traumatic conditions. A retrospective review of emergency airway management in an emergency department during a 30-month period found 35 patients who underwent fiberoptic-aided endotracheal intubation; 31 were treated for medical conditions, and four were trauma patients. Indications in the medical group included failed nasotracheal intubation (ten), anatomic abnormalities (six), and the initial airway maneuver attempted (15). Indications in the trauma group with suspected cervical-spine injury included failed nasotracheal intubation (one) and initial airway maneuver attempted (three). In the medical subgroup, 25 of 31 patients were intubated successfully fiberoptically. All four trauma patients were intubated successfully, and all attempts were done nasally. The limitations of the technique were varied. Twenty of the 25 successful intubations had times recorded for completion (mean time, 1.8 +/- 1.4 minutes [SD]). Four of the six failed attempts had recorded times of 7.8 +/- 1.4 minutes. The mean time of the four trauma cases was 3 +/- 2.2 minutes. The presence of secretions, blood, or vomitus was the cause in five of the six failed intubations. The sixth patient kept swallowing the distal end of the scope. Fiscal restraints may also limit its use. At our institution, the financial commitment has been approximately +17,000 during the past nine years. Repair or replacement of broken equipment appears to be necessary every two or three years. Immediate airway control is often difficult with fiberoptic-aided endotracheal intubation and should be used only in selected patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of hypertonic sodium bicarbonate on encainide overdose

Abstract Encainide is an experimental type IC antiarrhythmic agent. Experience with acute encainide toxicity is limited. Two fatal overdoses have occurred but both patients died before reaching the hospital (personal communication, M. Cool, Bristol Myers Co., 3 85 ). We report a case of acute, massive encainide overdose associated with central nervous system and cardiovascular toxicity.

Randomized, Double-Blinded, Clinical Trial of Propofol, 1:1 Propofol/Ketamine, and 4:1 Propofol/Ketamine for Deep Procedural Sedation in the Emergency Department

STUDY OBJECTIVE We compare the frequency of airway and respiratory adverse events leading to an intervention between propofol with 1:1 and 4:1 mixtures of propofol and ketamine (ketofol). METHODS We performed a randomized, double-blinded trial in which emergency department adults undergoing deep sedation received propofol, 1:1 propofol and ketamine, or 4:1 propofol and ketamine. Our primary outcome was the frequency of airway and respiratory adverse events leading to an intervention. Other outcomes included sedation depth, efficacy, procedure and recovery time, patient satisfaction, pain, and procedural recall. RESULTS Two hundred seventy-one subjects completed the trial, 90 receiving propofol, 85 receiving 1:1 propofol and ketamine, and 96 receiving 4:1 propofol and ketamine. Airway or respiratory adverse events leading to an intervention were similar between groups: 29%, 19%, and 32%, respectively (P=.21). There were no serious adverse events in any group. Secondary outcomes were generally similar between groups, with greater recovery agitation observed in the 1:1 ketofol group (8%, 21%, and 10%, respectively). CONCLUSION We found a similar frequency of airway and respiratory adverse events leading to intervention between propofol alone and either 1:1 or 4:1 ketofol.

A comparison of the supraclavicular approach and the infraclavicular approach for subclavian vein catheterization

Five hundred emergency department patients requiring subclavian vein catheterization were randomized prospectively into one of two groups, supraclavicular or infraclavicular. If catheterization was unsuccessful in a few attempts using the randomized approach, catheterization with the alternate approach was attempted. Two catheters were available for use, a short, 8-French introducer and a long, 16-gauge catheter. There were 38 failures (15.5%) among 245 patients in the supraclavicular group, with one malposition and five complications. There were 51 failures (20.0%) among 255 patients in the infraclavicular group, with 21 malpositions and 13 complications. No differences were significant except that of malpositions (P less than .01). The combination of infraclavicular approach and 16-gauge catheter accounted for 21 of 22 malpositions. When catheterization by the randomized approach failed, catheterization by the alternate approach was successful in all but seven cases, resulting in an overall success rate of 98.6%. Analysis of this series suggests that both the infraclavicular and supraclavicular approaches to subclavian vein catheterization are acceptable alternatives, with little difference in success rate or complications. Using an alternate approach if the initial approach was unsuccessful produced a high overall success rate and a low overall complication rate. A physician who is familiar with both approaches will be more successful at placing central venous catheters safely.

Emergency Department Two-Dimensional Echocardiography in the Diagnosis of Nontraumatic Cardiac Rupture ☆ ☆☆ ★

Myocardial rupture is a catastrophic complication of acute myocardial infarction that usually results in sudden death. If diagnosed quickly, patients with myocardial rupture may be salvaged. This report describes the application of emergency department two-dimensional echocardiography in the diagnosis of six cases of myocardial rupture over two years. Each demonstrated a characteristic hemopericardium on limited single-window examination. These included four patients who met institutional guidelines for thrombolytic therapy. Three patients survived surgical repair, with two long-term survivors.

Use of esmolol after failure of standard cardiopulmonary resuscitation to treat patients with refractory ventricular fibrillation

INTRODUCTION We compare the outcomes for patients who received esmolol to those who did not receive esmolol during refractory ventricular fibrillation (RVF) in the emergency department (ED). METHODS A retrospective investigation in an urban academic ED of patients between January 2011 and January 2014 of patients with out-of-hospital or ED cardiac arrest (CA) with an initial rhythm of ventricular fibrillation (VF) or ventricular tachycardia (VT) who received at least three defibrillation attempts, 300mg of amiodarone, and 3mg of adrenaline, and who remained in CA upon ED arrival. Patients who received esmolol during CA were compared to those who did not. RESULTS 90 patients had CA with an initial rhythm of VF or VT; 65 patients were excluded, leaving 25 for analysis. Six patients received esmolol during cardiac arrest, and nineteen did not. All patients had ventricular dysrhythmias refractory to many defibrillation attempts, including defibrillation after administration of standard ACLS medications. Most received high doses of adrenaline, amiodarone, and sodium bicarbonate. Comparing the patients that received esmolol to those that did not: 67% and 42% had temporary return of spontaneous circulation (ROSC); 67% and 32% had sustained ROSC; 66% and 32% survived to intensive care unit admission; 50% and 16% survived to hospital discharge; and 50% and 11% survived to discharge with a favorable neurologic outcome, respectively. CONCLUSION Beta-blockade should be considered in patients with RVF in the ED prior to cessation of resuscitative efforts.

Prehospital Ultrasound Diagnosis of Traumatic Pericardial Effusion

A 41-year-old male was stabbed in the left chest. When paramedics arrived at the scene, the patient was unconscious. The airway was managed with a nasal trumpet, and the patient was quickly moved to the ambulance. The systolic blood pressure was 85 mm Hg. In the ambulance, one paramedic performed a bedside, prehospital ultrasound (PUS) using a SonoSite MicroMaxx (Sonosite Inc., Bothell, WA) with a P17 probe using a subcostal cardiac view. A large pericardial effusion with hyperechoic and anechoic fluid in the pericardial sac was identified (Figure 1, Video Clip S1, available as supporting information in the online version of this paper). Based on this ultrasound finding, the decision was made to immediately transport the patient to the closest Level 1 trauma center, with intravenous fluids administered enroute. The total emergency medical systems (EMS) scene time was 9 minutes and transport time was 6 minutes. The PUS took less than 1 minute to obtain and did not impact transport times. The emergency department was alerted that a patient with a hypotensive stab wound to the heart with a positive sonographic pericardial effusion was enroute. The patient was quickly assessed in the emergency department. The emergency physicians and trauma surgeons reviewed the PUS video. The patient was taken directly to the operating room based on the PUS video, and a median sternotomy was performed with evacuation of a large mixed-density clot and repair of a right ventricular stab wound using a single 3.0 Prolene suture with pledget. The patient had an uneventful postoperative course and was discharged from the hospital 4 days later with complete neurologic recovery. Prehospital ultrasound has been used in our EMS system on a limited basis for the past 12 months. This case demonstrates that EMS personnel can be adequately trained to utilize this technology to shorten time to determining certain diagnoses and facilitate proper destination decisions, which can improve overall patient care. This case is part of a larger PUS study that was approved by our institutional review board.

Randomized Clinical Trial of the Effect of Supplemental Opioids in Procedural Sedation with Propofol on Serum Catecholamines

OBJECTIVES The objective was to assess the effect on stress biomarkers of supplemental opioid to a standard propofol dosing protocol for emergency department (ED) procedural sedation (PS). The hypothesis was that there is no difference in the change in serum catecholamines between PS using propofol with or without supplemental alfentanil. METHODS This was a randomized, nonblinded pilot study of adult patients undergoing PS in the ED for the reduction of fractures and dislocations. Patients with pain before the procedure were treated with intravenous (IV) morphine sulfate until their pain was adequately treated for at least 20 minutes before starting the procedure. Patients were randomized to receive either 10 μg/kg alfentanil followed by 1 mg/kg propofol, followed by 0.5 mg/kg every 3 minutes as needed, or propofol only, dosed in similar fashion without supplemental alfentanil. Doses, vital signs, nasal end-tidal CO2 (ETCO2), pulse oximetry, and bispectral electroencephalogram (EEG) analysis scores were recorded. Subclinical respiratory depression was defined as a change in ETCO2 > 10 mm Hg, an oxygen saturation of < 92% at any time, or an absent ETCO2 waveform at any time. Clinical events related to respiratory depression were noted during the procedure, including the addition of or increase in the flow rate of supplemental oxygen, the use of a bag-valve-mask apparatus, airway repositioning, or stimulation to induce breathing. Blood was drawn 1 minute prior to the administration of the medications for PS and again 1 minute after completion of the procedure for which the patient was sedated. Serum was tested for total catecholamines, epinephrine, norepinephrine, and dopamine. Postprocedure, patients were asked to report any pain perceived during the procedure. Data were analyzed using descriptive statistics, Wilcoxon rank sum tests, and chi-square tests, as appropriate. RESULTS Twenty patients were enrolled; 10 received propofol and 10 received propofol with alfentanil. No clinically significant complications were noted. Subclinical respiratory depression was seen in four of 10 (40%) patients in the propofol group and five of 10 (50%) patients in the propofol/alfentanil group (effect size = -10%, 95% confidence interval [CI] = -53% to 33%). There was no difference in the rate of clinical signs of respiratory depression between the two groups. Pain during the procedure was reported by two of 10 (20%) patients in the propofol group and five of 10 (50%) patients in the propofol/alfentanil group (effect size = -30%, 95% CI = -70% to 10%). Recall of some part of the procedure was reported by 0 of 10 (0%) patients in the propofol group and five of 10 (50%) of patients in the propofol/alfentanil group (effect size = -50%, 95% CI = -81% to -19%). There was no difference in the baseline or postprocedure catecholamine levels between the groups. CONCLUSIONS No difference in serum catecholamines was detected immediately after PS between patients who receive propofol with and without supplemental opioid in this small pilot study. PS using propofol only without supplemental opioid did not appear to induce markers of physiologic stress in this small pilot study.

Alfentanil for procedural sedation in the emergency department.

STUDY OBJECTIVE We administer alfentanil sedation for minor procedures in the emergency department (ED), and our primary objective is to assess the incidence of airway and respiratory adverse events leading to an intervention. Our secondary goals are to assess for other adverse events, the depth and duration of sedation, the incidence of subclinical respiratory depression, and patient perceptions of the quality of the sedation. METHODS In this observational study of adults receiving alfentanil for ED procedures, we recorded the incidence of airway or respiratory adverse events leading to an intervention (increase/addition of supplemental oxygen, bag-valve-mask ventilation, airway repositioning, or stimulation to induce breathing). Secondary goals were assessed with monitoring (including capnography), the Observers Assessment of Alertness/Sedation (OAA/S) scale, and postprocedure patient visual analog scale ratings of pain, recall, and satisfaction. RESULTS Airway or respiratory events leading to intervention were observed in 39% of the 148 subjects (supplemental oxygen 18%, bag-valve mask 3%, airway repositioning 2%, stimulation 18%); none were clinically significant. The median OAA/S nadir was 4 (interquartile range 3 to 5). Median patient ratings were positive (pain 26 mm, recall 98, satisfaction 100 mm). CONCLUSION Alfentanil appears effective for ED procedural sedation but displays a rate of airway or respiratory events leading to an intervention similar to that of previous reports of deeper sedation with propofol.