Hyuk Joong Choi

Comparison of manikin versus porcine models in cricothyrotomy procedure training

Objective: To compare the usefulness for training of a porcine model (larynx, trachea, and pig skin) and a manikin model using a Portex cricothyrotomy kit (PCK). Methods: In a prospective randomised crossover trial, participants in the airway workshop performed crico-thyrotomy using a PCK on the porcine and manikin models (Tracheostomy Trainer and Case). The porcine model was made with larynxes and trachea from freshly slaughtered pigs and covered with a piece of thinned pigskin stapled to a wooden board. Participants were asked to assess the following: reality of skin turgor; difficulty with skin penetration, landmark recognition and procedure; reality of the model; and preference for each model using a visual analogue scale (VAS) of 0–10 cm. The VAS scores for each model were compared. Results: 49 participants were included in the study. Mean (SD) VAS scores for the reality of skin turgor, degree of difficulty with skin penetration and landmark recognition were higher with the porcine model than with the manikin model (7.0 (2.1) vs 4.7 (2.0), 6.4 (2.4) vs 3.6 (2.2), 5.1 (2.2) vs 4.2 (2.5), respectively). There was no difference between the models in the difficulty of the procedure (5.0 (2.4) vs 4.7 (3.2)). The porcine model had a higher VAS score for overall reality and preference of the model (7.1 (2.0) vs 4.8 (2.3) and 7.1 (2.0) vs 4.8 (2.2), respectively). Conclusion: The porcine model is a more useful training tool than the manikin model for cricothyrotomy with PCK because of its reality and similarity to human anatomy.

Endotracheal intubation using a GlideScope video laryngoscope by emergency physicians: a multicentre analysis of 345 attempts in adult patients

Objective To investigate the use and success rates of the GlideScope (GVL) by emergency physicians (EPs) during the initial two years after its introduction. Methods We performed an observational study using registry data of five emergency departments. The success rates in adult patients were evaluated and compared with those of conventional laryngoscope (CL). Results The GVL was used in 345 (10.7%) of 3233 intubation attempts by EPs. The overall success rate of the GVL was not higher than a CL (79.1% vs 77.6%, p=0.538). The success rate for the patients with difficult airway was higher in the GVL than a CL (80.0% vs 50.4%, p<0.001). Conclusion The GVL was not used frequently by EPs during the initial two years after its introduction. Although the GVL provides a better glottic view, the overall success rates were similar to a CL. The GVL may be useful in patients with difficult airway.

An assessment of the iPad 2 as a CT teleradiology tool using brain CT with subtle intracranial hemorrhage under conventional illumination.

We examined the potential of the iPad 2 as a teleradiologic tool for evaluating brain computed tomography (CT) with subtle hemorrhage in the conventional lighting conditions which are common situations in the remote CT reading. The comparison of the clinician’s performance was undertaken through detecting hemorrhage by the iPad 2 and the clinical liquid crystal display (LCD) monitor. We selected 100 brain CT exams performed for head trauma or headache. Fifty had subtle radiological signs of intracranial hemorrhage (ICH), while the other 50 showed no significant abnormality. Five emergency medicine physicians reviewed these brain CT scans using the iPad 2 and the LCD monitor, scoring the probability of ICH on each exam on a five-point scale. Result showed high sensitivities and specificities in both devices. We generated receiver operating characteristic curves and calculated the average area under the curve of the iPad 2 and the LCD (0.935 and 0.900). Using the iPad 2 and reliable internet connectivity, clinicians can provide remote evaluation of brain CT with subtle hemorrhage under suboptimal viewing condition. Considering the distinct advantages of the iPad 2, the popular out-of-hospital use of mobile CT teleradiology would be anticipated soon.

What factors affect the success rate of the first attempt at endotracheal intubation in emergency departments

Study objective This study aimed to determine the factors associated with successful endotracheal intubation (ETI) on the first-attempt in an emergency department. Method We studied all of the ETI data at two urban emergency departments over a 5-year period. We assessed the intubators specialty and training level, intubation method, device used, predicted airway difficulty and cause of ETIs. Univariate and multivariate logistic regression models were used to identify factors affecting the first-attempt success (FAS) of ETI in emergency departments. Results A total of 1478 adult ETIs were analysed. A multivariate logistic analysis revealed that factors such as a non-difficult airway (OR=5.11; 95% CI 3.38 to 7.72), senior physicians (2nd-year to 4th-year resident and attending physicians) (OR=2.39; 95% CI 1.61 to 3.55) and the rapid sequence intubation/induction (RSI) method (OR=2.06; 95% CI 1.04 to 3.03) had significant associations with the FAS for emergency medicine (EM) physicians. For non-EM physicians, however, a non-difficult airway was the only independent predictor of FAS (OR=3.10; 95% CI 1.82 to 5.28). Conclusions The predicted airway difficulty was the major factor associated with FAS in emergency department ETI on adults regardless of intubators specialty. Especially in EM physician group, level of training and using of RSI also affecting on first–attempt success. The overall ETI success rate on first attempt was 80.1%, but EM physicians had success rate of 87.3%. Systematic technical and non-technical airway skill training focused on RSI and continuous quality control and ETI recording could help non-EM physicians increase their FAS rate.

An application of the learning curve–cumulative summation test to evaluate training for endotracheal intubation in emergency medicine

Objective The learning curve–cumulative summation (LC-CUSUM) test allows for quantitative and individual assessments of the learning process. In this study, we evaluated the process of skill acquisition for performing endotracheal intubation (ETI) in three emergency medicine (EM) residents over a 2 year period in their first 2 years of their EM residency. Methods We evaluated 342 ETI cases performed by three EM residents using the LC-CUSUM test according to their rate of success or failure of ETI. A 90% success rate (SR) was chosen to define adequate performance and an SR of 80% was considered inadequate. After the learning phase, the standard CUSUM test was applied to ensure that performance was maintained. Results The mean number of ETI cases required to reach the predefined level of performance was 74.7 (95% CI 62.0 to 87.3). CUSUM tests confirmed that performance was maintained after the learning phase. Conclusions By using the LC-CUSUM test, we were able to quantitatively monitor the acquisition of the skill of ETI by EM residents. The LC-CUSUM could be useful for monitoring the learning process for the training of airway management in the practice of EM.

Feasibility of dynamic cardiac ultrasound transmission via mobile phone for basic emergency teleconsultation

We assessed the feasibility of using a camcorder mobile phone for teleconsulting about cardiac echocardiography. The diagnostic performance of evaluating left ventricle (LV) systolic function was measured by three emergency medicine physicians. A total of 138 short echocardiography video sequences (from 70 subjects) was selected from previous emergency room ultrasound examinations. The measurement of LV ejection fraction based on the transmitted video displayed on a mobile phone was compared with the original video displayed on the LCD monitor of the ultrasound machine. The image quality was evaluated using the double stimulation impairment scale (DSIS). All observers showed high sensitivity. There was an improvement in specificity with the observers increasing experience of cardiac ultrasound. Although the image quality of video on the mobile phone was lower than that of the original, a receiver operating characteristic (ROC) analysis indicated that there was no significant difference in diagnostic performance. Immediate basic teleconsulting of echocardiography movies is possible using current commercially-available mobile phone systems.

Remote CT reading using an ultramobile PC and web-based remote viewing over a wireless network

We developed a new type of mobile teleradiology system using an ultramobile PC (UMPC) for web-based remote viewing over a wireless network. We assessed the diagnostic performance of this system for abdominal CT interpretation. Performance was compared with an emergency department clinical monitor using a DICOM viewer. A total of 100 abdominal CT examinations were presented to four observers. There were 56 examinations showing appendicitis and 44 which were normal. The observers viewed the images using a UMPC display and an LCD monitor and rated each examination on a five-point scale. Receiver operating characteristics (ROC) analysis was used to test for differences. The sensitivity and specificities of all observers were similarly high. The average area under the ROC curve for readings performed on the UMPC and the LCD monitor was 0.959 and 0.976, respectively. There were no significant differences between the two display systems for interpreting abdominal CTs. The web-based mobile teleradiology system appears to be feasible for reading abdominal CTs for diagnosing appendicitis and may be valuable in emergency teleconsultation.

Nationwide online social networking for cardiovascular care in Korea using Facebook.

To examine the use of online social networking for cardiovascular care using Facebook. All posts and comments in a Facebook group between June 2011 and May 2012 were reviewed, and a survey was conducted. A total of 298 members participated. Of the 277 wall posts, 26.7% were question posts requesting rapid replies, and 50.5% were interesting cases shared with other members. The median response time for the question posts was 16 min (IQR 8-47), which tended to decrease as more members joined the group. Many members (37.4%) accessed the group more than once a day, and more than half (64%) monitored the group posts in real time with automatic notifications of new posts. Most members expressed confidence in the content posted. Facebook enables online social networking between physicians in near-real time and appears to be a useful tool for physicians to share clinical experience and request assistance in decision-making.

GlideScope video laryngoscopy versus direct laryngoscopy in the emergency department: a propensity score-matched analysis

Objective To evaluate whether the use of a GlideScope video laryngoscope (GVL) improves first-attempt intubation success compared with the Macintosh laryngoscope (MAC) in the emergency department (ED). Design A propensity score-matched analysis of data from a prospective multicentre ED airway registry—the Korean Emergency Airway Management Registry (KEAMR). Setting 4 academic EDs located in a metropolitan city and a province in South Korea. Participants A total of 4041 adult patients without cardiac arrest who underwent emergency intubation from January 2007 to December 2010. Outcome measures The primary and secondary outcomes were successful first intubation attempt and intubation failure, respectively. To reduce the selection bias and potential confounding effects, we rigorously adjusted for the baseline differences between two groups using a propensity score matching. Results Of the 4041 eligible patients, a GVL was initially used in 540 patients (13.4%). Using 1:2 propensity score matching, 363 and 726 patients were assigned to the GVL and MAC groups, respectively. The adjusted relative risks (95% CIs) for the first-attempt success rates with a GVL compared with a MAC were 0.76 (0.56 to 1.04; p=0.084) and the respective intubation failure rates 1.03(0.99 to 1.07; p=0.157). Regarding the subgroups, the first-attempt success of the senior residents and attending physicians was lower with the GVL (0.47 (0.23 to 0.98), p=0.043). In the patients with slight intubation difficulty, the first-attempt success was lower (0.60 (0.41 to 0.88), p=0.008) and the intubation failure was higher with the GVL (1.07 (1.02 to 1.13), p=0.008). Conclusions In this propensity score-matched analysis of data from a prospective multicentre ED airway registry, the overall first-attempt intubation success and failure rates did not differ significantly between GVL and MAC in the ED setting. Further randomised controlled trials are needed to confirm our findings.

Factors associated with successful second and third intubation attempts in the ED.

PURPOSE The aim of this study was to identify the factors associated with successful second and third attempts in adults following a failed first intubation attempt in the emergency department (ED). METHODS This was a retrospective analysis of the data from a multicenter, prospective, observational airway registry in South Korea. We obtained demographic and clinical data of intubated adult patients in 6 academic EDs from January 2007 to December 2010. The primary outcome was successful rescue attempt, which was defined as the successful placement of an endotracheal tube following a failed first intubation attempt. Logistic regression analyses were conducted to develop a multivariate model identifying factors associated with successful second and third attempts. RESULTS Of 5905 adult patients, 1122 (19.0%) failed a first intubation attempt. The success rates of the second and third attempts were 79.2% and 78.5%, respectively. In the multivariate logistic regression analysis, factors associated with a successful second attempt were emergency physicians, senior physicians, nondifficult airway, and the use of a rapid sequence intubation (RSI) (odds ratio = 2.81 [95% confidence interval, 1.80-4.37], 1.50 [1.10-2.07], 2.15 [1.53-3.01], and 1.53 [1.01-2.33], respectively). Nondifficult airway and the use of RSI were associated with successful third attempts (5.48 [2.69-11.18] and 2.63 [1.08-6.40], respectively). CONCLUSIONS Nondifficult airway and the use of RSI were associated with successful second and third intubation attempts. The use of RSI, backup by experienced senior physicians, and preparation for management of a difficult airway could be strategies for successful rescue intubation attempts in the ED.