Jay G. Ladde

Can paramedics accurately identify patients who do not require emergency department care

Objective. To determine whether paramedics can identify patients contacting 9-1-1 who do not require emergency department (ED) care. Methods. The setting was an urban county with a two-tiered, dual response to 9-1-1 calls comprising eight local fire departments with advanced life support capabilities and a private advanced life support 9-1-1 agency with primary transport responsibilities (approximately 39,000 of the 78,000 total system patient transports in this county per year). The study population consisted of consecutive patients transported by a private transporting paramedic agency. After patient contact and stabilization, paramedics completed a survey detailing the necessity for transport to an ED for each patient. Prior to data analysis, it was determined that patients would be designated as requiring ED care if they 1) were admitted, 2) required surgical, surgical subspecialty, obstetric, or gynecologic consult, or 3) required advanced radiologic procedures (excluding plain films). Sensitivity, specificity, and predictive values for paramedic assessment of necessity for ED care were calculated with 95% confidence intervals (95% CIs). Results. Over the study period, 313 patients were enrolled. Paramedic assessment was 81% sensitive (72-88%, 95% CI) and 34% specific (28-41%, 95% CI) in predicting requirement for ED care. In 85 cases where paramedics felt ED transport was unnecessary, 27 (32%) met criteria for ED treatment, including 15 (18%) who were admitted and five (6%) who were admitted to an intensive care unit. Conclusion. In this urban system, paramedics cannot reliably predict which patients do and do not require ED care.

Endotracheal tube placement confirmation: 100% sensitivity and specificity with sustained four-phase capnographic waveforms in a cadaveric experimental model

BACKGROUND Waveform capnography is considered the gold standard for verification of proper endotracheal tube placement, but current guidelines caution that it is unreliable in low-perfusion states such as cardiac arrest. Recent case reports found that long-deceased cadavers can produce capnographic waveforms. The purpose of this study was to determine the predictive value of waveform capnography for endotracheal tube placement verification and detection of misplacement using a cadaveric experimental model. METHODS We conducted a controlled experiment with two intubated cadavers. Tubes were placed within the trachea, esophagus, and hypopharynx utilizing video laryngoscopy. We recorded observations of capnographic waveforms and quantitative end-tidal carbon dioxide (ETCO2) values during tracheal versus extratracheal (i.e., esophageal and hypopharyngeal) ventilations. RESULTS 106 and 89 tracheal ventilations delivered to cadavers one and two, respectively (n=195) all produced characteristic alveolar waveforms (positive) with ETCO2 values ranging 2-113mmHg. 42 esophageal ventilations (36 to cadaver one and 6 to cadaver two), and 6 hypopharyngeal ventilations (4 to cadaver one and 2 to cadaver two) all resulted in non-alveolar waveforms (negative) with ETCO2 values of 0mmHg. Esophageal and hypopharyngeal measurements were categorized as extratracheal (n=48). A binary classification test showed no false negatives or false positives, indicating 100% sensitivity (NPV 1.0, 95%CI 0.98-1.00) and 100% specificity (PPV 1.0, 95%CI 0.93-1.00). CONCLUSION Though current guidelines question the reliability of waveform capnography for verifying endotracheal tube location during low-perfusion states such as cardiac arrest, our findings suggest that it is highly sensitive and specific.

The loop technique: a novel incision and drainage technique in the treatment of skin abscesses in a pediatric ED

OBJECTIVE This study assesses outcome in pediatric patients with skin abscess using the LOOP compared to the standard incision and drainage (I&D) with packing method. METHODS This retrospective study used ICD-9 codes to identify pediatric patients aged 0 to 17 years with a skin abscess presenting to a level I pediatric trauma emergency department (ED). Patients requiring surgical debridement were excluded; as were patients with abscesses on the face, scalp, hands or feet. The primary outcome was failure rate, defined as those requiring admission, intravenous antibiotics, or repeat drainage. RESULTS Over a 1-year period there were 233 pediatric abscesses identified: 79 cases (34%) treated with the LOOP technique and 154 cases with standard I&D (66%). The overall mean age of patients was 6.2 yrs: children in the LOOP group were younger than those in the standard group, 4.4 vs 7.1 years respectively (P=.001). Abscess location also differed between the two groups; however they had a similar gender distribution and mean temperature. Of the cases identified by chart review, clinical outcome could be assessed in 143 patients (61%): 52 (36%) patients with LOOP vs 91 (64%) with I&D. Failure rate was 1.4% in the LOOP group and 10.5% in the standard I&D (P<.030). CONCLUSION There was a significant difference in failure rate between the LOOP and the standard I&D groups. A prospective randomized trial is needed to confirm these results, but this novel technique shows promise as an alternative to I&D with packing in the management of skin abscesses in pediatric ED patients.

A Case of Spontaneous Pneumomediastinum and Epidural Pneumatosis in a Young Woman in the Emergency Department

BACKGROUND Pneumomediastinum is a relatively rare, yet typically benign, clinical condition that usually presents in young men. OBJECTIVE This report will describe a relatively rare event of pneumomediastinum with epidural extension in a young woman and will discuss the etiology, clinical manifestations, and treatment options for this condition. CASE REPORT The patient presented to the Emergency Department (ED) with typical symptoms of shortness of breath and chest pain, but was found on computed tomography to have epidural pneumatosis. No precipitating event was found. CONCLUSION This case of spontaneous pneumomediastinum with associated epidural pneumatosis in a young woman presenting to the ED is a relatively benign condition that typically does not require any significant work-up or treatment.