John H. Burton

Clinical Policy: Procedural Sedation and Analgesia in the Emergency Department

This clinical policy from the American College of Emergency Physicians is the revision of a 2005 clinical policy evaluating critical questions related to procedural sedation in the emergency department.1 A writing subcommittee reviewed the literature to derive evidence-based recommendations to help clinicians answer the following critical questions: (1) In patients undergoing procedural sedation and analgesia in the emergency department,does preprocedural fasting demonstrate a reduction in the risk of emesis or aspiration? (2) In patients undergoing procedural sedation and analgesia in the emergency department, does the routine use of capnography reduce the incidence of adverse respiratory events? (3) In patients undergoing procedural sedation and analgesia in the emergency department, what is the minimum number of personnel necessary to manage complications? (4) Inpatients undergoing procedural sedation and analgesia in the emergency department, can ketamine, propofol, etomidate, dexmedetomidine, alfentanil and remifentanil be safely administered? A literature search was performed, the evidence was graded, and recommendations were given based on the strength of the available data in the medical literature.

Procedural Sedation and Analgesia in the Emergency Department: Recommendations for Physician Credentialing, Privileging and Practice

INTRODUCTION Procedural sedation refers to the technique of administering sedatives or dissociative agents with or without analgesics to induce an altered state of consciousness that allows the patient to tolerate unpleasant procedures while preserving cardiorespiratory function. Procedural sedation and analgesia is a core competency in emergency medicine and a daily part of emergency department (ED) practice. As noted by the United States Centers for Medicare & Medicaid Services (CMS): “The ED is a unique environment where patients present on an unscheduled basis with often very complex problems that may require several emergent or urgent interventions to proceed simultaneously to prevent further morbidity or mortality.” The CMS guidelines also state that “. . . emergency medicine–trained physicians have very specific skill sets to manage airways and ventilation that is necessary to provide patient rescue. Therefore, these practitioners are uniquely qualified to provide all levels of analgesia/sedation and anesthesia (moderate to deep to general).” Emergency medicine residency and pediatric emergency medicine fellowship core curricula include all of the requisite procedural sedation skills, eg, advanced airway management, resuscitation, critical care, monitoring, sedation pharmacology, pain management. Emergency physicians have a wellestablished track record of safe sedation and are important research and thought leaders in this multidisciplinary field. The American College of Emergency Physicians (ACEP) is an authoritative body that has established guidelines for the use of sedation, analgesia, and anesthesia by emergency physicians. CMS guidelines support the use of the ACEP guideline: “A hospital could use multiple guidelines, for example, ACEP for sedation in the ED and American Society of Anesthesiologists (ASA) for anesthesia/sedation in surgical services, etc.” ACEP convened this task force in 2011 to provide this update to guide hospital policy for the administration of analgesia, sedation, and anesthesia by emergency physicians.

ENDOTRACHEAL INTUBATION IN A RURAL EMS STATE: PROCEDURE UTILIZATION AND IMPACT OF SKILLS MAINTENANCE GUIDELINES

Objective. Recent American Heart Association (AHA) guidelines have suggested that advanced life support (ALS) providers should have “regular field experience,” defined as six to 12 intubations/year, as a prerequisite to patient endotracheal intubation (EI). The authors sought to assess the impact of this guideline on rural emergency medical services (EMS) practice. Methods. Statewide EMS records were reviewed for the calendar years 1997-2001. Data reviewed included the number of providers eligible to perform ALS skills (including EI), number of procedures performed per year by EMS provider, patient age, gender, and prehospital diagnosis. The institutional review board approved the study. Results. During the study period, a total of 957,836 patient encounters occurred with an average of 1,352 ALS providers annually eligible to perform EI. In the five-year period, there were 5,615 total EI attempts with a range of 37%-42% of eligible providers annually performing EI. A mean of 18 providers per year with a range of 1.8%-0.8% of EI-eligible providers annually attempted EI in more than five patients. One hundred thirty-seven pediatric EI encounters occurred during the five-year period with an annual range of 1.4%–2.7% of eligible providers attempting pediatric EI. During the five-year investigation, EI success rate was reported as 84% by providers with fewer than five annual intubation encounters and 86% by providers with more than five encounters. Conclusion. Rural EMS providers rarely use EI skills, particularly in pediatric patients. If recent AHA intubation guidelines are to be followed in rural EMS settings, a small number of EMS providers will meet minimum EI utilization requirements.

Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Seizures

This clinical policy from the American College of Emergency Physicians is the revision of a 2004 policy on critical issues in the evaluation and management of adult patients with seizures in the emergency department. A writing subcommittee reviewed the literature to derive evidence-based recommendations to help clinicians answer the following critical questions: (1) In patients with a first generalized convulsive seizure who have returned to their baseline clinical status, should antiepileptic therapy be initiated in the emergency department to prevent additional seizures? (2) In patients with a first unprovoked seizure who have returned to their baseline clinical status in the emergency department, should the patient be admitted to the hospital to prevent adverse events? (3) In patients with a known seizure disorder in which resuming their antiepileptic medication in the emergency department is deemed appropriate, does the route of administration impact recurrence of seizures? (4) In emergency department patients with generalized convulsive status epilepticus who continue to have seizures despite receiving optimal dosing of a benzodiazepine, which agent or agents should be administered next to terminate seizures? A literature search was performed, the evidence was graded, and recommendations were given based on the strength of the available data in the medical literature.

EMS Provider Findings andInterventions with a Statewide EMS Spine-Assessment Protocol

Objective. To describe the utilization andfindings with a statewide, prehospital spine-assessment protocol for emergency medical services (EMS) providers in a rural state. Methods. The study was a prospective sample of EMS patients evaluated by prehospital providers for trauma-related injury during a one-year investigation period. Prehospital providers prospectively completed supplementary spine data-collection forms that reported patient demographics andEMS provider findings with the spine-assessment protocol. Data were analyzed using descriptive statistics. Results. There were 207,545 EMS encounters during the study period, including 31,885 transports for acute trauma-related illness. Prehospital providers provided spine-assessment forms for 2,220 patient encounters. Providers reported a decision to immobilize 1,301 (59%) patients. For these immobilized patients, spine protocol findings included 416 (32%) patients deemed as unreliable, 358 (28%) with distracting injury, 80 (6%) with an abnormal neurologic examination, and709 (54%) with spine pain or tenderness. Linkage of EMS andhospital data revealed seven acute spine fracture patients among the 2,220 reported encounters, all of whom were immobilized by EMS providers. Conclusions. Use of this prehospital spine-assessment protocol resulted in an EMS provider decision not to immobilize approximately 40% of EMS trauma patients. Few spine fracture patients were encountered during the investigational period, though all were immobilized.

A STANDING-ORDER PROTOCOL FOR CRICOTHYROTOMY IN PREHOSPITAL EMERGENCY PATIENTS

Objective. To study utilization, indications, and outcomes associated with the use of a statewide, emergency medical services (EMS) standing-order protocol for cricothyrotomy. Methods. A statewide EMS database was queried for patients who received cricothyrotomy under a standardized, standing-order protocol. Patient EMS and hospital records were reviewed in a defined sequence with information recorded on a standardized collection form. Results. EMS records included eight years of practice with 1.5 million patient encounters. For each year studied, approximately 540 emergency medical technicians (EMTs) were certified to perform cricothyrotomy. State EMS providers performed a collective mean of eight cricothyrotomy procedures per year (range, 1–17), for a total of 68 cricothyrotomies performed within the eight-year period. Hospital records were available for review in 61 patients. Fifty-six patients received cricothyrotomy by open surgical incision, six by needle with jet ventilation, and one by both methods. Categorization of cricothyrotomy patients as trauma or medical was 61% trauma and 39% medical. Thirty-six patients (59%) were in cardiac arrest on EMS arrival and 12 patients (20%) died during transport. Thirteen trauma patients (21%) were admitted with eight patients surviving to discharge (13%). The neurologic impairment at time of hospital discharge was severe in four, moderate in two, and minimal or none in two patients (3%). Conclusion. A considerable percentage of cricothyrotomy procedures were performed on patients with non-trauma-related diagnoses in this investigation describing a standing-order EMS protocol for cricothyrotomy. The majority of patients undergoing cricothyrotomy with this protocol were in cardiac arrest at the time of cricothyrotomy, with a small minority of patients surviving to hospital discharge and fewer surviving neurologically intact.

Intrathoracic stomach presenting as acute tension gastrothorax

Total intrathoracic stomach creating pulmonary and hemodynamic compromise is a rare life-threatening complication in patients with hiatal hernia. The presentation and clinical course of this condition are discussed. Physicians should consider this entity in patients presenting with apparent tension pneumothorax without history or other evidence of trauma or positive pressure ventilation who do not respond to standard interventions.

Clinical Policy: Use of Intravenous Tissue Plasminogen Activator for the Management of Acute Ischemic Stroke in the Emergency Department.

This clinical policy from the American College of Emergency Physicians is the revision of a clinical policy approved in 2012 addressing critical questions in the evaluation and management of patients with acute ischemic stroke. A writing subcommittee conducted a systematic review of the literature to derive evidence-based recommendations to answer the following clinical questions: (1) Is intravenous tissue plasminogen activator safe and effective for patients with acute ischemic stroke if given within 3 hours of symptom onset? (2) Is intravenous tissue Volume 66, no. 3 : September 2015

Aminophylline as an Adjunct to Standard Advanced Cardiac Life Support in Prolonged Cardiac Arrest

STUDY HYPOTHESIS We hypothesized that the addition of aminophylline to Advanced Cardiac Life Support (ACLS) interventions would improve the initial resuscitation success rate in an animal model of prolonged cardiac arrest. METHODS We used a double-blind, placebo-controlled, randomized-block design with a follow-up open-label uncontrolled phase. We studied 24 female domestic mixed-breed swine (body mass, 20 to 25 kg). After electrical induction of ventricular fibrillation, animals were subjected to 8 minutes of no-flow cardiac arrest followed by 1 minute of mechanical ventilation and closed-chest compressions. Nine minutes after arrest, equal numbers of swine received 6 mg/kg intravenous aminophylline (treatment group) and a saline solution placebo (control group), another minute of basic CPR, and standardized ACLS interventions beginning at 10 minutes. Initial resuscitation efforts were continued for at least 20 minutes. In all animals, if initial efforts failed, 6.0 mg/kg intravenous aminophylline, open label, and 10 minutes of additional resuscitation were administered. The primary outcome variables were return of spontaneous circulation (ROSC) and 1-hour survival. We compared groups with the two-tailed Fisher exact test. RESULTS ROSC occurred in 4 of 12 animals in the treatment group (33%) and 3 of 12 in the control group (25%) (P=.50). Late administration of aminophylline did not result in ROSC in any animal. Survival to 1 hour was greater in the treatment group (4 of 12, 33%) than in the control group (1 of 12, 8%) (P=.16). CONCLUSION Addition of aminophylline to standard ACLS interventions did not increase the incidence of ROSC or the 1-hour survival rate in a swine model of prolonged cardiac arrest.

Moving Beyond Confidence and Competence: Educational Outcomes Research in Emergency Medicine

T his edition of the Council of Emergency Medicine Residency Directors (CORD) ⁄ Clerkship Directors in Emergency Medicine (CDEM) supplement represents the third installment of this education-focused collaboration with Academic Emergency Medicine (AEM). The consensus of the editors is that it has been a remarkable 3 years for educators in emergency medicine (EM), with the supplement serving to capture many of the efforts, interests, and research within the field. To that end, the supplement represents a valuable and maturing product to academicians within the field of EM. The issue of maturity is a timely matter to consider for education research in EM. Specifically, the question of ‘‘So what, who cares?’’ merits a brief editorial. ‘‘So what?’’ reigns supreme in academic efforts, with the perennial pondering of the value of published works in the literature, such as the AEM CORD ⁄ CDEM supplement. So what if residents prefer simulation? Do they actually learn more this way, and do patients benefit? So what if postgraduate learners engage in asynchronous learning? Are they able to apply what they learn when treating patients in the emergency department (ED)? So what if learners know more about a given topic after receiving a well-designed education intervention? Does this translate to better patient care? Who cares about resident attitudes or differences in site curriculums, particularly in the context of a survey? How do these attitudes and differences affect the lives and outcomes of the next ED patient? So what? Who cares? Projects that assess physician skill acquisition and knowledge have value. This value is limited, however, and only significant as part of a larger effort of demonstrating differences in clinical patient outcomes. In this edition of the CORD ⁄ CDEM supplement, Biese et al. investigate the effect of an educational intervention on geriatric health. After assessing attitudes of the residents and testing their knowledge, researchers demonstrated that the number of inappropriately placed urinary catheters decreased significantly. Another recent study investigated the effect of education and training on the prevention of catheter-associated bloodstream infections. Warren et al. assessed knowledge acquisition and retention and then demonstrated that infection rates decreased significantly in the intervention group. As a direct result of the educational intervention, there was an estimated savings projection of