Joshua Nagler

End-tidal carbon dioxide as a measure of acidosis among children with gastroenteritis

OBJECTIVES. We aimed to determine the correlation between end-tidal carbon dioxide levels and serum bicarbonate concentrations among patients with gastroenteritis, to compare the end-tidal carbon dioxide with other clinical parameters that might also be associated with the degree of acidosis, and to examine the relationship between end-tidal carbon dioxide levels and return visits. METHODS. Our prospective sample included patients presenting to the emergency department with a chief complaint of vomiting and/or diarrhea. The association between end-tidal carbon dioxides and serum bicarbonate concentrations was determined with simple linear-regression analysis. Receiver operating characteristic curves were computed to determine the predictive ability of the end-tidal carbon dioxide to detect metabolic acidosis. RESULTS. One hundred thirty of 146 subjects who were approached were included in the final analysis. For those for whom laboratory studies were performed, the mean serum bicarbonate concentration was 17.3 ± 4.3 mmol/L and the mean end-tidal carbon dioxide level was 34.2 ± 5.2 mm Hg. End-tidal carbon dioxide levels and serum bicarbonate concentrations were correlated linearly in bivariate analysis. Receiver operating characteristic curves were calculated for end-tidal carbon dioxide as a predictor of serum bicarbonate concentrations of ≤13, ≤15, and ≤17 mmol/L, with areas under the curves of 0.94, 0.95, and 0.90, respectively. The relationship between end-tidal carbon dioxide levels and serum bicarbonate concentrations was independent of other potential predictors of acidosis in multivariable analysis. The mean end-tidal carbon dioxide level for patients who required an unanticipated return visit (33.0 ± 4.0 mm Hg) was lower than the level for those who did not seek reevaluation (36.6 ± 3.6 mm Hg). CONCLUSIONS. End-tidal carbon dioxide levels were correlated with serum bicarbonate concentrations among children with vomiting and diarrhea, independent of other clinical parameters. Capnography offers an objective noninvasive measure of the severity of acidosis among patients with gastroenteritis.

Capnography: A Valuable Tool for Airway Management

Capnography provides continuous, dynamic assessment of the ventilatory status of patients. Carbon dioxide physiology and the technology utilized in end-tidal carbon dioxide monitor devices are reviewed. Clinical applications with regard to ventilation and airway management are discussed, including: verification of endotracheal tube placement, continuous monitoring of tube position, monitoring during procedural sedation and in the obtunded patient, and assessment of patients with respiratory illnesses. Current guidelines for use of capnography within emergency medicine are included. Potential future applications are also presented.

Pediatric Emergency Medicine Fellow Training in Ultrasound: Consensus Educational Guidelines

The importance of point-of-care emergency ultrasound (EUS) to the practice of emergency medicine (EM) is well established, and mounting research continues to demonstrate how EUS can benefit pediatric emergency department (ED) patients. As members of the EM community, pediatric EM (PEM) physicians should understand the potential value of EUS and seek opportunities to incorporate EUS into their daily practice. Currently, EUS education and training is at an early developmental stage for PEM fellows and varies greatly between programs. The goal of this article is to provide consensus education guidelines and to describe a sample curriculum that can be used by PEM fellowship programs when developing or revising their US training curricula. The authors recognize that programs may be at different stages of EUS development and will consequently need to tailor curricula to individual institutional needs and capabilities. This guideline was developed through a collaborative process between EUS educators and members of the American Academy of Pediatrics Section of EM Fellowship Directors Subcommittee. The guideline includes the following topics: important considerations regarding EUS in PEM, PEM US program framework, PEM US curriculum, PEM US education program, and competency assessment.

Advanced airway management.

Purpose of review Advanced airway management in children can be challenging, and the potential for morbidity following failed attempts is high. Recent findings Supraglottic rescue devices, including the laryngeal mask airway, esophageal–tracheal combination tube, and laryngeal tube have been shown to be suitable ventilation strategies following failed intubation and in arrest scenarios. In addition, a newly developed reversal agent for rocuronium is being investigated as a means of limiting the duration of neuromuscular blockade following rapid sequence induction. Finally, the advent of video laryngoscopy has been shown to have advantages over traditional direct laryngoscopy, in terms of both patient care and training. Summary Pediatric providers are encouraged to develop familiarity with emerging rescue ventilation devices, as well as recent advances in the practice of rapid sequence induction and laryngoscopy.

Use of an Automated Electronic Case Log to Assess Fellowship Training : Tracking the Pediatric Emergency Medicine Experience

The Accreditation Council for Graduate Medical Education has mandated the assessment of medical training across 6 core competencies. The patient care competency is at the core of medical training. With the introduction of patient tracking systems used in emergency departments, patient-physician encounters can be systematically studied. The combination of tracking data with other clinical information systems can be used to create an electronic case log to quantify the experience of fellows, thereby offering a summative measure of the patient care competency. We used an automated case log to assess clinical exposure in our pediatric emergency medicine fellowship.

Sudden infant death syndrome.

Fifty years ago, health care providers first reported on the entity we now call sudden infant death syndrome (SIDS) [1]. Through continued investigation and interventions, significant progress has been made in decreasing the incidence of this tragic, yet not uncommon cause of death in infants. This review of the literature updates the reader on the definition, epidemiologic trends, risk factors, and proposed etiologies of SIDS. It also provides commentary on potential future directions in further reducing the number of SIDS victims in this country and throughout the world.

Comparison between direct and video‐assisted laryngoscopy for intubations in a pediatric emergency department

OBJECTIVES The objective was to compare video-assisted laryngoscopy (VAL) to direct laryngoscopy (DL) on success rate and complication rate of intubations performed in a pediatric emergency department (ED). METHODS This is a retrospective cohort study of attempted intubations of children aged 0-18 years in a pediatric ED between 2004 and 2014 with first attempt by an ED provider. In VAL, the laryngoscopist attempts direct visualization of the glottis with a C-MAC video laryngoscope while the video monitor is used for real-time guidance by a supervisor, back-up visualization for the laryngoscopist should the direct view be inadequate, and confirmation of endotracheal tube passage through the vocal cords. We performed univariate comparisons of intubations using DL to intubations using VAL on rates of first-pass success, complications, and whether the patient was successfully intubated by an ED provider. We then created a logistic regression model to adjust for provider experience level, difficult airway characteristics, and indications for intubation to compare intubations using DL to intubations using VAL for each outcome. RESULTS We identified 452 endotracheal intubations of 422 unique patients, of which 445 intubations had a first attempt by an ED provider. Six intubations were excluded due to insufficient information available in the record. Of the included intubations, 240 (55%) were attempted with DL and 199 (45%) with VAL. The overall first-pass success rate was 71% in the DL group and 72% in the VAL group. After adjustment for covariates, the first-pass success rate was similar between laryngoscopy approaches (adjusted odds ratio = 1.23, 95% confidence interval = 0.78 to 1.94). CONCLUSIONS We found no difference between DL and VAL with regard to first-pass intubation success rate, complication rate, or rate of successful intubation by ED providers for children undergoing intubation in a pediatric ED.

Use of an automated case log to improve trainee evaluations on a pediatric emergency medicine rotation.

Objective Providing meaningful evaluation to trainees rotating through the pediatric emergency medicine is important yet challenging. Information systems can be used to autopopulate an electronic case log, which can be leveraged to assist in the evaluation process. The objective of this study was to determine if a novel educational initiative using an automated case log improved faculty evaluation of trainees. Methods This retrospective study examined faculty completion rate, as well as the content of medical student evaluations over a 3-academic-year study period. Three phases of evaluation were utilized: written, electronic, and electronic enhanced with individualized case reports created with the automated case log. The primary outcome was faculty response rate. Secondary outcomes included word count and the number of themes identified following qualitative analysis of narrative responses. Logistic regression was performed. Results Forty-one faculty members completed evaluations of 43 students. The rates of completion for the written, electronic, and automated case log phases were 18%, 16%, and 62%, respectively. Faculty in the automated case log phase were significantly more likely to complete evaluations compared with those in the written evaluation phase (odds ratio, 7.6; 95% confidence interval, 4.5–13.0). The median word counts across the 3 phases were 19, 36, and 43, respectively. The median numbers of themes identified during the 3 phases were 3, 4, and 5, respectively. The differences in the word count and median number of themes between the written and automated case log phases were significantly different (P < 0.001). Conclusions The process of trainee evaluation can be improved by utilizing an automated case log to provide faculty members with individualized reports of shared patient encounters.

Using Video-recorded Laryngoscopy to Evaluate Laryngoscopic Blade Approach and Adverse Events in Children.

OBJECTIVES Using recordings of endotracheal intubation attempts obtained with a video-enabled laryngoscope with Miller and Macintosh blades, the authors sought to evaluate the association between laryngoscopic approach (right-sided vs. midline) and intubation success, as well as adverse event rates in the pediatric emergency department (ED). METHODS This was a retrospective cohort study of children younger than 21 years who underwent endotracheal intubation with a C-MAC video laryngoscope in a tertiary care ED between August 2009 and May 2013. The primary outcome was successful endotracheal intubation on the first attempt. The secondary outcomes included time to intubation, video-recorded adverse events (oropharyngeal mucosal injury and aspiration), and physiologic adverse events. Multivariate regression models were used to determine the relationship between laryngoscope blade position and outcome measures adjusted for patient and provider factors. RESULTS The cohort consisted of complete video recordings for 105 of 143 (73%) patient encounters with intubations. The first-pass success rate did not significantly differ based on laryngoscopic approach (adjusted odds ratio [aOR] = 0.76, 95% confidence interval [CI] = 0.29 to 2.0). Among patients successfully intubated on the first attempt, the median time to intubation was longer for the right-sided approach compared to the midline approach (42 seconds vs. 31.5 seconds; p < 0.05). The odds of mucosal injury and aspiration were higher among patients intubated using a right-sided approach compared to a midline approach (aOR = 4.1, 95% CI = 1.2 to 14.5; aOR = 7.7, 95% CI = 1.5 to 39.5, respectively). Rates of physiologic adverse events did not differ based on approach. CONCLUSIONS First-pass success rate did not differ based upon laryngoscopic approach type; however, a right-sided approach was associated with a longer time to intubation, as well as higher rates of mucosal injury and aspiration among patients undergoing video-enabled intubation in a pediatric ED.

Intraosseous Catheter Placement in Children

This video demonstrates the placement of intraosseous catheters in children and reviews the indications, contraindications, placement techniques, and potential complications. Both manual insertion and insertion with the use of a power-assisted device are shown.