Mark J. Sagarin

Rapid sequence intubation for pediatric emergency airway management.

Objectives To characterize current practice with respect to pediatric emergency airway management using a multicenter data set. Methods A multicenter collaboration was undertaken to gather data prospectively regarding emergency intubation. Analysis of data on adult emergency department (ED) intubations clearly demonstrated that rapid sequence intubation (RSI) was the method used most often. We then conducted an observational study of the prospectively collected database of pediatric ED intubations (EDIs) using the National Emergency Airway Registry Phase One data, gathered in 11 participating EDs over a 16-month time period. A data form completed at the time of EDI enabled analysis of patients’ ages, weights, and indications for EDI; personnel; methods employed to facilitate EDI; success rates; and adverse events. Data forms were analyzed regarding the methods of intubation employed, and frequencies, success rates, and adverse event rates among various intubation modalities were compared. Results Of 1288 EDIs, there were 156 documented pediatric patients. Initial intubation attempts were all oral, including rapid sequence intubation in 81%, without medications (NOM) in 13%, and sedation without neuromuscular blockade (SED) in 6%. Older children and trauma patients were more likely to be intubated with RSI compared to younger children and patients presenting with medical illnesses. Intubation using RSI was more successful on the first attempt (78%) compared with either NOM (47%, P < 0.01) or SED (44%, P < 0.05), though this finding is likely explainable by the age differences among groups. Intubation was successfully performed by the initial intubator in 85% of RSI, 75% of NOM, and 89% of SED attempts (P = NS for both comparisons vs RSI). Overall, successful intubation occurred in 99% of RSI and 97% of non-RSI intubation attempts (P = NS). Only one of 156 patients required surgical airway management. True complications occurred in 1%, 5%, and 0% of RSI, NOM, and SED attempts, respectively (P = NS for both comparisons vs RSI). The majority of initial intubation attempts were by emergency medicine residents (59%), pediatric emergency medicine fellows (17%), and pediatrics residents (10%). These groups were 77%, 77%, and 50% successful, respectively, on the first laryngoscopy attempt, and 89%, 89%, and 69% successful overall. Conclusions A large, prospective, multicenter observational study of pediatric EDIs was conducted at university-affiliated EDs. RSI is the method of choice for the majority of pediatric emergency intubations; it is associated with a high success rate and a low rate of serious adverse events. Pediatric intubation as practiced in academic EDs, with most initial attempts by emergency and pediatrics residents and fellows under attending physician supervision, is safe and highly successful.

ULTRASONOGRAPHY BY EMERGENCY PHYSICIANS IN PATIENTS WITH SUSPECTED URETERAL COLIC

We performed a prospective study of patients with suspected ureteral colic to evaluate the test characteristics of bedside renal ultrasonography (US) performed by emergency physicians (EPs) for detecting hydronephrosis, and to evaluate how US can be used to predict the likelihood of nephrolithiasis. Thirteen EPs performed US, recorded the presence of hydronephrosis, and made an assessment of the likelihood of nephrolithiasis. All patients underwent i.v. pyelography (IVP) or unenhanced helical computed tomography (CT). There were 126 patients in the study: 84 underwent IVP; 42 underwent helical CT. Test characteristics of bedside US for detecting hydronephrosis were: sensitivity 72%, specificity 73%, positive predictive value (PPV) 85%, negative predictive value (NPV) 54%, accuracy 72%. The PPV and NPV for the ability of the EP to predict nephrolithiasis after performing US were 86% and 75%, respectively. We conclude that bedside US performed by EPs may be used to detect hydronephrosis and help predict the presence of nephrolithiasis.

Delay in thrombolysis administration: causes of extended door-to-drug times and the asymptote effect

We retrospectively analyzed medical records and critical pathway data forms of all patients who received thrombolytic therapy for acute myocardial infarction (AMI) over a 2 1/2-year period. The time spent by each patient in the emergency department (ED) prior to receiving thrombolytic therapy (the door-to-drug time) was determined. Records of those patients with door-to-drug times exceeding the median were closely examined to determine the cause of treatment delays. Results indicated that treatment delays resulted from delays in obtaining the initial electrocardiogram (24%), atypical presentations (11%), the need to rule out a potential contraindication (11%), the need to confirm the diagnosis (14%), and miscellaneous causes (8%). Many patients had no identifiable reason for their delay (32%). A certain population of AMI patients either do not satisfy thrombolytic criteria upon initial ED presentation or require prolonged evaluation to investigate possible contraindications to thrombolysis such as aortic dissection. The inclusion of patients in this separate population in a general analysis of median door-to-drug times results in an artificial asymptote effect and may confound quality initiatives.

Altered mental status in alcoholism.

Dr. Mark Sagarin: Today’s case is that of a 56-year-old man with alcoholism who presented with tremor and confusion. He reported feeling poorly for 1 week with subjective fever, cough productive of yellow sputum, decreased appetite, and decreased urine output. The past medical history was notable for a transient ischemic attack 1-year previously, alcohol abuse, and smoking. He took no medications regularly and had no drug allergies. He consumed approximately five quarts of beer and one package of cigarettes each day. He was homeless. He denied drug use or unprotected sexual activity. Dr. David Brown: Are there any questions about the patient’s initial presentation? Dr. Ted Benzer: Could he tell you when his last drink was, and was there any recent history of trauma? Dr. Sagarin: His last alcoholic beverage was 2 to 3 days previously, and he thought it was possible he had fallen and had struck his head but could not say definitively. Dr. Stephen Thomas: Did he arrive in the Emergency Department (ED) by ambulance? If so, can you describe his prehospital course? Dr. Sagarin: He was found seated on a park bench, slightly confused, by a bystander who activated 911. Prehospital providers found him alert but tremulous. Prehospital vital signs were: systolic blood pressure 140 mmHg, heart rate 115 beats/min, respiratory rate 20 breaths/min, oxygen saturation 93% on room air. Paramedics administered oxygen by 100% facemask, which increased his saturation to 99%. Blood sugar was 100 mg/dL. One 18-gauge intravenous (i.v.) line was established and thiamine 100 mg i.v. was administered. He was transported rapidly to the ED. On physical examination, he was alert but slightly confused. Vital signs were: temperature 40.3°C, blood pressure 133/81 mmHg, heart rate 120 beats/min, respiratory rate 20 breaths/min, oxygen saturation 93% on room air. Skin examination was normal. Cranial examination revealed no deformities or scalp lacerations. Tympanic membranes were obscured by impacted cerumen. Nasopharyngeal, midface, and mandibular examinations were unremarkable. Oral mucous membranes were dry. There was a small amount of dried blood on the anterior tongue and lower incisors. There was poor dentition but no dental injury. The neck was supple without jugular venous distension. There were no carotid bruits, enlarged nodes, or thyromegaly. Lung auscultation revealed diffuse crackles in the right lung field. Cardiac examination revealed a rapid, regular rhythm with no murmurs, rubs, or gallops. The abdomen was soft, nontender, nondistended, with no rebound, guarding, or masses. The rectum was nontender with soft heme-negative stool in the vault. Prostate examination was normal. Extremity examination revealed no cyanosis, clubbing or edema, and 21 pulses throughout. The patient was anxious, alert, and oriented to name, hospital, and season. He could not recall the date or United States president’s name. He had a slight resting tremor. His strength was 5/5 throughout,

Respiratory distress and leg pain.

*Harvard Affiliated Emergency Medicine Residency, Harvard Medical School, Boston, Massachusetts; †Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts; and ;‡Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts Reprint Address: David F. M. Brown, MD, Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114

Respiratory distress and leg 1 pain

*Harvard Affiliated Emergency Medicine Residency, Harvard Medical School, Boston, Massachusetts; †Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts; and ;‡Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts Reprint Address: David F. M. Brown, MD, Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114

Respiratory distress and leg1 pain

*Harvard Affiliated Emergency Medicine Residency, Harvard Medical School, Boston, Massachusetts; †Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts; and ;‡Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts Reprint Address: David F. M. Brown, MD, Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114