Michael D. April

Isopropyl Alcohol Nasal Inhalation for Nausea in the Emergency Department: A Randomized Controlled Trial

STUDY OBJECTIVE We compare nasal inhalation of isopropyl alcohol versus placebo in treating nausea among emergency department (ED) patients. METHODS A convenience sample of adults with chief complaints of nausea or vomiting was enrolled in a randomized, double-blind, placebo-controlled trial conducted in an urban tertiary care ED. Patients were randomized to nasally inhaled isopropyl alcohol versus nasally inhaled normal saline solution. Patient nausea and pain were measured with previously published 11-point verbal numeric response scale scores; patient satisfaction was measured by a 5-point Likert scale. The primary outcome was reduction in nausea 10 minutes poststart. Secondary outcomes included patient satisfaction and pain reduction measured at 10 minutes poststart. RESULTS Of 84 recruited patients, 80 (95.2%) completed the study. Thirty-seven (46.3%) received nasally inhaled isopropyl alcohol and 43 (53.8%) received nasally inhaled normal saline solution. At 10 minutes postintervention, median nausea verbal numeric response scale score was 3 in the isopropyl alcohol arm versus 6 in the placebo arm, for an effect size of 3 (95% confidence interval 2 to 4). Median satisfaction score was 4 in the isopropyl alcohol arm versus 2 in the placebo arm, for an effect size of 2 (95% confidence interval 2 to 2). There were no significant differences between the 2 arms in median pain verbal numeric response scale scores or subsequent receipt of rescue antiemetics. CONCLUSION We found that nasally inhaled isopropyl alcohol achieves increased nausea relief compared with placebo during a 10-minute period.

Emergency department imaging of pediatric trauma patients during combat operations in Iraq and Afghanistan

BackgroundMilitary hospitals in Iraq and Afghanistan treated children with traumatic injuries during the recent conflicts. Diagnostic imaging is an integral component of trauma management; however, few published data exist on its use in the wartime pediatric population.ObjectiveThe authors describe the emergency department (ED) utilization of radiology resources for pediatric trauma patients in Iraq and Afghanistan.Materials and methodsWe queried the Department of Defense Trauma Registry (DODTR) for all pediatric patients admitted to military fixed-facility hospitals in Iraq and Afghanistan from January 2007 to January 2016. We retrieved ED data on ultrasound (US), radiographic and computed tomography (CT) studies.ResultsDuring the study period, there were 3,439 pediatric encounters, which represented 8.0% of all military hospital trauma admissions. ED providers obtained a total of 12,376 imaging studies on 2,920 (84.9%) children. Of the 12,376 imaging studies, 1,341 (10.8%) were US, 4,868 (39.3%) were radiographic and 6,167 (49.8%) were CT exams. Most children undergoing radiographic evaluation were boys (77.8%) and located in Afghanistan (70.4%), and they sustained penetrating injuries (68.0%). Children who underwent imaging had higher composite injury severity scores in comparison to those who did not undergo imaging (10 versus 9).ConclusionMilitary health care providers frequently utilized radiographic studies in the evaluation of pediatric trauma casualties in Iraq and Afghanistan. Deployed military hospitals that treat children would benefit from dedicated pediatric-specific imaging training and protocols.

Single rescuer ventilation using a bag-valve mask with internal handle: a randomized crossover trial☆☆☆★

OBJECTIVE To compare tidal volume received during single rescuer ventilation with a modified bag-valve mask (BVM) with integrated internal handle vs standard BVM among healthy volunteers using a manikin model. METHODS This study was a randomized crossover trial of adult healthcare provider volunteers performing ventilation on a manikin. We randomized participants to perform single rescuer ventilation first using either a modified BVM with integrated internal handle or a standard unmodified BVM. Participants were responsible for mask placement and delivery of 10 breaths per minute for 3 minutes as guided by a metronome. After a 3-minute rest period, they performed ventilation using the alternative device. The primary outcome measure was mean received tidal volume as measured by the manikin (IngMar RespiTrainer model). Secondary outcomes included participant reported device preference. RESULTS Of 70 recruited participants, all completed the study. Mean received tidal volume was higher using the modified BVM with integrated internal handle vs standard BVM by 90 mL (95% confidence interval, 60-120 mL; P< .0001). There were no significant differences in mean received tidal volume based on the order of study arm allocation. Eighty percent of participants reported preference for the modified BVM over the standard BVM (95% confidence interval, 70.0%-80.0%). CONCLUSIONS The modified BVM with integrated internal handle results in greater mean received tidal volume compared with standard BVM during single rescuer ventilation in a manikin model. This modified BVM design may prove a useful airway adjunct for ventilation.

An unusual cause of postcolonoscopy abdominal pain.

Colonoscopy is a common procedure used for screening, diagnosis, and treatment of gastrointestinal disease. Life-threatening complications are uncommon (28/10 000 procedures) but include perforation, hemorrhage, diverticulitis, and postpolypectomy syndrome. Although previously reported, the association between appendicitis and colonoscopy is not widely known. This case report highlights the underlying pathophysiology, clinical presentation, and diagnosis of postcolonoscopy appendicitis. A 52-year-old man presented to the emergency department with abdominal pain 8 hours after an uncomplicated routine screening colonoscopy. He initially reported mild generalized abdominal discomfort which 3 hours after the procedure intensified and localized to the periumbilical region. Computed tomography of the abdomen with oral and intravenous contrast revealed appendicitis as the cause of his abdominal pain. He underwent laparoscopic appendectomy and recovered uneventfully. Colonoscopy is a common procedure that rarely has life-threatening complications. Although establishing causality is difficult, there is an association between colonoscopy and appendicitis, which may be underreported with literature-based estimates as high as 3.8 appendicitis cases per 10 000 procedures. Timely diagnosis of postcolonoscopy appendicitis may prove challenging given limited knowledge of this association between colonoscopy and appendicitis and similarity of presentation with other more well-known complications. This case report demonstrates that a recent history of colonoscopy should not preclude consideration of a traditionally broad differential diagnosis for abdominal pain, including appendicitis.

Single Rescuer Ventilation Using a Bag Valve Mask with Removable External Handle: A Randomized Crossover Trial

Introduction Ventilation with a bag valve mask (BVM) is a challenging but critical skill for airway management in the prehospital setting. Hypothesis Tidal volumes received during single rescuer ventilation with a modified BVM with supplemental external handle will be higher than those delivered using a standard BVM among health care volunteers in a manikin model. METHODS This study was a randomized crossover trial of adult health care providers performing ventilation on a manikin. Investigators randomized participants to perform single rescuer ventilation, first using either a BVM modified by addition of a supplemental external handle or a standard unmodified BVM (Spur II BVM device; Ambu; Ballerup, Denmark). Participants performed mask placement and delivery of 10 breaths per minute for three minutes, as guided by a metronome. After a three-minute rest period, they performed ventilation using the alternative device. The primary outcome measure was mean received tidal volume as measured by the manikin (IngMar RespiTrainer model; IngMar Medical; Pittsburgh, Pennsylvania USA). Secondary outcomes included subject device preference. RESULTS Of 70 recruited participants, all completed the study. The difference in mean received tidal volume between ventilations performed using the modified BVM with external handle versus standard BVM was 20 ml (95% CI, -16 to 56 ml; P=.28). There were no significant differences in mean received tidal volume based on the order of study arm allocation. The proportion of participants preferring the modified BVM over the standard BVM was 47.1% (95% CI, 35.7 to 58.6%). CONCLUSIONS The modified BVM with added external handle did not result in greater mean received tidal volume compared to standard BVM during single rescuer ventilation in a manikin model. Reed P , Zobrist B , Casmaer M , Schauer SG , Kester N , April MD . Single rescuer ventilation using a bag valve mask with removable external handle: a randomized crossover trial. Prehosp Disaster Med. 2017;32(6):625-630.

Whole body computed tomography versus selective radiological imaging strategy in trauma: An evidence-based clinical review

Background: Trauma patients often present with injuries requiring resuscitation and further evaluation. Many providers advocate for whole body computed tomography (WBCT) for rapid and comprehensive diagnosis of life‐threatening injuries. Objective: Evaluate the literature concerning mortality effect, emergency department (ED) length of stay, radiation, and incidental findings associated with WBCT. Discussion: Physicians have historically relied upon history and physical examination to diagnose life‐threatening injuries in trauma. Diagnostic imaging modalities including radiographs, ultrasound, and computed tomography have demonstrated utility in injury detection. Many centers routinely utilize WBCT based on the premise this test will improve mortality. However, WBCT may increase radiation and incidental findings when used without considering pre‐test probability of actionable traumatic injuries. Studies supporting WBCT are predominantly retrospective and incorporate trauma scoring systems, which have significant design weaknesses. The recent REACT‐2 trial randomized trauma patients with high index of suspicion for actionable injuries to WBCT versus selective imaging and found no mortality difference. Additional prospective trials evaluating WBCT in specific trauma subgroups (e.g. polytrauma) are needed to evaluate benefit. In the interim, the available data suggests clinicians should adopt a selective imaging strategy driven by history and physical examination. Conclusions: While observational data suggests an association between WBCT and a benefit in mortality and ED length of stay, randomized controlled data suggests no mortality benefit to this diagnostic tool. The literature would benefit from confirmatory studies of the use of WBCT in trauma sub‐groups to clarify its impact on mortality for patients with specific injury patterns.

Face mask leak with nasal cannula during noninvasive positive pressure ventilation: A randomized crossover trial

Background Nasal cannula can achieve apneic oxygenation during emergency intubation. However, pre‐procedure nasal cannula placement may be difficult in patients undergoing non‐invasive positive pressure ventilation (NPPV) prior to intubation. Our objective was to compare mask leak during NPPV with versus without simultaneous application of nasal cannula. We hypothesized mask leak would be no worse with concomitant use of nasal cannula (non‐inferiority design). Methods We performed a randomized crossover non‐inferiority study of healthy volunteers. We randomized subjects undergoing 60 s trials of NPPV (10 cm H2O continuous positive airway pressure) to either NPPV alone (NPPV‐a) or NPPV with nasal cannula at 15 L/min (NPPV‐nc). After a brief rest period, all subjects underwent the alternative intervention. The primary outcome was time averaged mask leak over 60 s (L/min). We defined a non‐inferiority margin of 5 L/min. Results We enrolled 64 subjects. Mean time‐averaged mask leak was 2.2 L/min for NPPV‐a versus 4.0 L/min for NPPV‐nc for a difference of 1.7 L/min (one‐sided 95% CI −∞ to 3.2 L/min). NPPV‐a resulted in higher mean minute volume received (13.5 versus 12.2 L) and higher mean respiratory rates (14.8 versus 13.5 breaths per minute). Conclusion The addition of nasal cannula during NPPV does not significantly increase mask leak. The simultaneous application of nasal cannula with NPPV may be a useful strategy to streamline airway management among patients undergoing NPPV prior to intubation.

Soft tissue oxygen saturation to predict admission from the emergency department: A prospective observational study

Objective We evaluated a soft tissue oxygen saturation (Sto2) measurement at triage for predicting admission to the hospital in adults presenting to the emergency department (ED) in addition to data routinely gathered at triage. Methods This was a prospective, observational, single center study of adults presenting to the ED for evaluation. Research assistants obtained thenar eminence Sto2 measurements on subjects in ED triage. ED providers not involved in the study then made all management and disposition decisions. We prospectively collected data on each subjects final ED disposition (admission versus discharge). We identified the optimal Sto2 cutoff value for predicting admission. We then used logistic regression modeling to describe the added predictive value of Sto2 beyond routinely collected triage data including Emergency Severity Index level, age, and vital signs. Results We analyzed 2588 adult (> 17 years) subjects with 743 subjects (28.7%) admitted to the hospital. Sto2 < 76% was the optimal diagnostic cutoff for predicting admission. Of subjects with Sto2 < 76%, 158 of 384 (41.1%) underwent admission versus 585 of 2204 (26.5%) subjects with Sto2 ≥ 76. After controlling for age, vital signs, and ESI level in the logistic regression analysis, Sto2 < 76% had an odds ratio of 1.54 (95% confidence interval (CI), 1.19 to 1.98) for predicting admission. Conclusions Sto2 may provide additional prognostic data to routine triage assessment regarding the disposition for undifferentiated adult patients presenting to the ED.

Emergency department septic shock patient mortality with refractory hypotension vs hyperlactatemia: A retrospective cohort study

Background: Our objective was to compare in‐hospital mortality among emergency department (ED) patients meeting trial‐based criteria for septic shock based upon whether presenting with refractory hypotension (systolic blood pressure < 90 mm Hg after 1 L intravenous fluid bolus) versus hyperlactatemia (initial lactate ≥ 4 mmol/L). Methods: We conducted a retrospective cohort analysis by chart review of ED patients admitted to an intensive care unit with suspected infection during 1 August 2012–28 February 2015. We included all patients with body fluid cultures sampled either during their ED stay without antibiotic administration or within 24 h of antibiotic administration in the ED. We excluded patients not meeting criteria for either refractory hypotension or hyperlactatemia. Trained chart abstractors blinded to the study hypothesis double entered data from each patients record including demographics, clinical data, treatments, and in‐hospital mortality. We compared in‐hospital mortality among patients with isolated refractory hypotension, isolated hyperlactatemia, or both. We also calculated odds ratios (ORs) via logistic regression for in‐hospital mortality based on presence of refractory hypotension or hyperlactatemia. Results: Of 202 patients included in the analysis, 38 (18.8%) died during hospitalization. Mortality was 10.9% among 101 patients with isolated refractory hypotension, 24.4% among 41 patients with isolated hyperlactatemia, and 28.3% among 60 patients with both (p = 0.01). Logistic regression analyses yielded in‐hospital mortality OR for refractory hypotension of 1.3 (95% CI 0.5–3.8) versus OR for hyperlactatemia of 2.9 (95% CI 1.2–7.4). Conclusions: Hyperlactatemia appears associated with higher in‐hospital mortality compared to refractory hypotension among ED patients with septic shock.

Topical ethyl chloride to reduce pain associated with venous catheterization: a randomized crossover trial

OBJECTIVE To compare pain associated with venous catheterization after administration of topical ethyl chloride vs placebo among emergency department health care providers. METHODS We conducted a randomized, double-blind, placebo-controlled, crossover trial among a convenience sample of health care provider volunteers in a tertiary care urban emergency department. We randomly allocated subjects to initial treatment (ethyl chloride vs sterile water aerosol spray) and catheterization site (left or right antecubital fossa). After venous catheterization placement and discontinuation, subjects underwent a 5-minute washout period. All subjects then underwent venous catheterization in the contralateral antecubital fossa after administration of the alternative agent. We measured all outcomes after discontinuation of the second catheter. The primary outcome was difference in pain verbal numeric rating scale score (0-10) between the 2 agents. Secondary outcomes included preferred agent (binary) and future willingness to use agent on patients (5-point Likert scale). RESULTS Thirty-eight health care providers were recruited; all completed the study. Median pain verbal numeric rating scale scores were 4 (interquartile range, 2-5) for placebo vs 2 (1-4) for ethyl chloride. The effect size for pain reduction with ethyl chloride compared with placebo was 2 (95% confidence interval, 0.5-2; P = .001). Most subjects (68.4%) preferred ethyl chloride to placebo. Five-point Likert scale scores measuring willingness to use preferred product on future patients were higher by 2 (95% confidence interval, 1-3) among subjects preferring ethyl chloride vs placebo. CONCLUSIONS We found that topical ethyl chloride yields a greater reduction in pain associated with venous catheterization compared with topical placebo.