Scott D. Weingart

Delayed Sequence Intubation: A Prospective Observational Study

STUDY OBJECTIVEnWe investigate a new technique for the emergency airway management of patients with altered mental status preventing adequate preoxygenation.nnnMETHODSnThis was a prospective, observational, multicenter study of patients whose medical condition led them to impede optimal preintubation preparation because of delirium. A convenience sample of emergency department and ICU patients was enrolled. Patients received a dissociative dose of ketamine, allowing preoxygenation with high-flow nonrebreather mask or noninvasive positive pressure ventilation (NIPPV). After preoxygenation, patients were paralyzed and intubated. The primary outcome of this study was the difference in oxygen saturations after maximal attempts at preoxygenation before delayed sequence intubation compared with saturations just before intubation. Predetermined secondary outcomes and complications were also assessed.nnnRESULTSnA total of 62 patients were enrolled: 19 patients required delayed sequence intubation to allow nonrebreather mask, 39 patients required it to allow NIPPV, and 4 patients required it for nasogastric tube placement. Saturations increased from a mean of 89.9% before delayed sequence intubation to 98.8% afterward, with an increase of 8.9% (95% confidence interval 6.4% to 10.9%). Thirty-two patients were in a predetermined group with high potential for critical desaturation (pre-delayed sequence intubation saturations ≤93%). All of these patients increased their saturations post-delayed sequence intubation; 29 (91%) of these patients increased their post-delayed sequence intubation saturations to greater than 93%. No complications were observed in the patients receiving delayed sequence intubation.nnnCONCLUSIONnDelayed sequence intubation could offer an alternative to rapid sequence intubation in patients requiring emergency airway management who will not tolerate preoxygenation or peri-intubation procedures. It is essentially procedural sedation, with the procedure being preoxygenation. Delayed sequence intubation seems safe and effective for use in emergency airway management.

Quick SOFA Scores Predict Mortality in Adult Emergency Department Patients With and Without Suspected Infection

Study objective The Quick Sequential Organ Failure Assessment (qSOFA) score (composed of respiratory rate ≥22 breaths/min, systolic blood pressure ≤100 mm Hg, and altered mental status) may identify patients with infection who are at risk of complications. We determined the association between qSOFA scores and outcomes in adult emergency department (ED) patients with and without suspected infection. Methods We performed a single‐site, retrospective review of adult ED patients between January 2014 and March 2015. Patients triaged to fast‐track, dentistry, psychiatry, and labor and delivery were excluded. qSOFA scores were calculated with simultaneous vital signs and Modified Early Warning System scores. Patients receiving intravenous antibiotics were presumed to have suspected infection. Univariate and multivariate analyses were performed to explore the association between qSOFA scores and inpatient mortality, admission, and length of stay. Receiver operating characteristics curve analysis and c statistics were also calculated for ICU admission and mortality. Results We included 22,530 patients. Mean age was 54 years (SD 21 years), 53% were women, 45% were admitted, and mortality rate was 1.6%. qSOFA scores were associated with mortality (0 [0.6%], 1 [2.8%], 2 [12.8%], and 3 [25.0%]), ICU admission (0 [5.1%], 1 [10.5%], 2 [20.8%], and 3 [27.4%]), and hospital length of stay (0 [123 hours], 1 [163 hours], 2 [225 hours], and 3 [237 hours]). Adjusted rates were also associated with qSOFA. The c statistics for mortality in patients with and without suspected infection were similarly high (0.75 [95% confidence interval 0.71 to 0.78) and 0.70 (95% confidence interval 0.65 to 0.74), respectively. Conclusion qSOFA scores were associated with inpatient mortality, admission, ICU admission, and hospital length of stay in adult ED patients likely to be admitted both with and without suspected infection and may be useful in predicting outcomes.

Risk for Clinically Relevant Adverse Cardiac Events in Patients With Chest Pain at Hospital Admission

IMPORTANCEnPatients with potentially ischemic chest pain are commonly admitted to the hospital or observed after a negative evaluation in the emergency department (ED) owing to concern about adverse events. Previous studies have looked at 30-day mortality, but no current large studies have examined the most important information regarding ED disposition: the short-term risk for a clinically relevant adverse cardiac event (including inpatient ST-segment elevation myocardial infarction, life-threatening arrhythmia, cardiac or respiratory arrest, or death).nnnOBJECTIVEnTo determine the incidence of clinically relevant adverse cardiac events in patients hospitalized for chest pain with 2 troponin-negative findings, nonconcerning initial ED vital signs, and nonischemic, interpretable electrocardiographic findings.nnnDESIGN, SETTING, AND PARTICIPANTSnWe conducted a blinded data review of 45,416 encounters obtained from a prospectively collected database enrolling adult patients admitted or observed with the following inclusion criteria: (1) primary presenting symptom of chest pain, chest tightness, chest burning, or chest pressure and (2) negative findings for serial biomarkers. Data were collected and analyzed from July 1, 2008, through June 30, 2013, from the EDs of 3 community teaching institutions with an aggregate census of more than 1 million visits. We analyzed data extracted by hypothesis-blinded abstractors.nnnMAIN OUTCOMES AND MEASURESnThe primary outcome was a composite of life-threatening arrhythmia, inpatient ST-segment elevation myocardial infarction, cardiac or respiratory arrest, or death during hospitalization.nnnRESULTSnOf the 45,416 encounters, 11,230 met criteria for inclusion. Mean patient age was 58.0 years. Of the 11 230 encounters, 44.83% of patients arrived by ambulance and 55.00% of patients were women. Relevant history included hypertension in 46.00%, diabetes mellitus in 19.72%, and myocardial infarction in 13.16%. The primary end point occurred in 20 of the 11 230 patients (0.18% [95% CI, 0.11%-0.27%]). After excluding patients with abnormal vital signs, electrocardiographic ischemia, left bundle branch block, or a pacemaker rhythm, we identified a primary end point event in 4 of 7266 patients (0.06% [95% CI, 0.02%-0.14%]). Of these events, 2 were noncardiac and 2 were possibly iatrogenic.nnnCONCLUSIONS AND RELEVANCEnIn adult patients with chest pain admitted with 2 negative findings for serial biomarkers, nonconcerning vital signs, and nonischemic electrocardiographic findings, short-term clinically relevant adverse cardiac events were rare and commonly iatrogenic, suggesting that routine inpatient admission may not be a beneficial strategy for this group.

The Past, Present, and Future of the Centers for Medicare and Medicaid Services Quality Measure SEP-1: The Early Management Bundle for Severe Sepsis/Septic Shock

SEP-1, the new national quality measure on sepsis, resulted from an undertaking to standardize care for severe sepsis and septic shock regardless of the size of the emergency department where the patient is being treated. SEP-1 does not necessarily follow the best current evidence available. Nevertheless, a thorough understanding of SEP-1 is crucial because all hospitals and emergency providers will be accountable for meeting the requirements of this measure. SEP-1 is the first national quality measure on early management of sepsis care. This article provides a review of SEP-1 and all its potential implications on sepsis care in the United States.

Managing Initial Mechanical Ventilation in the Emergency Department.

INTRODUCTION The ventilator lectures given to most fledgling emergency physicians are often so complex and abstruse that many simply resign themselves to mute dependence on the respiratory therapist’s settings. I have been guilty of delivering lectures such as these in the past. This piece represents a hopeful departure from this complexity. Understanding 2 simple ventilator strategies, lung protective and obstructive, will give a good foundation and management base for the first few hours of an emergency department (ED) patient’s care. The following recommendations, when not specifically referenced, are based on my practice because there is a dearth of trials analyzing most components of ventilator management.

Apneic oxygenation reduces the incidence of hypoxemia during emergency intubation: A systematic review and meta-analysis

Study objective Apneic oxygenation has been advocated for the prevention of hypoxemia during emergency endotracheal intubation. Because of conflicting results from recent trials, the efficacy of apneic oxygenation remains unclear. We performed a systematic review and meta‐analysis to investigate the effect of apneic oxygenation on the incidence of clinically significant hypoxemia during emergency endotracheal intubation. Methods MEDLINE, EMBASE, and PubMed databases were searched without language and time restrictions for studies of apneic oxygenation performed in a critical care setting. Meta‐analysis was conducted with a random‐effect model, and according to intention‐to‐treat allocation wherever applicable. Subgroup analyses were performed to ensure the robustness of findings across various clinical outcomes. Results Eight studies (n = 1953) were included in the meta‐analysis. The pooled absolute risk of clinically significant hypoxemia was 27.6% in the usual care group and 19.1% in the apneic oxygenation group, without any heterogeneity across studies (I2 = 0%; p = 0.42). Apneic oxygenation reduced the relative risk of hypoxemia by 30% (95% confidence interval 0.59 to 0.82). There was a trend toward lower mortality in the apneic oxygenation group (relative risk of death 0.77; 95% confidence interval 0.59 to 1.02). Conclusion Apneic oxygenation significantly reduces the incidence of hypoxemia during emergency endotracheal intubation. These findings support the inclusion of apneic oxygenation in everyday clinical practice.

The online hierarchy of needs: a beginner's guide to medical social media and FOAM.

Online medical education is expanding rapidly with learners and practitioners engaging with online resources to varying degrees. Although many descriptions of online resources have been published in the medical literature, the way in which practitioners establish themselves online and make use of these resources has not been discussed. Abraham Maslow’s hierarchy of needs is an important conceptual framework, which underpins psychological and sociological phenomena that can be observed in our daily lives. In a liberal re-imagination of this theory, we propose an online hierarchy of needs for medical practitioners. The model presents five stages of online interaction (existence, safety, consumption, collaboration and creation) that we believe healthcare practitioners must move through as they establish themselves online. The first stage requires the creation of an online presence. In the second stage the practitioner learns the rules to avoid problems with this new online existence. In the third stage the practitioner begins to effectively use online resources. The collaboration stage requires engagement with other online practitioners and the development of mutual respect within the online community. Finally, in the ultimate stage practitioners begin to create their own content. For each level of the organisational hierarchy, this lecture provides advice and resources. It should be helpful to both clinicians just entering the online world and senior educators seeking a greater understanding of online medical education.

The 2018 Surviving Sepsis Campaign’s Treatment Bundle: When Guidelines Outpace the Evidence Supporting Their Use

Inadvertent catastrophes often arise from good intentions. One recent medical care example of this phenomenon was the 2002 Centers for Medicare & Medicaid Services (CMS) National Hospital Quality Measure for the initial management of communityacquired pneumonia. This measure called for obtaining blood cultures and administering antibiotics within 4 hours of emergency department (ED) triage in patients being admitted with pneumonia, even if pneumonia was not clearly present on arrival. These metrics had little evidentiary basis but led to an institutional-fostered culture of overdiagnosis and overtreatment. Eventually, many recognized the downstream harms of antibiotic overuse and misuse, prompting the loss of the National Quality Forum measure endorsement and the measure’s subsequent removal as a CMS quality metric. Have we learned from this folly or does a new sepsis guideline promote similar time-based treatment strategies with little direct supporting evidence? The most recent iteration of the Surviving Sepsis Campaign treatment bundle now exists, published simultaneously in Critical Care Medicine and Intensive Care Medicine by Levy et al. The newest guidelines from this group propose a novel 1-hour care bundle, in contrast to the National Quality Forum 0-500 and the Sepsis CMS Core measures that defined 3and 6-hour target care bundles. The Surviving Sepsis Campaign group argues that the temporal nature of sepsis means benefit from even more rapid identification and intervention. They identify the start of the bundle as patient arrival at triage, when sepsis may or may not be present. Items to be successfully initiated within this brief window include the following:

Blowing Smoke: Examining the Benefits of High-Flow Nasal Cannula in Hypoxic Respiratory Failure: November 2015 Annals of Emergency Medicine Journal Club

1 Editor’s Note: You are reading the 48th installment of Annals of Emergency Medicine Journal Club. This Journal Club refers to the article by Frat et al published in the June 2015 edition of the New England Journal of Medicine. This bimonthly feature seeks to improve the critical appraisal skills of emergency physicians and other interested readers through a guided critique of actual Annals of Emergency Medicine articles. Each Journal Club will pose questions that encourage readers—be they clinicians, academics, residents, or medical students—to critically appraise the literature. During a 2to 3-year cycle, we plan to ask questions that cover the main topics in research methodology and critical appraisal of the literature. To do this, we will select articles that use a variety of study designs and analytic techniques. These may or may not be the most clinically important articles in a specific issue, but they are articles that serve the mission of covering the clinical epidemiology curriculum. Journal Club entries are published in 2 phases. In the first phase, a list of questions about the article is published in the issue in which the article appears. Questions are rated “novice,” ( ) “intermediate,” ( ), and “advanced” ( ) so that individuals planning a journal club can assign the right question to the right student. The answers to this journal club will be published in the April 2016 issue. US residency directors will have immediate access to the answers through the Council of Emergency Medicine Residency Directors Share Point Web site. International residency directors can gain access to the questions by e-mailing journalclub@acep.org. Thus, if a program conducts its journal club within 5 months of the publication of the questions, no one will have access to the published answers except the residency director. The purpose of delaying the publication of the answers is to promote discussion and critical review of the literature by residents and medical students and discourage regurgitation of the published answers. It is our hope that the Journal Club will broaden Annals of Emergency Medicine’s appeal to residents and medical students. We are interested in receiving feedback about this feature. Please e-mail journalclub@acep.org with your comments.