Thomas A. Sweeney

Failed prehospital intubations: An analysis of emergency department courses and outcomes ☆

Objective. To examine the reasons for failed prehospital endotracheal intubation (ETI) and to identify how the airway was subsequently managed in the emergency department (ED). Methods. Data were collected from January to December 1998 for a county-wide paramedic system. Failed prehospital ETIs and perceived reasons for failure were identified. Subsequent ED airway management was reviewed. Results. During the study period there were 13,112 patient contacts resulting in ETI attempts on 592 patients, of whom 536 (90.5%) were successfully intubated. Of the 56 failed field intubations, 49 (87.5%) had ED charts available for review. Endotracheal intubation failure was associated with inadequate relaxation in 24 (49%), difficult anatomy in ten (20%), and obstruction in five (10%). Successful ETI was achieved in the ED in 42 cases (86%). Twenty cases (41%) were facilitated by rapid-sequence intubation (RSI) in the ED. For those with incomplete relaxation in the field, 13 of 24 (54%) were intubated in the ED using RSI. Factors associated with the use of ED RSI include attempted prehospital nasotracheal intubation or attempted prehospital midazolam-facilitated intubation (p < 0.001). The predicted need for RSI in this prehospital system is approximately 3.9%. In eight cases, three or more ETI attempts or the use of rescue airways was required in the ED. The predicted minimum incidence of “truly difficult” intubation in this system is approximately 0.8–1.6%. Conclusions. Paramedic intubation failures result from a variety of factors. Less than half of field intubation failures were remedied in the ED by the use of neuromuscular-blocking agents. A similar number were intubated without the use of RSI. A fraction of failed field ETIs may have resulted from inadequate operator training or experience. A small percentage of field patients were “truly difficult” and required advanced resources in the ED to facilitate airway management. Medical directors should be cognizant of the numerous factors affecting intubation performance when designing and implementing approaches to difficult prehospital airways.

An Algorithmic Approach to Prehospital Airway Management

Airway management, including endotracheal intubation, is considered one of the most important aspects of prehospital medical care. This concept paper proposes a systematic algorithm for performing prehospital airway management. The algorithm may be valuable as a tool for ensuring patient safety andreducing errors as well as for training rescuers in airway management.

SUBCLAVIAN CENTRAL VENOUS CATHETERIZATION COMPLICATED BY GUIDEWIRE LOOPING AND ENTRAPMENT

The placement of central venous catheters is a technically challenging procedure with known risks and complications. We report an attempted left subclavian central venous catheterization that was complicated by looping and entrapment of the guidewire. We hypothesize that this complication occurred because the straight guidewire that was used may have perforated the wall of the vein, allowing the guidewire to loop upon itself. Although catheter looping and knotting are well known potential complications of central venous catheterization, similar complications are rarely reported with guidewires. Clinicians should be aware of these potential complications when performing or teaching central venous catheterization.

Considerations in establishing emergency medical services response time goals.

• Medical directors should have the authority to lead the establishment of response interval performance standards and possess the resources needed to monitor response interval data. • The dispatch process should be carefully analyzed and streamlined. Calls should be prioritized based on severity and response interval performance standards established for emergent, urgent, and nonurgent complaints.

E FFECTIVENESS OF A M EDICAL P RIORITY D ISPATCH P ROTOCOL FOR A BDOMINAL P AIN

Objective. Medical Priority Dispatch System (MPDS) protocols are used to determine the appropriate level of emergency medical services (EMS) response that is sent to care for patients in the prehospital setting. The objective of this study was to determine the proportion of patients with abdominal pain who would benefit from advanced life support (ALS) when called for by these protocols. Methods. All 9-1-1 calls were processed using MPDS protocols to determine whether the patient required ALS or basic life support (BLS) services. Consecutive patients having an ALS response for a chief complaint of abdominal pain were included. Dispatch decisions that did not follow the MPDS protocols, and cases taken to facilities other than the primary study hospitals, were excluded. EMS run sheets and hospital records were reviewed to determine: 1) whether prehospital ALS interventions were required, 2) emergency department (ED) disposition, 3) hospital course, and 4) final diagnosis. Calls were classified according to the need for ALS and the seriousness of the subsequent diagnosis. Data analysis was performed by determining 95% confidence intervals (CIs). Results. Of the 343 patients classified as 1C1 or 1C2 who were transported by ALS during the time period, 227 (67%) were transported to the study hospitals. Nine (4%) were excluded because of inappropriate dispatch, leaving 218 for analysis. Hospital records were available for 186 (86%) cases, of which 12 (6%; CI 3%, 9%) were potentially life-threatening, requiring ALS intervention. Seventeen (9%; CI 5%, 1%) were non-life-threatening, but potentially benefited from ALS intervention. The remaining 157 (84%; CI 79%, 89%) were classified as not requiring ALS. Conclusions. Use of age- and gender-specific MPDS protocols for patients with a chief complaint of abdominal pain results in significant overtriage and overuse of ALS. Steps should be taken to develop key questions that provide more accurate classification of these patients that goes beyond age and gender classification alone.

Another false alarm? Apnea monitor activation in a Neonatal Intensive care unit graduate☆

Neonatal emergencies have become more common as increasingly sophisticated Neonatal Intensive Care Units graduate lower birth-weight babies born at younger gestational ages. These patients present a number of challenges to emergency physicians. They are often discharged with apnea monitors, which generate a high number of false alarms. Neonatal Intensive Care Unit graduates, however, are predisposed to a number of conditions that can result in true episodes of apnea. We present such a case and will discuss the unusual underlying cause of apnea, the utility of apnea monitors, and the need for emergency physicians to be prepared to evaluate and treat these potentially complicated patients.

QUALITY MEASURE PERFORMANCE VARIES AMONG HOSPITALS BY PROPORTION OF LOW-INCOME PATIENTS

The Centers for Medicare and Medicaid Services (CMS) Value Based Purchasing Initiative ties hospital reimbursement to quality metric Results. We examined the relationship between performance on cardiac quality indicators and the proportion of low-income patients treated. Data were hospital-level