Comparison of Video Versus Direct Laryngoscopy: A Prospective Prehospital Air Medical Services Study.

OBJECTIVE: Videolaryngoscopy (VL) in the prehospital setting remains controversial, with conflicting data on its utility. We compared C-MAC VL (Karl Storz, Tuttlingen, Germany) versus direct laryngoscopy (DL) in the prehospital setting, recording the grade of the glottic view, first pass success (FPS), overall success, and equipment functionality. METHODS: We conducted a prospective observational study with a convenience sample of 49 adult patients who were intubated by flight crew nurses and paramedics using the C-MAC videolaryngoscope from April to November 2013. We compared Cormack-Lehane (CL) grades of view for DL and VL, intubation success rates, and equipment functionality. RESULTS: CL grades 1 or 2 were obtained with 24 patients (49%) with DL and 45 patients (92%) with VL. Of the 25 patients (51%) who had a CL grade 3 or 4 view on DL, 22 of those patients (88%) converted to a CL grade 1 or 2 with VL (P < .001). There was an overall success rate of 96% and an FPS rate of 71%. The C-MAC videolaryngoscope was functional during intubation 100% of the time. CONCLUSION: VL improved glottic visualization compared with DL. The FPS and overall intubation success rates were similar to other published prehospital studies using VL. The C-MAC provided reliable, high-quality video despite demanding prehospital conditions.

Methamphetamine, Amphetamine, and MDMA Use and Emergency Department Recidivism.

BACKGROUND: Emergency department (ED) recidivism and the use of amphetamine and associated derivatives such as methamphetamine and MDMA (MAE), are intersecting public health concerns. OBJECTIVE: This study aims to determine the frequency of ED recidivism of patients who use MAE and associated factors. METHODS: The study was a retrospective 6-year electronic medical record review of patients with MAE-positive toxicology screens and single and multiple ED visits in the span of 12 months. RESULTS: There were 7844 ED visits by 5568 MAE-positive patients. Average age was 42 ± 13 years. The majority were male (65%), white (46%), tobacco smokers (55%), and in the psychiatric discharge diagnostic-related group (41%), followed by blunt trauma (20%). Admission rate was 35%, with another 17% transferred to inpatient psychiatric treatment facilities. Occasional (2-5 visits/year), heavy (6-11 visits/year), and super users (≥12 visits/year) altogether accounted for 20% of patients and 43% of visits. Heavy and super users combined represented 2% of patients and 10% of visits, with significant differences for race/ethnicity, health insurance, tobacco smoking, and psychiatric/cardiovascular/trauma discharge diagnostic-related groups. Heavy and super users were less likely to be admitted and more likely to be discharged to an inpatient psychiatric treatment facility. Regression analysis revealed racial/ethnic differences, female gender, and tobacco smoking to be associated with super and heavy use. Heavy users were more likely to have cardiovascular-related discharge diagnoses. CONCLUSIONS: The prevalence of ED recidivism in patients who use MAE is similar to published ranges for general ED users. Significant differences in demographics, discharge diagnoses, insurance, smoking, and disposition exist between nonfrequent and frequent ED users.

The care of patients using methamphetamine in the emergency department: Perception of nurses, residents, and faculty.

Background: To determine differences in perception between nurses, residents, and faculty regarding characteristics and treatment of patients who use methamphetamine (meth). Methods: Survey study performed at an urban, university Level I trauma medical center. Results: A total of 80 nurses, 39 residents, and 45 faculty completed the survey. All groups agreed that meth was a significant problem nationwide and in our emergency department (ED). Nurses estimated that 33% of their patients used meth, which differed from residents (18%) and faculty (15%). All agreed that these patients required more effort to care for, utilized more hospital resources, and were more often violent toward staff. Nurses reported higher prevalence of actual assault by patients using meth (70%) than did residents (36%) and faculty (47%), and total lifetime number of assaults. All agreed that patients using meth appropriated prehospital resources at a higher rate than nonusers, had a higher rate of recidivism, and longer ED length of stay. Nurses preferred antipsychotics over benzodiazepines for treatment of meth-induced tachycardia and a lower threshold for treatment of associated hypertension than residents and faculty. For treatment of hypertension, nurses preferred beta-blockers and hydralazine over benzodiazepines. Conclusion: All agreed that meth use is a serious problem in our ED, with high resource utilization, recidivism, and violence against staff. Nurses experienced higher rates of assaults by patients using meth and differed with regard to their disposition and treatment. Treatment guidelines, strategies to mitigate violence towards staff, and interprofessional education may be beneficial, as the stakes of caring for these patients are high and preferences vary between caregivers.

Acute Toxicity from Topical Cocaine for Epistaxis: Treatment with Labetalol.

BACKGROUND: Topical cocaine is sometimes used for the treatment of epistaxis, as it has both potent anesthetic and vasoconstrictive properties. Cocaine has unpredictable cardiovascular effects, such as sudden hypertension, tachycardia, coronary arterial vasoconstriction, and dysrhythmia. CASE REPORT: We report a case of acute iatrogenic cardiovascular toxicity from the use of topical cocaine in a 56-year-old man presenting to the Emergency Department with profound epistaxis. To prepare for cauterization and nasal packing, the patient received 4% topical cocaine-soaked nasal pledgets. He became hypertensive, tachypneic, tachycardic, and dysphoric immediately after administration. To directly counter these adverse hyperadrenergic effects, the patient was given 10 mg intravenous labetalol, a mixed ß- and α-blocker. This instantly normalized his vital signs and adverse subjective effects. His epistaxis was successfully treated, and he was discharged 1 h later. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: We believe that emergency physicians should be aware of the unpredictable acute cardiovascular toxicity of topical cocaine. Labetalol represents an effective first-line treatment, which, unlike benzodiazepines, directly counters the pharmacologic effects of cocaine and has no respiratory or sedative side effects. Labetalol, with its mixed ß/α-blocking properties, also mitigates the potential for "unopposed α-stimulation."

Malignancy-associated Sweet syndrome: acute febrile neutrophilic dermatosis associated with recurrence of metastatic cervical cancer.

We present a rare case of acute febrile neutrophilic dermatosis, also known as Sweet syndrome, associated with recurrence of metastatic cervical cancer. This report highlights similar reports and serves as an important reminder of the relationship between Sweet syndrome and cervical cancer. Increasing awareness of Sweet syndrome assists clinicians in recognizing characteristic findings and encourages evaluation of patients for new-onset or recurrent neoplastic disease. Additionally, we discuss the typical presentation of the syndrome, the proper workup and treatment, and a common pitfall encountered in the diagnosis of Sweet syndrome.

Fracture of a GlideScope® Cobalt GVL® Stat disposable blade during an emergency intubation.

BACKGROUND: Emergency airway management is a diverse discipline, often utilizing advanced equipment with video technology to enable the intubator to visualize a patient's vocal cords that would be difficult or impossible to see with routine direct laryngoscopy. The GlideScope® Cobalt (Saturn Biomedical Systems, Inc., Burnaby, BC, Canada) is one type of video laryngoscope with disposable plastic GVL® Stat blades (Saturn Biomedical Systems) that can improve glottic view over direct laryngoscopy. It also benefits from rapid turnaround time and few infection control issues due to its disposable blade. OBJECTIVE: To report what we believe to be the first GlideScope® blade failure to be reported in the medical literature. The circumstances surrounding the blade failure may raise awareness of GVL® Stat usage in obese patients with limited mouth opening. CASE REPORT: During a standard emergency intubation, insertion of the GVL® Stat into the patient's mouth resulted in breakage of the distal segment of the blade. The patient was severely obese and had limited mouth opening, which required the blade to be inserted obliquely, rather than in the midline, into the patient's mouth. As the handle was repositioned back to midline, the distal segment of the blade broke off. No excessive force was used during blade repositioning when breakage occurred. CONCLUSION: Twisting forces on the distal flat segment of the GVL® Stat may have caused its failure. Because this was only a single occurrence of breakage, it is not clear if design issues or atypical insertion of the blade was responsible for breakage. Care must be exercised when midline insertion is not possible, which can occur in obese patients with limited mouth opening.

Anterior Lung Evisceration Following an Assault with Knife: A Case Report.

INTRODUCTION: Evisceration of the lung is a rare consequence of open chest trauma that can be fatal. Evisceration of the lung refers to the protrusion of lung parenchyma through a defect of the thoracic wall, without parietal pleural or skin coverage. CASE REPORT: A 20-year-old man was brought to the emergency department (ED) with left lung evisceration from stab wounds. The eviscerated lung was left in place, and the patient was not intubated in the ED. He was immediately taken to the operating room (OR) for intubation and surgical repair. Other significant injuries were ruled out, the eviscerated lung was retrieved, the chest wall defect was closed, and the patient recovered well. He was discharged after seven days in good condition. CONCLUSION: The initial management of patients with lung evisceration is critical to prevent rapid decompensation and death. Appropriate ED airway management, lung retrieval in the OR, and thoracic wall repair is recommended for patients with lung evisceration.

Improved glottic exposure with the Video Macintosh Laryngoscope in adult emergency department tracheal intubations.

STUDY OBJECTIVE: Glottic visualization with video is superior to direct laryngoscopy in controlled operating room studies. However, glottic exposure with video laryngoscopy has not been evaluated in the emergency department (ED) setting, where blood, secretions, poor patient positioning, and physiologic derangement can complicate laryngoscopy. We measure the difference in glottic visualization with video versus direct laryngoscopy. METHODS: We prospectively studied a convenience sample of tracheal intubations at 2 academic EDs. We performed laryngoscopy with the Karl Storz Video Macintosh Laryngoscope, which can be used for conventional direct laryngoscopy, as well as video laryngoscopy. We rated glottic visualization with the Cormack-Lehane (C-L) Scale, defining "good" visualization as C-L I or II and "poor" visualization as C-L III or IV. We compared glottic exposure between direct and video laryngoscopy, determining the proportion of poor direct visualizations improved to good visualization with video laryngoscopy. We also determined the proportion of good direct visualizations worsened to poor visualization by video laryngoscopy. RESULTS: We report data on 198 patients, including 146 (74%) medical, 51 (26%) trauma, and 1 (0.51%) unknown indications. All were tracheally intubated by emergency physicians. Postgraduate year 3 or 4 residents performed 102 (52.3%) of the laryngoscopies, postgraduate year 2 residents performed 60 (30.8%), interns performed 20 (10.3%), attending physicians performed 9 (4.6%), and operator experience and specialty were not reported in 4. Overall, good visualization (C-L grade I or II) was attained in 158 direct (80%) versus 185 video laryngoscopies (93%; McNemar's P<.0001). Of the 40 patients with poor glottic exposure on direct laryngoscopy, video laryngoscopy improved the view in 31 (78%; 95% confidence interval 62% to 89%). Of the 158 patients with good glottic view on direct laryngoscopy, video laryngoscopy worsened the view in 4 (3%; 95% confidence interval 0.7% to 6%). CONCLUSION: Video laryngoscopy affords more grade I and II views than direct laryngoscopy and improves glottic exposure in most patients with poor direct glottic visualization. In a small proportion of cases, glottic exposure is worse with video than direct laryngoscopy.

Frequency of non-ST-segment elevation injury patterns on prehospital electrocardiograms.

INTRODUCTION: Prehospital electrocardiograms (ECGs) have been recommended to facilitate early diagnosis of ST-segment elevation myocardial infarction (STEMI). However, prehospital ECGs can also be used to triage patients with non-ST-segment elevation acute coronary syndromes, who comprise a majority of patients with ischemic events presenting by ambulance to overcrowded emergency departments. OBJECTIVE: We assessed the frequency of non-ST-segment elevation injury patterns on prehospital ECGs in patients with a chief complaint of chest pain evaluated by the emergency medical services (EMS) system. METHODS: We analyzed prehospital ECGs of patients with the chief complaint of chest pain during a nine-month period. The ECGs were divided into three categories: injury pattern; no injury pattern; and technically uninterpretable. Injury pattern criteria were as follows: 1) regional ST depression >or=1.0 mm; 2) regional T-wave inversion (TWI) >or=3 mm; 3) left bundle branch block (LBBB); and 4) regional ST-segment elevation >or=1.0 mm. Descriptive statistics with 95% confidence intervals (CIs) are presented. RESULTS: Prehospital ECGs were obtained for 322 of 340 chest pain patients: 72% were men; the average age was 60 years (range 18-96 years). Seventy-seven ECGs (24%, 95% CI 19.3-28.9%) met the criteria for injury pattern, 230 (71%) did not show injury, and 15 (5%) were uninterpretable. Of the 77 ECGs that exhibited an injury pattern, 39 (51%) showed ST depression, seven (9%) TWI, seven (9%) LBBB, and 24 (31%) ST-segment elevation. Thus, non-ST-segment elevation injury patterns (ST depression/TWI/LBBB) accounted for 53 (17%, 95% CI 12.6-20.9) of the total 322 prehospital ECGs. CONCLUSION: Our findings demonstrate a relatively high frequency (17%) of non-ST-segment elevation injury patterns on prehospital ECGs of patients who summon EMS because of chest pain. These results suggest the potential of prehospital ECGs to facilitate early triage in these high-risk chest pain patients who present to overcrowded emergency departments.

Feasibility of the preoperative Mallampati airway assessment in emergency department patients.

BACKGROUND: Multiple predictors have been proposed to assist in identifying patient features that would predict difficult airway management. The Mallampati score (MS) has been shown to be useful in the preoperative assessment of patients being intubated in the operating room. OBJECTIVE: We sought to define the feasibility of this assessment in the Emergency Department. METHODS: A prospective, observational study was performed on all patients being intubated at a university Level I trauma center over a period of 6 months. We recorded and calculated the proportion of patients who were successfully assessed using the MS. Reasons given by individual intubators for failure to assess were recorded. We also tracked patient characteristics between groups and complication rates. RESULTS: Of 328 patients, 32 (10%) were excluded due to incomplete data. Among the remaining 296, 58% were intubated for non-trauma indications, 70% were male, and the mean age was 45.9 years. Only 76 of 296 (26%) (95% confidence interval 21-31%) were able to have the MS performed. Lack of patient cooperation and clinical instability were listed as factors that precluded evaluation in patients whose assessment was unsuccessful. The frequency of procedure-related minor events did not differ significantly between the assessed and non-assessed groups. Major events included two cricothyrotomies in the non-assessed group. CONCLUSIONS: We were unable to perform a Mallampati assessment in three-quarters of our patients requiring emergency intubation. These findings call into question the feasibility of the standard Mallampati assessment in the practice of Emergency Medicine.

Metoprolol treatment of dual cocaine and bupropion cardiovascular and central nervous system toxicity.

Cardiovascular and central nervous system (CNS) toxicity, including tachydysrhythmia, agitation, and seizures, may arise from cocaine or bupropion use. We report acute toxicity from the concomitant use of cocaine and bupropion in a 25-year-old female. She arrived agitated and uncooperative, with a history of possible antecedent cocaine use. Her electrocardiogram demonstrated tachycardia at 130 beats/min, with a corrected QT interval of 579 ms. Two doses of 5 mg intravenous metoprolol were administered, which resolved the agitation, tachydysrhythmia, and corrected QT interval prolongation. Her comprehensive toxicology screen returned positive for both cocaine and bupropion. We believe clinicians should be aware of the potential for synergistic cardiovascular and CNS toxicity from concomitant cocaine and bupropion use. Metoprolol may represent an effective initial treatment. Unlike benzodiazepines, metoprolol directly counters the pharmacologic effects of stimulants without respiratory depression, sedation, or paradoxical agitation. A lipophilic beta-blocker, metoprolol has good penetration of the CNS and can counter stimulant-induced agitation.

Cannabis use and acute coronary syndrome.

Introduction: Cannabis smoking can result in elevation of heart rate and blood pressure immediately after use, possibly from sympathetic nervous system stimulation and parasympathetic nervous system inhibition. Vascular inflammation, platelet activation, and carboxyhemoglobin generation have also been proposed as potential side effects of cannabis smoking. As such, an association between cannabis use and acute coronary syndrome has been postulated. Objective: The objective of our study was to analyze systematically the medical literature pertaining to this putative association. Methods: PubMed, Google Scholar, and OpenGrey were queried using a unique search string. All human trials, case series, or case reports of cannabis use and acute coronary syndrome in any language were considered in the literature search. The definition of acute coronary syndrome represented a penumbra that included chest pain, angina pectoris, unstable angina, myocardial infarction, myocardial ischemia, and cardiac arrest. Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were followed. Our final search strategy included free-text words (TW): ("cannabis"[TW] OR "marijuana"[TW]) AND ("acute coronary syndrome"[TW] OR "myocardial" OR "ischemia"[TW] OR "infarction"[TW] OR "chest pain"[TW] OR "cardiac arrest"[TW] OR "angina"[TW]). To remain consistent over a span of five decades, we specifically did not include any publications with non-phytogenic, non-smoked cannabis as the sole etiology, as these are relatively recent and may possess additional pharmacologic characteristics compared to phytogenic cannabinoids. Therefore, for the purpose of this review, the term "cannabis" refers to the smoked phytogenic form. The search resulted in 325 articles. References in each selected publication were carefully hand-searched for any additional reports having relevance, and a total of 12 publications were identified in this manner. Following comparison and discussion amongst the co-authors, duplicate and non-relevant publications were removed, and a total of 85 publications involving 541,518 human subjects were selected for inclusion. Results were synthesized and reviewed by the authors for relevance. Clinical trials, observational studies, retrospective studies, case series, and case reports were graded using Oxford Centre for Evidence-based Medicine guidelines. Results: There were no Level I randomized blinded controlled studies specifically addressing the cannabis/acute coronary syndrome association. However, there were five Level I systematic reviews, 14 Level II studies with 83,961 subjects, and 14 Level III studies with 457,495 subjects. Conclusions from 28 of these 33 studies highlighted an increased risk of both acute coronary syndrome and chronic cardiovascular disease from cannabis use. The systematic reviews were wide-ranging in topic and scale, and none specifically focused on the association between cannabis use and acute coronary syndrome. The dissenting studies included two systematic reviews, one concluding there was limited and weak evidence for association of cardiovascular disease and acute coronary syndromes with cannabis use, and another citing the evidence was inconclusive. The other dissenting articles were two longitudinal prospective studies and a retrospective review concluding cannabis users had lower post-myocardial infarction mortality. There were 51 case series (Level IV) and case reports (Level V) with 62 subjects. Six cases were female (10%). Average age was 31 ± 12 years, reported maximum heart rate was 88 ± 21 bpm, systolic blood pressure was 125 ± 32 mmHg, and diastolic blood pressure was 80 ± 17 mmHg. ST-segment elevation was documented on 37 (60%) electrocardiograms, and the most common angiographic finding was left anterior descending coronary arterial occlusion and/or stenosis in 22 (35%) patients. Concomitant cardiomyopathy was described in 21 (34%) cases. There were 14 (23%) deaths attributed to acute coronary syndrome associated with cannabis use. Conclusion: There were five Level I systematic reviews, 14 Level II studies with 83,961 subjects, and 14 Level III studies with 457,495 subjects. All but five Level I-III publications highlighted an increased risk of both acute coronary syndrome and chronic cardiovascular disease associated with cannabis use.

Night shift preparation, performance, and perception: are there differences between emergency medicine nurses, residents, and faculty?

OBJECTIVE: Determine differences between faculty, residents, and nurses regarding night shift preparation, performance, recovery, and perception of emotional and physical health effects. METHODS: Survey study performed at an urban university medical center emergency department with an accredited residency program in emergency medicine. RESULTS: Forty-seven faculty, 37 residents, and 90 nurses completed the survey. There was no difference in use of physical sleep aids between groups, except nurses utilized blackout curtains more (69%) than residents (60%) and faculty (45%). Bedroom temperature preference was similar. The routine use of pharmacologic sleep aids differed: nurses and residents (both 38%) compared to faculty (13%). Residents routinely used melatonin more (79%) than did faculty (33%) and nurses (38%). Faculty preferred not to eat (45%), whereas residents (24%) preferred a full meal. The majority (>72%) in all groups drank coffee before their night shift and reported feeling tired despite their routine, with 4:00 a.m. as median nadir. Faculty reported a higher rate (41%) of falling asleep while driving compared to residents (14%) and nurses (32%), but the accident rate (3% to 6%) did not differ significantly. All had similar opinions regarding night shift-associated health effects. However, faculty reported lower level of satisfaction working night shifts, whereas nurses agreed less than the other groups regarding increased risk of drug and alcohol dependence. CONCLUSION: Faculty, residents, and nurses shared many characteristics. Faculty tended to not use pharmacologic sleep aids, not eat before their shift, fall asleep at a higher rate while driving home, and enjoy night shift work less.

Treatment of cocaine cardiovascular toxicity: a systematic review.

INTRODUCTION: Cocaine abuse is a major worldwide health problem. Patients with acute cocaine toxicity presenting to the emergency department may require urgent treatment for tachycardia, dysrhythmia, hypertension, and coronary vasospasm, leading to pathological sequelae such as acute coronary syndrome, stroke, and death. OBJECTIVE: The objective of this study is to review the current evidence for pharmacological treatment of cardiovascular toxicity resulting from cocaine abuse. METHODS: MEDLINE, PsycINFO, Database of Abstracts of Reviews of Effects (DARE), OpenGrey, Google Scholar, and the Cochrane Library were searched from inception to November 2015. Articles on pharmacological treatment involving human subjects and cocaine were selected and reviewed. Evidence was graded using Oxford Centre for Evidence-Based Medicine guidelines. Treatment recommendations were compared to current American College of Cardiology/American Heart Association guidelines. Special attention was given to adverse drug events or treatment failure. The search resulted in 2376 articles with 120 eligible involving 2358 human subjects. Benzodiazepines and other GABA-active agents: There were five high-quality (CEBM Level I/II) studies, three retrospective (Level III), and 25 case series/reports (Level IV/V) supporting the use of benzodiazepines and other GABA-active agents in 234 subjects with eight treatment failures. Benzodiazepines may not always effectively mitigate tachycardia, hypertension, and vasospasm from cocaine toxicity. Calcium channel blockers: There were seven Level I/II, one Level III, and seven Level IV/V studies involving 107 subjects and one treatment failure. Calcium channel blockers may decrease hypertension and coronary vasospasm, but not necessarily tachycardia. Nitric oxide-mediated vasodilators: There were six Level I/II, one Level III, and 25 Level IV/V studies conducted in 246 subjects with 11 treatment failures and two adverse drug events. Nitroglycerin may lead to severe hypotension and reflex tachycardia. Alpha-adrenoceptor blocking drugs: There were two Level I studies and three case reports. Alpha-1 blockers may improve hypertension and vasospasm, but not tachycardia, although evidence is limited. Alpha-2-adrenoceptor agonists: There were two high-quality studies and one case report detailing the successful use of dexmedetomidine. Beta-blockers and ß/α-blockers: There were nine Level I/II, seven Level III, and 34 Level IV/V studies of ß-blockers, with 1744 subjects, seven adverse drug events, and three treatment failures. No adverse events were reported for use of combined ß/α-blockers such as labetalol and carvedilol, which were effective in attenuating both hypertension and tachycardia. Antipsychotics: Seven Level I/II studies, three Level III studies, and seven Level IV/V case series and reports involving 168 subjects have been published. Antipsychotics may improve agitation and psychosis, but with inconsistent reduction in tachycardia and hypertension and risk of extrapyramidal adverse effects. Other agents: There was only one high level study of morphine, which reversed cocaine-induced coronary vasoconstriction but increased heart rate. Other agents reviewed included lidocaine, sodium bicarbonate, amiodarone, procainamide, propofol, intravenous lipid emulsion, propofol, and ketamine. CONCLUSIONS: High-quality evidence for pharmacological treatment of cocaine cardiovascular toxicity is limited but can guide acute management of associated tachycardia, dysrhythmia, hypertension, and coronary vasospasm. Future randomized prospective trials are needed to evaluate new agents and further define optimal treatment of cocaine-toxic patients.

Frequency of acute coronary syndrome in patients with normal electrocardiogram performed during presence or absence of chest pain.

OBJECTIVES: The authors hypothesized that patients with active chest pain at the time of a normal electrocardiogram (ECG) have a lower frequency of acute coronary syndrome (ACS) than patients being evaluated for chest pain but with no active chest pain at the time of a normal ECG. The study objective was to describe the association between chest pain in patients with a normal ECG and the diagnosis of ACS. METHODS: This was a prospective observational study of emergency department (ED) patients with a chief complaint of chest pain and an initial normal ECG admitted to the hospital for chest pain evaluation over a 1-year period. Two groups were identified: patients with chest pain during the ECG and patients without chest pain during the ECG. Normal ECG criteria were as follow: 1) normal sinus rhythm with heart rate of 55-105 beats/min, 2) normal QRS interval and ST segment, and 3) normal T-wave morphology or T-wave flattening. "Normal" excludes pathologic Q waves, left ventricular hypertrophy, nonspecific ST-T wave abnormalities, any ST depression, and discrepancies in the axis between the T wave and the QRS. Patients' initial ED ECGs were interpreted as normal or abnormal by two emergency physicians (EPs); differences in interpretation were resolved by a cardiologist. ACS was defined as follows: 1) elevation and characteristic evolution of troponin I level, 2) coronary angiography demonstrating >70% stenosis in a major coronary artery, or 3) positive noninvasive cardiac stress test. Chi-square analysis was performed and odds ratios (ORs) are presented. RESULTS: A total of 1,741 patients were admitted with cardiopulmonary symptoms; 387 met study criteria. The study group comprised 199 males (51%) and 188 females (49%), mean age was 56 years (range, 25-90 years), and 106 (27%) had known coronary artery disease (CAD). A total of 261 (67%) patients experienced chest pain during ECG; 126 (33%) patients experienced no chest pain during ECG. There was no difference between the two groups in age, sex, cardiac risk factors, or known CAD. The frequency of ACS for the total study group was 17% (67/387). There was no difference in prevalence of ACS based on the presence or absence of chest pain (16% or 42/261 vs. 20% or 25/126; OR = 0.77, 95% confidence interval = 0.45 to 1.33, p = 0.4). CONCLUSIONS: Contrary to our hypothesis concerning patients who presented to the ED with a chief complaint of chest pain, our study demonstrated no difference in the frequency of acute coronary syndrome between patients with chest pain at the time of acquisition of a normal electrocardiogram and those without chest pain during acquisition of a normal electrocardiogram.

An assessment of a tracheal tube introducer as an endotracheal tube placement confirmation device.

INTRODUCTION: Early detection of an inadvertent esophageal intubation can be particularly challenging in cases when the current standard of care, carbon dioxide detection, is unreliable. We sought to determine the sensitivity and specificity of an inexpensive and portable device, the gum elastic bougie (Eschmann Tracheal Tube Introducer, SIMS Portex, Inc, Keene, NH), as an endotracheal tube placement confirmation device. METHODS: We conducted a prospective blinded trial in 20 human cadavers. Each cadaver was randomized to a mixed series of 5 esophageal and 5 tracheal intubations. Each intubation was assessed with the bougie twice, once by a novice to the technique, and once by an assessor who was constant through the trial. Assessors used the bougie to "feel" for "clicks" of the tracheal rings and to appreciate "hang up" of the bougie as it was advanced into the smaller airways. Absence of these findings was presumed to indicate an esophageal intubation. Actual placement was confirmed by bronchoscopy. Each assessor made an independent determination of tube location. Descriptive statistics were used to summarize the data. RESULTS: Overall, 93% (95% confidence interval [CI], 86%-97%) of tracheal placements were correctly identified. The constant assessor was able to correctly identify 98% (95% CI, 90%-100%). Tracheal rings were detected in 92% of tracheal placements. Ring clicks were 95% specific for tracheal intubation. Hang up was reported in 100% of tracheal placements with a specificity of 84%. Overall, 95% (95% CI, 88%-98%) of esophageal intubations were detected. The constant assessor detected 100% of esophageal intubations. CONCLUSION: In the cadaver model used in this study, the gum elastic bougie (Eschmann Tracheal Tube Introducer) shows promise as an endotracheal tube confirmation device.

Cricoid ring integrity: implications for cricothyrotomy.

STUDY OBJECTIVES: The rapid 4-step technique for cricothyrotomy was originally described as making use of a single traction hook on the cricoid ring. However, it is possible that such hook placement could lead to damage of the cricoid ring. As an alternative, a double-hook device was developed to augment the rapid 4-step technique by dispersing forces applied to the cricoid ring. The objectives of this study were to compare the requisite forces for intubation and the structural tolerances of the cricoid ring between the single- and double-hook techniques. METHODS: We randomized 56 human cadaver specimens to undergo either cricothyrotomy with intubation followed by cricoid ring breakage or cricoid ring breakage alone. We randomized those cadaver specimens undergoing cricothyrotomy with intubation with respect to the initial hook technique used and then crossed over to the alternate technique for repeat intubation and subsequent cricoid ring breakage. We performed all cricothyrotomies in a similar manner with a consistent technique. We measured the intubation and breakage forces for the single- and double-hook techniques and calculated 95% confidence intervals (CIs). RESULTS: The mean force to intubate with the single-hook technique was 18 N (95% CI 14 to 22 N), and the mean force to intubate with the double-hook technique was 23 N (95% CI 17 to 29 N). There was a significant difference between the mean forces required to break the cricoid ring with the single-hook technique (54 N; 95% CI 47 to 62 N) versus with the double-hook technique (101 N; 95% CI 89 to 113 N; difference in means 47 [95% CI 34 to 60 N]). CONCLUSION: When applying the rapid 4-step technique for cricothyrotomy, the force required to intubate with either the single- or double-hook technique is small. The cricoid ring, however, tolerates significantly more force without breakage when the double-hook technique is used.