Emergency Department use of Apneic Oxygenation Versus Usual Care During Rapid Sequence Intubation: A Randomized Controlled Trial (The ENDAO Trial).

OBJECTIVES: Desaturation leading to hypoxemia may occur during rapid sequence intubation (RSI). Apneic oxygenation (AO) was developed to prevent the occurrence of oxygen desaturation during the apnea period. The purpose of this study was to determine if the application of AO increases the average lowest oxygen saturation during RSI when compared to usual care (UC) in the emergency setting. METHODS: A randomized controlled trial was conducted at an academic, urban, Level I trauma center. All patients requiring intubation were included. Exclusion criteria were patients in cardiac or traumatic arrest or if preoxygenation was not performed. An observer, blinded to study outcomes and who was not involved in the procedure, recorded all times, while all saturations were recorded in real time by monitors on a secured server. Two-hundred patients were allocated to receive AO (n = 100) or UC (n = 100) by predetermined randomization in a 1:1 ratio. RESULTS: A total of 206 patients were enrolled. There was no difference in lowest mean oxygen saturation between the two groups (92, 95% confidence interval [CI] = 91 to 93 in AO vs. 93, 95% CI = 92 to 94 in UC; p = 0.11). CONCLUSION: There was no difference in lowest mean oxygen saturation between the two groups. The application of AO during RSI did not prevent desaturation of patients in this study population.

Re-evaluating the diagnostic accuracy of the tongue blade test: still useful as a screening tool for mandibular fractures?

BACKGROUND: Mandibular fractures are one of the most frequently seen injuries in trauma. In terms of facial trauma, mandible fractures constitute 40%-62% of all facial bone fractures. The tongue blade test (TBT) has been shown to be a sensitive screening tool when compared with plain films. However, recent studies have demonstrated that computed tomography (CT) scan is more sensitive for determining mandible fractures than the traditionally used plain films. OBJECTIVE: The purpose of the study was to determine the sensitivity and specificity of the TBT as compared with the new gold standard of radiologic imaging, CT scan. METHODS: Any patient suffering from facial trauma was prospectively enrolled during the study period (August 1, 2010 to April 11, 2012) at a single urban, academic Emergency Department. A TBT was performed by the resident physician and confirmed by the supervising attending. CT facial bones were then obtained for the ultimate diagnosis. Inter-rater reliability (κ) was calculated, along with sensitivity, specificity, negative predictive value, and likelihood ratio (-) based on a 2 × 2 contingency table generated. RESULTS: During the study period, 190 patients were enrolled. Inter-rater reliability was κ = 0.96 (95% confidence interval [CI] 0.93-0.99). The following parameters were then calculated based on the contingency table: sensitivity 0.95 (95% CI 0.88-0.98), specificity 0.68 (95% CI 0.57-0.77), negative predictive value 0.92 (95% CI 0.82-0.97), and likelihood ratio (-) 0.07 (95% CI 0.03-0.18). CONCLUSIONS: Based on the test characteristics calculated (negative predictive value 0.92, sensitivity 0.95, likelihood ratio -0.07), the TBT is a useful screening tool to determine the need for radiologic imaging.

Paroxysmal neuropathic pain in an adolescent female with syringomyelia: a review of literature.

Paroxysmal neuropathic pain is an uncommon complaint among pediatric patients visiting the emergency department. It is a rare presentation in children with syringomyelia. Patients with syringomyelia may present with a variety of pain symptoms. It is the site and extension of the syrinx, which determines the character of pain. We report an adolescent with Chiari malformation type 1 with syringomyelia who presented with neuropathic pain, dysesthesia, and absent triceps (C7) reflex. The pertinent literature is reviewed.

Hip pain in a child: myositis or appendicitis?

Hip pain is a common presenting complaint in the pediatric emergency department, which can be attributed to many possible causes. It may be due to a benign "growing pain" or a potentially serious illness requiring urgent evaluation. At times, hip pain can be a manifestation of an underlying appendicitis in a child; thus, it can be confused with many other conditions. Children can be at particular risk for misdiagnosis or delayed diagnosis of appendicitis as it often can have an uncommon presentation with atypical signs and symptoms. Early identification, however, is important to prevent potential complications of delaying the diagnosis. We present a case that illustrates an atypical presentation of acute appendicitis. This report also highlights the diagnostic dilemma encountered during the evaluation of hip pain in children.