First attempt success with continued versus paused chest compressions during cardiac arrest in the emergency department.

AIM: Tracheal intubation is associated with interruption in cardiopulmonary resuscitation (CPR). Current knowledge of tracheal intubation during active CPR focuses on the out-of-hospital environment. We aim to describe characteristics of tracheal intubation during active CPR in the emergency department (ED) and determine whether first attempt success was associated with CPR being continued vs paused. MEASUREMENTS: We reviewed overhead video from adult ED patients receiving chest compressions at the start of the orotracheal intubation attempt. We recorded procedural detail including method of CPR, whether CPR was continued vs paused, and first attempt intubation success (primary outcome). We performed logistic regression to determine whether continuing CPR was associated with first attempt success. RESULTS: We reviewed 169 instances of tracheal intubation, including 143 patients with continued CPR and 26 patients with paused CPR. Those with paused CPR were more likely to be receiving manual rather than mechanical chest compressions. Video laryngoscopy and bougie use were common. First attempt success was higher in the continued CPR group (87%, 95% CI 81% to 92%) than the interrupted CPR group (65%, 95% CI 44% to 83%, difference 22% [95% CI 3% to 41%]). The multivariable model demonstrated an adjusted odds ratio of 0.67 (95% CI 0.17 to 2.60) for first attempt intubation success when CPR was interrupted vs continued. CONCLUSIONS: It was common to continue CPR during tracheal intubation, with success comparable to that achieved in patients without cardiac arrest. It is reasonable to attempt tracheal intubation without interrupting CPR, pausing only if necessary.

The Pediatric Bougie for the First Tracheal Intubation Attempt in Critically Ill Children.

STUDY OBJECTIVE: Bougie use during emergency tracheal intubation has not been well studied in children. METHODS: This was a 10-year observational study of pediatric intubations (<18 years of age) in the emergency department (ED) of an academic institution. Bougie training and use are standard in our ED, including for emergency medicine residents. Study data were collected by a combination of charts and video reviews. We compare first-attempt intubation success and procedural complications between pediatric patients with and without bougie use during tracheal intubation in the ED. In addition, we evaluate the independent association of bougie use with first-attempt intubation success using multivariable logistic regression. RESULTS: We collected data on intubation success and bougie use for 195 pediatric patients over more than 10 years. On the first tracheal intubation attempt, a pediatric bougie was used in 126 patients (65%). Median patient age was 5 years (interquartile range 1.7 to 9) in the bougie group and 1.7 years (interquartile range 0.2 to 5) in the no bougie group. Intubation was successful on the first attempt in 72% of intubations with a bougie versus 78% without a bougie (absolute difference -6%, 95% confidence interval [CI] -19 to 6%); the adjusted odds of first-attempt success with a bougie were 0.54 (95% CI 0.24 to 1.19). A procedural complication occurred for 38% of patients in the bougie group versus 51% in the no bougie group (-13%, 95% CI -27% to 2%). Two neonates, one in each group, experienced a potential injury to the airway or lower respiratory tract. CONCLUSION: In an academic ED where the bougie is commonly used, bougie use in children was not associated with procedural success or complications. Our study suggests that a randomized clinical trial is needed to determine the effect of bougie use during emergency pediatric intubation.

Validation of a decision rule to predict patients at low risk of variceal upper gastrointestinal hemorrhage.

BACKGROUND: Determining the likelihood of a variceal versus nonvariceal source of upper gastrointestinal bleeding (UGIB) guides ED therapy, but can be difficult to determine on clinical grounds. A simple decision rule, using only platelet and international normalized ratio (INR) values, was previously derived in a single center and had high sensitivity (97%). We sought to validate this decision rule using multi-center data. MATERIALS AND METHODS: We performed this decision rule validation using data collected from 21 Canadian hospitals, comprising 2020 patients. The parent study enrolled patients aged ≥18 years at participating hospitals with nonvariceal or variceal UGIB from January 2004 through May 2005. To validate the existing decision rule, we computed the test characteristics of the rule on this study population. The existing decision rule, in order to predict patients at low risk for variceal hemorrhage, is designed to be highly sensitive for variceal UGIB. In the previously derived rule, patients are not low risk if either is present: INR ≥1.3 or platelet count ≤200 × 109/L. We additionally added a third common-sense criterion to the decision rule in a separate analysis: whether the patient has previously had variceal hemorrhage. RESULTS: 2001 patients were eligible for analysis, including 214 (10.7%) with a variceal source of gastrointestinal hemorrhage. Median age was 69 (IQR 55-79), and 764 (38%) were women. The two-step rule correctly identified 204 of the 214 (95.3%) patients with variceal hemorrhage; adding prior variceal hemorrhage as a variable identified 5 more patients (209/214 [97.7%]). Of the 2001 patients, 953 (47%) would have been classified as low risk for variceal hemorrhage; of these patients, 5 (0.5%) experienced variceal hemorrhage. The sensitivity of the rule in this validation cohort was 95.3% (95% CI 91.6-97.7%), with a negative likelihood ratio of 0.09 (95% CI 0.05-0.16). Adding prior variceal hemorrhage increased sensitivity to 97.7% (95% CI 94.6-99.2%), with a negative likelihood ratio of 0.04 (95% CI 0.02-0.11). CONCLUSION: We have validated a simple decision rule to identify patients at low risk for variceal UGIB. This two-step (three-step if prior history of variceal hemorrhage is known) rule is simple to use, and may enable safe deferment of unnecessary or harmful therapies.

Human Errors and Adverse Hemodynamic Events Related to "Push Dose Pressors" in the Emergency Department.

BACKGROUND: Though the use of small bolus doses of vasopressors, termed "push dose pressors," has become common in emergency medicine, data examining this practice are scant. Push dose pressors frequently involve bedside dilution, which may result in errors and adverse events. The objective of this study was to assess for instances of human error and adverse hemodynamic events during push dose pressor use in the emergency department. METHODS: This was a structured chart and video review of all patients age ≥ 16 years undergoing resuscitation and receiving push dose pressors from a single center from January 2010 to November 2017. Push dose pressors were defined as intended intravenous boluses of phenylephrine (any dose) or epinephrine (≤ 100 mcg). RESULTS: A total of 249 patients were analyzed. Median age was 60 years (range, 16-97), 58% were male, 49% survived to discharge. Median initial epinephrine dose was 20 mcg (n = 139, IQR 10-100, range 1-100); median phenylephrine dose was 100 mcg (n = 110, IQR 100-100, range 25-10,000). Adverse hemodynamic events occurred in 98 patients (39%); 30 in the phenylephrine group (27%; 95% CI, 19-36%), and 68 in the epinephrine group (50%; 95% CI, 41-58%). Human errors were observed in 47 patients (19%), including 7 patients (3%) experiencing dosing errors (all overdoses; range, 2.5- to 100-fold) and 43 patients (17%) with a documentation error. Only one dosing error occurred when a pharmacist was present. CONCLUSIONS: Human errors and adverse hemodynamic events were common with the use of push dose pressors in the emergency department. Adverse hemodynamic events were more common than in previous studies. Future research should determine if push dose pressors improve outcomes and if so, how to safely implement them into practice.

Emergency Department Management of Out-of-Hospital Laryngeal Tubes.

STUDY OBJECTIVE: Laryngeal tubes are commonly used by emergency medical services (EMS) personnel for out-of-hospital advanced airway management. The emergency department (ED) management of EMS-placed laryngeal tubes is unknown. We seek to describe ED airway management techniques, success, and complications of patients receiving EMS laryngeal tubes. METHODS: Using a keyword text search of ED notes, we identified patients who arrived at our ED with a laryngeal tube from 2010 through 2017. We performed structured chart and video reviews for all eligible patients. In our ED, emergency physicians perform all airway management, and there is no protocol dictating airway management for patients arriving with a laryngeal tube. Using descriptive methods, we report the techniques, success, and complications of ED airway management. RESULTS: We analyzed data on 647 patients receiving out-of-hospital laryngeal tubes, including 472 (73%) with cardiac arrest from medical causes, 75 (21%) with cardiac arrest from trauma, and 100 (15%) with other conditions. For 580 patients (89%), emergency physicians exchanged the laryngeal tube for a definitive airway in the ED. Of the 67 patients not intubated in the ED, 66 died in the ED without further airway management. Of the 580 patients intubated in the ED, orotracheal intubation was the first method attempted for 578 (>99%) and was successful on the first attempt for 515 of 578 (89%). Macintosh video laryngoscopy (88% of initial attempts) and a bougie (68% of initial attempts) were commonly used adjuncts. For 345 of 578 patients (60%), the laryngeal tube was removed before intubation attempts. For 112 of 578 patients (19%), the first intubation attempt occurred with the deflated laryngeal tube left in place. Three patients (<1%) required a surgical airway. CONCLUSION: In this cohort, emergency physicians successfully exchanged an out-of-hospital laryngeal tube for an endotracheal tube, using commonly available airway management techniques. ED clinicians should be familiar with techniques for exchanging out-of-hospital extraglottic airways for an endotracheal tube.

Rescue Sedation When Treating Acute Agitation in the Emergency Department With Intramuscular Antipsychotics.

BACKGROUND: Rapid treatment of agitation in the emergency department (ED) is critical to avoid injury to patients and providers. Treatment with intramuscular antipsychotics is often utilized, but there is a paucity of comparative effectiveness evidence available. OBJECTIVE: The purpose of this investigation was to compare the effectiveness of droperidol, olanzapine, and haloperidol for treating agitation in the ED. METHODS: This was a retrospective observational study of adult patients who received intramuscular medication to treat agitation. Patients were classified based on the initial antipsychotic they received. The primary effectiveness outcome was the rate of additional sedation administered (rescue medication) within 1 h. Secondary outcomes included rescue sedation for the entire encounter and adverse events. RESULTS: There were 15,918 patients included (median age 37 years, 75% male). Rescue rates at 1 h were: 547/4947 for droperidol (11%, 95% confidence interval [CI] 10-12%), 988/8825 olanzapine (11%, 95% CI 10-12%), and 390/2146 for haloperidol (18%, 95% CI 17-20%). Rescue rates for the entire ED encounter were: 832/4947 for droperidol (17%, 95% CI 16-18%), 1665/8825 for olanzapine (19%, 95% CI 18-20%), and 560/2146 for haloperidol (26%, 95% CI 24-28%). Adverse events were uncommon: intubation (49, 0.3%), akathisia (7, 0.04%), dystonia (5, 0.03%), respiratory arrest (1, 0.006%), and torsades de pointes (0), with no significant differences between drugs. CONCLUSIONS: Olanzapine and droperidol lead to lower rates of rescue sedation at 1 h and overall, compared with haloperidol. There were no significant differences in major adverse events.

Intramuscular Midazolam, Olanzapine, Ziprasidone, or Haloperidol for Treating Acute Agitation in the Emergency Department.

STUDY OBJECTIVE: Agitation in the emergency department (ED) can pose a threat to patient and provider safety; therefore, treatment is indicated. The purpose of this study is to compare haloperidol, olanzapine, midazolam, and ziprasidone to treat agitation. METHODS: This was a prospective observational study of consecutive patients receiving intramuscular medication to treat agitation in the ED. Medications were administered according to an a priori protocol in which the initial medication given was predetermined in the following 3-week blocks: haloperidol 5 mg, ziprasidone 20 mg, olanzapine 10 mg, midazolam 5 mg, and haloperidol 10 mg. The primary outcome was the proportion of patients adequately sedated at 15 minutes, assessed with the Altered Mental Status Scale. RESULTS: Seven hundred thirty-seven patients were enrolled (median age 40 years; 72% men). At 15 minutes, midazolam resulted in a greater proportion of patients adequately sedated (Altered Mental Status Scale <1) compared with ziprasidone (difference 18%; 95% confidence interval [CI] 6% to 29%), haloperidol 5 mg (difference 30%; 95% CI 19% to 41%), haloperidol 10 mg (difference 28%; 95% CI 17% to 39%), and olanzapine (difference 9%; 95% CI -1% to 20%). Olanzapine resulted in a greater proportion of patients adequately sedated at 15 minutes compared with haloperidol 5 mg (difference 20%; 95% CI 10% to 31%), haloperidol 10 mg (difference 18%; 95% CI 7% to 29%), and ziprasidone (difference 8%; 95% CI -3% to 19%). Adverse events were uncommon: cardiac arrest (0), extrapyramidal adverse effects (2; 0.3%), hypotension (5; 0.5%), hypoxemia (10; 1%), and intubation (4; 0.5%), and occurred at similar rates in each group. CONCLUSION: Intramuscular midazolam achieved more effective sedation in agitated ED patients at 15 minutes than haloperidol, ziprasidone, and perhaps olanzapine. Olanzapine provided more effective sedation than haloperidol. No differences in adverse events were identified.