Using color flow detection of air insufflation to improve accuracy in verifying nasogastric tube position.

OBJECTIVES: Previous studies have shown that ultrasonography (USG), as an alternative to radiography, has a good accuracy in confirming nasogastric tube (NGT) position. Color flow detection of air insufflation is a novel approach in verifying NGT position. In our study, we aimed at evaluating its sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy in confirming the NGT position, as compared with 2-dimensional (2D) USG. METHODS: The study was conducted on adult patients over a period of 38months in an emergency department in Hong Kong. 2D USG and color flow Doppler imaging were conducted for each subject. Chest X-ray was used as the gold standard for NGT position confirmation. RESULTS: 100 patients (59 males and 41 females) were recruited totally. Their mean age was 82. The sensitivity, specificity, PPV and NPV of 2D USG were 11.1% (95% CI 4.6%-17.6%), 100% (95% CI 100%-100%), 100% (95% CI 100%-100%), and 11.1% (95% CI 4.6%-17.6%) respectively. For color flow Doppler USG, the sensitivity, specificity, PPV and NPV were 90% (95% CI 83.7%-96.2%), 80% (95% CI 55.2%-100%), 97.6% (95% CI 94.3%-100%), and 47.1% (95% CI 23.3%-70.8%) respectively. The overall accuracy of color Doppler imaging was 89%, which was higher than that of 2D USG (20% only). CONCLUSIONS: Color flow detection of air insufflation improves the diagnostic accuracy of ultrasound in verifying NGT position. It is a quick investigation such that fasting time of patients and their length of ED stay can be shortened.

Intramuscular midazolam, olanzapine, or haloperidol for the management of acute agitation: A multi-centre, double-blind, randomised clinical trial.

BACKGROUND: The safety and effectiveness of intramuscular olanzapine or haloperidol compared to midazolam as the initial pharmacological treatment for acute agitation in emergency departments (EDs) has not been evaluated. METHODS: A pragmatic, randomised, double-blind, active-controlled trial was conducted from December 2014 to September 2019, in six Hong Kong EDs. Patients (aged 18-75 years) with undifferentiated acute agitation requiring parenteral sedation were randomised to 5 mg intramuscular midazolam (n = 56), olanzapine (n = 54), or haloperidol (n = 57). Primary outcomes were time to adequate sedation and proportion of patients who achieved adequate sedation at each follow-up interval. Sedation levels were measured on a 6-level validated scale (ClinicalTrials.gov Identifier: NCT02380118). FINDINGS: Of 206 patients randomised, 167 (mean age, 42 years; 98 [58·7%] male) were analysed. Median time to sedation for IM midazolam, olanzapine, and haloperidol was 8·5 (IQR 8·0), 11·5 (IQR 30·0), and 23·0 (IQR 21·0) min, respectively. At 60 min, similar proportions of patients were adequately sedated (98%, 87%, and 97%). There were statistically significant differences for time to sedation with midazolam compared to olanzapine (p = 0·03) and haloperidol (p = 0·002). Adverse event rates were similar across the three arms. Dystonia (n = 1) and cardiac arrest (n = 1) were reported in the haloperidol group. INTERPRETATION: Midazolam resulted in faster sedation in patients with undifferentiated agitation in the emergency setting compared to olanzapine and haloperidol. Midazolam and olanzapine are preferred over haloperidol's slower time to sedation and potential for cardiovascular and extrapyramidal side effects. FUNDING: Research Grants Council, Hong Kong.