Comparison of intubation performance by emergency medicine residents using gum elastic bougie versus standard stylet in simulated easy and difficult intubation scenarios.

OBJECTIVE: We sought to evaluate the success rate and time to endotracheal intubation by emergency medicine residents with stylet reinforced endotracheal tube (ETT-S) versus intubation with a gum elastic bougie (GEB) in simulated easy and difficult airways on a cadaveric model. METHODS: The study was a prospective cross-over design using a cohort of 29 emergency medicine residents. A fresh frozen cadaver was used in either standard positioning to facilitate a Cormack Lehane Grade 1 laryngoscopy, or with a hard cervical collar applied a Cormack Lehane Grade 3 laryngoscopy. Each participant then intubated the cadaver in each setting. The primary end-point of our investigation was the time to intubation. Secondary end-points were: success rate of intubation, mean ratings by study participants of perceived ease of intubation for each intubation technique in each simulated degree of difficulty, and overall preference of intubation technique in each simulated degree of difficulty. RESULTS: Mean time to intubation in all scenarios ranged from 28.8-116.6 s. Time to intubation was significantly different only when comparing Grade 3 ETT-S to Grade 3 GEB. There was no significant difference in success rate when comparing Grade 1 ETT-S to Grade 1 GEB (P = 0.99) nor Grade 3 ETT-S to Grade 3 GEB (P = 0.21). CONCLUSION: Time to intubation in a simulated grade 3 view was significantly longer in the GEB group versus the ETT-S group. Although the differences in success rates were not statistically significant, there was a trend toward more successful intubations with the GEB in the simulated grade 3 view.

Impact of decontamination therapy on ultrasound visualization of ingested pills.

INTRODUCTION: Acute toxic ingestion is a common cause of morbidity and mortality. Emergency physicians (EP) caring for overdose (OD) patients are often required to make critical decisions with incomplete information. Point of care ultrasound (POCUS) may have a role in assisting EPs manage OD patients. We evaluated the impact of different liquid adjuncts used for gastric decontamination on examiners' ability to identify the presence of tablets using POCUS, and assessed examiners' ability to quantify the numbers of tablets in a simulated massive OD. METHODS: This prospective, blinded, pilot study was performed at an academic emergency department. Study participants were volunteer resident and staff EPs trained in POCUS. Five nontransparent, sealed bags were prepared with the following contents: 1 liter (L) of water, 1 L of water with 50 regular aspirin (ASA) tablets, 1 L of water with 50 enteric-coated aspirin tablets (ECA), 1 L of polyethylene glycol (PEG) with 50 ECA, and 1 L of activated charcoal (AC) with 50 ECA. After performing POCUS on each of the bags using a 10-5 MHz linear array transducer, participants completed a standardized questionnaire composed of the following questions: (1) Were pills present? YES/NO; (2) If tablets were identified, estimate the number (1-10, 11-25, >25). We used a single test on proportions using the binomial distribution to determine if the number of EPs who identified tablets differed from 50% chance. For those tablets identified in the different solutions, another test on proportions was used to determine whether the type of solution made a difference. Since 3 options were available, we used a probability of 33.3%. RESULTS: Thirty-seven EPs completed the study. All (37/37) EP's correctly identified the absence of tablets in the bag containing only water, and the presence of ECA in the bags containing water and PEG. For Part 2 of the study, most participants - 25/37 (67.5%) using water, 23/37 (62.1%) using PEG, and all 37 (100%) using AC - underestimated the number of ECA pills in solution by at least 50%. CONCLUSION: There may be a potential role for POCUS in the evaluation of patients suspected of acute, massive ingested OD. EPs accurately identified the presence of ECA in water and PEG, but underestimated the number of tablets in all tested solutions.

Meningitis secondary to Cryptococcus gattii, an emerging pathogen affecting immunocompetent hosts.

BACKGROUND: Meningitis continues to be one of the most important infections diagnosed and treated by emergency physicians. Despite the advent of anti-infective therapy, meningitis carries a mortality rate of 20%-40%. In this study, we describe the first reported emergency medicine case of meningitis associated with Cryptococcus gattii to alert providers of this insidious, emerging global pathogen infecting immunocompetent individuals. METHODS: We provided a case report and accompanying review of the literature. A MEDLINE search for the term Cryptoccocus gattii was performed to obtain background information on Cryptococcus gattii. RESULTS: After two months of hospitalization, the patient was eventually discharged neurologically intact except for a continued mild bilateral hearing deficit. CONCLUSION: Cryptococcus gattii is an emerging world pathogen, which affects otherwise healthy, immunocompetent patients and requires timely identification and treatment in order to prevent severe neurological sequelae.

Three cases of "spice" exposure.

INTRODUCTION: We describe three cases with confirmed exposure to "spice" by detection of the metabolites JWH-018 and/or JWH-073 in urine. All cases had a negative urine drug screen. Case 1. A 25-year-old male with possible seizure, tachycardia, acidosis, and unresponsiveness, presented to a local emergency department (ED) after smoking a "spice" product. His symptoms resolved with benzodiazepines, fluid, and observation. His urine tested positive for JWH-018 and negative for JWH-073 metabolites. Case 2. A 21-year-old male was found unresponsive after smoking "spice." He had hypertension, was agitated, and had a Glasgow Coma Score of 7; the patient was intubated. The skin was warm and dry. His symptoms resolved with IV fluids and he was discharged home after 24 h. His urine tested positive for metabolites of JWH-018 and JWH-073. Case 3. A 19-year-old male was brought to the ED 1 h after smoking a "spice" product and having paranoia and delusions. His urine tested positive for JWH-018 and JWH-073 metabolites. He was discharged asymptomatic after observation for a few hours. DISCUSSION: Spice products are new and abused for their psychogenic effects and mood alteration. These cases exhibited changes consistent with either an anticholinergic or sympathomimetic agent that resolved following general supportive care.