Appropriate Needle Length for Emergent Pediatric Needle Thoracostomy Utilizing Computed Tomography.

Objective: Needle thoracostomy is a life-saving procedure. Advanced Trauma Life Support guidelines recommend insertion of a 5 cm, 14-gauge needle for pneumothorax decompression. High-risk complications can arise if utilizing an inappropriate needle size. No study exist evaluating appropriate needle length in pediatric patients. Utilizing computed tomography (CT), we determined the needle length required to access the pleural cavity in children matched to Broselow™ Pediatric Emergency Tape color. Methods: Three investigators reviewed chest CTs of children <13 years of age obtained between 2010 and 2015. Patient exclusions included those with a chest wall mass, muscle disease, pectus deformity, anasarca, prior open thoracotomy, inadequate imaging, or missing height documentation. We established 4 groups based upon Broselow™ color as determined by recorded height. Investigators, trained by a pediatric board-certified radiologist, obtained standardized CT measurements of chest wall thickness at 4 points: right/left second intercostal space at the midclavicular line (ICS-MCL) and right/left fourth intercostal space in the anterior axillary line (ICS-AAL). Our outcome was the median chest wall thickness and 95% confidence intervals for each Broselow grouping and anatomic site. Results: A total of 273 chest CTs were reviewed, of which 23 were excluded, for a resultant study population of 250 scans and 498 total measurements. Median patient age was 4 years, 52.8% were male. Children measuring Broselow Gray/Pink (<68 cm), had a median chest wall thickness at the 2nd ICS-MCL of 1.57 cm (95% CI 1.42 cm, 1.72 cm), 4th ICS-AAL 1.67 cm (95% CI 1.48 cm, 1.86 cm). Broselow Red/Purple (68.1-90 cm): 2nd ICS-MCL of 1.96 cm (95% CI 1.84 cm, 2.08 cm), 4th ICS-AAL 1.73 cm (95% CI 1.62 cm, 1.84 cm). Broselow Yellow/White (90.1-115cm): 2nd ICS-MCL of 2.12 cm (95% CI 2.03 cm, 1.22 cm), 4th ICS-AAL 1.91 cm (95% CI 1.8 cm, 2.01 cm). Broselow Blue/Orange/Green (>115.1 cm): 2nd ICS-MCL of 2.45 cm (95% CI 2.3 cm, 2.6 cm), 4th ICS-AAL 2.19cm (95% CI 2.02 cm, 2.36 cm). Conclusion: Median chest wall thickness varies little by height or location in children <13 years of age. The standard 5-cm needle is twice the chest wall thickness of most children. Commercially available 14 g or 16 g standard-length 3.8 cm (1½ inch) needles are of adequate length to access the pleural cavity, regardless of height as measured by Broselow LBT.

Reducing indwelling urinary catheter use in the emergency department: a successful quality-improvement initiative.

INTRODUCTION: This quality-improvement project aimed to evaluate the effectiveness of implementing multidisciplinary education and deploying utilization tools aimed at reducing the inappropriate insertion of indwelling urinary catheters (IUCs) in the emergency department. Literature supports the use of decision support tools and education as proven techniques to reduce IUC use. Few studies have implemented a multidisciplinary approach involving the use of focus groups to understand the thought processes behind deciding to place an IUC. METHODS: Focus groups were used to understand the current practice for inserting an IUC in the emergency department. These data were then used to create a nursing-based IUC decision support tool and educational presentation regarding appropriate uses for IUCs. Live, in-person education sessions were given to emergency nurses, emergency medical technicians, physicians, and residents; in addition, electronic education was assigned to all emergency nurses and technicians. Seventy-eight percent of ED staff received some form of education regarding appropriate IUC insertion criteria. Physicians and residents also received an in-person presentation on the topic. A survey was sent to all emergency nurses and emergency medical technicians to assess actual practice changes. In addition, an IUC utilization and appropriateness audit was completed before and immediately after the interventions. RESULTS: The project resulted in a 25% decrease in the proportion of patients admitted to inpatient status with IUCs placed in the emergency department and a 9% decrease in the inappropriate use of IUCs. Staff surveys after education showed that staff members were more likely to document the reason for placing an IUC and to use alternatives to IUCs. CONCLUSIONS: The potential risks associated with IUCs often go overlooked by direct-care staff members. Educating staff and creating new standards and utilization tools have often been used to decrease the initial insertion of IUCs and to improve recognition of appropriate removal of IUCs. Using direct feedback from staff to develop the interventions led to a reduction in IUC insertions in the emergency department in the short-term, but long-term changes were not seen. The project results suggest that incorporating staff into the decision making and implementation will lead to long-term acquisition of knowledge and longer-term results. Ongoing regularly scheduled education refreshers need to be assessed for their potential to affect long-term change.

Cardiac output, coronary blood flow, and blood gases during open-chest standard and compression-active-decompression cardiopulmonary resuscitation.

OBJECTIVE: To determine whether open-chest compression-active-decompression (CAD) could improve cardiac output, coronary blood flow, blood gases, and resuscitation compared to open-chest manual compression in a porcine model of cardiac arrest. DESIGN: Prospective, randomized laboratory investigation for measurement of cardiac output, coronary blood flow, arterial and mixed venous blood gases and potassium levels, and return of spontaneous circulation. SUBJECTS: Ten pigs each weighing approximately 36.4 kg. INTERVENTIONS: Following preparation of the model and opening of the chest, ultrasonic flow probes were placed on the ascending aorta and left anterior descending artery. Cardiac arrest was induced by epicardial pacing. Subjects received either open-chest CAD or open-chest manual compression. After 10 min of arrest, defibrillation was attempted. MEASUREMENTS AND MAIN RESULTS: Cardiac output fell to 46+/-53% (95% CI: -20 to 112) and 41+/-14% (95% CI: 23-59) (P>0.05) of baseline with CAD and manual methods at 5 min after arrest, respectively. Similarly, coronary blood flow fell to 33+/-14% (95% CI: 16-50) and 42+/-16% (95% CI: 22-62) (P>0.05) of baseline at 5 min. Both groups developed similar levels of metabolic acidosis, mixed venous hypoxemia, and hyperkalemia, with potassium levels: 6.5+/-4.0 meq/l (95% CI: 1.6-11.4) at 5 min and 7.5+/-4.6 meq/l (95% CI: 1.8-13.2) at 10 min in the CAD group and 5.8+/-2.0 meq/l (95% CI: 3.4-8.3) at 5 min and 6.1+/-1.4 meq/l (95% CI: 4.4-7.9) at 10 min in the manual group. Levels of hyperkalemia were inversely proportional to the square of PvO(2). One pig in each group was resuscitated after defibrillation. CONCLUSION: We found no benefit using CAD. Both low coronary blood flow and hyperkalemia may have limited resuscitation.

Surgical emergencies in the intravenous drug user.

Numerous surgical complications arise from parenteral drug use. Some complications have severe sequelae and most prove to be a diagnostic challenge. It is likely that these problems will remain a significant burden on the health care system as a result of continued widespread drug abuse. EPs must always maintain vigilance when evaluating medical complaints in the IVDU.

Intraosseous infusion of ice cold saline is less efficacious than intravenous infusion for induction of mild therapeutic hypothermia in a swine model of cardiac arrest.

BACKGROUND: Intravenous (IV) infusion of ice cold saline is an effective method to initiate induction of mild therapeutic hypothermia (MTH) following resuscitation from out-of-hospital cardiac arrest (OOHCA). Intraosseous (IO) infusion of cold saline may be an alternative method to induce MTH. OBJECTIVE: The goal of this study was to determine if IO infusion of cold saline is a comparable alternative to IV infusion for inducing MTH in a laboratory swine model of cardiac arrest. METHODS: Ten mixed breed swine were resuscitated from cardiac arrest and randomized post-resuscitation to infusion with ice cold saline using either IO (n = 5) or IV (n = 5) access. The study endpoints were either a goal esophageal temperature of 34 °C or the elapse of a 30 min time period, simulating a long prehospital transport. RESULTS: Four of five pigs in the IV infusion group achieved goal temperature within 30 min compared to 0/5 in the IO infusion group (p = 0.048). The mean esophageal temperature change was significantly higher in the IV group when compared to the IO group (p < 0.001). Post-arrest hemodynamic parameters were similar between the two groups. CONCLUSIONS: IV infusion of ice cold saline is an efficacious method to achieve MTH in this swine model of cardiac arrest. Furthermore, IO infusion of cold saline is not sufficient to induce MTH in the time routinely available in the prehospital setting following OOHCA.