Pharmacobezoar Associated Prolonged Clinical Course in a Patient with Immediate Release Quetiapine Overdose.

INTRODUCTION: Quetiapine is available in both immediate-release (IR) and extended-release (XR) formulations. Quetiapine XR overdose is known to cause delayed increase in serum quetiapine concentrations. However, it is not certain whether quetiapine IR overdose would similarly cause a delayed increase in serum quetiapine concentrations. CASE REPORT: A 57-year-old woman with depression who was taking half a tablet of 25 mg quetiapine IR daily was transported to our emergency department with a complaint of disturbance of consciousness 12 h after a quetiapine IR overdose. On arrival, her initial vital signs were heart rate of 116 beats per minute, blood pressure of 77/43 mm Hg, and oxygen saturation of 91% under 10 L oxygen administration. Whole body plain computed tomography showed a large amount of gastric hyperdense content suggesting pharmacobezoar with a volume of 71.2 ml. After treatment with respiratory and circulatory support, gastric lavage was performed. Her disturbance of consciousness persisted until day 5, and she was extubated on day 7. The serum concentrations of quetiapine were 2690 ng/mL at 12 h after overdose, 5940 ng/mL at 40 h, and 350 ng/mL at 124 h after overdose. Serum concentrations of other co-ingestions were all below lethal levels. CONCLUSION: A massive quetiapine IR overdose with pharmacobezoars can cause a delayed increase in serum quetiapine concentrations.

Prospective multicenter study of the epidemiological features of emergency patients with overdose of over-the-counter drugs in Japan.

Aim: To investigate the epidemiological characteristics of patients presenting to the emergency department with an overdose of over-the-counter (OTC) drugs. Methods: A questionnaire survey was conducted to examine the sociodemographic characteristics of patients with OTC drugs overdoses visiting emergency departments at eight sites across the country. The patients were divided into "habitual" and "nonhabitual" groups according to their history of OTC drugs overdose. Student's t-test or Welch's t-test was performed for numerical variables, and Pearson's χ 2 test was performed for dichotomous and nominal variables between the two groups. Results: Of the 124 patients included in this study, 79% were women. The habitual (26.6%) and the nonhabitual (73.4%) groups showed no differences in sex, occupation, cohabitants, history of mental illness, or history of alcohol consumption or smoking; however, those in the habitual group were significantly younger. The proportion of OTC drugs obtained from physical stores was higher in the habitual group, whereas the nonhabitual group used more household medicines. Suicide and self-harm were more common reasons for overdose in the nonhabitual group. Antipyretic analgesics were significantly more common in the nonhabitual group, whereas antitussive expectorants and antihistamines were significantly more common in the habitual group. Conclusion: This is the first multicenter study to determine the status of OTC drugs overdose patients treated at emergency departments of medical facilities in Japan. To prevent new overdoses of OTC drugs, continued detailed epidemiologic studies of patient backgrounds and drug acquisition routes, and investigation of the components of OTC drugs that cause dependency are necessary.

Giant T waves and QT interval prolongation associated with guanfacine toxicity.

INTRODUCTION: Guanfacine is a central α2-adrenergic receptor agonist that produces drowsiness, bradycardia, hypotension, and occasionally QT interval prolongation. We discuss giant T waves associated with guanfacine toxicity. CASE SUMMARIES: Three patients presented to the hospital with histories and physical findings compatible with guanfacine toxicity. Supratherapeutic concentrations were confirmed in two of them. All three developed QT interval prolongation and giant T waves on the electrocardiogram. Giant T waves occur commonly in patients with acute myocardial infarct and hyperkalemia, as well as rarely with a number of other cardiac and non-cardiac causes. CONCLUSION: Guanfacine toxicity may cause the novel electrocardiographic finding of 'giant T wave with QT interval prolongation'. Further studies are warranted to investigate the association between the novel electrocardiographic finding and guanfacine toxicity, as well as its diagnostic utility in such cases.

Diagnostic challenges in a patient with dengue shock syndrome presenting with acute meningoencephalitis.

Dengue is a systemic viral infection, and clinical findings vary from asymptomatic to life-threatening, including shock and neurological complications. Despite efforts in vector control, the disease continues to spread worldwide, and the number of annual dengue infections is estimated to be 390 million. For patients with severe dengue, early diagnosis is important; however, owing to the wide range of symptoms and severity, diagnosis can be difficult. Herein, we report the case of a 24-year-old man from Vietnam who was found to have dengue shock syndrome complicated by meningoencephalitis, even though he did not show the typical clinical manifestations of dengue infection. He was transported to our hospital by ambulance because of fever and altered mental status. Brain magnetic resonance imaging revealed hyperintensities in the bilateral thalamus and brainstem on the T2 sequence. After hospitalization, polymerase chain reaction testing of cerebrospinal fluid, serum, and urine revealed the presence of dengue virus serotype 2. This confirmed the diagnosis of dengue encephalitis. The patient was discharged on day 49 with impaired abduction of the left eye and urinary retention. In this case, the initial differential diagnosis was broad because the patient was unable to provide any medical history owing to altered mental status. In addition, the fact that he did not show the characteristic symptoms of dengue infection initially made the diagnosis very difficult. In conclusion, dengue fever should always be considered as a part of the differential diagnosis when a patient from an endemic area presents with fever and impaired consciousness.

Impact of increased reimbursement for ambulance transportation on hospital acceptance in Japan: a difference-in-difference study.

OBJECTIVE: Emergency medical services (EMS) often face difficulties in finding accepting hospitals in Japan. The universal medical insurance system in Japan increased the reimbursement for ambulance transportation acceptance at night, and on Sundays and holidays from 1 April 2016. This study investigated the effect of the reimbursement increase on the number of EMS calls, and transportation time from arrival at the scene to arrival at the hospital. DESIGN: A difference-in-difference study. The treatment group consisted of people who called an ambulance at night while the control group consisted of people who called an ambulance during the daytime. SETTING: The national ambulance records of the Fire and Disaster Management Agency in Japan from 1 April 2015 to 31 December 2016. PARTICIPANTS: 7 625 463 ambulance dispatches were eligible for inclusion. PRIMARY AND SECONDARY OUTCOME MEASURES: The changes in EMS calls, transportation time and the number of ambulance transports per 1000 population in one month in a comparison of daytime and night-time transport. RESULTS: The treatment effect (night-time vs daytime) on the number of EMS calls was -0.013 (95% CI, -0.023 to -0.004), which was significant. The transportation time decreased slightly by 0.080 min (95% CI, -0.157 to -0.004). No impact was observed on the number of ambulance transports per 1000 population per month (0.00; 95% CI, -0.008 to 0.002). CONCLUSION: An increase in reimbursement for ambulance transportation acceptance was associated with a decrease in the number of EMS calls. Further strategies for decreasing the number of EMS calls are needed to avoid delays in the treatment of emergency patients with critical illness.

Prevalence and Risk Factors of Insomnia and Sleep-aid Use in Emergency Physicians in Japan: Secondary Analysis of a Nationwide Survey.

INTRODUCTION: Emergency physicians (EP) are suspected to have a high prevalence of insomnia and sleep-aid use. Most prior studies about sleep-aid use in EPs have been limited by low response rates. In this study our aim was to investigate the prevalence of insomnia and sleep-aid use among early-career Japanese EPs and assess the factors associated with insomnia and sleep-aid use. METHODS: We collected anonymous, voluntary, survey-based data regarding chronic insomnia and sleep-aid use from board-eligible EPs taking the initial Japanese Association of Acute Medicine board certification exam in 2019 and 2020. We describe the prevalence of insomnia and sleep-aid use and analyzed demographic and job-related factors using multivariable logistic regression analysis. RESULTS: The response rate was 89.71% (732 of 816). The prevalence of chronic insomnia and sleep-aid use was 24.89% (95% CI 21.78-28.29%) and 23.77% (95% CI 20.69-27.15%), respectively. Factors associated with chronic insomnia were long working hours (odds ratio [OR] 1.02, 1.01-1.03, per one-hour/week), and "stress factor" (OR 1.46, 1.13-1.90). Factors associated with sleep-aid use were male gender (OR 1.71, 1.03-2.86), unmarried status (OR 2.38, 1.39-4.10), and "stress factor" (OR 1.48, 1.13-1.94). The "stress factor" was mostly influenced by stressors in dealing with patients/families and co-workers, concern about medical malpractice, and fatigue. CONCLUSIONS: Early-career EPs in Japan have a high prevalence of chronic insomnia and sleep-aid use. Long working hours and stress were associated with chronic insomnia, while male gender, unmarried status, and stress were associated with the use of sleep aids.

Are hospitals with both medical/surgical and psychiatric services associated with decreased difficulty in ambulance transfer for patients with self-harm behaviour? A nationwide retrospective observational study using ambulance transfer data in Japan.

OBJECTIVES: Ambulance diversion and prolonged prehospital transfer time have a significant impact on patient care outcomes. Self-harm behaviour in particular is associated with difficulty in hospital acceptance and longer prehospital transfer time. This study aimed to determine if hospitals with both medical/surgical and psychiatric inpatient beds and high-level emergency care centres are associated with a decreased rate of difficulty in hospital acceptance and shorter prehospital transfer time for patients seeking medical care after self-harm behaviour. DESIGN AND SETTING: A retrospective observational study using the database of Japanese ambulance dispatch data in 2015. PARTICIPANTS: Patients who were transferred by ambulances after self-harm behaviour. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Multivariable logistic regression analysis and multivariable linear regression analysis were performed to assess whether the presence of hospitals with both medical/surgical and psychiatric inpatient beds and high-level emergency care centres in the city were associated with a decreased rate of difficulty in hospital acceptance and shorter prehospital transfer time. RESULTS: The number of transfers due to self-harm behaviour in 2015 was 32 849. There was an association between decreased difficulty in hospital acceptance and the presence of high-level emergency care centres (OR 0.63, 95% CI 0.55 to 0.71, p<0.01) and hospitals with both medical/surgical and psychiatric inpatient beds (OR 0.50, 95% CI 0.38 to 0.66, p<0.01). There was a significant reduction in prehospital transfer time in the city with high-level emergency care centres (4.21 min, 95% CI 3.53 to 4.89, p<0.01) and hospitals with medical/surgical and psychiatric inpatient beds (3.46 min, 95% CI 2.15 to 4.77, p<0.01). CONCLUSION: Hospitals with both medical/surgical and psychiatric inpatient beds and high-level emergency care centres were associated with significant decrease in difficulty in hospital acceptance and shorter prehospital transfer time.

Factors Associated with an Increase in On-Site Time of Pediatric Trauma Patients in a Prehospital Setting: A Nationwide Observational Study in Japan.

The factors that prolong the on-site time in pediatric trauma cases in a prehospital setting are unknown. We investigated these factors using a national trauma registry in Japan. We identified pediatric trauma patients aged ≤18 years, from January 2004 to May 2019. We categorized cases into shorter (≤13 min) and longer (>13 min) prehospital on-site time groups. We performed multivariable logistic regression analysis with multiple imputations to assess the factors associated with longer prehospital on-site time. Overall, 14,535 patients qualified for inclusion. The median prehospital on-site time was 13 min. In the multivariable logistic regression analysis, the longer prehospital on-site time was associated with higher age; suicide (Odds ratio [OR] 1.27; 95% confidence interval [CI] 1.03−1.57); violence (OR 1.74; 95%CI 1.27−2.38); higher revised trauma score, abbreviated injury scale > 3 in the spine (OR 1.25; 95%CI 1.04−1.50), upper extremity (OR 1.26; 95%CI 1.11−1.44), and lower extremity (OR 1.25; 95%CI 1.14−1.37); immobilization (OR 1.16; 95%CI 1.06−1.27); and comorbid mental retardation (OR 1.56; 95%CI 1.11−2.18). In light of these factors, time in the field could be reduced by having more pediatric emergency physicians and orthopedic surgeons available.

Epidemiology and clinical outcomes of poisoning-induced cardiac arrest in Japan: Retrospective analysis of a nationwide registry.

BACKGROUND: Poisoning is an important cause of out-of-hospital cardiac arrest which can be challenging to manage. Neurological outcomes after poisoning-induced out-of-hospital cardiac arrest (POHCA) are yet to be fully elucidated. This retrospective cohort study sought to describe the characteristics of POHCA, and identify factors associated with favourable neurologic outcomes. METHODS: Cardiac arrests recorded in the "All Japan Utstein Registry" from 1 January 2012 to 31 December 2017 were included. A descriptive analysis of the characteristics of POHCA and non-POHCA patients was performed. Neurological outcomes were compared between the POHCA and non-POHCA groups using logistic regression analysis. Subgroup analysis was performed for patients who underwent prolonged resuscitation. RESULTS: Compared to non-POHCA patients (n = 665,262), POHCA patients (n = 1,868) were younger (median age, 80 vs 51 years) and had a lower likelihood of having a witness, bystander cardiopulmonary resuscitation, and an initial shockable rhythm. Multivariable logistic regression analysis showed that POHCA was associated with favourable neurologic outcomes (odds ratio 1.54, 95 % confidence interval 1.19-2.01, p = 0.001). Among patients who received > 30 min of resuscitation, neurologic outcomes were similar in those with POHCA and non-POHCA (favourable neurologic outcome, 1.03 % vs 0.98 %, p = 0.87). CONCLUSIONS: POHCA is associated with favourable neurological outcomes and requires aggressive resuscitation. However, in patients who required prolonged resuscitation, the outcomes of POHCA were not different from those of non-POHCA. The decision to perform prolonged resuscitation should be guided on a case-by-case basis based on a range of factors.

Performance-enhancing drugs and the Olympics.

The rules of fair play in sport generally prohibit the use of performance-enhancing drugs (PEDs). The World Anti-Doping Agency (WADA) oversees global antidoping regulations and testing for elite athletes participating in Olympic sports. Efforts to enforce antidoping policies are complicated by the diverse and evolving compounds and strategies employed by athletes to gain a competitive edge. Now between the uniquely proximate 2021 Tokyo and 2022 Beijing Olympic Games, we discuss WADA's efforts to prevent PED use during the modern Olympic Games. Then, we review the major PED classes with a focus on pathophysiology, complexities of antidoping testing, and relevant toxicities. Providers from diverse practice environments are likely to care for patients using PEDs for a variety of reasons and levels of sport; these providers should be aware of common PED classes and their risks.

A Case Report of Cake Frosting as a Source of Copper Toxicity in a Pediatric Patient.

INTRODUCTION: Copper is an uncommon source of metal toxicity in children that requires a high index of suspicion for diagnosis. CASE REPORT: We describe the unique presentation of a 12-month-old girl who developed acute onset of vomiting and diarrhea after ingestion of a copper-contaminated birthday cake. CONCLUSION: This case highlights the presentation, evaluation, and management of the rare pediatric patient who presents with copper poisoning. This case also illuminates the public health implications of potential metal poisoning when using non-edible decorative products in homemade and commercially prepared baked goods.

Thoracic Spine Fracture in a Survivor of Out-of-Hospital Cardiac Arrest with Mechanical CPR.

This is a report of a thoracic vertebral fracture in a 79-year-old male survivor of out-of-hospital cardiac arrest with chest compressions provided by a LUCAS 2 (Physio-Control Inc.; Lund Sweden) device. This is the first such report in the literature of a vertebral fracture being noted in a survivor of cardiac arrest where an automated compression device was used. Marshall RT , Kotecha H , Chiba T , Tennyson J . Thoracic spine fracture in a survivor of out-of-hospital cardiac arrest with mechanical CPR. Prehosp Disaster Med. 2016;31(6):684-686.

Multicentre observational study of adults with asthma exacerbations: who are the frequent users of the emergency department in Japan?

OBJECTIVES: Emergency department (ED) visits for asthma exacerbation reflect a failure of longitudinal asthma management. However, little is known about the characteristics of patients with frequent ED visits (≥2 visits in a 1-year period). We aimed to characterise the adult patients who frequently presented to the ED for asthma exacerbation in Japan. DESIGN: A multicentre chart review study of 23 EDs across Japan. PARTICIPANTS: Adults aged 18-54 years who presented to the ED with asthma exacerbation from 2009 to 2011. OUTCOME MEASURES: Frequency of ED visits for asthma exacerbation in a 1-year period, including the index ED visit. RESULTS: Of the 1002 eligible patients, 218 (22%) had frequent ED visits, accounting for 48% of total ED visits for asthma exacerbation in the 1-year period. Specifically, 12% had 2 ED visits and 10% had ≥3 visits. In these patients, guideline-recommended chronic management was suboptimal. For example, among patients with ≥3 ED visits, only 63% were treated with inhaled corticosteroids and 49% were current smokers. In a multinomial logistic regression model, markers of chronic asthma severity (history of hospitalisation for asthma and use of inhaled corticosteroids) were significantly associated with a higher frequency of ED visits (both p<0.05). CONCLUSIONS: This multicentre study in Japan demonstrated that many patients are frequent ED users for asthma exacerbation. We also found that their asthma control management is suboptimal, most likely contributing to worse chronic severity and more frequent ED visits. Further dissemination and adoption of evidence-based guidelines are required to reduce asthma morbidity in this high-risk population.

Residency and career satisfaction among Anglo-American model emergency medicine residents in Japan.

AIM: The number of institutions providing Anglo-American model emergency medicine has increased with the rise in its social demand in Japan. The ER Committee of the Japanese Association for Acute Medicine has introduced a residency model for use in Japanese hospitals that have adopted the Anglo-American emergency medicine model. Despite the critical importance of its quality, no studies have examined Japanese emergency medicine residents' level of satisfaction with their training. This study investigated their residency and career satisfaction, and factors associated with satisfaction. METHODS: We developed a cross-sectional, anonymous survey. Data were obtained from 67 Anglo-American model emergency medicine residents in Japan in February 2010. Data were analyzed with factor analysis and multivariable analysis with a logistic regression model. RESULTS: Response rate was 100% (n = 67). Overall, 50.7% and 67.2% of residents reported high residency and career satisfaction, respectively. Factor analysis derived four factors: working conditions; stress reduction; training systems; education. Logistic regression analysis revealed that the training system factor was significantly associated with high residency satisfaction (odds ratio [OR], 2.9; 95% confidence interval [CI], 1.2-8.4) and the stress reduction factor was significantly associated with high career satisfaction (OR, 3.0; 95%CI, 1.2-8.4). A total of 28.8% reported intentions to switch specialties. The intention was not significantly associated with low residency satisfaction (OR, 1.7; 95%CI, 0.6-5.0), but was associated with low career satisfaction (OR, 5.1; 95%CI, 1.6-16.0). CONCLUSION: Improvements in training systems and stress reduction may increase residency and career satisfaction of emergency medicine residents, respectively. This study suggested that high career satisfaction was required to secure future emergency physicians.

Increased incidence of hypotension in elderly patients who underwent emergency airway management: an analysis of a multi-centre prospective observational study.

BACKGROUND: Although the number of elderly increases disproportionately throughout the industrialised nations and intubation-related cardiovascular compromise is associated with hospital mortality, no emergency medicine literature has reported the direction and magnitude of effect of advanced age on post-intubation hypotension. We seek to determine whether advanced age is associated with an increased rate of hypotension at airway management in emergency departments (EDs). METHODS: We conducted an analysis of a multi-centre prospective observational study of 13 Japanese EDs from April 2010 to March 2012. Inclusion criteria were all adult non-cardiac-arrest patients who underwent emergency intubation. We excluded patients in whom airway management was performed for shock or status asthmaticus as the principal indication. Patients were divided into two groups defined a priori: age ≥ 65 years old (elderly group) and age < 65 years old (younger group). The primary outcome measure was post-intubation hypotension in the ED. RESULTS: During the 24-month period, 4,043 subjects required emergency airway management at 13 EDs. Among these, the database recorded 3,872 intubations (capture rate 96%). Of 1,903 eligible patients, 975 patients were age ≥ 65 years (51%) and 928 patients were age < 65 years (49%). The elderly group had a significantly higher rate of post-intubation hypotension compared with the younger group [3% vs. 1%; unadjusted OR 2.7 (95% CI, 1.3-5.6); P = 0.005]. In a model controlling for potential confounders (sex, principal indication, method, medication used to intubate, multiple intubation attempts), advanced age had an adjusted OR for post-intubation hypotension of 2.6 (95% CI, 1.3-5.6; P = 0.01). CONCLUSIONS: In this large multi-centre study of ED patients who underwent emergent airway management, we found that elderly patients have a significantly higher risk of post-intubation hypotension. These data provide implications for the education and practice of ED airway management that may lead to better clinical outcomes and improved patient safety.

Quality of care for acute asthma in emergency departments in Japan: a multicenter observational study.

BACKGROUND: Little is known about the quality of acute asthma care in emergency departments (EDs) outside of North America. OBJECTIVE: We evaluated concordance of acute asthma management in Japanese EDs with recommendations in the 2007 National Institutes of Health asthma guidelines and investigated whether guideline concordance was associated with risk of hospital admission. METHODS: We conducted a multicenter chart review study in 23 EDs across Japan. We identified ED patients aged 18 to 54 years with acute asthma between 2009 and 2011. Concordance with evidence-based guideline recommendations was evaluated by using item-by-item quality measures and composite concordance scores both at patient and ED levels. These scores ranged from 0 to 100. RESULTS: Among 1380 patients, the median age was 35 years and 11% were hospitalized. Overall guideline concordance score was suboptimal both at the patient level (mean ± SD, 72 ± 14) and ED level (mean ± SD, 72 ± 6). Specifically, asthma care at the patient level was suboptimal in several areas: inhaled anticholinergics in ED (2%), systemic corticosteroid in ED (56%) and at discharge (36%), and peak flow assessment (9%). A multivariable model that adjusted for severity at presentation and several ED characteristics showed that higher guideline concordance was associated with significantly lower risk of hospital admission (odds ratio, 0.70 per 10-unit increase in composite score; 95% CI, 0.62-0.79 per 10-unit increase in composite score). CONCLUSION: The management of acute asthma in Japanese EDs is suboptimal. Greater concordance with guideline-recommended management might reduce unnecessary hospitalizations. Knowledge translation initiatives are warranted to increase adherence with best practice in acute asthma management.

Association between repeated intubation attempts and adverse events in emergency departments: an analysis of a multicenter prospective observational study.

STUDY OBJECTIVE: Although repeated intubation attempts are believed to contribute to patient morbidity, only limited data characterize the association between the number of emergency department (ED) laryngoscopic attempts and adverse events. We seek to determine whether multiple ED intubation attempts are associated with an increased risk of adverse events. METHODS: We conducted an analysis of a multicenter prospective registry of 11 Japanese EDs between April 2010 and September 2011. All patients undergoing emergency intubation with direct laryngoscopy as the initial device were included. The primary exposure was multiple intubation attempts, defined as intubation efforts requiring greater than or equal to 3 laryngoscopies. The primary outcome measure was the occurrence of intubation-related adverse events in the ED, including cardiac arrest, dysrhythmia, hypotension, hypoxemia, unrecognized esophageal intubation, regurgitation, airway trauma, dental or lip trauma, and mainstem bronchus intubation. RESULTS: Of 2,616 patients, 280 (11%) required greater than or equal to 3 intubation attempts. Compared with patients requiring 2 or fewer intubation attempts, patients undergoing multiple attempts exhibited a higher adverse event rate (35% versus 9%). After adjusting for age, sex, principal indication, method, medication, and operator characteristics, intubations requiring multiple attempts were associated with an increased odds of adverse events (odds ratio 4.5; 95% confidence interval 3.4 to 6.1). CONCLUSION: In this large Japanese multicenter study of ED patients undergoing intubation, we found that multiple intubation attempts were independently associated with increased adverse events.

Emergency airway management in Japan: Interim analysis of a multi-center prospective observational study.

OBJECTIVES: Emergency medicine is increasingly recognized as a medical specialty in Japan. However, comprehensive studies evaluating emergency airway management practice are lacking. We describe emergency department (ED) airway management using a large multi-center registry. METHODS: We formed the Japanese Emergency Airway Network, a consortium of 10 academic and community medical centers in Japan, and prospectively collected data on ED intubations from April 2010 to February 2011. All patients undergoing emergency intubation were eligible for inclusion. Data were entered in real time by the intubator using a standardized data form. Variables included patient's age, sex, weight, indication for intubation, methods of intubation, drugs, level of training and specialty of the intubator, number of attempts, success or failure, and adverse events. We present descriptive data as proportions with 95% confidence intervals. RESULTS: We recorded 1486 intubations (compliance rate 99%). Intubation was ultimately successful in 99.7%. The initial method of intubation varied substantially among the hospitals, including rapid sequence intubation (0-79%), sedation without paralysis (4-88%), paralysis without sedation (0-18%), and oral without medication (12-67%), in non-cardiac arrest encounters. Success rates in first and ≤3 attempts ranged from 40 to 83% and from 74 to 100%, respectively. The overall adverse event rate was 11%, without significant difference by the method used. CONCLUSIONS: In this multi-center study characterizing ED airway management across Japan, we observed a high overall success rate but a high degree of variation among hospitals in the methods of intubation and success rates.