Low- versus high-dose nitroglycerin infusion in the management of acute pulmonary edema.

BACKGROUND: Nitroglycerin (NTG) is commonly used for the management of pulmonary edema in acute heart failure presentations. Although commonly initiated at low infusion rates, higher infusion rates have favorable pharmacodynamic properties and may improve outcomes in the management of acute pulmonary edema. OBJECTIVES: To characterize the clinical outcomes including the time to resolution of severe hypertension when using an initial low dose (<100 µg/min) versus high-dose (≥100 µg/min) strategy. METHODS: This was a retrospective study performed at a single, tertiary academic emergency department in Atlanta, GA. We describe the blood pressure effects and key safety outcomes (intubation, hypotension, intensive care unit admissions) during the first hour of treatment of acute pulmonary edema. RESULTS: 41 patients were included in the final sample. 27 (66%) received low dose NTG and 14 (34%) received high dose NTG. The high dose group reached their blood pressure faster on average (hazard ratio = 3.5, 95% CI: 1.2-10.1). 8/14 (57%) of patients in the high dose group reached their BP target within the first hour of treatment, compared to 6/27 (22%) in the low dose group. Observed incidence of safety outcomes were similar between the two groups. CONCLUSIONS: Higher initial NTG doses may be an effective way to decrease times to achieve blood pressure targets and should be the focus of future trials.

Anatomic Characteristics of the Adolescent Cricothyroid Membrane on Computed Tomography Scans.

BACKGROUND: The cricothyroid membrane (CTM) is the most important anatomic structure when performing emergency front-of-neck access (FONA) procedures. Adolescence is a period of rapid morphologic change in laryngeal structures, including the CTM. We hypothesized that the adolescent CTM would be sufficiently different from pediatric or adult anatomy to merit special consideration in FONA. OBJECTIVE: The aim of the study was to define the procedurally relevant CTM anatomy in an adolescent population. METHODS: This was a retrospective, multicenter cohort study composed of patients who underwent a diagnostic computed tomography scan during routine clinical care. Inclusion criteria were ages 16 to 19 years and a computed tomography of the neck with or without contrast. The primary outcome was CTM height measured in the midsagittal plane using electronic calipers. RESULTS: One hundred thirty-four imaging studies met inclusion criteria. The average CTM height was strongly associated with age and ranged between 5.4 and 6.2 mm in male adolescents and 4.6 and 5.8 mm in female adolescents. We predicted that standard cuffed endotracheal and tracheostomy tubes recommended for FONA procedures (5.0- and 6.0-mm devices) could potentially fail for most patients in our cohort. CONCLUSIONS: The adolescent CTM is smaller than previously recognized. We recommend having a variety of equipment sizes readily available at any site where airway management in adolescents may occur.

Pediatric Difficult Airway Response Team Utilization in the Emergency Department: A Case Series.

OBJECTIVES: A multidisciplinary pediatric difficult airway team was created at our institution to respond to hospital-wide airway emergencies. We report the characteristics, indications, and outcomes of these activations that occur in the pediatric emergency department (PED). METHODS: Retrospective, single-center cohort study comprised all difficult airway team activations occurring in the PED from the program's inception in 2008 to 2018. Ages of ≤18 years were included. For each case, detailed information was abstracted, including patient factors, PED context and milieu, airway interventions, and airway outcomes. RESULTS: There were 15 difficult airway response team activations in the PED during the study period, or 1.4 activations per year. The most common indications for activation were contaminated airways (n = 7; 47%) and history of difficult intubation (n = 4; 27%). Definitive airway management was successful in all cases, except for a single case where intervention was unnecessary. The most commonly performed definitive airway intervention was direct laryngoscopy (n = 6; 40%). There were no instances of emergency front-of-neck access. CONCLUSIONS: Difficult airways in the PED were uncommon. Most cases were resolved with familiar equipment including direct laryngoscopy, video laryngoscopy, and supraglottic airways.

Improving out-of-hospital notification in traumatic cardiac arrests with novel usage of smartphone application.

INTRODUCTION: Timely out-of-hospital notifications in patients with traumatic cardiac arrest are associated improvements in mortality. Details surrounding these events are often limited, and decisions to perform advanced resuscitative procedures must be made based on limited data. This study evaluated the ability of a mobile application (app) called Citizen (sp0n Inc., New York, NY) to address these issues by providing a novel, secondary source of out-of-hospital information in traumatic cardiac arrest. Citizen sends notifications to mobile devices in response to nearby detected public safety events, and we sought to evaluate its utility in prenotification for traumatic cardiac arrest. METHODS: This was a retrospective observational study. Patients ≥ 15 years of age with traumatic cardiac arrest attributed to penetrating trauma were included. The 2 coprimary outcomes observed were the time difference between the app notification and emergency medical services notification, and the app's success rate in generating a notification for each patient in traumatic cardiac arrest. RESULTS: From February 2, 2019 to October 10, 2019, there were 43 patients who met the criteria for this study. On average, the Citizen app notification arrived 12.9 minutes before emergency medical services radio notification (95% confidence interval, 9.2-16.6; P < 0.001). Citizen generated a notification for 36 of 43 patients (84%). CONCLUSION: The Citizen app generates earlier notifications in traumatic cardiac arrest compared with standard radio communications. It also provides a previously unavailable secondary source of information for making rapid resuscitative decisions upon the arrival of the arresting patient to the emergency department. Further research is needed to determine how to optimally integrate the app into existing trauma systems.

Cyclical Abdominal Pain in an Adolescent Female: A Case Report of Agenesis of the Lower Vagina.

Congenital agenesis of the lower vagina is a rare disorder characterized by separation between the unaffected proximal vagina and the distal vagina by a band of fibrous tissue. The typical presentation is an early adolescent female with chronic, cyclic abdominal pain and primary amenorrhea. In this case report, we describe an adolescent who presented to the pediatric emergency department on 2 occasions with a chief complaint of lower abdominal pain.

High-flow nasal cannula use in children with respiratory distress in the emergency department: predicting the need for subsequent intubation.

BACKGROUND: High-flow nasal cannula (HFNC) is a safe, well-tolerated, and noninvasive method of respiratory support that has seen increasing use in the care of children with respiratory distress. High-flow nasal cannula may be able to prevent intubations in infants and children with respiratory distress. OBJECTIVE: The objective of this study was to determine the clinical and patient characteristics that predict success or failure of HFNC therapy in children presenting to the pediatric emergency department (PED) with respiratory distress. DESIGN/METHODS: A retrospective cohort review was conducted of all children younger than 2 years evaluated in 2 PEDs between June 2011 and September 2012 who received HFNC therapy within 24 hours of initial triage. Data extraction included clinical variables, demographic variables, and patient outcomes. Therapy failure was defined as the clinical decision to intubate a patient after an antecedent trial of HFNC. Multivariable logistic regression was performed to identify factors associated with intubation following HFNC. RESULTS: Four hundred ninety-eight cases meeting criteria for inclusion were identified. The most common final diagnosis was acute bronchiolitis (n = 231, 46%), followed by pneumonia (n = 138, 28%) and asthma (n = 38, 8%). Of the 498 patients, 42 (8%) of patients failed therapy and required intubation following HFNC trial. Risk factors associated with HFNC failure were triage respiratory rate greater than 90th percentile for age (odds ratio [OR], 2.11; 95% confidence interval [CI], 1.01-4.43), initial venous PCO2 greater than 50 mm Hg (OR, 2.51; 95% CI, 1.06-5.98), and initial venous pH less than 7.30 (OR, 2.53; 95% CI, 1.12-5.74). A final diagnosis of bronchiolitis was observed to be protective with respect to intubation (OR, 0.40; 95% CI, 0.17-0.96). CONCLUSIONS: In infants with all-cause respiratory distress presenting in the PED, triage respiratory rate greater than 90th percentile for age, initial venous PCO2 greater than 50 mm Hg, and initial venous pH less than 7.30 were associated with failure of HFNC therapy. A diagnosis of acute bronchiolitis was protective with respect to intubation following HFNC. This finding may help guide clinicians who use HFNC by identifying a patient population at higher risk of failing therapy.