A prospective intervention study to identify drug-related emergency department visits comparing a standard care group and a pharmaceutical care group.

BACKGROUND AND IMPORTANCE: Adverse drug reactions impose a major burden. Those adverse drug reactions might lead to hospitalization but are often not correctly identified in the emergency department (ED). Clinical pharmacists, although not routinely implemented, can help identify adverse drug reactions. OBJECTIVE: The primary objective was to examine the drug association of ED visits in a pharmaceutical group with a clinical pharmacist integrated in the ED team compared with a standard group without additional support. DESIGN/SETTING/PARTICIPANTS: This prospective intervention study was performed in the ED of a tertiary care university hospital in Leipzig, Germany. Patients who were ≥50 years old were included. From 1 March 2020 to May 31, 2020 patients were enrolled in the standard group. From 1 March 2021 to 31 May 2021, the pharmaceutical group was enrolled. The clinical pharmacist supported the ED team with patient´s detailed medication history and medication analysis. In both groups, patients were evaluated whether their ED visit was drug-related. OUTCOME MEASURES AND ANALYSIS: The number of identified drug-related ED presentations were compared between the two groups. Interventions performed on adverse drug reaction management, causative drugs and patient characteristics were evaluated. MAIN RESULTS: A total of 798 patients were enrolled in the standard group and 827 patients in the pharmaceutical group. Patients whose ED visit was drug-related had a median age of 77 years [(Q25-Q75) 63.5-83.5] and took 7 [(Q25-Q75) 5-8] drugs in standard group. In the pharmaceutical group median age was 78 years [(Q25-Q75) 66-83] and number of drugs taken was 9 [(Q25-Q75) 5.25-11]. 31 (3.9%) drug-related ED visits were identified in the standard group compared to 104 (12.6%) in the pharmaceutical group (OR 3.56; 95% CI 2.35-5.38). An intervention on the patient's pharmacotherapy was performed in 16 drug-related ED visits in standard group compared to 77 in the pharmaceutical group. CONCLUSION: In this study the implementation of a clinical pharmacist was associated with improved identification of drug-related ED visits. Discontinuations of causal medications and dose reductions were significantly higher in the pharmaceutical group compared to the standard care group.

[Adverse drug reactions as cause of nonspecific symptoms in patients in the emergency department]. / Unerwünschte Arzneimittelwirkungen als Ursache unspezifischer Symptome bei Patienten in der zentralen Notaufnahme.

BACKGROUND: In a large proportion of patients admitted to the emergency department (ED), the initial main symptom is nonspecific. One possible reason for this, especially in older patients, may be adverse drug reactions (ADR) due to their frequent polypharmacy. AIM: To illustrate the incidence of ADRs, the affected patient population including risk factors, and drug classes with ADRs leading to nonspecific symptoms. To provide practice recommendations for the management of ADRs in the ED. MATERIAL AND METHODS: Presentation of the pharmacological principles on ADRs, statistics of pharmacovigilance centers as well as original literature including experiences from clinical practice and own projects. RESULTS: In 10% of patients with nonspecific symptoms an ADR is responsible for presentation in the ED. In 60% of cases these ADRs are not correctly identified in the ED setting. A small number of drug classes are responsible for most of these referrals. Databases, risk stratification, clinical pharmacists, or clinical decision support systems are available to improve ADR identification and management. As these options are partly associated with considerable costs or the validation for German EDs is missing, a widespread application does not take place. CONCLUSION: Correct identification of ADRs in patients with nonspecific symptoms in the ED is necessary to initiate adequate treatment. These ADRs are often overlooked because processes and tools for identification and management are not applied in the ED, leading to a lack of awareness. For high-risk patients in the ED, the focus should be on drug history, ideally considering patient-specific risk factors and specific drug classes.

Feasibility of digital contact tracing in low-income settings - pilot trial for a location-based DCT app.

BACKGROUND: Data about the effectiveness of digital contact tracing are based on studies conducted in countries with predominantly high- or middle-income settings. Up to now, little research is done to identify specific problems for the implementation of such technique in low-income countries. METHODS: A Bluetooth-assisted GPS location-based digital contact tracing (DCT) app was tested by 141 participants during 14 days in a hospital in Monrovia, Liberia in February 2020. The DCT app was compared to a paper-based reference system. Hits between participants and 10 designated infected participants were recorded simultaneously by both methods. Additional data about GPS and Bluetooth adherence were gathered and surveys to estimate battery consumption and app adherence were conducted. DCT apps accuracy was evaluated in different settings. RESULTS: GPS coordinates from 101/141 (71.6%) participants were received. The number of hours recorded by the participants during the study period, true Hours Recorded (tHR), was 496.3 h (1.1% of maximum Hours recordable) during the study period. With the paper-based method 1075 hits and with the DCT app five hits of designated infected participants with other participants have been listed. Differences between true and maximum recording times were due to failed permission settings (45%), data transmission issues (11.3%), of the participants 10.1% switched off GPS and 32.5% experienced other technical or compliance problems. In buildings, use of Bluetooth increased the accuracy of the DCT app (GPS + BT 22.9 m ± 21.6 SD vs. GPS 60.9 m ± 34.7 SD; p = 0.004). GPS accuracy in public transportation was 10.3 m ± 10.05 SD with a significant (p = 0.007) correlation between precision and phone brand. GPS resolution outdoors was 10.4 m ± 4.2 SD. CONCLUSION: In our study several limitations of the DCT together with the impairment of GPS accuracy in urban settings impede the solely use of a DCT app. It could be feasible as a supplement to traditional manual contact tracing. DKRS, DRKS00029327 . Registered 20 June 2020 - Retrospectively registered.

Medical and cardio-vascular emergency department visits during the COVID-19 pandemic in 2020: is there a collateral damage? A retrospective routine data analysis.

BACKGROUND: In this retrospective routine data analysis, we investigate the number of emergency department (ED) consultations during the COVID-19 pandemic of 2020 in Germany compared to the previous year with a special focus on numbers of myocardial infarction and acute heart failure. METHODS: Aggregated case numbers for the two consecutive years 2019 and 2020 were obtained from 24 university hospitals and 9 non-university hospitals in Germany and assessed by age, gender, triage scores, disposition, care level and by ICD-10 codes including the tracer diagnoses myocardial infarction (I21) and heart failure (I50). RESULTS: A total of 2,216,627 ED consultations were analyzed, of which 1,178,470 occurred in 2019 and 1,038,157 in 2020. The median deviation in case numbers between 2019 and 2020 was - 14% [CI (- 11)-(- 16)]. After a marked drop in all cases in the first COVID-19 wave in spring 2020, case numbers normalized during the summer. Thereafter starting in calendar week 39 case numbers constantly declined until the end of the year 2020. The decline in case numbers predominantly concerned younger [- 16%; CI (- 13)-(- 19)], less urgent [- 18%; CI (- 12)-(- 22)] and non-admitted cases [- 17%; CI (- 13)-(- 20)] in particular during the second wave. During the entire observation period admissions for chest pain [- 13%; CI (- 21)-2], myocardial infarction [- 2%; CI (- 9)-11] and heart failure [- 2%; CI (- 10)-6] were less affected and remained comparable to the previous year. CONCLUSIONS: ED visits were noticeably reduced during both SARS-CoV-2 pandemic waves in Germany but cardiovascular diagnoses were less affected and no refractory increase was noted. However, long-term effects cannot be ruled out and need to be analysed in future studies.

Hospital Emergency Departments­Utilization and Resource Deployment in the Hospital as a Function of the Type of Referral

BACKGROUND: Inpatient admission rates and the resources required upon admission to the hospital were studied as a function of the type of referral to the emergency department (ED) of a university hospital. METHODS: We retrospectively analyzed data concerning patients who were treated in the ED of the University of Leipzig Medical Center in 2019. The following data were recorded: process data, type of referral, hospital admission vs. discharge from the ED, and leading symptom according to classification as "trauma" or "non-trauma." For all admitted patients, the Patient Clinical Complexity Level (PCCL), length of hospital stay, and intensive care (yes/no) with or without ventilation were recorded. RESULTS: Data on 34 178 patients (50.9 ± 22.2 years, 53.8% male) were analyzed; 28.8% of patients were referred because of "trauma," and the remaining 71.2% for "non trauma". The most common sources of referral were the rescue and emergency medical services (47.7%) and the patients themselves (self-referrals, 44.7%); 7.6% of the patients were referred by a resident doctor or general practitioner (physician). 62.6% were discharged from the ED after diagnosis and treatment, while 37.4% were admitted to the hospital. In comparison with self-referred patients as a baseline, the likelihood of inpatient admission was higher when the patient was referred by a physician (adjusted odds ratio [OR] 2.2), by the emergency rescue service without an emer - gency physician (OR 3.4), by an emergency physician (OR 9.3), or by the helicopter rescue service (OR 44.1). 49.1% of patients with trauma referred themselves to the ER, and 36% were referred by the emergency rescue service. Older and male patients were more likely to be admitted to the hospital, especially for non-trauma. 30.4% of the admitted patients required intensive care, and 35.5% of the patients in intensive care required ventilation. CONCLUSION: Whether a patient is admitted to the hospital depends on the source of the referral and the leading symptom on arrival in the ED. One in every six self-referred patients is admitted to the hospital, particularly when the reason for presenting to the ER is non-traumatic and some of them go on to receive intensive care. The high percentage (around 95%) of self-referred trauma patients that are discharged from the ED presumably indicates that they were referred mainly for the exclusion of dangerous conditions, and/or that appropriate care options are lacking in the community setting.

Identification and validation of objective triggers for initiation of resuscitation management of acutely ill non-trauma patients: the INITIATE IRON MAN study.

BACKGROUND: While there are clear national resuscitation room admission guidelines for major trauma patients, there are no comparable alarm criteria for critically ill nontrauma (CINT) patients in the emergency department (ED). The aim of this study was to define and validate specific trigger factor cut-offs for identification of CINT patients in need of a structured resuscitation management protocol. METHODS: All CINT patients at a German university hospital ED for whom structured resuscitation management would have been deemed desirable were prospectively enrolled over a 6-week period (derivation cohort, n = 108). The performance of different thresholds and/or combinations of trigger factors immediately available during triage were compared with the National Early Warning Score (NEWS) and Quick Sequential Organ Failure Assessment (qSOFA) score. Identified combinations were then tested in a retrospective sample of consecutive nontrauma patients presenting at the ED during a 4-week period (n = 996), and two large external datasets of CINT patients treated in two German university hospital EDs (validation cohorts 1 [n = 357] and 2 [n = 187]). RESULTS: The any-of-the-following trigger factor iteration with the best performance in the derivation cohort included: systolic blood pressure < 90 mmHg, oxygen saturation < 90%, and Glasgow Coma Scale score < 15 points. This set of triggers identified > 80% of patients in the derivation cohort and performed better than NEWS and qSOFA scores in the internal validation cohort (sensitivity = 98.5%, specificity = 98.6%). When applied to the external validation cohorts, need for advanced resuscitation measures and hospital mortality (6.7 vs. 28.6%, p < 0.0001 and 2.7 vs. 20.0%, p < 0.012) were significantly lower in trigger factor-negative patients. CONCLUSION: Our simple, any-of-the-following decision rule can serve as an objective trigger for initiating resuscitation room management of CINT patients in the ED.

Admission Blood Glucose in the Emergency Department is Associated with Increased In-Hospital Mortality in Nontraumatic Critically Ill Patients.

BACKGROUND: Abnormal admission blood glucose was reported as a useful predictor of outcome in critically ill patients. OBJECTIVES: To identify patients at higher risk, this study aimed to evaluate the relationship between admission blood glucose levels and patient mortality during the management of nontraumatic critically ill patients in the emergency department (ED). METHODS: In this prospective, single-center observational study in a German university ED, all adult patients admitted to the resuscitation room of the ED were included between September 1, 2014 and August 31, 2015. Directly after resuscitation room admission, blood samples for admission blood glucose were taken, and adult patients were divided into groups according to predefined cut-offs between the admission blood glucose. Study endpoint was in-hospital mortality. RESULTS: During the study period, 532 patients were admitted to the resuscitation room. The data of 523 patients (98.3%) were available for analysis. The overall in-hospital mortality was 34.2%. In comparison with an in-hospital mortality of 25.2% at an admission blood glucose of 101-136 mg/dL (n = 107), admission blood glucose of ≤ 100 mg/dL (n = 25, odds ratio [OR] 6.30, 95% confidence interval [CI] 2.44-16.23, p < 0.001), 272-361 mg/dL (n = 63, OR 2.53, 95% CI 1.31-4.90, p = 0.007), and ≥ 362 mg/dL (n = 44, OR 2.96, 95% CI 1.42-6.18, p = 0.004) were associated with a higher mortality. CONCLUSIONS: Abnormal admission blood glucose is associated with a high in-hospital mortality. Admission blood glucose is an inexpensive and rapidly available laboratory parameter that may predict mortality and help to identify critically ill patients at risk in a general nontraumatic critically ill ED patient cohort. The breakpoint for in-hospital mortality may be an admission blood glucose ≤ 100 and ≥ 272 mg/dL.

Elevated admission lactate levels in the emergency department are associated with increased 30-day mortality in non-trauma critically ill patients.

BACKGROUND: Elevated blood lactate levels were reported as useful predictors of clinical outcome and mortality in critically ill patients. To identify higher-risk patients, this investigation evaluated the relationship between patient mortality and admission lactate levels during the management of non-trauma critically ill patients in the emergency department (ED). METHODS: In this prospective, single centre observational study in a German university ED, all adult patients who were admitted to the ED resuscitation room were evaluated between September 1, 2014 and August 31, 2015. Blood samples for blood gas analysis, including lactate levels, were obtained immediately at admission. Study endpoint was 30-day mortality. RESULTS: During the study period, 532 patients were admitted to the resuscitation room of the ED. The data of 523 patients (98.3%) were available. The overall 30-day mortality was 34.2%. Patients presenting to the resuscitation room with admission lactate levels < 2.0 mmol/l had a 30-day mortality of 22.7%, while admission lactate levels above 8.0 mmol/l were associated with higher mortality (8.0-9.9 mmol/l: OR: 2.83, 95%CI: 1.13-7.11, p = 0.03, and ≥ 10 mmol/l: OR: 7.56, 95%CI: 4.18-13.77, p < 0.001). CONCLUSION: High lactate levels at admission are associated with an increased 24-h and 30-day mortality. These measurements may be used not only to predict mortality, but to help identify patients at risk for becoming critically ill. The breakpoint for mortality may be an ALL ≥8.0 mmol/l.

Association between rapid weather changes and incidence of chiefly cardiovascular complaints in the emergency department.

INTRODUCTION: Studies suggest that there is an association between weather and cardiovascular disease (CVD) related visits in emergency departments (ED). METHODS: We used a case-crossover study design to investigate the association between ED visits for CVD and changes in temperature, atmospheric pressure, and relative humidity. Patient and weather data from the years 2014 and 2015 were used to investigate relevance of changes associated with weather in the frequency of CVD-related ED visits. They were correlated to overall variability of the visits adjusted to day of the week. RESULTS: In the study period 20,558 ED visits were related to CVD (mean per day: 28.3). Significant associations were identified for all three variables (temperature, atmospheric pressure, and relative humidity). Significant odds ratio (OR) was found for a large decrease in temperature 1.29 (95%-CI, 1.1-1.52). However, the related effects, although significant, were small compared to overall variability of visits. CONCLUSION: We found an association between rapid weather changes on the day before ED admission and ED visits due to CVD. In conclusion, a drop in temperature and an increase or decrease in atmospheric pressure and relative humidity are associated with a slight increase in CVD admissions. However, the observed significant effects seem to be too small to draw any conclusions in terms of ED capacity due to weather changes.

The impact of the Sepsis-3 definition on ICU admission of patients with infection.

BACKGROUND: Sepsis is defined as a life-threatening organ dysfunction due to a dysregulated inflammation following an infection. However, the impact of this definition on patient care is not fully clear. This study investigated the impact of the current definition on ICU admission of patients with infection. METHODS: We performed a prospective observational study over twelve months on consecutive patients presented to our emergency department and admitted for infection. We analyzed the predictive values of the quick sequential organ failure assessment (qSOFA) score, the SOFA score and blood lactate regarding ICU admission. RESULTS: We included 916 patients with the diagnosis of infection. Median age was 74 years (IQR 62-82 years), and 56.3% were males. There were 219 direct ICU admissions and 697 general ward admissions. A qSOFA score of ≥2 points had 52.9% sensitivity and 98.3% specificity regarding sepsis diagnosis. A qSOFA score of ≥2 points had 87.2% specificity but only 39.9% sensitivity to predict ICU admission. A SOFA score of ≥2 points had 97.4% sensitivity, but only 17.1% specificity to predict ICU admission, while a SOFA score of ≥4 points predicted ICU admission with 82.6% sensitivity and 71.7% specificity. The area under the receiver operating curve regarding ICU admission was 0.81 (95 CI, 0.77-0.86) for SOFA score, 0.55 (95% CI, 0.48-0.61) for blood lactate, and only 0.34 (95% CI, 0.28-0.40) for qSOFA on emergency department presentation. CONCLUSIONS: While a positive qSOFA score had a high specificity regarding ICU admission, the low sensitivity of the score among septic patients as well as among ICU admissions considerably limited its value in routine patient management. The SOFA score was the better predictor of ICU admission, while the predictive value of blood lactate was equivocal.

Airway Management in the Emergency Department (The OcEAN-Study) - a prospective single centre observational cohort study.

BACKGROUND: Emergency airway management (AM) is a major key for successful resuscitation of critically ill non-traumatic (CINT) patients. Details of the AM of these patients in German emergency departments (ED) are unknown. This observational study describes epidemiology, airway techniques, success rates and complications of AM in CINT ED patients in the resuscitation room (RR). METHODS: Data was collected prospectively on adult CINT patients admitted to the RR of a single German university ED September 2014 to August 2015. Patient characteristics, out-of-hospital and in-hospital RR AM, complications and success rates were recorded using a self-developed airway registry form. RESULTS: During the study period 34,303 patients were admitted to the ED, out of those 21,074 patients for non-trauma emergencies. Suffering from severe acute life-threatening problems, 532 CINT patients were admitted to the RR. 150 (28.2%) CINT patients had received out-of-hospital AM. In 16 of these cases (10.7%) the inserted airway needed to be changed after RR admission (unrecognized oesophageal intubation: n = 2, laryngeal tube exchange: n = 14). 136 (25.6%) CINT patients without out-of-hospital AM received RR AM immediately after admission. The first-pass and overall success rate in the RR were 71 and 100%, respectively, and multiple intubation attempts were necessary in 29%. A lower Cormack/Lehane (C/L) grade was associated with less intubation attempts (C/L1/2 vs. 3/4: 1.2 ± 0.5 vs. 1.8 ± 1.2, p = 0.0002). Complication rate was 43%. CONCLUSIONS: OcEAN demonstrates the challenges of AM in CINT patients in a German ED RR. We propose a nation-wide ED airway registry to better track outcomes in the future.

Early Lactate Dynamics in Critically Ill Non-Traumatic Patients in a Resuscitation Room of a German Emergency Department (OBSERvE-Lactate-Study).

BACKGROUND: Management of critically ill non-trauma patients in the resuscitation room of an emergency department (ED) is very challenging, and it is difficult to identify patients with a higher risk of death. Previous studies have shown that lactate indices can predict survival for selected diseases and syndromes. OBJECTIVE: As reported for other patient populations, we set out to determine whether admission lactate or lactate dynamics (LD) within 24 h can predict 30-day mortality in unselected critically ill non-traumatic patients. METHODS: In this retrospective study over a 1-year period, admission lactate, time weighted average lactate (LacTW) and LD of all critically ill adult patients admitted from ED to intensive care unit were analyzed. A linear regression model was implemented to estimate lactate data 1 h after admission. RESULTS: The admission lactate, LacTW, and LD within 24 h were analyzed from 392 critically ill patients. The overall 30-day mortality rate was around 29%. Admission lactate (4.1 ± 4.0 mmol/L vs. 6.6 ± 6.1 mmol/L; p < 0.01) and LacTW (1.8 ± 1.7 mmol/L vs. 4.1 ± 4.8 mmol/L; p < 0.01) were different between survivors and non-survivors. LD between survivors and non-survivors did not differ at 1 h, 6 h, 12 h, or 24 h. After excluding patients with out-of-hospital or in-hospital cardiac arrest during resuscitation room management, admission lactate and LD between survivors and non-survivors did not differ at 1 h, 12 h, and 24 h. LD at 6 h (44% ± 42% vs. 33% ± 58%; p = 0.042) and LacTW (1.7 ± 1.6 mmol/L vs. 2.6 ± 3.0 mmol/L; p < 0.01) did differ. CONCLUSIONS: In critically ill ED patients initially requiring treatment in a resuscitation room setting, LD at 6 h and LacTW may predict their survival beyond 30 days. These findings need to be confirmed in a prospective study design.

Intra-individual alterations of serum markers routinely used in forensic pathology depending on increasing post-mortem interval.

Post-mortem biochemistry of serum markers has been the subject of numerous studies, but in-situ marker stability after death has not been sufficiently evaluated yet. Such laboratory analyses are especially necessary in the cases of functional deaths without morphological evidence of the death causes and also in cardiac death cases with only very short survival times. The aim of the study was to determine the post-mortem stability of commonly-used serum markers at predefined time points. In 20 cases, peripheral venous samples were taken starting immediately after circulatory arrest and ending 48 hours after death. Serum creatinine, urea, 3-ß-hydroxybutyrate, tryptase, myoglobin, troponin T, creatin kinase and creatin kinase-MB have been included. For all markers, we observed increasing marker levels for longer post-mortem intervals. Significant marker level changes began two hours after death. Excessive increases were observed for cardiac and muscle markers. Marker levels showed high intra-assay precision. Furthermore, the markers were robust enough to withstand freeze-thaw cycles. Potential contamination of arteriovenous blood did not influence the post-mortem marker levels. Post-mortem blood should be sampled as soon as possible, as increased post-mortem intervals may heavily change marker levels in-situ in individual cases, whereas the markers are mostly unaffected by laboratory conditions.

Resuscitation room management of critically ill nontraumatic patients in a German emergency department (OBSERvE-study).

BACKGROUND: Management of critically ill nontrauma (CINT) patients in the resuscitation room (RR) of the emergency department (ED) is very challenging. Detailed data describing the characteristics and management of this population are lacking. This observational study describes the epidemiology, management and outcome in CINT ED patients in the RR. PATIENTS AND METHODS: From September 2014 to August 2015, data were collected prospectively on adult CINT patients admitted to the RR of a single German University ED. Patient characteristics, out-of-hospital/in-hospital treatment, admission-related diseases, time intervals for diagnostics and interventions plus outcome were recorded using a self-developed questionnaire. RESULTS: A total of 34 303 patients were admitted to the ED; of these 21 074 patients were admitted for nontrauma emergencies and because of acute life-threatening problems. Five hundred and thirty-two CINT patients were admitted to the RR (median age: 71 years, 58.3% men). The main problems on admission were obstructed airway (3.8%, A), respiratory insufficiency (26.5%, B), shock (35.5%, C), unconsciousness (33.3%, D) or other (0.9%, E). Out-of-hospital and in-hospital management included intravenous access (96.8 vs. 76.9%), 12-lead ECG (50.0 vs. 86.5%), invasive airway management (30.1 vs. 27.1%), noninvasive and invasive ventilation (7.0 vs. 16.4% and 30.1 vs. 57.2%), catecholamines (16.2 vs. 24.1%), arterial line (0.2 vs. 58.1%) and cardiopulmonary resuscitation (18.4 vs. 12.2%). The mean length of stay was 34±24 min. At day 30, all-cause mortality was 34.2% (patients with and without cardiopulmonary resuscitation: 72.7 vs. 24.0%, P<0.001). CONCLUSION: Observation of critically ill patients in the resuscitation room of the Emergency Department shows the challenge of care for CINT patients in the ED. With high levels of mortality, there is an urgent need for structured ED management guidelines.

Insertion Success of the Laryngeal Tube in Emergency Airway Management.

Background. Emergency airway management (AM) is a priority when resuscitating critically ill or severely injured patients. The goal of this study was to determine the success rates of LT insertion during AM. Methods. Studies that included LT first-pass insertion (FPI) and overall-pass insertion (OPI) success by emergency medical services and in-hospital providers performing AM for emergency situations as well as for scheduled surgery published until July 2014 were searched systematically in Medline. Results. Data of 36 studies (n = 1,897) reported a LT FPI success by physicians of 82.5% with an OPI success of 93.6% (p < 0.001). A cumulative analysis of all 53 studies (n = 3,600) led to FPI and OPI success of 80.1% and 92.6% (p < 0.001), respectively. The results of 26 studies (n = 2,159) comparing the LT with the laryngeal mask airway (LMA) demonstrated a FPI success of 77.0 versus 78.7% (p = 0.36) and an OPI success of 92.2 versus 97.7% (p < 0.001). Conclusion. LT insertion failed in the first attempt in one out of five patients, with an overall failure rate in one out of 14 patients. When compared with the LT, the LMA had a cumulative 5.5% better OPI success rate.

Acute emergency care and airway management of caustic ingestion in adults: single center observational study.

BACKGROUND: Caustic ingestions are rare but potentially life-threatening events requiring multidisciplinary emergency approaches. Although particularly respiratory functions may be impaired after caustic ingestions, studies involving acute emergency care are scarce. The goal of this study was to explore acute emergency care with respect to airway management and emergency department (ED) infrastructures. METHODS: We retrospectively evaluated adult patients after caustic ingestions admitted to our university hospital over a 10-year period (2005-2014). Prognostic analysis included age, morbidity, ingested agent, airway management, interventions (endoscopy findings, computed tomography (CT), surgical procedures), intensive care unit (ICU) admission, length of stay in hospital and hospital mortality. RESULTS: Twenty-eight patients with caustic ingestions were included in the analysis of which 18 (64%) had suicidal intentions. Ingested agents were caustic alkalis (n = 22; 79%) and acids (n = 6; 21%). ICU admission was required in 20 patients (71%). Fourteen patients (50%) underwent tracheal intubation and mechanical ventilation, of which 3 (21%) presented with difficult airways. Seven patients (25%) underwent tracheotomy including one requiring awake tracheotomy due to progressive upper airway obstruction. Esophagogastroduodenoscopy (EGD) was performed in 21 patients (75%) and 11 (39%) underwent CT examination. Five patients (18%) required emergency surgery with a mortality of 60%. Overall hospital mortality was 18% whereas the need for tracheal intubation (P = 0.012), CT-diagnostic (P = 0.001), higher EGD score (P = 0.006), tracheotomy (P = 0.048), and surgical interventions (P = 0.005) were significantly associated with mortality. CONCLUSIONS: Caustic ingestions in adult patients require an ED infrastructure providing 24/7-availability of expertise in establishing emergent airway safety, endoscopic examination (EGD and bronchoscopy), and CT diagnostic, intensive care and emergency esophageal surgery. We recommend that - even in patients with apparently stable clinical conditions - careful monitoring of respiratory functions should be considered as long as diagnostic work-up is completed.

Comparison of the Fluid Resuscitation Rate with and without External Pressure Using Two Intraosseous Infusion Systems for Adult Emergencies, the CITRIN (Comparison of InTRaosseous infusion systems in emergency medicINe)-Study.

INTRODUCTION: Intraosseous infusion is recommended if peripheral venous access fails for cardiopulmonary resuscitation or other medical emergencies. The aim of this study, using body donors, was to compare a semi-automatic (EZ-IO®) device at two insertion sites and a sternal intraosseous infusion device (FASTR™). METHODS: Twenty-seven medical students being inexperienced first-time users were randomized into three groups using EZ-IO and FASTR. The following data were evaluated: attempts required for successful placement, insertion time and flow rates with and without external pressure to the infusion. RESULTS: The first-pass insertion success of the EZ-IO tibia, EZ-IO humerus and FASTR was 91%, 77%, and 95%, respectively. Insertion times (MW ± SD) did not show significant differences with 17 ± 7 (EZ-IO tibia) vs. 29 ± 42 (EZ-IO humerus) vs. 33 ± 21 (FASTR), respectively. One-minute flow rates using external pressures between 0 mmHg and 300 mmHg ranged between 27 ± 5 to 69 ± 54 ml/min (EZ-IO tibia), 16 ± 3 to 60 ± 44 ml/min (EZ-IO humerus) and 53 ± 2 to 112 ± 47 ml/min (FASTR), respectively. Concerning pressure-related increases in flow rates, negligible correlations were found for the EZ-IO tibia in all time frames (c = 0.107-0.366; p ≤ 0.013), moderate positive correlations were found for the EZ-IO humerus after 5 minutes (c = 0.489; p = 0.021) and strong positive correlations were found for the FASTR in all time frames (c = 0.63-0.80; p ≤ 0.007). Post-hoc statistical power was 0.62 with the given sample size. CONCLUSIONS: The experiments with first-time users applying EZ-IO and FASTR in body donors indicate that both devices may be effective intraosseous infusion devices, likely suitable for fluid resuscitation using a pressure bag. Variations in flow rate may limit their reliability. Larger sample sizes will prospectively be required to substantiate our findings.