Elimination of Routine Screening Laboratory Tests for Psychiatric Admission: A Quality Improvement Initiative.

OBJECTIVE: Research has shown that routine screening laboratory tests for patients with mental health symptoms admitted to psychiatry units find little unexpected clinical abnormalities. This study examined the effects on cost of care and patient safety measures of a hospital change in policy in which such routine tests were no longer required. METHODS: This retrospective cohort study analyzed data from all patients admitted from the emergency department (ED) to inpatient psychiatry at a tertiary care hospital 4 months before and 4 months after the policy change. Primary outcome measures were number and costs of laboratory tests ordered in the ED and during the inpatient stay. Secondary measures included length of stay (LOS) and number of hospital consultations during admission, patient transfers to nonpsychiatry services, and inpatient deaths. Chi-square tests and Wilcoxon rank sum tests were used to examine group differences. RESULTS: In total, data from 1,910 patients were included (886 preimplementation and 1,024 postimplementation). The median number of lab tests ordered during the hospital stay decreased from three (interquartile range [IQR]=3) to two (IQR=3). The median total lab charges decreased from $445 (IQR=$291) to $312 (IQR=$497). Mean ED LOS decreased by 5.5 hours, and the proportion of patients with no blood lab orders increased from 22% to 40%. No increases in consultations or transfers were noted. No patients died at any point. CONCLUSIONS: A policy that avoids routine laboratory screening tests for patients admitted to inpatient psychiatry can save money, improve patient care, and decrease LOS, without increasing adverse outcomes.

Intraosseous Pressure Monitoring in Healthy Volunteers.

STUDY OBJECTIVE: Invasively monitoring blood pressure through the IO device has not been thoroughly demonstrated. This study attempted to establish baseline values of IO pressure in a healthy human population. METHODS: This was a prospective, healthy volunteer, observational study. Participants had two IO devices placed (humerus and tibia), and participant IO pressures, vital signs, and pain scores were monitored for up to 60 minutes. Participants were contacted at 24-hours and 7 days post-testing to assess for adverse events. Summary statistics were calculated for systolic, diastolic, and mean humeral and tibial IO pressure. The ratio of IO to non-invasive blood pressure was calculated, and Bland Altman plots were created. The slope (linear) of the mean humeral and the tibial IO pressures were also calculated. RESULTS: Fifteen subjects were enrolled between April and July 2015. Fourteen of 15 humeral IOs were placed successfully (93.3%) and all 15 of the tibial IOs were placed successfully. Mean tibial systolic, diastolic, and mean IO pressure were 55.8 ± 27.9, 49.3 ± 27.1, and 48.4 ± 29.4 mm Hg, respectively. Humeral systolic, diastolic, and mean IO pressure were 32.9 ± 16.0, 27.4 ± 15.2, and 24.5 ± 14.3 mm Hg. The mean tibial IO pressure was 52.5% ± 32.0% of external cuff pressure ratio. The mean humeral IO pressure was 26.5% ± 15.2% of the external mean blood pressure. The Bland Altman plots showed an inconsistent relationship between the systolic and diastolic cuff pressure and the IO pressures. We observed a 1% per minute decrease in IO pressure from the initial placement until the final reading. CONCLUSIONS: Intraosseous pressure readings can be obtained in healthy human volunteers. However, absolute IOP values were not consistent between subjects. Future research may determine how IO pressure can be used to guide therapy in ill and injured patients.

Achieving a Safe Endotracheal Tube Cuff Pressure in the Prehospital Setting: Is It Time to Revise the Standard Cuff Inflation Practice?

Numerous studies have reported unsafe endotracheal tube (ETT) cuff pressures (CP) in the prehospital environment. The purpose of this study was to identify an optimal cuff inflation volume (CIV) to achieve a safe CP (20-30 cmH2O). This observational study utilized 30 recently harvested ovine tracheae, which were warmed from refrigeration in a water bath at 85°F prior to testing. Each trachea was intubated with five different ETT sizes (6.0-8.0 mm), and each size tube was tested with six cuff inflation volumes (5-10 cc). The order of ETT size for each trachea and CIV for each size ETT was randomly pre-assigned. Data were descriptively summarized and categorized before mixed-effects logistic regression was used to determine optimal CIV. Only 113 CP measurements (12.6%, N = 900) were within the optimal range (M = 54.75 cmH2O, SD = 38.52), all of which resulted from a CIV 6 or 7 cc (61% and 39%, respectively). CIVs of 5 cc (n = 150) resulted in underinflation (<20 cmH2O) in all instances, while CIVs of 8, 9, or 10 cc (n = 150 each) resulted in overinflation (>30 cmH2O) in all instances, regardless of ETT size. The odds of achieving a safe CP were greater with CIV of 6 cc for tube sizes 6.0 (OR = 15.9, 95% CI = 3.85-65.58, p < 0.01) and 6.5 mm (OR = 3.16, 95% CI = 1.06-9.39, p = 0.039); however, there was no significant difference in the odds of achieving a safe CP between CIV of 6 and 7 cc for tube sizes 7.0, 7.5, or 8.0 mm. Neither trachea circumference (M = 7.11 cm, SD = 0.40), nor tissue temperature (M = 81.32°F, SD = 0.93) were found to be significant predictors of CP (p = 0.20 and 0.81, respectively). Our study showed a high frequency of CP measurements outside of the desired norms. The CIV range of 6-7 cc resulted in the highest likelihood of achieving the desired cuff pressure range, while cuffs inflated with 8-10 cc resulted in dangerously high CPs in all instances. In the absence of a more ideal solution, the results of this study suggest that narrowing the recommended CIV from 5-10 cc to 6-7 cc might be a reasonable target for any tube size.

Demographic, Operational, and Healthcare Utilization Factors Associated with Emergency Department Patient Satisfaction.

INTRODUCTION: The primary aim of this study was to determine which objectively-measured patient demographics, emergency department (ED) operational characteristics, and healthcare utilization frequencies (care factors) were associated with patient satisfaction ratings obtained from phone surveys conducted by a third-party vendor for patients discharged from our ED. METHODS: This is a retrospective, observational analysis of data obtained between September 2011 and August 2012 from all English- and Spanish-speaking patients discharged from our ED who were contacted by a third-party patient satisfaction vendor to complete a standardized nine-item telephone survey by a trained phone surveyor. We linked data from completed surveys to the patient's electronic medical record to abstract additional demographic, ED operational, and healthcare utilization data. We used univariate ordinal logistic regression, followed by two multivariate models, to identify significant predictors of patient satisfaction. RESULTS: We included 20,940 patients for analysis. The overall patient satisfaction ratings were as follows: 1=471 (2%); 2=558 (3%); 3=2,014 (10%), 4=5,347 (26%); 5=12,550 (60%). Factors associated with higher satisfaction included race/ethnicity (Non-Hispanic Black; Hispanic patients), age (patients ≥65), insurance (Medicare), mode of arrival (arrived by bus or on foot), and having a medication ordered in the ED. Patients who felt their medical condition did not improve, those treated in our ED behavioral health area, and those experiencing longer wait times had reduced satisfaction. CONCLUSION: These findings provide a basis for development and evaluation of targeted interventions that could be used to improve patient satisfaction in our ED.

The association of health status and providing consent to continued participation in an out-of-hospital cardiac arrest trial performed under exception from informed consent.

OBJECTIVES: Emergency medical research performed under federal regulation 21 § CFR 50.24 provides a means to protect human subjects and investigate novel time-sensitive treatments. Although prospective individual consent is not required for studies conducted under this regulation, consent from a legally authorized representative (LAR) or the patient at the earliest feasible opportunity is required to obtain short- and long-term outcome data. The objective of this study was to determine which demographic, cardiac arrest, and patient outcome characteristics predicted the likelihood of obtaining informed consent following enrollment under exception from informed consent in a multicenter cardiac arrest study. METHODS: This investigation was an analysis of data collected during a multisite, randomized, controlled, out-of-hospital cardiac arrest clinical trial performed under 21 § CFR 50.24. Research personnel attempted to obtain informed consent from LARs and subjects for medical records review of primary outcome data, as well as consent for neurologic outcome assessments up to 1 year post-cardiac arrest. Hospital discharge and neurologic status were obtained from public records and/or medical records up until the time consent was formally denied, in accordance with federal regulations and guidance. Local institutional review boards also allowed medical records review for cases where consent was neither obtained nor declined despite multiple consent attempts. Patient demographic, cardiac arrest, and clinical outcome characteristics were analyzed in univariate multinomial regression models, with consent status (obtained, denied, neither obtained nor denied) as the dependent variable. A multivariate multinomial logistic regression was then performed. An exploratory secondary analysis following the same process was performed after assigning patients who neither consented nor declined to the declined consent group. RESULTS: Among a total study population of 1,655 cardiac arrest subjects, 457 were transported and had consent attempted (27.6%). The survival status and neurologic function at the time of hospital discharge were known in 440 of 457 (96%) subjects. In the multivariate analysis, initial rhythm of ventricular fibrillation/ventricular tachycardia (VF/VT) and survival with good neurologic outcome were strong predictors of obtaining consent (odds ratio [OR] = 3.15, 95% confidence interval [CI] = 1.73 to 5.75; OR = 7.64, 95% CI = 2.28 to 25.63, respectively). The exploratory secondary analysis also showed initial rhythm of VF/VT and survival with good neurologic outcome as strong predictors of obtaining consent (OR = 1.86, 95% CI = 1.17 to 2.95; OR = 4.52, 95% CI = 2.21 to 9.26, respectively). CONCLUSIONS: Initial arrest rhythm and survival with good neurologic outcome were highly predictive of obtaining consent in this cardiac arrest trial. This phenomenon could result in underrepresentation of outcome data in the study arm with the worse outcome and represents a significant potential confounder in studies performed under 21 § CFR 50.24. Future revisions to the exception from informed consent regulations should allow access to critical survival data recorded as part of standard documentation, regardless of patient consent status.

Evaluation of intraosseous pressure in a hypovolemic animal model.

BACKGROUND: In emergent situations, access to the vascular bed is frequently required for fluid and medication administration. Central venous catheter placement is associated with risk and may slow resuscitation in the unstable patient. The purpose of this study was to determine whether intraosseous pressure (IOP) could be consistently recorded and how similar this pressure was to central venous and arterial pressure in a porcine hemorrhagic shock model. MATERIALS AND METHODS: After sedation, eight female swine had catheters placed in the femoral vein, aorta via femoral artery, and superior vena cava. IOP lines were placed in the proximal humerus, distal femur, and proximal tibia. Pressure readings were recorded continuously through the five stages of progressive hypovolemia. Pressure data were descriptively summarized, with the percent of change of IOP at each stage compared with arterial pressure using a multilevel mixed effects linear model with log transformation. RESULTS: The IOP baseline values were between 16 and 18 mm Hg, approximately 22% of baseline arterial pressure. The intraosseous (IO) waveform mostly closely resembled the arterial pressure waveform, including the presence of a dichroitic notch. Pressure variations caused by ventilation (respiratory variability) were also identified in all the tracings. The rate of pressure change in the humeral IO most closely matched the change in arterial pressure rate. IO blood gas analysis showed gas composition to most closely match venous blood. CONCLUSIONS: IOP was reliably obtained in this porcine model and suggests potential for clinical application in humans.

Prehospital oxygen administration for chest pain patients decreases significantly following implementation of the 2010 AHA guidelines.

OBJECTIVES: The purpose of this study was to examine trends in oxygen administration following the 2010 American Heart Association guidelines recommendation to withhold oxygen therapy for patients with uncomplicated presentations of ACS whose SpO2 is 94% or higher. METHODS: Following IRB review and approval, we performed a retrospective analysis of data obtained from Fisdap(TM), a national, clinical skills tracking system for paramedic students between June 2010 and December 2012. Inclusion criteria included: 1) student consent for research, 2) cardiac chest pain recorded as the chief complaint, and 3) SpO2 data available for review. O2 administration, route, and dose were abstracted, and the percent of patient encounters with oxygen administration was calculated for each year. Unadjusted logistic regression was used to determine if O2 administration rates changed significantly over the study period. Unadjusted logistic regression was also used to determine if there was a difference in the odds of receiving oxygen based on a patient's SpO2 value. RESULTS: 10,552 patient encounters by 2,447 paramedic students from 195 paramedic programs representing 49 states were included for analysis. Prior to release of the new guidelines (2010), 71.9% (95% CI 69.8-74.0%) of patients with SpO2 ≥ 94% received supplemental O2. Rates of O2 administration were significantly lower in 2011 (64%; 95% CI 62.7-65.3%) and in 2012 (53.1%; 95% CI 51.5-54.7). The odds of a hemodynamically stable chest pain patient with SpO2 ≥ 94% receiving supplemental oxygen in 2011 were 1.4 times lower compared to patients in 2010 (95% CI 1.3-1.6). Similarly, the odds of patients in 2012 receiving supplemental oxygen were 2.3 times lower compared to patients in 2010 (95% CI 2.0-2.6). The odds of receiving supplemental oxygen decreased by 4% for each 1% increase in SpO2 beyond the 94% threshold (OR = 0.96; 95% CI 0.94-0.98). CONCLUSIONS: The prehospital administration of supplemental O2 decreased significantly following release of the 2010 updated guidelines; however, our data revealed that 50% of patients not meeting criteria for administration still received supplemental O2.

Magnetic resonance imaging and computed tomography utilization trends in an academic ED.

OBJECTIVE: The objective of this study is to examine the annual utilization trends of emergency department (ED)-ordered magnetic resonance imaging (MRI) and computed tomography (CT) at an urban academic hospital from 2007 to 2011. We hypothesized that MRI and CT use would increase annually over the study period. METHODS: This was a retrospective observational study of ED encounters between January 1, 2007, and December 31, 2011. All patients seen by a provider were identified, and demographics were abstracted. Type of CT and/or MRI examination, clinical indication, and final disposition were collected. Records of patients with an ED-ordered MRI were also examined for presence of a CT within ±3 days of their encounter date. Unadjusted linear regression was used to assess for differences among years for both CT and MRI. Secondary outcomes were descriptively summarized. RESULTS: A total of 7089 MRI (20 per 1000) and 85,673 CT (243 per 1000) examinations were ordered over a 60-month period. Computed tomography use decreased significantly (P=.021). Magnetic resonance imaging use significantly increased (2.2 per 1000 ED visits each year, P=.005). Magnetic resonance imaging of the head was ordered most frequently (10.7 per 1000). The overwhelming majority of MRI images were completed for acute neurologic/behavioral problem. Of patients with an MRI completed, 89.4% had a CT completed within 3 calendar days with most of the CT examinations (81%) completed during the encounter. CONCLUSION: There was a steady increase in MRI testing in our academic ED, with most MRIs ordered for acute neurologic or behavioral changes. There was a corresponding decreasing trend for CT scans.

Does computed tomographic scan affect diagnosis and management of patients with suspected renal colic?

BACKGROUND: Patients with renal colic commonly present to the emergency department (ED) and are usually treated with analgesics, antiemetics and hydration. Computed tomographic (CT) scan is commonly utilized in evaluating patients with suspected renal colic. OBJECTIVES: We compared diagnosis and treatment plans before and after CT in patients with suspected renal colic with the aim to evaluate how often changes in diagnosis, treatment and disposition are made. METHODS: In this prospective observational study, we enrolled a convenience sample of clinically Stable ED patients older than 17 with suspected renal colic for whom CT was planned. Exclusion criteria were: chronic kidney disease, urinary tract infection, recent CT and history of previous kidney stone. Pre-CT and Post-CT surveys were completed by the treating provider. RESULTS: The discharge diagnosis was renal colic in 62 of 93 enrolled patients (67%). Urinalysis showed blood in 52 of these patients (84%). CT confirmed obstructing kidney or bladder stone in 50 patients. There were five cases of alternative diagnoses noted on CT scan. After CT scan, 7 patients had changes in disposition. Sixteen providers felt that CT would not change management. In these cases, CT offered no alternative diagnosis and didn't change disposition. CONCLUSION: CT scan didn't change management when providers did not expect it would. This indicates that providers who are confident with the diagnosis of renal colic should consider forgoing a CT scan. CT scan did occasionally find important alternative diagnoses and should be utilized when providers are considering other concerning pathology.

Use of an intraosseous device for invasive pressure monitoring in the ED.

Venous access is essential to providing emergency care for critically ill or injured patients. Obtaining peripheral or central access can be problematic and time consuming. Intraosseous (IO) fluid administration provides similar flow rates and central circulation times compared to central lines, but use of these devices to monitor blood pressure has not been explored. We report a case of successful IO pressure (IOP) monitoring through an IO during the resuscitation of a 31-year-old male. This is the first report of monitoring IOP in a clinical setting and comparing it to traditional measures of central pressure.

Comparison of success rates between two video laryngoscope systems used in a prehospital clinical trial.

OBJECTIVES: The primary aims of this study were to compare paramedic success rates and complications of two different video laryngoscopes in a prehospital clinical study. METHODS: This study was a multi-agency, prospective, non-randomized, cross over clinical trial involving paramedics from four different EMS agencies. Following completion of training sessions, six Storz CMAC™ video laryngoscopes and six King Vision™ (KV) video laryngoscopes were divided between agencies and placed into service for 6 months. Paramedics were instructed to use the video laryngoscope for all patients estimated to be ≥ 18 years old who required advanced airway management per standard operating procedure. After 6 months, the devices were crossed over for the final 6 months of the study period. Data collection was completed using a telephone data collection system with a member of the research team (available 24/7). First attempt success, overall success, and success by attempt, were compared between treatment groups using exact logistic regression adjusted for call type and user experience. RESULTS: Over a 12-month period, 107 patients (66 CMAC, 41 KV) were treated with a study device. The CMAC had a significantly higher likelihood of first attempt success (OR = 1.85; 95% CI 0.74, 4.62; p = 0.188), overall success (OR = 7.37; 95% CI 1.73, 11.1; p = 0.002), and success by attempt (OR = 3.38; 95% CI 1.67, 6.8; p = 0.007) compared to KV. Providers reverted to direct laryngoscopy in 80% (27/34) of the video laryngoscope failure cases, with the remaining patients having their airways successfully managed with a supraglottic airway in 3 cases and bag-valve mask in 4 cases. The provider-reported complications were similar and none were statistically different between treatment groups. Complication rates were not statistically different between devices. CONCLUSION: The CMAC had a higher likelihood of successful intubation compared to the King Vision. Complication rates were not statistically different between groups. Video laryngoscope placement success rates were not higher than our historical direct laryngoscopy success rates.

Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device.

BACKGROUND: A recent out-of-hospital cardiac arrest (OHCA) clinical trial showed improved survival to hospital discharge (HD) with favorable neurologic function for patients with cardiac arrest of cardiac origin treated with active compression decompression cardiopulmonary resuscitation (CPR) plus an impedance threshold device (ACD+ICD) versus standard (S) CPR. The current analysis examined whether treatment with ACD+ITD is more effective than standard (S-CPR) for all cardiac arrests of non-traumatic origin, regardless of the etiology. METHODS: This is a secondary analysis of data from a randomized, prospective, multicenter, intention-to-treat, OHCA clinical trial. Adults with presumed non-traumatic cardiac arrest were enrolled and followed for one year post arrest. The primary endpoint was survival to hospital discharge (HD) with favorable neurologic function (Modified Rankin Scale score ≤ 3). RESULTS: Between October 2005 and July 2009, 2738 patients were enrolled (S-CPR=1335; ACD+ITD=1403). Survival to HD with favorable neurologic function was greater with ACD+ITD compared with S-CPR: 7.9% versus 5.7%, (OR 1.42, 95% CI 1.04, 1.95, p=0.027). One-year survival was also greater: 7.9% versus 5.7%, (OR 1.43, 95% CI 1.04, 1.96, p=0.026). Nearly all survivors in both groups had returned to their baseline neurological function by one year. Major adverse event rates were similar between groups. CONCLUSIONS: Treatment of out-of-hospital non-traumatic cardiac arrest patients with ACD+ITD resulted in a significant increase in survival to hospital discharge with favorable neurological function when compared with S-CPR. A significant increase survival rates was observed up to one year after arrest in subjects treated with ACD+ITD, regardless of the etiology of the cardiac arrest.

Supraglottic airway device use as a primary airway during rapid sequence intubation.

INTRODUCTION: This study compared first-attempt placement success rates of the King LTS-D as a primary airway for patients requiring medication-assisted airway management (MAAM) against historical controls. SETTING: Rotor-wing division of a single critical care transportation company METHODS: 53 providers (RNs/EMT-P) consented to participation and were trained in the use of the King LTS-D. All patients in need of MAAM per agency treatment guidelines were screened for inclusion and exclusion criteria. After each placement attempt, providers completed data collection via telephone. The primary endpoint was comparison of first-attempt placement success rate between the King LTS-D and historical control endotracheal intubation (ETI) MAAM patients. Overall placement success, time to placement, pre- and post-placement SaO2, ETCO2 at 2 minutes after placement, and complications were also analyzed. RESULTS: 38 patients received rapid sequence intubation with the King LTS-D by 23 of 58 consented providers. First-attempt success rate was 76% (29/38), with an overall success rate of 84% (32/38). The primary endpoint analysis showed no difference in first-attempt success rate between historical control ETI MAAM data and King LTS-D (71% vs 76%; OR = 0.1.34 [95% CI Intubation time to insertion was 26 seconds (IQR = 12-46). Pre- and post-insertion SaO(1)2 values were 88.9 ± 12.6% and 92.1 ± 12.7%, respectively. Mean ETCO2 at 2 minutes after placement was 34.8 ± 4.0. Vomit in the patient's airway was the most frequently reported complication (46%). CONCLUSION: Success rates with the King LTS-D were not significantly different from historical control ETI data. Time to placement was comparable to previous reports.

Longitudinal and regional trends in paramedic student exposure to advanced airway placement: 2001-2011.

OBJECTIVES: The primary aims of this study were to determine whether the frequency of placement, type of advanced airway, and settings of advanced airway placement (clinical vs. field) have changed for paramedic students over the last 11 years, and to describe regional differences regarding the same set of variables. METHODS: This study was a retrospective review of prospectively reported airway procedures documented by paramedic students in Fisdap ( http://www.fisdap.net ). Students were included if they graduated from a paramedic program, had procedure entries verified by a preceptor, and provided consent for research. Exclusion criteria included students who had a total number of airway placements ≥2 standard deviations from the mean or had 0 airway placements recorded, and programs with <10 graduating students total over the study period. Airway device types and educational settings were descriptively compared over the 11-year study period by year and region. RESULTS: A total of 8,934 paramedic student records were reviewed, with 2,811 excluded based on a priori criteria, leaving 6,123 records for analysis. In each year, the median number of airway devices placed per student was greater in the clinical setting. Endotracheal intubation (ETI) was more common than alternative airway placement in both the field and clinical settings. The median number of clinical ETIs per student has remained relatively constant at 7. The median number of field ETIs per student ranged from 0 to 1 over the study period, with a median alternative airway placement rate of 0 for both clinical and field settings. For all regions, the majority of procedures were performed in a clinical environment. The median number of clinical alternative airway device placements was 0 for all regions. The number of clinical ETIs ranged from 5 to 11 per student, with the highest number of ETIs per student in the West North Central and New England regions and the lowest in the West South Central and East South Central regions. CONCLUSION: Paramedic students gain the majority of their advanced airway experience in the clinical setting. ETI remains more common than alternative airway placement, although there is significant geographic variation in the number of ETIs per student. High rates of clinical intubations do not correlate with high rates of field intubations.

Evaluation of the Storz CMAC®, Glidescope® GVL, AirTraq®, King LTS-D™, and direct laryngoscopy in a simulated difficult airway.

OBJECTIVE: The aim of this study was to compare first-attempt and overall success rates and success rates in relation to placement time among 5 different airway management devices: Storz CMAC, Glidescope GVL, AirTraq, King LTS-D, and direct laryngoscopy (DL). METHODS: Emergency medical technician basic (EMT-B), EMT-paramedics (EMT-P), and emergency medicine residents and staff physicians placed each of the 5 devices in a random order into an AirSim (TruCorp, Belfast, UK) part-task training manikin. The difficult airway scenario was created by fixing the manikin head to a stationary object and introducing simulated emesis into the hypopharynx. First-attempt and overall success and success in relation to placement time were compared. Provider feedback about device performance was also evaluated. RESULTS: Ninety-four providers (16 EMT-basics, 54 EMT-paramedics, and 24 emergency department doctors of medicine) consented to participation. First-attempt and overall success rates for DL, King LTS-D, GVL, and CMAC were not statistically different. Compared with DL, the AirTraq was 96% less likely to be placed successfully (odds ratio, 0.04; 95% confidence interval [CI], 0.01-0.14). When time was factored into the model, the odds of successful placement of the King LTS-D were higher compared with DL (hazard ratio [HR], 1.80; 95% CI, 1.34-2.42) and lower for GVL (HR, 0.59; 95% CI, 0.44-0.80) and AirTraq (HR, 0.228; 95% CI, 0.16-0.325). Providers ranked the CMAC first in terms of performance and preference for use in their practice setting. CONCLUSION: Overall success rates for DL, King-LTS-D, and both video laryngoscope systems were not different. When time was factored into the model, the King LTS-D was more likely to be placed successfully.

The emergency department experience with prehospital ketamine: a case series of 13 patients.

BACKGROUND: There are no published reports examining the effects that ketamine administered prior to hospital arrival has on patients after their transfer to the emergency department (ED). OBJECTIVE: In order to better understand the risk-benefit ratio for the prehospital use of ketamine, we examined the ED courses of 13 patients to whom emergency medical services (EMS) had administered ketamine for chemical restraint. METHODS: This project was undertaken as part of our EMS system's continuous quality improvement (CQI) process. Data were collected retrospectively. All patients who were given ketamine by EMS providers under our medical direction were identified by prehospital care report queries. The treating paramedic and emergency physician were provided a CQI form after disposition of the patient from their care. The data were tabulated and descriptive statistics were calculated. RESULTS: Thirteen patients were given ketamine by EMS providers, with 13 of 13 having EMS records and 12 of 13 having ED records available for review. Time from ketamine administration to peak sedation was <5 minutes in 11 patients and 20 minutes for two patients. On emergency physician examination, five of 12 patients had Richmond Agitation Sedation Scale (RASS) scores of -5 (unarousable), one of 12 had a RASS score of -4 (deep sedation), four of 12 had RASS scores of -3 (moderate sedation), and two of 12 had RASS scores of -2 (light sedation). Three patients developed hypoxia, two in the ED and one prior to hospital arrival. Two of these patients required intubation and one was treated with jaw thrust. Indications for intubation were recurrent laryngospasm and intracranial bleeding. One additional patient experienced a single episode of hypersalivation, which was successfully treated with suctioning of the oropharynx. Of the nonintubated patients, three of 10 were diagnosed with an emergence reaction and five of 10 required additional sedation. The primary diagnosis on ED disposition was drug/ethanol intoxication (3), psychosis (4), intracranial bleeding (1), seizure (1), suicidal ideation (1), agitation (1), and altered mental status (1). Five patients were discharged from the ED, seven were admitted (two to the intensive care unit, four to medicine, and one to psychiatry), and one patient's disposition was unknown. CONCLUSIONS: In this series of 13 patients, ketamine administered by EMS produced moderate or deeper sedation. Respiratory complications included hypoxia, laryngospasm, and hypersalivation. Emergence reactions occurred in 30% of nonintubated patients, but they were successfully treated with small doses of benzodiazepines.

Potential negative effects of epinephrine on carotid blood flow and ETCO2 during active compression-decompression CPR utilizing an impedance threshold device.

OBJECTIVES: This study examines the effects of IV epinephrine administration on carotid blood flow (CBF) and end tidal CO(2) (ETCO(2)) production in a swine model of active compression-decompression CPR with an impedance threshold device (ACD-CPR+ITD). METHODS: Six female swine (32 ± 1 kg) were anesthetized, intubated and ventilated. Intracranial, thoracic aorta and right atrial pressures were measured via indwelling catheters. CBF was recorded. ETCO(2), SpO(2) and EKG were monitored. V-fib was induced and went untreated for 6 min. Three minutes each of standard CPR (STD), STD-CPR+impedance threshold device (ITD) and active compression-decompression (ACD)-CPR+ITD were performed. At minute 9 of the resuscitation, 40 µg/kg of IV Epinephrine was administered and ACD-CPR+ITD was continued for 1 min. Statistical analysis was performed with a paired t-test. p values of <0.05 were considered statistically significant and all values are reported in mmHg unless otherwise noted. RESULTS: Aortic pressure, cerebral and coronary perfusion pressures increased from STD

Comparison of prehospital insertion success rates and time to insertion between standard endotracheal intubation and a supraglottic airway.

OBJECTIVE: To compare paramedic insertion success rates and time to insertion between standard ETI and a supraglottc airway device (King LTS-D™) in patients needing advanced airway management. METHODS: Between June 2008 and June 2009, consented paramedics from 4 EMS systems performed ETI or placed a King LTS-D according to a predetermined randomization calendar. Data collection occurred following each placement via telephone. Placement success (ability to ventilate to chest rise, absence of gastric sounds, presence of bilateral lung sounds, and when applicable, quantitative end-tidal CO(2) reading) was compared between treatment groups. Time to ventilation (time from airway device in hand ready to place to time of first successful ventilation) was also compared. RESULTS: A total of 213 patients in need of advanced airway management were treated during the study period, with 9 patients excluded from the analysis. The remaining 204 placements by 110 of the 272 consented paramedics were analyzed (median placements per paramedic=1; range=1-7). The overall placement success rate was virtually equal across the two groups (ETI=80.2%, King LTS-D=80.5%; p=0.97). The median time to placement between ETI and the King LTS-D was also not significantly different (ETI=19.5s vs. King LTS-D=20.0s; z=-0.25; p=0.80). CONCLUSION: In this study, no differences in placement success rate or time to insertion were detected between the King LTS-D and ETI.

Use of the King LTS-D during medication-assisted airway management.

OBJECTIVE: This case series evaluated provider use of the King LTS-D as a primary airway in patients requiring rapid-sequence intubation (RSI). METHODS: Twenty-seven paramedics completed a one-hour training session on the use of the device. All patients meeting the service's standard criteria for medication-assisted airway management were included in the study. Following each insertion, paramedics contacted a research hotline to complete data collection. The primary endpoint was successful insertion, with secondary endpoints including time from succinylcholine administration to successful ventilation, pre- and post-insertion vital signs (oxygen saturation [SaO(2)], pulse rate, and systolic and diastolic blood pressure), and end-tidal carbon dioxide [ETCO(2)] value 2 minutes after insertion. Analysis between pre- and postinsertion variables was completed using the Wilcoxon signed-rank test. RESULTS: A total of 11 patients met the enrollment criteria and were treated with the device by nine of the 27 paramedics enrolled in the study. All 11 insertions (100%) were successful, with 10 of the 11 (91%) successes achieved on the first insertion attempt. No significant difference existed between pre- and post-insertion pulse rate or blood pressure measures. A significant difference in SaO(2) values was present (p = 0.007). Median ETCO(2) for the study sample was 40 mmHg (interquartile range [IQR] = 33-46 mmHg). Seventy-three percent (8/11) of patients had a time interval of succinylcholine administration to first ventilation of 1 minute or less (range = 1-3 minutes). One case of aspiration was noted on hospital chart review. CONCLUSION: In this case series, paramedics were able to successfully place and use the King LTS-D in patients meeting our emergency medical services (EMS) system indications for RSI.