Rapid sequence intubation in Scottish urban emergency departments.

OBJECTIVE: Airway care is the cornerstone of resuscitation. In UK emergency department practice, this care is provided by anaesthetists and emergency physicians. The aim of this study was to determine current practice for rapid sequence intubation (RSI) in a sample of emergency departments in Scotland. METHODS: Two year, multicentre, prospective observational study of endotracheal intubation in the emergency departments of seven Scottish urban teaching hospitals. RESULTS: 1631 patients underwent an intubation attempt in the emergency department and 735 patients satisfied the criteria for RSI. Emergency physicians intubated 377 patients and anaesthetists intubated 355 patients. There was no difference in median age between the groups but there was a significantly greater proportion of men (73.2% versus 65.3%, p=0.024) and trauma patients (48.5% versus 37.4%, p=0.003) in the anaesthetic group. Anaesthetists had a higher initial success rate (91.8% versus 83.8%, p=0.001) and achieved more good (Cormack-Lehane Grade I and II) views at laryngoscopy (94.0% versus 89.3%, p=0.039). There was a non-significant trend to more complications in the group of patients intubated by emergency physicians (8.7% versus 12.7%, p=0.104). Emergency physicians intubated a higher proportion of patients with physiological compromise (91.8% versus 86.1%, p=0.027) and a higher proportion of patients within 15 minutes of arrival (32.6% versus 11.3%, p<0.0001). CONCLUSION: Anaesthetists achieve more good views at laryngoscopy with higher initial success rates during RSI. Emergency physicians perform RSI on a higher proportion of critically ill patients and a higher proportion of patients within 15 minutes of arrival. Complications may be fewer in the anaesthetists' group, but this could be related to differences in patient populations. Training issues for RSI and emergency airway care are discussed. Complication rates for both groups are in keeping with previous studies.

The management of syncope in a British emergency department compared to recent American guidelines.

This descriptive study aims to determine current clinical practice in an emergency department when assessing patients presenting with syncope and then to compare this with recent guidelines from the American College of Physicians. Key points on history, examination, investigation and disposition of patients from the department were measured. Of 100 patients recruited, few had relevant symptoms documented. Seventy-five patients had an electrocardiogram performed, in which 18 were defined as abnormal. 40% of those with a history of organic heart disease were sent home. 28% of those with an abnormal electrocardiogram were discharged. 44% of those aged over 70 were discharged. A total of 45 patients were admitted. An extra 17 to 26 patients may have been admitted if the American guidelines had been adhered to. This study highlights deficiencies in assessment and a difference in current practice when compared with the recommendations from the American College of Physicians. Further research is required to produce guidelines on disposition applicable to emergency departments in the United Kingdom.

Difficult mitral valvuloplasty: an "over the wire" modification of Inoue technique.

Failure to cross the mitral valve remains an important cause of the technical failure in performing mitral valvuloplasty with the Inoue technique, especially during initial experience of the operator. We report two such cases where conventional methods failed and an "over the wire" modification of the Inoue technique had to be utilized. This particular modification can be beneficial in the rare cases where negotiating the Inoue balloon across the mitral valve is particularly difficult.