Incidence of Bradycardia and the Use of Atropine in Pediatric Rapid Sequence Intubation in the Emergency Department.

OBJECTIVE: Bradycardia during rapid sequence intubation (RSI) is an uncommon but serious adverse effect encountered in pediatric intubations. Atropine has historically been used in the pediatric population as RSI premedication to prevent bradycardia, especially when using succinylcholine as an induction agent. The objective of this analysis was to identify the incidence of bradycardia with or without atropine use. METHODS: This single-center, retrospective, observational case series reviewed pediatric patients up to 18 years old requiring intubation from January 1, 2015, to December 31, 2018. Bradycardia was determined by analyzing heart rates associated with time during and up to 5 minutes after intubation. RESULTS: A total of 62 patients were included. Three (4.8%) patients experienced a bradycardic event during intubation. A total of 15 (24.2%) patients received atropine for pretreatment of RSI. Incidence of bradycardia was similar between those who received atropine and those who did not. An increasing trend in atropine use was shown throughout the assessment period, yet only 18 (29%) patients met criteria for atropine pretreatment based on the 2015 Pediatric Advanced Life Support guideline recommendations for RSI. CONCLUSION: Bradycardia incidence was low in pediatric patients undergoing RSI in our emergency department. Use of atropine or succinylcholine did not affect the incidence of bradycardia during pediatric intubation over this study period. Our results show a low incidence of bradycardia and support the 2015 Pediatric Advanced Life Support Guideline recommendation of limiting the use of atropine premedication in pediatric intubations.

Benzodiazepines vs barbiturates for alcohol withdrawal: Analysis of 3 different treatment protocols.

INTRODUCTION: Alcohol withdrawal treatment varies widely. Benzodiazepines are the standard of care, with rapid onset and long durations of action. Recent drug shortages involving IV benzodiazepines have required incorporation of alternative agents into treatment protocols. Phenobarbital has similar pharmacokinetics to select benzodiazepines frequently used for alcohol withdrawal. The objective of this study is to describe the effectiveness and safety of our institutional protocols during three time periods utilizing benzodiazepines and barbiturates for the acute treatment of alcohol withdrawal in the emergency department. METHODS: Adult patients presenting to the ED for acute alcohol withdrawal from April 1st, 2016 to January 31st, 2018 were reviewed. Patients who received at least one dose of treatment were included. Treatments were based on availability of medication and given protocol at time of presentation. The primary outcome was the rate of ICU admission. RESULTS: 300 patient encounters were included. Overall baseline characteristics were equal across groups, except for age. There was no difference in rate of ICU admission from the ED between groups (D:8, L&P:11, P:13 patients, p = 0.99). Rate of mechanical ventilation was no different across all groups (D:1, L&P:3, P:3 patients, p = 0.55). CONCLUSION: During benzodiazepine shortages, phenobarbital is a safe and effective treatment alternative for alcohol withdrawal. Incorporating phenobarbital into a benzodiazepine based protocol or as sole agent led to similar rates of ICU admission, length of stay, and need for mechanical ventilation in patients treated for alcohol withdrawal in the emergency department.