Use of a lighted stylet to confirm correct endotracheal tube placement.

Despite the fact that endotracheal intubation is a skill essential for clinicians of varied specialties, the procedure is not without risk, especially when practiced in an emergency setting, particularly the field environment. Of all complications, none is more serious than unrecognized esophageal intubation. Clinical experience with a method of guided orotracheal intubation using a rigid-wire lighted stylet prompted us to develop a technique to confirm correct intratracheal placement of an endotracheal tube using a new flexible lighted stylet designed for nasotracheal intubation. Endotracheal tubes were placed under direct vision at three sites in the upper airway of five unembalmed human cadavers: esophagus (20 cm from the teeth), trachea (20 cm from the teeth) and the right or left pyriform fossa. Thirty-five volunteer intubators were asked to identify tube placement using the transilluminated glow from the flexible nasotracheal lighted stylet. A total of 168 placements were made in 40 trials. Only one of 56 intratracheal placements was misidentified as esophageal. Of 112 extratracheal placements (esophagus or pyriform fossa), one was misidentified as intratracheal. The level of experience or training bore no relationship to the ability of the intubator to identify correct placement. We conclude from the study that this technique is a rapid and reliable method of confirming correct placement of endotracheal tubes. The use of this method could reduce, if not eliminate, unrecognized esophageal intubation in the field, emergency department, the critical care unit, and the operating room.

Treatment of toad venom poisoning with digoxin-specific Fab fragments.

Toxicity from toad venom poisoning is similar to digoxin toxicity and carries a high mortality rate. We report on six previously healthy men who developed vomiting and bradycardia after ingesting a purported topical aphrodisiac. Each patient had positive apparent digoxin levels and the first four patients died of cardiac dysrhythmias. The last two patients recovered following treatment with digoxin Fab fragments. We analyzed samples of the purported aphrodisiac and found that it was identical to Chan Su, a Chinese medication made from toad venom. To our knowledge, this is the first reported use of digoxin Fab fragments to treat toad venom poisoning.

Use of practice tracks in the medical specialties.

OBJECTIVES: To evaluate the use of practice tracks by each of the 24 medical specialty boards and to compare this with the experience in emergency medicine (EM). METHODS: Scripted telephone surveys were conducted with representatives of each of the specialty boards. RESULTS: Of 24 specialties currently recognized by the American Board of Medical Specialties (ABMS), 14 (58%) reported a history of a practice track. Eight boards reported never having a practice track and 2 were unsure. All practice tracks have been limited in duration, most commonly closing after a specified period. The mean duration of the practice tracks was 9.8 years, the median was 7.5 years, and the range was 3-27 years. The practice track in EM was open for 9 years. CONCLUSIONS: Practice tracks were common in the early years of most specialties and most were limited by duration. The history of the practice track in EM is not dissimilar to those of other specialties.

The focused abdominal sonography for trauma (FAST) examination: considerations and recommendations for training physicians in the use of a new clinical tool.

Focused abdominal sonography for trauma (FAST) is being used by growing numbers of emergency physicians and surgeons because it has proven to be an accurate, rapid, and repeatable bedside test for evaluating abdominal trauma victims. Controversy exists about the optimal means of FAST education and the number of examinations necessary to demonstrate competency. Most FAST educators agree that FAST education should consist of three phases: didactic, practical, and experiential. This article summarizes options and preliminary recommendations suitable for developing a FAST curriculum.

Ultrasonography in emergency medicine.

The use of ultrasonography in emergency medicine is an area of rapid growth and controversy. This article reviews the current and future applications of emergency ultrasonography with particular emphasis on the role of bedside scanning by the emergency practitioner. Abdominal, pelvic, and cardiac ultrasonographic applications are reviewed, as are the uses of ultrasonography as an adjunct to the performance of procedures in the Emergency Department.

The practice of teaching endotracheal intubation on recently deceased patients.

There are few data available regarding the emergency department practice of using recently dead patients (RDP) for practice and training in endotracheal intubation (ETI/RDP). We investigated several aspects of practice by means of a survey sent to all 5,397 emergency departments in the country. Of the 992 (18.3%) responses, 537 (54.1%) did practice ETI/RDP; 455 (45.8%) did not (P less than 0.005). ETI/RDP was used significantly more commonly for instruction of paramedics (411 institutions [77%]), than for other classes of health providers (P less than 0.0001). Overall, only 69 emergency departments (7%) had any written policy governing ETI/RDP; even among those actually practicing ETI/RDP, 84% had no written policy. Likewise, patients and families were rarely informed of the practice. In institutions where ETI/RDP does occur, only 15 (3%) of emergency departments have a policy which mandates such notification. There was widespread agreement as to the educational value of the practice, although it was more favored in hospitals practicing ETI/RDP than those that do not: 411 of 418 (98%) hospitals practicing ETI/RDP agreed that it was an important component of medical education, as did 240 (80%) of institutions not practicing it (P less than 0.0001). Nearly equal percentages of teaching hospitals (53.8%) and nonteaching facilities (57.9%) engage in ETI/RDP (P = 0.35). Objections to ETI/RDP had been noted in 25% of the institutions where it was practiced.

Effectiveness of different crystalloid i.v. solutions in establishing urine flow.

There are several situations in Emergency Medicine when it is desirable to promote a prompt diuresis to fill the bladder or obtain urine for diagnostic tests. We attempted to determine which of 3 commonly used intravenous solutions is most effective in establishing urine flow. In a prospective, randomized double-blind crossover study of 12 healthy male volunteers, we rapidly infused 20 cc/kg of D5W, D51/2NS, or 1/2NS immediately after voiding. Voided urine volumes were then recorded at 30, 60, 90, and 120 min postinfusion and the degree of glycosuria, if any, was noted. Total mean urine volume after D5W was 1181 ml, significantly greater than after 1/2NS (825 ml) and 1/2NS (630 ml), which did not differ between each other. Mean urine volume was greater at every time interval for the D5W group, and glycosuria was common in both D5-containing groups. We conclude that in healthy subjects, D5W is more effective in promoting rapid diuresis than are sodium-containing solutions.

Does wearing a necktie influence patient perceptions of emergency department care?

We conducted a prospective study of discharged emergency department (ED) patients to determine the effect of wearing a necktie by emergency physicians (EPs) had on patients' impression of their medical care. All male EPs were assigned randomly by dates to wear a necktie or no necktie, and the attire worn was otherwise similar in all respects. The study was conducted at a community teaching hospital with an Emergency Medicine residency and an annual census of 40,000. A total of 316 patients were surveyed. There were no statistically significant differences between patient groups in any of the five areas surveyed, including patient perception of physicians' appearance. Nearly 30% of patients incorrectly identified their doctor as wearing a necktie when no necktie was worn, and the perception of tie wearing was correlated with a positive impression of physician appearance. Wearing or not wearing a necktie did not significantly affect patients' impression of their physician or the care they received. However, patients seemingly preferred the appearance of physicians who were perceived to wear neckties.

Metered-dose aerosolized bronchodilators in prehospital care: a feasibility study.

The prehospital use of aerosolized bronchodilators was studied in 50 adult patients with bronchospasm. The specific beta 2-agonist, albuterol, was discharged from a metered-dose inhaler (MDI) into the Inhal-aid reservoir-delivery device. No serious adverse effects were encountered, although a substantial proportion of the patients (36%) had difficulty utilizing the device. Ability to use the system properly correlated with improvement in symptoms; inability to use the device was most clearly related to severity of clinical presentation. It is concluded that the use of aerosolized bronchodilators is feasible in prehospital care and most useful in patients with mild or moderately severe symptoms.

Emergency transcutaneous pacing in the management of patients with bradyasystolic rhythms.

Survival rates in cases of bradyasystolic cardiac arrest are uniformly low, being reported at from 0% to 3%. Recent advances in technology and microcircuitry have produced lightweight, portable external pacing devices that are less painful to the patient. In an on-going clinical trial of early transcutaneous pacing, five cases were seen in which transcutaneous pacing was begun at the onset of the patients' rhythm disturbance. All five patients survived to leave the hospital. Three of the patients were treated in the prehospital setting. Because of the rapidity with which pacing can be implemented, the ease of application and simplicity of operation, transcutaneous pacing has several advantages over the placing of transvenous pacemakers in the field or emergency department setting. In hemodynamically-compromising bradydysrhythmias unresponsive to pharmacologic intervention, the early use of transcutaneous pacing may improve survival in a group of patients who might otherwise die.

An evaluation of nitrous oxide analgesia during transcutaneous pacing.

Transcutaneous cardiac pacing (TCP) is a promising prehospital intervention, but there are little data available regarding protocols to improve patient tolerance to TCP. A 50:50 nitrous oxide:oxygen analgesic mixture also is a commonly employed prehospital intervention. In this randomized, prospective study, we compared the discomfort experienced by 18 healthy subjects when paced in two trials at the capture threshold: one following breathing of a 50:50 nitrous oxide:oxygen mixture; and the second only breathing room air. Discomfort was rated on an analog scale from 1 (minimal discomfort) to 10 (severe pain). Of the 18 subjects, 15 (83%) reported that nitrous oxide improved the tolerance to pacing at capture threshold. The median pain scores at capture threshold in the nitrous oxide and room air group were 3.8 and 5.0 respectively (P less than .05). Nine of the subjects tolerated TCP for the maximum allotted time of 30 seconds in each trial; six tolerated TCP for a longer time period in the nitrous oxide trial; three tolerated TCP longer in the room air trial. These data suggest that inhalation of 50:50 nitrous oxide:oxygen mixture may improve tolerance to TCP in the conscious patient.

Are race, age, gender, and insurance status determinants in interhospital helicopter transport time and frequency?

OBJECTIVE: To examine the effects of age, race, gender, and insurance status on utilization and times-to-transport (TTT) for interhospital air medical transfers from rural hospitals to tertiary care centers. DESIGN: A retrospective review of interhospital transport records. The TTT was examined as a function of age, gender, race, and insurance status using the Student's t-test for unpaired samples. The Exact Binomial Test (alpha error at 0.05) was used to compare the observed versus expected transport rates for non-whites. SETTING/PARTITIPANTS: A total of 268 patient transfers from hospitals within a two-county region in central Pennsylvania to tertiary care centers was analyzed. All records with sufficient demographic, TTT, or insurance data were included. Absence of data was the only exclusion. RESULTS: The TTT (mean +/-SD) was longer (2666 +/-3940 minutes (min.) versus 619 +/-909 min., respectively) for adult than pediatric patients (p less than .01), and (2588 +/-4041 min. versus 640 +/-1301 min., respectively) for insured versus uninsured patients (p less than .01). The observed proportion of non-whites transported was less than expected (.41% versus 2.1%) based on the proportion of non-whites in the region (p less than .05). CONCLUSION: The TTT was longer for adults than for children and for the insured than the uninsured. Non-whites were transported less frequently than predicted.

Saliva alcohol reagent strips in altered response protocols.

The prehospital care provider has been limited in his or her initial assessment of patients due to having available only a limited number of simple diagnostic tests. There has not been an accurate field test available to rule out significant ethanol intoxication. We designed a prospective trial for the prehospital setting to test the utility of a rapid, semi-quantitative, saliva alcohol reagent strip for patients with an altered level of consciousness. We found that these strips were useful in ruling out significant ethanol intoxication as a cause of an altered level of consciousness with a sensitivity of 85.7% and a specificity of 94.4%, but were not useful in accurately predicting the blood alcohol level. We conclude that these reagent strips are useful in the prehospital setting to provide information about patients with an altered level of consciousness.

Open-chest cardiac massage. The possible rebirth of an old procedure.

Open-chest cardiac massage was widely and successfully used for many decades before its virtual abandonment 25 years ago. Both experimental evidence and basic physiologic evidence indicate that it has many advantages over closed-chest massage (especially increased cardiac output). Both resuscitation techniques have specific and unique advantages and disadvantages: They are not mutually exclusive. However, significant increases in rates of survival after cardiac arrest cannot be expected with variations of closed-chest cardiac massage and standard advanced life support services. Therefore, physicians must be willing to support controlled human studies that can definitively determine the proper role of each in resuscitation after cardiac arrest.

Emergency management of acute pain. New options and strategies.

Emergency physicians often encounter patients in pain and may also have to cope with other problems (eg, alcohol intoxication, a patient's stubborn will to drive after the emergency department visit, narcotic "allergy"). Novel approaches can be used to treat these patients. Dr Heller discusses such approaches, including measures for treating patients with drug-seeking behavior (eg, use of nonnarcotic parenteral agents), and describes treatment options for patients with such specific conditions as hypotension, chest pain, and renal colic.

Overdoses.

Certain basic principles are applicable to most drug overdose emergencies. These include emptying the stomach, administering activated charcoal, supporting vital functions, protecting target organs and using specific antidotes in appropriate cases. There are certain steps to be taken automatically in an unconscious patient with an unknown overdose. Drug screens rarely affect management. Special situations involve overdoses of acetaminophen, salicylates, tricyclic antidepressants, anticholinergics and narcotics.

Effectiveness of commercially available aqueous activated charcoal products.

A human research project was conducted to compare the relative effectiveness of five commercially available aqueous activated charcoal products in 25-g amounts--Acta-Char, Actidose-Aqua, Insta-Char, Liqui-Char, and Super-Char. Seven healthy adult human fasting volunteers participated. The study was double-blinded and subjects served as their own controls. Aspirin 2,592 mg was administered to each subject in the control phase to establish baseline aspirin absorption as measured by serial serum salicylate levels. During each of the five study phases 2,592 mg aspirin and a specific brand of activated charcoal were administered to the subjects and serial serum salicylate levels were drawn. Aspirin absorption was calculated using the trapezoidal rule for measuring the area under the concentration-time curve. Total aspirin absorption was reduced as follows: Super-Char, 57.76%; Actidose-Aqua, 50.42%; Insta-Char, 39.55%; Liqui-Char, 33.40%; and Acta-Char, 27.46%. Although there were large apparent differences in the adsorptive capacities of the products, the only statistically significant difference was between Super-Char and Acta-Char. The failure to show statistical differences in the face of large apparent differences may have been a reflection of type II beta error due to the small sample size. The most common factor responsible for the apparent differences in the adsorptive capacities of the products was most likely the surface area of the activated charcoals that were used. The higher surface area products, Super-Char (3,150 m2/g) and Actidose-Aqua (1,500 m2/g) prevented the absorption of aspirin more effectively than the other three products that had surface areas of 950 m2/g.