The National Hospital Ambulatory Medical Care Survey is a massive database of abstracted patient records, systematically generated to produce a representative sample of the nation’s Emergency Department visits.
It should come as no surprise that retrospectively abstracted data from the electronic medical record sometimes fails to accurately reflect patient care. The important question, however, is “how often?” This review of NHAMCS by one of the Annals editors looked at a measurement that ought to be pretty obvious – intubation. If you can’t figure out whether a patient has been intubated via chart review, there’s some serious issues with your data sourcing. However, in this review of NHAMCS, the author interprets up to one in four charts as being potentially inaccurate due to inconsistencies between documented intubation and the final disposition of the patient (e.g., non-ICU settings, home, observation status, etc.)
Now, there are some instances in which patients are intubated in the Emergency Department – yet not subsequently dispositioned to a critical care or morgue – but these “temporary” intubations certainly do not constitute 25% of intubations. The author goes on to note that Annals publishes a NHAMCS study at least twice a year – relatively influential towards practice given the Impact Factor – and the flaws in this data should limit the relative weighting of its importance.
“Congruence of Disposition After Emergency Department Intubation in the National Hospital Ambulatory Medical Care Survey”
Category: Intubation
Pediatric Intubation – Not Always Successful
This is an observational study of pediatric medical resuscitation, published in Annals of Emergency Medicine, using video to evaluate the frequency of various adverse events during pediatric intubation.
As expected in a teaching institution, there is a fair bit of variability in initial success rates – ranging from 35% first-pass success for pediatrics residents up to 89% for PEM or anesthesia attendings. Overall 52% had success on the first attempt. Unfortunately, 61% experienced at least one adverse event during intubation. These were typically not clinically important with regard to patient-oriented outcomes.
However, what is more entertainingly concerning is how few of the complications make it into the medical record. The written documentation overestimates first-attempt success, underestimates desaturation during the procedure, and even completely omits any mention of one of the two episodes of CPR required during resuscitation.
My guess is that Cincinnati Children’s may have had a documentation quality review after this data were collected.
“Rapid Sequence Intubation for Pediatric Emergency Patients: Higher Frequency of Failed Attempts and Adverse Effects Found by Video Review”
www.ncbi.nlm.nih.gov/pubmed/22424653
The Papermate Flexgrip Cricothyroidotomy
Emergency Medicine has more than a little MacGyver instinct to it – and one of the semi-urban legend aspects of EM is the ability to perform a cricothyroidotomy as a life-saving measure in any situation. The most commonly described version is performed using simple, commonly available tools – any sort of cutting blade and a hollow tube, such as a hollow pen.
Several studies have approached feasibility by describing the flow dynamics of various pens, but this is the first study to evaluate the procedural feasibility of bystander cric. This is an observational, cadaveric study using non-EM junior physicians and medical students in which they used a 26-blade scalpel and a Papermate ballpoint pen of 8.9mm external diameter to attempt an “off-the-cuff” cric. The 9 participants attempting 14 procedures were successful 8 times, although complications were frequent, including vascular and muscular/cartilaginous injuries.
Whether this is externally valid to the living, or to patient-oriented outcomes of effective ventilation, I’m not so certain – but, then again, if the alternative is 100% mortality via no possible ventilation, it’s a fun study to see.
“Observational cadaveric study of emergency bystander cricothyroidotomy with a ballpoint pen by untrained junior doctors and medical students”
http://emj.bmj.com/content/early/2012/05/04/emermed-2012-201317.short
Endotracheal Tube Verification Via Ultrasound
I think I’ve discovered the new paradigm of research in ultrasound. Every time you do a procedure or make a diagnosis, slap the ultrasound on someone and see if you can reliably identify anatomic changes.
It looks like, with their practiced ultrasonographers, that they can get some preliminary information regarding endotracheal tube placement by performing transtracheal ultrasound. Their “gold standard” was waveform capnography – which is a fair gold standard, but not universally sensitive and specific for tube placement in all clinical situations. Essentially, if the ETT is in the correct place, there is only one “air-mucosal interface” observed with high-frequency linear probe, and, if the ETT is in the esophagus, you have a second, posterior air-mucosal interface.
Seems reasonable.
Experts did it correctly with 99% sensitivity and 94% specificity, and the main advantage was speed.
“Tracheal rapid ultrasound exam (T.R.U.E.) for confirming endotracheal tube
placement during emergency intubation.”
Surfactant for Hydrocarbon Aspiration
I’ve seen surfactant administered for alveolar collapse following near-drowning, but this is a case report regarding surfactant use in severe pneumonitis after low viscosity/low volatility lamp oil. Less than 1mL of similar aspirated hydrocarbons may result in significant lung injury. In their specific case they administered 80 mL/m2 of surfactant intratracheally as rescue therapy when their patient continued to become hypoxemic despite recruitment maneuvers on mechanical ventilation.
Definitely something to keep in mind depending on the pathophysiology of the lung injury.
“Early administration of intratracheal surfactant (Calfactant) after hydrocarbon aspiration.”
http://www.ncbi.nlm.nih.gov/pubmed/21624880
Difficult Intubations and Association With Complications
Retrospective data out of the ketamine vs. etomidate prospective survival study.
Doesn’t prove anything – and it makes me want to go back and look at the original ketamine vs etomidate article to see if difficulty of intubation was included as a demographic factor – and, I wish this study indicated which sedative medication was used as well.
In any event, the more complicated an intubation was, the more likely there were complications with the intubation. And, further down the road, more patients who had intubation complications were deceased at the end of their follow-up period. Things that predicted complications during procedure included age, illness severity, BMI, specific medical disorders, respiratory distress, and difficult intubation.
Nothing here changes practice – since intubation is not an elective procedure. This is more a recognition that, yet again, sick people die.