Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health

Objective: To determine the relationship between emergent intubation (emergency department and field intubation cases combined) and mortality in patients with traumatic brain injury (TBI) while controlling for injury severity.

Methods: Retrospective observational study of 981 (35.2% intubated, 64.8% not intubated) patients with TBI evaluating the association between intubation status and mortality. Logistic regression was used to analyze the data. Injury severity measures included Head/Neck Abbreviated Injury Scale (H-AIS), systolic blood pressure, type of head injury (blunt vs. penetrating), and a propensity score combining the effects of several other potential confounding variables. Age was also included in the model.

Results: The simple association of emergent endotracheal intubation with death had an odds ratio (OR) of 14.3 (95% CI = 9.4 – 21.9). The logistic regression model including relevant covariates and a propensity score that adjusted for injury severity and age yielded an OR of 5.9 (95% CI = 3.2 – 10.9).

Conclusions: This study indicates that emergent intubation is associated with increased risk of death after controlling for a number of injury severity indicators. We discuss the need for optimal paramedic training, and an understanding of the factors that guide patient selection and the decision to intubate in the field. [WestJEM.2008;9:184-189]

Objectives: Airway management is a critical procedure performed frequently in emergency departments (EDs). Previous studies have evaluated the complications associated with this procedure but have focused only on the immediate complications. The purpose of this study is to determine the incidence and nature of delayed complications of tracheal intubation performed in the ED at an academic center where intubations are performed by emergency physicians (EPs).

Methods: All tracheal intubations performed in the ED over a one-year period were identified; 540 tracheal intubations were performed during the study period. Of these, 523 charts (96.9%) were available for review and were retrospectively examined. Using a structured datasheet, delayed complications occurring within seven days of intubation were abstracted from the medical record. Charts were scrutinized for the following complications: acute myocardial infarction (MI), stroke, airway trauma from the intubation, and new respiratory infections. An additional 30 consecutive intubations were examined for the same complications in a prospective arm over a 29-day period.

Results: The overall success rate for tracheal intubation in the entire study group was 99.3% (549/553). Three patients who could not be orally intubated underwent emergent cricothyrotomy. Thus, the airway was successfully secured in 99.8% (552/553) of the patients requiring intubation. One patient, a seven-month-old infant, had unanticipated subglottic stenosis and could not be intubated by the emergency medicine attending or the anesthesiology attending. The patient was mask ventilated and was transported to the operating room for an emergent tracheotomy. Thirty-four patients (6.2% [95% CI 4.3 – 8.5%]) developed a new respiratory infection within seven days of intubation. Only 18 patients (3.3% [95% CI 1.9 – 5.1%]) had evidence of a new respiratory infection within 48 hours, indicating possible aspiration pneumonia secondary to airway management. Three patients (0.5% [95% CI 0.1 – 1.6%]) suffered an acute MI, but none appeared to be related to the intubation. One patient was having an acute MI at the time of intubation and the other two patients had MIs more than 24 hours after the intubation. No patient suffered a stroke (0% [95% CI 0 – 0.6%]). No patients suffered any serious airway trauma such as a laryngeal or vocal cord injury.

Conclusions: Emergency tracheal intubation in the ED is associated with an extremely high success rate and a very low rate of delayed complications. Complication rates identified in this study compare favorably to reports of emergency intubations in other hospital settings. Tracheal intubation can safely be performed by trained EPs.

[WestJEM. 2008;9:190-194.]

Background: Because of its many desirable properties, etomidate is widely used as an induction agent for endotracheal intubation. However, some have recently called into question the safety of etomidate for even single-bolus use due to its known effects on adrenal suppression.

Objectives: We sought to compare the in-hospital mortality between septic patients given etomidate and those given alternative induction agents for intubation.

Methods: We performed a retrospective chart review of intubated septic patients treated in our hospital. We collected data from patients over the age of 18 with sepsis who were intubated in the pre-hospital setting, in our emergency department, or on the wards of our hospital, and calculated the in-hospital mortality of each group.

Results: We identified 181 patients with sepsis who were intubated over the study period; 135 received etomidate and 46 received alternative agents or no induction agent. Baseline characteristics, vital signs, and laboratory values were similar between the two groups. Of the 46 patients receiving alternative agents or no agent, 18 died, yielding an unadjusted mortality of 39.1% (95% CI 25.5% to 54.6%), while of the 135 patients receiving etomidate, 63 died, for an unadjusted mortality of 46.7% (95% CI 38.1% to 55.4%), P=0.38.

Conclusion: We found a non-statistically significant 7.6% absolute increase in mortality in patients given etomidate in our small-sized study population.

[WestJEM. 2008;9:195-200.]

Objectives: This study describes a means of assessing the external jugular venous pressure (JVP) as an indicator of normal or elevated central venous pressure (CVP).

Methods: Intensive care unit patients having CVP monitoring were examined. With patients in bed, the external jugular vein (EJV) was occluded at the base of the neck and observed to distend. The occlusion was then removed and the vein observed for collapse. Complete collapse was hypothesized to indicate a non-elevated CVP (≤8cm of water). In those patients whose EJV collapsed incompletely, the vein was then occluded with the finger near the angle of the jaw. With the occlusion maintained, the vein was milked downwards with the other hand to cause its emptying and was then observed for filling from below. Filling from below was hypothesized to indicate an elevated CVP (>8cm of water).

Results: In 12 of the 40 patients examined, the EJV could not be assessed (EJV not seen at all: 5, and difficult to visualize: 7). For the remaining 28 patients, 11 had a CVP > 8 cm, while 17 had a CVP of < 8. EJV assessment was 100% accurate (95% Confidence Interval 88-100) in predicting whether or not a patient’s CVP was greater or less than 8 cm of water.

Conclusion: EJV assessment, when visible, is accurate to clinically assess a patient’s CVP in the hands of the author. Further studies are needed to see if they are reproducible by other observer.

[WestJEM. 2008;9:201-205.]

Background: Cardiopulmonary resuscitation (CPR) is now widely used as a treatment for ventricular fibrillation, though numerous studies have shown the outcome of standard CPR to be dismal. Alternative methods of CPR, including interposed abdominal compression, constant aortic occlusion, and the use of intrathoracic pressure regulator, have been shown to increase cardiac output and affect the mortality rate of CPR.

Objectives: Here we suggest the Trendelenburg position as yet another method of increasing cardiac output and therefore improving the effectiveness of chest compressions. We hypothesized that the use of the Trendelenburg position during CPR would increase cardiac output as measured by carotid blood flow.

Methods: We anaesthetized six pigs and measured their pre-arrest carotid flow rate for two minutes. We then induced ventricular fibrillation in those pigs and performed open-chest CPR on them. Post-arrest carotid blood flow was measured for two minutes each at 0 (supine position), 10, 20, and 30 degrees of head-down tilt in each pig. The mean carotid flow for each degree of tilt was compared to mean carotid flow at 0 degrees of tilt using a paired student t-test.

Results: We found an increase of up to 1.4-fold in carotid blood flow during CPR in the Trendelenburg position, though only 20 and 30 degrees of Trendelenburg showed a statistically significant increase from the 0 degrees of tilt in pigs.

Conclusion: The Trendelenburg position can lead to increased blood flow through the carotid arteries during CPR in this pig model. Future studies should investigate whether this increased blood flow through the carotid arteries leads to improved brain perfusion and better neurologic outcomes.

[WestJEM. 2008;9:206-211.]

Background: Acute dermatologic conditions are a concern for acute care practitioners. Comprising 1.4% of presenting complaints to emergency departments, most skin complaints are relatively benign; however, some conditions can be quite severe. Prompt diagnosis is essential to avoid unnecessary morbidity and mortality.

Objectives: To review drug-induced vasculitis.

Case Report: We present the case of a 43-year-old female with a chief complaint of bruising to her ear, arm, and leg. She was found to have necrotizing vasculitis induced by propylthiouracil.

Conclusion: In this case, we look at the highlights of this presentation and review key aspects of cutaneous vasculitis for the practicing emergency provider.

[WestJEM. 2008;9:212-215.]

Objectives: Intravenous (IV) access in children treated in the emergency department (ED) is frequently required and often difficult to obtain. While it has been shown that ultrasound can be useful in adults for both central and peripheral venous access, research regarding children has been limited. We sought to determine if the use of a static ultrasound technique could, a) allow clinicians to visualize peripheral veins and b) improve success rates of peripheral venous cannulation in young children in the ED. Methods: We performed a randomized clinical trial of children < 7 years in an academic pediatric ED who required IV access and who had failed the first IV attempt. We randomized patients to either continued standard IV attempts or ultrasound-assisted attempts. Clinicians involved in the study received one hour of training in ultrasound localization of peripheral veins. In the ultrasound group, vein localization was performed by an ED physician who marked the skin overlying the target vessel. Intravenous cannulation attempts were then immediately performed by a pediatric ED nurse who relied on the skin mark for vessel location. We allowed for technique cross-over after two failed IV attempts. We recorded success rate and location of access attempts. We compared group success rates using differences in 95% confidence intervals (CI). Results: We enrolled 44 children over a one-year period. The median age of enrollees was 9.5 months. We visualized peripheral veins in all patients in the ultrasound group (n=23) and in those who crossed over to ultrasound after failed standard technique attempts (n= 8). Venipuncture was successful on the first attempt in the ultrasound group in 13/23 (57%, CI, 35% to 77%), versus 12/21 (57%, CI, 34% to 78%) in the standard group, difference between groups 0.6% (95% CI -30% to 29%). First attempt cannulation success in the ultrasound group was 8/23 (35%, CI, 16% to 57%), versus 6/21 (29%, CI, 11% to 52%) in the standard group, difference between groups 6% (95% CI -21% to 34%). Conclusion: Ultrasound allows physicians to visualize peripheral veins of young children in the ED. We were unable to demonstrate, however, a clinically important benefit to a static ultrasound aided vein cannulation technique performed by clinicians with limited ultrasound training over standard technique after one failed IV attempt in an academic pediatric ED. [WestJEM. 2008;9:219-224.]

Acute ischemic stroke in a pediatric patient is a complex disease with a variety of etiologies that differ from adults. Though rare, they are a real phenomenon with potentially devastating consequences. Some treating institutions are using anti-thrombotic drug therapy with unclear benefits. Available literature, which is limited to case reports and retrospective reviews of databases, clouds this topic with both positive and negative outcomes. Emergency department management should focus on stabilization and resuscitation with immediate involvement of a pediatric neurologist and intensivist. The decision to use anti-thrombotic drug therapy, including anti-platelet drugs and thrombolytics, should be in consult with the specialists involved until randomized controlled trials determine their safety and efficacy in the pediatric population. [WestJEM. 2008;9:225-227.]

Background: Ovarian torsion (OT) occurs primarily in women of child-bearing age, but is rare in the pediatric population. The clinical presentation often consists of nonspecific abdominal complaints making the diagnosis difficult. Radiologic and sonographic evidence can be misleading. Although the delay in diagnosis from symptom onset is common, rapid diagnosis of ovarian torsion is imperative to prevent morbidity.

Case Report: We present the case of a four-year-old female who presented to the emergency department (ED) with a five-day history of intermittent abdominal pain and emesis. Initial diagnosis was suspicious for intussusception; however, on operative exploration, she was found to have a right adnexal torsion secondary to an ovarian teratoma. A right salpingo-oophorectomy was performed.

Conclusion: Early diagnosis of ovarian torsion may increase ovarian salvage and reduce morbidity. Faced with abdominal pain of uncertain etiology in a female child, emergency physicians should include ovarian torsion secondary to an ovarian mass in the differential diagnosis.

[WestJEM. 2008;9:228-231.]

Uterine incarceration is an uncommon but serious presentation in the emergency department that requires early recognition to improve maternal and fetal outcomes.

Case: A 29-year-old female, at 12 weeks gestation, presented to the emergency department (ED) with complaints of fever, sacral pain and urgency. Based on history and physical examination, she was found to have a retroverted, incarcerated uterus. After a failed attempt at reduction in the ED, her uterus was successfully reduced under general anesthesia.

Discussion: Pain and urinary difficulties, such as retention and hesitancy, are frequent in pregnancy, yet incarcerated uterus is an uncommon emergency department diagnosis that often presents with these symptoms. Clues to the diagnosis include a retroverted uterus, urinary retention, and pain in a patient presenting in the third to fourth months of gestation. Treatment is by manual reduction of the uterus. Complications range from spontaneous abortion to uterine rupture.

[WestJEM. 2008;9:232-234.]

Clitoral priapism is a rare condition that is associated with an extended duration of clitoral erection due to local engorgement of clitoral tissue resulting in pain. Although the pathophysiology is not completely understood, it has been associated with specific classes of medications, diseases that alter clitoral blood flow or others associated with small to large vessel disease. We present a case report of a 26-year-old patient who developed clitoral priapism without a clear medication or disease related etiology. The patient was treated with opiates, imipramine, non-steroidal anti-inflammatory medication, and local ice packs. She recovered uneventfully. [WestJEM. 2008;9:235-237.]

There is no doubt that in today’s practice of emergency medicine it is imperative to be familiar with how the law relates to administrative and clinical practice. It is my pleasure to announce, as section editor, the new Legal Medicine section of the Western Journal of Emergency Medicine. It is anticipated that the articles will cover a variety of areas and cases in the law. Some articles may focus on a particular disease or entity, with representative malpractice cases, and clinical caveats. Other articles may focus on legal concepts that enter the arena of emergency medicine. I have provided brief examples of each of these in this initial manuscript. Other articles could also cover original research related to law such as the standard of care in a given clinical situation or legal concepts such as consent, do-not-resuscitate, and AMA among others. I am hopeful that it will be of great interest to the readers. We welcome submissions and contributions for consideration. [WestJEM. 2008;9:238-239.]