Critical Care

Critical Care

The Utility of Color Doppler to Confirm Endotracheal Tube Placement: A Pilot Study

Gildea, TH.

Grayscale ultrasound (US) imaging has been used as an adjunct for confirming endotracheal tube (ETT) placement in recent years. The addition of color Doppler imaging (CDI) has been proposed to improve identification but has not been well studied. The aim of this study was to assess whether CDI improves correct localization of ETT placement.

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Critical Care

Emergency Department-based Intensive Care Unit Use Peaks Near Emergency Department Shift Turnover

Haas, NL.

The Emergency Critical Care Center (EC3) is an emergency department-based intensive care unit (ED-ICU) designed to improve timely access to critical care for ED patients. ED patients requiring intensive care are initially evaluated and managed in the main ED prior to transfer to a separate group of ED-ICU clinicians. The timing of patient transfers to the ED-ICU may decrease the number of handoffs between main ED teams and have an impact on both patient outcomes and optimal provider staffing models, but has not previously been studied. We aimed to analyze patterns of transfer to the ED-ICU and the relationship with shift turnover times in the main ED. We hypothesized that the number of transfers to the ED-ICU increases near main ED shift turnover times.

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Critical Care

Low-cost Videolaryngoscope in Response to COVID-19 Pandemic

Saoraya, J.

As the novel coronavirus 2019 (COVID-19) has rapidly become a global pandemic, emergency physicians worldwide play essential roles in the frontline management of critically ill patients with COVID-19. In emergency airway management, video laryngoscopes (VL) are recommended over direct laryngoscopy to minimize healthcare worker exposure to aerosolized particles.1 However, the VL may be too expensive or unavailable in resource-limited settings, where it is needed to protect the limited number of healthcare providers. We, therefore, reintroduce the idea of creating a low-cost VL from the direct laryngoscope (DL) and a low-cost (approximately $8) smartphone borescope, which is widely available to purchase online. The borescope camera should be secured at the same level as the light sources of the Macintosh blade for the optimal view (Figure, Video). Previous studies of such “Do-It-Yourself” (DIY) VL demonstrated an improved glottic view and increased ease of use in simulated settings for novices and may be comparable to the commercial VL for experienced intubators.2,3 Moreover, if the capability exists, the disposable blade could be produced from 3D printing.2

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Critical Care

Minimizing Pulse Check Duration Through Educational Video Review

Yamane, D.

The American Heart Association Guidelines for Cardiopulmonary Resuscitation (CPR) recommend pulse checks of less than 10 seconds. We assessed the effect of video review-based educational feedback on pulse check duration with and without point-of-care ultrasound (POCUS).

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Critical Care

Responding to a Pandemic: The Role of EM-CCM on ICU Boarders in an Urban Emergency Department

Pflaum-Carlson, J.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the novel coronavirus that was first detected in China, was declared a public health emergency of international concern on January 30, 2020. By March 11, 2020, the World Health Organization (WHO) characterized it as a global pandemic. The United States reported its first cases of coronavirus disease 2019 (COVID-19), the illness caused by SARS-CoV-2, on January 20, 2020. As of September 2, 2020, there have been over 6.26 million confirmed cases of COVID-19 in the United States with over 13,000 confirmed cases in the city of Detroit, Michigan.1 SARS-CoV-2 is a highly transmissible virus. The disease it causes, COVID-19, is a predominantly respiratory illness with varying symptom severity contributing to the potential for significant critical illness.

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Critical Care

Sternal Intraosseous Devices: Review of the Literature

Laney, JA.

The intraosseous (IO) route is one of the primary means of vascular access in critically ill and injured patients. The most common sites used are the proximal humerus, proximal tibia, and sternum. Sternal IO placement remains an often-overlooked option in emergency and prehospital medicine. Due to the conflicts in Afghanistan and Iraq the use of sternal IOs have increased.

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Critical Care

Alteplase for Acute Ischemic Stroke Beyond 3 hours: Enthusiasm Outpaces Evidence

Garg, R.

In a 2014 editorial, Shy pointed out a statistical error in ECASS III.3 The trial’s reported adjusted primary analysis did not account for the baseline imbalance in prior stroke status. The ECASS III authors have not addressed this statistical error in the literature. In a recent publication, Alper et al used the raw data to reanalyze the ECASS III data with appropriate adjustments. In a multivariate model adjusted for both baseline National Institutes of Health Stroke Scale (NIHSS) scores (P = .03 between groups) and prior stroke status (P = .003 between groups) there was a non-significant difference between alteplase and placebo for all efficacy outcomes.4

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Critical Care

Response to: “POCUS to Confirm Intubation in a Trauma Setting”

Gottlieb, M.

We thank the authors for their insights and for sharing this case. The authors describe a patient who was intubated with the endotracheal tube (ETT) located at the tip of the carina, thereby allowing for bilateral lung sliding, while placing the ETT at risk of converting to a mainstem intubation.

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Critical Care

POCUS to Confirm Intubation in a Trauma Setting

Scheier, E.

In the recent edition of the Western Journal of Emergency Medicine, Gottlieb and colleagues discuss point of care ultrasound (POCUS) confirmation of intubation.1 Up to 25% of intubations using the classic formula of endotracheal tube (ETT) depth equal to three times the ETT diameter are inappropriately positioned,2 and 35–60% of mainstem intubations are missed by auscultation.1 Therefore, chest radiograph (CXR) has traditionally been used for confirmation of appropriate ETT placement.

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Critical Care

Respone to: “Limitations of Retrospective Chart Reviews to Determine Rare Events, and the Unknown Relative Risk of Droperidol”

Cole, JB.

We thank the authors for their interest in our article, and for highlighting some important limitations of our work. 1 We are grateful for the opportunity to address these concerns further.

Regarding the authors’ first concern, indeed we already acknowledge in our limitations section that many of our patients did not receive continuous cardiac monitoring, and asymptomatic events could have been missed. While the clinical importance of asymptomatic self-terminating dysrhythmias is debatable, this question has fortunately been addressed by the DORM II investigators, who prospectively studied patients receiving droperidol for acute behavioral disturbance in multiple Australian emergency departments (ED). All patients in that study were initially treated in a critical care bed and attached to a cardiac monitor. When available, continuous ECG recordings were later analyzed, no patients had dysrhythmias, and while QT prolongation was observed the investigators found it was frequently due to causes other than droperidol. 2 We believe the incidence of such transient asymptomatic dysrhythmias in our study is likely miniscule.

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Critical Care

Comment on “The Incidence of QT Prolongation and Torsades des Pointes in Patients Receiving Droperidol in an Urban Emergency Department”

DiSalvo, PC.

We read with interest the recent article discussing QT prolongation and torsade des pointes (TdP) and droperidol.1 The paucity of readily available antipsychotics and antiemetics that are not associated with QT prolongation makes selection of an appropriate pharmaceutical challenging in ideal situations and decidedly complex when confronted with an agitated, delirious, or intoxicated patient.

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Critical Care

Impact of Providing a Tape Measure on the Provision of Lung-protective Ventilation

Ives Tallman, CM.

Emergency department (ED) patients are frequently ventilated with excessively large tidal volumes for predicted body weight based on height, which has been linked to poorer patient outcomes. We hypothesized that supplying tape measures to respiratory therapists (RT) would improve measurement of actual patient height and adherence to a lung-protective ventilation strategy in an ED-intensive care unit (ICU) environment.

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Critical Care

Transfer of Patients with Spontaneous Intracranial Hemorrhage who Need External Ventricular Drain: Does Admission Location Matter?

Tran, QC.

Patients with spontaneous intracranial hemorrhage (sICH) are associated with high mortality and require early neurosurgical interventions. At our academic referral center, the neurocritical care unit (NCCU) receives patients directly from referring facilities. However, when no NCCU bed is immediately available, patients are initially admitted to the critical care resuscitation unit (CCRU). We hypothesized that the CCRU expedites transfer of sICH patients and facilitates timely external ventricular drain (EVD) placement comparable to the NCCU.

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Critical Care

Randomized Controlled Trial of Ultrasound-guided Fluid Resuscitation of Sepsis-Induced Hypoperfusion and Septic Shock

Musikatavorn, K.

The ultrasound measurement of inferior vena cava (IVC) diameter change during respiratory phase to guide fluid resuscitation in shock patients is widely performed, but the benefit on reducing the mortality of sepsis patients is questionable. The study objective was to evaluate the 30-day mortality rate of patients with sepsis-induced tissue hypoperfusion (SITH) and septic shock (SS) treated with ultrasound-guided fluid management (UGFM) using ultrasonographic change of the IVC diameter during respiration compared with those treated with the usual-care strategy.

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Critical Care

First Pass Success Without Adverse Events Is Reduced Equally with Anatomically Difficult Airways and Physiologically Difficult Airways

Pacheco, GS.

The goal of emergency airway management is first pass success without adverse events (FPS-AE). Anatomically difficult airways are well appreciated to be an obstacle to this goal. However, little is known about the effect of the physiologically difficult airway with regard to FPS-AE. This study evaluates the effects of both anatomically and physiologically difficult airways on FPS-AE in patients undergoing rapid sequence intubation (RSI) in the emergency department (ED).

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Critical Care

The Use of Dexmedetomidine in the Emergency Department: A Cohort Study

Sinnott, J.

Management of sedation, analgesia, and anxiolysis are cornerstone therapies in the emergency department (ED). Dexmedetomidine (DEX), a central alpha-2 agonist, is increasingly being used, and intensive care unit (ICU) data demonstrate improved outcomes in patients with respiratory failure. However, there is a lack of ED-based data. We therefore sought to: 1) characterize ED DEX use; 2) describe the incidence of adverse events; and 3) explore factors associated with adverse events among patients receiving DEX in the ED.

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Critical Care

Comparing Drugs for Out-of-hospital, Shock-refractory Cardiac Arrest: Systematic Review and Network Meta-analysis of Randomized Controlled Trials

Srisurapanont, K.

The benefit of medications used in out-of-hospital, shock-refractory cardiac arrest remains controversial. This study aims to compare the treatment outcomes of medications for out-of-hospital, shock-refractory ventricular fibrillation (VF) or pulseless ventricular tachycardia (pVT).

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Critical Care

Utilization of Point-of-care Echocardiography in Cardiac Arrest: A Cross-sectional Pilot Study

Wolfe, Y.

Point-of-care (POC) echocardiography (echo) is a useful adjunct in the management of cardiac arrest. However, the practice pattern of POC echo utilization during management of cardiac arrest cases among emergency physicians (EP) is unclear. In this pilot study we aimed to characterize the utilization of POC echo and the potential barriers to its use in the management of cardiac arrest among EPs.

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Critical Care

Quality Improvement Initiative to Increase Rate of and Time to Post-intubation Analgesia in the Emergency Department

Imhoff, B.

Intubation and mechanical ventilation are common interventions performed in the emergency department (ED). These interventions cause pain and discomfort to patients and necessitate analgesia and sedation. Recent trends in the ED and intensive care unit focus on an analgesia-first model to improve patient outcomes. Initial data from our institution demonstrated an over-emphasis on sedation and an opportunity to improve analgesic administration. As a result of these findings, the ED undertook a quality improvement (QI) project aimed at improving analgesia administration and time to analgesia post-intubation.

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Critical Care

Randomised Controlled Trial Assessing Head Down Deep Breathing Method Versus Modified Valsalva Manoeuvre for Treatment of Supraventricular Tachycardia in the Emergency Department

Lim, HC.

Supraventricular tachycardia (SVT) is commonly encountered in the emergency department (ED). Vagal manoeuvres are internationally recommended therapy in stable patients. The head down deep breathing (HDDB) technique was previously described as an acceptable vagal manoeuvre, but there are no studies comparing its efficacy to other vagal manoeuvres. Our objective in this study was to compare the rates of successful cardioversion with HDDB and the commonly practiced, modified Valsalva manoeuvre (VM).

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Critical Care

Effectiveness of Mechanical Chest Compression Devices over Manual Cardiopulmonary Resuscitation: A Systematic Review with Meta-analysis and Trial Sequential Analysis

Sheraton, M.

Our goal was to systematically review contemporary literature comparing the relative effectiveness of two mechanical compression devices (LUCAS and AutoPulse) to manual compression for achieving return of spontaneous circulation (ROSC) in patients undergoing cardiopulmonary resuscitation (CPR) after an out-of-hospital cardiac arrest (OHCA).

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Critical Care

Efficacy of Laryngeal Tube versus Bag Mask Ventilation by Inexperienced Providers

Hart, MD, et al.

We performed a crossover study first year emergency medicine residents and third and fourth year medical students. After a brief instructional video followed by hands on practice, participants performed both techniques in random order on a simulated model for two minutes each. Returned tidal volumes and peak pressures were measured.

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Email: editor@westjem.org

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WestJEM
ISSN: 1936-900X
e-ISSN: 1936-9018

CPC-EM
ISSN: 2474-252X

Our Philosophy

Emergency Medicine is a specialty which closely reflects societal challenges and consequences of public policy decisions. The emergency department specifically deals with social injustice, health and economic disparities, violence, substance abuse, and disaster preparedness and response. This journal focuses on how emergency care affects the health of the community and population, and conversely, how these societal challenges affect the composition of the patient population who seek care in the emergency department. The development of better systems to provide emergency care, including technology solutions, is critical to enhancing population health.