Critical Care

Critical Care

Nasal Cannula Apneic Oxygenation Prevents Desaturation During Endotracheal Intubation: An Integrative Literature Review

Gleason, MS, et al.

We conducted a literature review of nasal-cannula apneic oxygenation during intubation, focusing on two components: oxygen saturation during intubation, and oxygen desaturation time. We performed an electronic literature search from 1980 to November 2017, using PubMed, Elsevier, ScienceDirect, and EBSCO.

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Critical Care

Comparison of Static versus Dynamic Ultrasound for the Detection of Endotracheal Intubation

Gottlieb, MD, et al.

Ultrasound is an increasingly studied modality for identifying ETT location. However, there has been significant variation in techniques between studies, with some using the dynamic technique, while others use a static approach. This study compared the static and dynamic techniques to determine which was more accurate for ETT identification.

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Critical Care

Higher Mallampati Scores Are Not Associated with More Adverse Events During Pediatric Procedural Sedation and Analgesia

Iyer, MD, et al.

Medical governing bodies have proposed guidelines for PSA performed by NAs, but these recommendations rarely suggest using Mallampati scores in pre-PSA evaluations. Our objective was to compare rates of adverse events during pediatric PSA in children with Mallampati scores of III/IV vs. scores of Mallampati I/II.

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Critical Care

Addition of Audiovisual Feedback During Standard Compressions Is Associated with Improved Ability

Aguilar, MD, et al.

A benefit of in-hospital cardiac arrest is the opportunity for rapid initiation of “high-quality” chest compressions as defined by current American Heart Association (AHA) adult guidelines as a depth 2–2.4 inches, full chest recoil, rate 100–120 per minute, and minimal interruptions with a chest compression fraction (CCF) ≥ 60%. The goal of this study was to assess the effect of audiovisual feedback on the ability to maintain high-quality chest compressions as per 2015 updated guidelines.

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Critical Care

Team Size and Stretching-Exercise Effects on Simulated Chest Compression Performance and Exertion

Schoen, MD, et al.

Investigators conducted a prospective experimental study to evaluate the effect of team size and recovery exercises on individual providers’ compression quality and exertion. Investigators hypothesized that 1) larger teams would perform higher quality compressions with less exertion per provider when compared to smaller teams; and 2) brief stretching and breathing exercises during rest periods would sustain compressor performance and mitigate fatigue.

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Critical Care

Sepsis Definitions: The Search for Gold and What CMS Got Wrong

Kalantari, DO, et al.

On October 1, 2015, the United States Centers for Medicare and Medicaid Services (CMS) issued a core measure addressing the care of septic patients. These core measures are controversial among healthcare providers. This article will address that there is no gold standard definition for sepsis, severe sepsis or septic shock and the CMS-assigned definitions for severe sepsis and septic shock are premature and inconsistent with evidence-based definitions.

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Critical Care

Appropriateness of Bolus Antihypertensive Therapy for Elevated Blood Pressure in the Emergency Department

Miller, MD, MS, et al.

Administration of bolus intravenous (IV) antihypertensive treatment to lower BP in patients without a true hypertensive emergency is a wasteful practice that is discouraged by hypertension experts; however, anecdotal evidence suggests this occurs with relatively high frequency. Accordingly, we sought to assess the frequency of inappropriate IV antihypertensive treatment in ED patients with elevated BP absent a hypertensive emergency.

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Critical Care

Severe Hyperkalemia: Can the Electrocardiogram Risk Stratify for Short-term Adverse Events?

Durfey, MD, et al.

The electrocardiogram (ECG) is often used to identify which hyperkalemic patients are at risk for adverse events. However, there is a paucity of evidence to support this practice. This study analyzes the association between specific hyperkalemic ECG abnormalities and the development of short-term adverse events in patients with severe hyperkalemia.

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Critical Care

Duration of Mechanical Ventilation in the Emergency Department

Angotti, MD, et al.

Due to hospital crowding, mechanically ventilated patients are increasingly spending hours boarding in emergency departments (ED) before intensive care unit (ICU) admission. This study aims to evaluate the association between time ventilated in the ED and in-hospital mortality, duration of mechanical ventilation, ICU and hospital length of stay (LOS).

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Critical Care

Derivation and Validation of The Prehospital Difficult Airway IdentificationTool (PreDAIT): A Predictive Model for Difficult Intubation

Jestin N. Carlson, MD, MS, et al.

Endotracheal intubation (ETI) in the prehospital setting poses unique challenges where multiple ETI attempts are associated with adverse patient outcomes. Early identification of difficult ETI cases will allow providers to tailor airway-management efforts to minimize complications associated with ETI.

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Critical Care

Efficacy and Safety of Tranexamic Acid in Prehospital Traumatic Hemorrhagic Shock: Outcomes of the Cal-PAT Study

Michael M. Neeki, DO, MS, et al.

The California Prehospital Antifibrinolytic Therapy (Cal-PAT) study seeks to assess the safety and impact on patient mortality of tranexamic acid (TXA) administration in cases of trauma-induced hemorrhagic shock. The current study further aimed to assess the feasibility of prehospital TXA administration by paramedics within the framework of North American emergency medicine standards and protocols.

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Critical Care

Evaluating the Laboratory Risk Indicator to Differentiate Cellulitis from Necrotizing Fasciitis in the Emergency Department

Michael M. Neeki, DO, MS, et al.

Necrotizing fasciitis (NF) is an uncommon but rapidly progressive infection that results in gross morbidity and mortality if not treated in its early stages. This study analyzed the ability of the LRINEC score to accurately rule out NF in patients who were confirmed to have cellulitis, as well as the capability to differentiate cellulitis from NF.

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Critical Care

First Report of Survival in Refractory Ventricular Fibrillation After Dual-Axis Defibrillation and Esmolol Administration

Kevin M. Boehm, DO, MSc et al.

here is a subset of patients who suffer a witnessed ventricular fibrillation (VF) arrest and despite receiving reasonable care with medications (epinephrine and amiodarone) and multiple defibrillations (3+ attempts at 200 joules of biphasic current) remain in refractory VF (RVF), also known as electrical storm. The mortality for these patients is as high as 97%. We present the case of a patient who, with a novel approach, survived RVF to outpatient follow up.

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Critical Care

Application of Circumferential Compression Device (Binder) in Pelvic Injuries: Room for Improvement

Rahul Vaidya, MD et al.

The use of a noninvasive pelvic circumferential compression device (PCCD) to achieve pelvic stabilization by both decreasing pelvic volume and limiting inter-fragmentary motion has become commonplace, and is a well-established component of Advanced Trauma Life Support (ATLS) protocol in the treatment of pelvic ring injuries. The purpose of this study was to evaluate the following: 1) how consistently a PCCD was placed on patients who arrived at our hospital with unstable pelvic ring injuries; 2) if they were placed in a timely manner; and 3) if hemodynamic instability influenced their use.

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Critical Care

Autoinjectors Preferred for Intramuscular Epinephrine in Anaphylaxis and Allergic Reactions

Ronna L. Campbell, MD, PhD et al.

Epinephrine is the treatment of choice for anaphylaxis. We surveyed emergency department (ED) healthcare providers regarding two methods of intramuscular (IM) epinephrine administration (autoinjector and manual injection) for the management of anaphylaxis and allergic reactions and identified provider perceptions and preferred method of medication delivery.

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Critical Care

Resuscitation Prior to Emergency Endotracheal Intubation: Results of a National Survey

Resuscitation Prior to Emergency Endotracheal Intubation: Results of a National Survey
Robert S. Green, MD, et al.

Respiratory failure is a common problem in emergency medicine (EM) and critical care medicine (CCM). However, little is known about the resuscitation of critically ill patients prior to emergency endotracheal intubation (EETI). Our aim was to describe the resuscitation practices of EM and CCM physicians prior to EETI.

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Critical Care

Anticoagulation Reversal and Treatment Strategies in Major Bleeding: Update 2016

Volume 17, Issue 3, May 2016
Steve Christos, DO, MS et al.

Anticoagulation is the mainstay of medical treatment, prevention and reduction of recurrent venous thromboembolism, stroke prevention in patients with non-valvular atrial fibrillation, and it reduces the incidence of recurrent ischemic events and death in patients with acute coronary syndrome. Options for anticoagulation have been steadily increasing. Physicians need to be aware of the clinical profile of anticoagulation agents, reversal agents and treatment strategies in the face of major bleeding.

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Critical Care

Academic Emergency Medicine Physicians’ Knowledge of Mechanical Ventilation

Volume 13, Issue 3, May 2016
Susan R. Wilcox, MD et al.

Introduction: Although emergency physicians frequently intubate patients, management of
mechanical ventilation has not been emphasized in emergency medicine (EM) education or clinical
practice. The objective of this study was to quantify EM attendings’ education, experience, and
knowledge regarding mechanical ventilation in the emergency department.
Methods: We developed a survey of academic EM attendings’ educational experiences with
ventilators and a knowledge assessment tool with nine clinical questions. EM attendings at key
teaching hospitals for seven EM residency training programs in the northeastern United States
were invited to participate in this survey study. We performed correlation and regression analyses
to evaluate the relationship between attendings’ scores on the assessment instrument and their
training, education, and comfort with ventilation.
Results: Of 394 EM attendings surveyed, 211 responded (53.6%). Of respondents, 74.5%
reported receiving three or fewer hours of ventilation-related education from EM sources over the
past year and 98 (46%) reported receiving between 0-1 hour of education. The overall correct
response rate for the assessment tool was 73.4%, with a standard deviation of 19.9. The factors
associated with a higher score were completion of an EM residency, prior emphasis on mechanical
ventilation during one’s own residency, working in a setting where an emergency physician bears
primary responsibility for ventilator management, and level of comfort with managing ventilated
patients. Physicians’ comfort was associated with the frequency of ventilator changes and EM
management of ventilation, as well as hours of education.
Conclusion: EM attendings report caring for mechanically ventilated patients frequently, but most
receive fewer than three educational hours a year on mechanical ventilation, and nearly half
receive 0-1 hour. Physicians’ performance on an assessment tool for mechanical ventilation is
most strongly correlated with their self-reported comfort with mechanical ventilation.

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Critical Care

Effects of Intraosseous Tibial vs. Intravenous Vasopressin in a Hypovolemic Cardiac Arrest Model

Volume 17, Issue 2, March 2016.
Justin Fulkerson, MSN, et al.

Introduction: This study compared the effects of vasopressin via tibial intraosseous (IO) and
intravenous (IV) routes on maximum plasma concentration (Cmax), the time to maximum
concentration (Tmax), return of spontaneous circulation (ROSC), and time to ROSC in a
hypovolemic cardiac arrest model.
Methods: This study was a randomized prospective, between-subjects experimental design. A
computer program randomly assigned 28 Yorkshire swine to one of four groups: IV (n=7), IO tibia
(n=7), cardiopulmonary resuscitation (CPR) + defibrillation (n=7), and a control group that received
just CPR (n=7). Ventricular fibrillation was induced, and subjects remained in arrest for two minutes.
CPR was initiated and 40 units of vasopressin were administered via IO or IV routes. Blood samples
were collected at 0.5, 1, 1.5, 2, 2.5, 3, and 4 minutes. CPR and defibrillation were initiated for
20 minutes or until ROSC was achieved. We measured vasopressin concentrations using highperformance
liquid chromatography.
Results: There was no significant difference between the IO and IV groups relative to achieving
ROSC (p=1.0) but a significant difference between the IV compared to the CPR+ defibrillation
group (p=0.031) and IV compared to the CPR-only group (p=0.001). There was a significant
difference between the IO group compared to the CPR+ defibrillation group (p=0.031) and IO
compared to the CPR-only group (p=0.001). There was no significant difference between the CPR
+ defibrillation group and the CPR group (p=0.127). There was no significant difference in Cmax
between the IO and IV groups (p=0.079). The mean ± standard deviation of Cmax of the IO group
was 58,709±25,463pg/mL compared to the IV group, which was 106,198±62,135pg/mL. There was
no significant difference in mean Tmax between the groups (p=0.084). There were no significant
differences in odds of ROSC between the tibial IO and IV groups.
Conclusion: Prompt access to the vascular system using the IO route can circumvent the
interruption in treatment observed with attempting conventional IV access. The IO route is an
effective modality for the treatment of hypovolemic cardiac arrest and may be considered first line for
rapid vascular access.

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Critical Care

Seldinger Technique for Placement of “Peripheral” Internal Jugular Line: Novel Approach for Emergent Vascular Access

Volume 17, Issue 1, January 2016.
Adam J. Ash, DO, et al.

This is a case report describing the ultrasound-guided placement of a peripheral intravenous
catheter into the internal jugular vein of a patient with difficult vascular access. Although this
technique has been described in the past, this case is novel in that the Seldinger technique was
used to place the catheter. This allows for safer placement of a longer catheter (2.25”) without the
need for venous dilation, which is potentially hazardous.

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Critical Care

The Physiologically Difficult Airway

Volume 16, Issue 7, December 2015.
Jarrod M. Mosier, MD, et al.

Airway management in critically ill patients involves the identification and management of the
potentially difficult airway in order to avoid untoward complications. This focus on difficult airway
management has traditionally referred to identifying anatomic characteristics of the patient that
make either visualizing the glottic opening or placement of the tracheal tube through the vocal
cords difficult. This paper will describe the physiologically difficult airway, in which physiologic
derangements of the patient increase the risk of cardiovascular collapse from airway management.
The four physiologically difficult airways described include hypoxemia, hypotension, severe
metabolic acidosis, and right ventricular failure. The emergency physician should account for
these physiologic derangements with airway management in critically ill patients regardless of the
predicted anatomic difficulty of the intubation.

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Critical Care

Lactate Clearance Predicts Survival Among Patients in the Emergency Department with Severe Sepsis

Volume 16, Issue 7, December 2015.
Sundeep R. Bhat, MD

Introduction: Lactate clearance has been implicated as a predictor of mortality among emergency
department (ED) patients with severe sepsis or septic shock. We aimed to validate prior studies
showing that lactate clearance during the ED stay is associated with decreased mortality.
Methods: Retrospective dual-centered cross-sectional study using patients identified in the YaleNew
Haven Hospital Emergency Medicine sepsis registry with severe sepsis or septic shock who
had initial lactate levels measured in the ED and upon arrival (<24 hours) to the hospital floor.
Lactate clearance was calculated as percent of serum lactate change from ED to floor measurement.
We compared mortality and hospital interventions between patients who cleared lactate and those
who did not.
Results: 207 patients (110 male; 63.17±17.9 years) were included. Two reviewers extracted data
with 95% agreement. One hundred thirty-six patients (65.7%) had severe sepsis and 71 patients
(34.3%) had septic shock. There were 171 patients in the clearance group and 36 patients in the
non-clearance group. The 28-day mortality rates were 15.2% in the lactate clearance group and
36.1% in the non-clearance group (p<0.01). Vasopressor support was initiated more often in the nonclearance
group (61.1%) than in the clearance group (36.8%, p<0.01) and mechanical ventilation
was used in 66.7% of the non-clearance group and 36.3% of the clearance group (p=0.001).
Conclusion: Patients who do not clear their lactate in the ED have significantly higher mortality than
those with decreasing lactate levels. Our results are confirmatory of other literature supporting that
lactate clearance may be used to stratify mortality-risk among patients with severe sepsis or septic
shock.

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Contact Information

WestJEM/ Department of Emergency Medicine
UC Irvine Health

333 The City Blvd. West, Rt 128-01
Suite 640
Orange, CA 92868, USA
Phone: 1-714-456-6389
Email: westjem@gmail.com

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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.