Emergency Endotracheal Intubation Research Articles

Variability in Critical Care–Related Charge Markups in Medicare Patients

Charge markups for health care are variable and inflated several times beyond cost. Using the 2015 Medicare Provider Fee-For-Service Utilization and Payment Data file, we identified providers who billed for critical care hours and related procedures, including CPR, EKG interpretation, central line placement, arterial line placement, chest tube/thoracentesis, and emergent endotracheal intubation. Markup ratios (MRs), defined as the amount charged divided by the amount allowable, were calculated and compared; 42.1 per cent of physicians billing for critical care-related services were specialized in emergency medicine (EM). EM had the highest overall MR (median 4.99, IQR 3.60-6.88) and provided most of the services. MRs differed between genders in select cases (critical care hours: anesthesiology, EM, internal medicine, pulmonary and critical care medicine; CPR, pulmonary and critical care medicine; chest tube placement/thoracentesis, internal medicine). These differences in MR did not correspond to higher rates of Medicare allowable amounts (P = NS). In conclusion, charge markups significantly varied by physician specialty. EM physicians had the highest MRs for most critical care-related services, including critical care hours, EKG interpretation, CPR, central venous line placement, and emergent endotracheal intubation. EM physicians also provided most of these services. Charge markups are associated with adverse consequences and represent potential targets for cost containment and consumer protection.

Comparison between Glidescope, Airtraq and Macintosh laryngoscopy for emergency endotracheal intubation in intensive care unit: Randomized controlled trial

BackgroundEmergency endotracheal intubation in intensive care is a major challenge that can be associated with life-threatening complications. The aim of this study was to evaluate the success of the first attempt of endotracheal intubation and incidence of complications using Macintosh laryngoscopy, Airtraq or Glidescope during emergency intubation in intensive care.Patients and methodsOne hundred twenty adult intensive care patients of ASA physical status III and IV who required emergency endotracheal intubation were randomly allocated into 3 groups. Group M (40 patients) were intubated using Macintosh laryngoscopy. Group G (40 patients) were intubated using Glidescope. Group A (40 patients) were intubated using Airtraq. The primary outcome was the success of the first attempt of endotracheal intubation. Secondary outcomes included the number of intubation attempts, duration of intubation, glottic view as assessed by Cormack-Lehane grade (C&L grade) and incidence of complications.ResultsSuccess of the first attempt of endotracheal intubation was significantly higher in both groups G and A compared to group M (p < 0.05). The number of intubation attempts was significantly higher in group M compared to both groups G and A (p < 0.05). The duration of endotracheal intubation was 28.80 ± 10.27 s in group M compared to 31.45 ± 12.17 s in group G and 32.25 ± 11.96 s in group A (p > 0.05). The C&L grade was significantly better in both groups G and A compared to group M (p < 0.05). No statistically significant difference between the three groups in HR or MAP. The incidence of oxygen desaturation was significantly more in group M compared to groups G and A. No statistically significant difference between the 3 studied groups regarding the incidence of other complications.ConclusionBoth Glidescope and Airtraq have higher first attempt success rate with a better glottic view and less incidence of oxygen desaturation than Macintosh laryngoscopy during emergency intubation in intensive care.

Sedative dose and patient variable impacts on postintubation hypotension in emergency airway management

PurposePostintubation hypotension (PIH) is an adverse event associated with poor outcomes in emergency department (ED) endotracheal intubation. This study aimed to evaluate the association between sedative dose adjustment and PIH during emergency airway management. We also investigated the impact of patient and procedural factors on the incidence of PIH. Materials and methodsThis was a single-center, retrospective study that used a prospectively collected registry of airway management performed at the ED from April 2014 to February 2017. Adult patients who received emergency endotracheal intubation were included. Multivariable logistic regression models were used to evaluate the association of PIH with sedative dose, patient variables, and procedural variables. ResultsOverall, 689 patients were included, and 233 (33.8%) patients developed PIH. In the patients overall, multivariable logistic regression demonstrated that age > 70 years, shock index >0.8, arterial acidosis (pH < 7.2), intubation indication, and use of non-depolarizing neuromuscular blocking agent were significantly related to PIH. In patients overall, the sedative dose was not related to PIH (overdose; OR: 1.09, 95%CI: 0.57–2.06), (reduction; OR: 0.93, 95%CI: 0.61–1.42), (none used; OR: 1.28, 95%CI: 0.64–2.53). In subgroup analysis, ketamine dose was not related to PIH (overdose; OR: 0.81, 95%CI: 0.27–2.38, reduction; OR: 1.41, 95%CI: 0.78–2.54). Reduction of etomidate dose was significantly associated with decreased PIH (reduction; OR: 0.46, 95%CI: 0.22–0.98, overdose; OR: 1.77, 95%CI: 0.79–3.93). ConclusionsPIH was mainly related to predisposing patient-related factors. Only adjustment of etomidate dose was associated with the incidence of PIH.

Effect of Use of a Bougie vs Endotracheal Tube and Stylet on First-Attempt Intubation Success Among Patients With Difficult Airways Undergoing Emergency Intubation

The tracheal tube introducer, known as the bougie, is typically used to aid tracheal intubation in poor laryngoscopic views or after intubation attempts fail. The effect of routine bougie use on first-attempt intubation success is unclear. To compare first attempt intubation success facilitated by the bougie vs the endotracheal tube + stylet. The Bougie Use in Emergency Airway Management (BEAM) trial was a randomized clinical trial conducted from September 2016 through August 2017 in the emergency department at Hennepin County Medical Center, an urban, academic department in Minneapolis, Minnesota, where emergency physicians perform all endotracheal intubations. Included patients were 18 years and older who were consecutively admitted to the emergency department and underwent emergency orotracheal intubation with a Macintosh laryngoscope blade for respiratory arrest, difficulty breathing, or airway protection. Patients were randomly assigned to undergo the initial intubation attempt facilitated by bougie (n = 381) or endotracheal tube + stylet (n = 376). The primary outcome was first-attempt intubation success in patients with at least 1 difficult airway characteristic (body fluids obscuring the laryngeal view, airway obstruction or edema, obesity, short neck, small mandible, large tongue, facial trauma, or the need for cervical spine immobilization). Secondary outcomes were first-attempt success in all patients, first-attempt intubation success without hypoxemia, first-attempt duration, esophageal intubation, and hypoxemia. Among 757 patients who were randomized (mean age, 46 years; women, 230 [30%]), 757 patients (100%) completed the trial. Among the 380 patients with at least 1 difficult airway characteristic, first-attempt intubation success was higher in the bougie group (96%) than in the endotracheal tube + stylet group (82%) (absolute between-group difference, 14% [95% CI, 8% to 20%]). Among all patients, first-attempt intubation success in the bougie group (98%) was higher than the endotracheal tube + stylet group (87%) (absolute difference, 11% [95% CI, 7% to 14%]). The median duration of the first intubation attempt (38 seconds vs 36 seconds) and the incidence of hypoxemia (13% vs 14%) did not differ significantly between the bougie and endotracheal tube + stylet groups. In this emergency department, use of a bougie compared with an endotracheal tube + stylet resulted in significantly higher first-attempt intubation success among patients undergoing emergency endotracheal intubation. However, these findings should be considered provisional until the generalizability is assessed in other institutions and settings. clinicaltrials.gov Identifier: NCT02902146.

A comparison between video laryngoscopy and direct laryngoscopy for endotracheal intubation in the emergency department: A meta-analysis of randomized controlled trials

Study objectivesDirect laryngoscopy is the most commonly used modality for endotracheal intubation in the emergency department. Video laryngoscopy may improve glottic view during laryngoscopy and intubation success rate in such patients. This meta-analysis has been designed to compare clinical efficacy of video laryngoscopy with direct laryngoscopy for endotracheal intubation in the emergency department. DesignMeta-analysis of randomized controlled trial. SettingRandomized controlled trials comparing video laryngoscopy and direct laryngoscopy for endotracheal intubation in adult patients in emergency department. PubMed (1946 to 20th October 2017) and The Cochrane Library databases (CENTRAL) were searched for potentially eligible trials on 20th October 2017. PatientsAdult patients presenting in the emergency department. InterventionsVideo laryngoscopy & direct laryngoscopy for intubation in emergency department. MeasurementPrimary outcome was ‘first intubation success rate’ and secondary outcomes were overall intubation success rate, in-hospital mortality and oesophageal intubation rate. Main resultsData of 1250 patients from 5 randomized controlled trials have been included in this study. Video laryngoscopy offers no advantage over direct laryngoscopy in terms of first intubation success rate (odds ratio 1.28, 95% CI 0.70, 2.36; p = 0.42), overall intubation success rate (OR 1.26, 95% CI 0.53, 3.01; p = 0.6) or in-hospital mortality (OR 1.25, 95% CI 0.8, 1.95; p = 0.32). However, oesophageal intubation rate is lower with the use of video laryngoscopy (OR 0.09, 95% CI 0.01, 0.7; p = 0.02). ConclusionUse of video laryngoscopy for emergency endotracheal intubation in adult patients is associated with reduced oesophageal intubation over direct laryngoscopy. However, no benefit was found in terms of overall intubation success.

Utilizing Anesthesiologists, Emergency and Critical Care Physicians with Telemedicine Monitoring to Develop Intubation and Ventilation Services in an Intensive Care Unit in the Austere Medical Environment: A Case Series. Expansion of the EP/CC GAS Project

Background: Significant resource constraints and critical care training gaps are responsible for the limited development of intensive care units (ICUs) in resource limited settings. We describe the implementation of an ICU in Haiti and report the successes and difficulties encountered throughout the process. We present a consecutive case series investigating an anesthesiologist, emergency, and critical care physician implemented endotracheal intubation and mechanical ventilation protocol in an austere environment with the assistance of telemedicine. Methods: A consecutive case series of fifteen patients admitted to an ICU at St. Luc Hospital located in Portau-Prince, Haiti, between the months of February 2012 to April 2014 is reported. Causes of respiratory failure and the clinical course are presented. Patients were followed to either death or discharge. Results: Fifteen patients (eight women and seven men) were included in the study with an average age of 37.7 years. The mean duration of ventilation was three days. Of the fifteen patients intubated, five patients (33.3%) survived and were discharged from the ICU. Of the five surviving patients, two were intubated for status epilepticus, one for status asthmaticus and one for hyperosmolar coma associated with intracerebral hemorrhage. Of the patients dying on the ventilator, four patients died from pneumonia, two from renal failure, and one from tetanus. The remaining three died from strokes and cardiac arrests. Conclusions: Mortality of mechanically ventilated patients in a resource-limited country is significant. Focused training in core critical care skills aimed at increasing the endotracheal intubation and ventilatory management capacity of local medical staff should be a priority in order to continue to develop ICUs in these austere environments. Collaborative educational and training efforts directed by anesthesiologists, emergency, and critical care physicians, and aided by telemedicine can facilitate realizing this goal.

Factors and outcomes associated with inpatient cardiac arrest following emergent endotracheal intubation

BackgroundInpatient peri-intubation cardiac arrest (PICA) following emergent endotracheal intubation (ETI) is an uncommon but potentially preventable type of cardiac arrest (CA). Limited published data exist describing factors associated with inpatient PICA and patient outcomes. This study identifies risk factors associated with PICA among hospitalized patients emergently intubated out of the operating room and compares PICA to other types of inpatient CA. MethodsRetrospective case-control study of patients at our institution over a five-year period. Cases were defined as inpatients emergently intubated outside of the operating room that experienced cardiac arrest within 20min after ETI. The control group consisted of inpatients emergently intubated out of the operating room without CA. Predictors of PICA were identified through univariate and multivariate analysis. Clinical outcomes were compared between PICA and other inpatient CAs, identified through a prospectively enrolled CA registry at our institution. Results29 episodes of PICA occurred over 5 years, accounting for 5% of all inpatient arrests. Shock index ≥1.0, intubation within one hour of nursing shift change, and use of succinylcholine were independently associated with PICA. Sustained ROSC, survival to discharge, and neurocognitive outcome did not differ significantly between groups. ConclusionPatients outcomes following PICA were comparable to other causes of inpatient CA. Potentially modifiable factors were associated with PICA. Hemodynamic resuscitation, optimized staffing strategies, and possible avoidance of succinylcholine were associated with decreased risk of PICA. Clinical trials testing targeted strategies to optimize peri-intubation care are needed to identify effective interventions to prevent this potentially avoidable type of CA.

Increased mortality in trauma patients who develop postintubation hypotension.

Postintubation hypotension (PIH) is common and associated with poor outcomes in critically ill patient populations requiring emergency endotracheal intubation (ETI). The importance of PIH in the trauma population remains unclear. The objective of this study was to determine the prevalence of PIH in trauma patients and assess the association of PIH with patient outcomes. Retrospective case series of adult (≥16 years) patients who were intubated on arrival at a tertiary trauma center in Halifax, Nova Scotia, Canada, between 2000 and 2015. Data were collected from the Nova Scotia Trauma Registry and patient chart, and included demographics, comorbidities, trauma characteristics, intubation time, as well as all fluids, medications, adverse events, interventions, and vital signs during the 15 minutes before/after ETI. We evaluated the prevalence of PIH and created a logistic regression model to determine likelihood of mortality in the PIH and non-PIH groups after controlling for patient and provider characteristics. Overall, 477 patients required ETI on assessment by the trauma service, of which 444 patients met eligibility criteria and were included in the analysis. The prevalence of PIH was 36.3% (161 of 444) in our study population. In-hospital mortality occurred in 29.8% (48 of 161) of patients in the PIH group, compared with 15.9% (45 of 283) of patients in the non-PIH group (p = 0.001). Development of PIH was associated with increased mortality in the emergency department (adjusted odds ratio, 3.45; 95% confidence interval, 1.42-8.36) and in-hospital (adjusted odds ratio, 1.83; 95% confidence interval, 1.01-3.31). In our study of trauma patients requiring ETI, development of PIH was common (36.3%) and associated with increased mortality. Intubation practices in critically ill trauma patients is an important patient safety issue that requires further investigation. Prognostic and epidemiological, level III; Level IV, Therapeutic.

Use of the TotalTrack VLM for emergent endotracheal intubation in predicted difficult airway with obstruction by expanding space-occupying lesions and reduced interincisor opening

Acute cervical pathology may lead to serious airway compromise resulting from anatomical distortion secondary to obstruction or deviation of the upper airway, scenarios where any airway device can be fallible. Passage of a fiberoptic bronchoscopy to expose the glottis may be very difficult and tracheostomy may be impractical or risky in advanced cases. We present the use of the TotalTrack VLM to secure the airway for emergent surgery in 2 uncooperative patients with difficult airway due to Ludwig's angina and neck hematoma, respectively, both accompanied by trismus.

Delayed Airway Obstruction after Craniotomy in the Park-Bench Position: Two Case Reports

The park-bench position is used for patients requiring posterior fossa procedures. Manipulation of the head and neck during positioning can have serious consequences, such as quadriplegia, cerebral infarction, or brachial plexus injury. However, delayed airway obstruction related to the park-bench position has been rarely reported in the medical literature. We report two cases in which the patients experienced delayed unilateral massive swelling of the neck and face after craniotomy in the park-bench position. One of the two patients required emergency endotracheal intubation and subsequent tracheotomy. We performed a literature search and found only seven reported cases in the English literature, including our two cases. All cases were reported from Asian countries; India, Japan and Taiwan. Four reports included patient height and weight, with body mass index ≤ 19.2kg/m2 . To gain optimal surgical access to the posterior fossa, the neck of some patients might be excessively flexed laterally, especially if they are underweight. We warn that hyperflexion of the neck in the park-bench position might cause delayed airway swelling, especially for patients who are underweight.

The occurrence of aspiration pneumonia after emergency endotracheal intubation

Study objectiveAdverse events, including aspiration, occur during Emergency Department (ED) intubation, but their contemporary incidence is not well described. We sought to estimate the rate of aspiration pneumonia potentially related to emergency intubation. MethodsWe conducted a prospective observational study of adult patients who were endotracheally intubated in the ED. Using a standard definition, we determined the proportion of patients who developed aspiration pneumonia after intubation. Aspiration pneumonia was defined as any of the following in patients without a diagnosis of community acquired pneumonia, healthcare-associated pneumonia, or aspiration prior to intubation: pathogenic growth in sputum culture, unexplained hypoxemia, or radiographic evidence of pneumonia in the first 48h after intubation. Baseline characteristics and intubation details were compared for those with and without aspiration pneumonia. Results879 patients were enrolled over a 30-month period. Intubation was facilitated by video laryngoscopy (49%), direct laryngoscopy (45%), nasal intubation (4%), a intubating laryngeal mask airway (1%), and a surgical airway (0.1%). 85% were intubated on the first attempt, 12% on the second, 3% on the third or more attempts. 25% of patients experienced an oxygen saturation <90% during the intubation. After excluding patients not eligible for the outcome assessment (those who died within 48h without findings of pneumonia), 66/823 (8%) developed aspiration pneumonia potentially related to ED intubation. In comparing those with and without aspiration pneumonia, there were no differences between first intubation attempt parameters and the occurrence of aspiration pneumonia. ConclusionAspiration pneumonia occurred commonly in this cohort. Although we did not identify any intubation factors that differed between those with and without with aspiration pneumonia, these findings should remind emergency physicians that emergency endotracheal intubation remains a high-risk procedure, and all care should be taken to minimize the risk of peri-intubation complications.

A Prospective Evaluation of Transverse Tracheal Sonography During Emergent Intubation by Emergency Medicine Resident Physicians.

Establishing a definitive airway is often the first step in emergency department treatment of critically ill patients. Currently, there is no agreed upon consensus as to the most efficacious method of airway confirmation. Our objective was to determine the diagnostic accuracy of real-time sonography performed by resident physicians to confirm placement of the endotracheal tube during emergent intubation. We performed a prospective cohort study of adult patients in the emergency department undergoing emergent endotracheal intubation. Thirty emergency medicine residents, who were blinded to end-tidal carbon dioxide detection results, performed real-time transverse tracheal sonography during intubation to evaluate correct endotracheal tube placement. Seventy-two patients were enrolled in the study. Sixty-eight instances (94.4%) were interpreted as correct placement in the trachea; 4 (5.6%) were interpreted as esophageal, of which 1 was a false-negative finding, therefore conferring sensitivity of 98.5% (95% confidence interval, 92.1%-99.9%) and specificity of 75.0% (95% confidence interval, 19.4%-99.4%) for correct placement. There was no significant difference in accuracy among resident sonographers with different levels of residency training. A simple transverse tracheal sonographic examination performed by emergency medicine resident physicians can be used as an adjunct to help confirm correct endotracheal tube placement during intubation. In our cohort, the level of training did not appear to affect the ability of residents to correctly identify the endotracheal tube position.

First-Pass Intubation Success Associated with Video Laryngoscopy and RSI

Emergency endotracheal intubation is considered by many the cornerstone of emergency medicine procedural knowledge. Increased first-pass intubation success is associated with decreased rates of uncommon serious complications. To examine changes in intubation practice and outcomes, researchers analyzed prospectively collected data for nearly 11,000 emergency intubations (96% capture rate) in the Japanese Emergency Airway …

A case of ingested laryngoscope bulb during emergency endotracheal intubation.

A case of ingested laryngoscope bulb during emergency endotracheal intubation.

Shock index, pediatric age-adjusted (SIPA) is more accurate than age-adjusted hypotension for trauma team activation

We demonstrated previously that shock index, pediatric age-adjusted identifies severely injured children accurately after blunt trauma. We hypothesized that an increased shock index, pediatric age-adjusted would identify more accurately injured children requiring the highest trauma team activation than age-adjusted hypotension. We reviewed all children age 4-16 admitted after blunt trauma with an injury severity score ≥15 from January 2007-June 2013. Criteria used as indicators of need for activation of the trauma team included blood transfusion, emergency operation, or endotracheal intubation within 24hours of admission. Shock index, pediatric age-adjusted represents maximum normal shock index based on age. Cutoffs included shock index >1.22 (ages 4-6), >1.0 (7-12), and >0.9 (13-16). Age-adjusted cutoffsfor hypotension were as follows: systolic blood pressure <90 (ages 4-6), systolic blood pressure <100 (7-16). A total of 559 children were included; 21% underwent operation, 37% endotracheal intubation, and 14% transfusion. Hypotension alone predicted poorly the need for operation (13%), endotracheal intubation (17%), or transfusion (22%). Operation (30%), endotracheal intubation (40%), and blood transfusion (53%) were more likely in children with an increased shock index, pediatric age-adjusted; 25 children required all three interventions, 3 (12%) were hypotensive at presentation, 15 (60%) had an increased shock index, pediatric age-adjusted (P<.001). An increased shock index, pediatric age-adjusted is superior to age-adjusted hypotension to identify injured children likely to require emergency operation, endotracheal intubation, or early blood transfusion.

Comparing the Effectiveness of a Novel Suction Set-up Using an Adult Endotracheal Tube Connected to a Meconium Aspirator vs. a Traditional Yankauer Suction Instrument

BackgroundIt has been suggested that an adult 8.0 endotracheal tube (ETT) connected to a neonatal meconium aspirator would improve suctioning during emergent endotracheal intubation compared to the Yankauer suction instrument, the standard tool used by emergency physicians. ObjectivesThis study was designed to compare the effectiveness of a Yankauer vs. an ETT-meconium aspirator set-up in suctioning liquids of different viscosities. MethodsThe Yankauer and ETT-meconium aspirator device underwent a head-to-head timed comparison, suctioning 250 mL of three different fluids, varying in viscosity. The first comparison test used tap water to represent simple oral secretions. The second comparison test used porcine whole blood as a proxy for human blood. The third comparison test used a coarsely blended mixture of a hamburger, French fries, and a soda to simulate emesis from a recently ingested meal. Five separate time trials were conducted for each liquid and for each suction device. ResultsThe ETT-meconium aspirator device compared to the Yankauer suctioned faster in both the water comparison test (mean = 2.6 s vs. 3.4 s; p < 0.001) and the porcine whole blood comparison test (mean = 2.9 s vs. 4.3 s; p = 0.0015). In the emesis trial, the Yankauer immediately clogged, whereas the ETT-meconium aspirator apparatus managed to suction an average of 90 mL prior to clogging. ConclusionCompared to the Yankauer, an adult 8.0 ETT connected to a meconium aspirator was superior in suctioning liquids of varying viscosities and should be considered when encountering a difficult airway due to copious secretions, blood, or emesis.

Refractory Hypoxemia From Intra-Cardiac Shunting Through Patent Foramen Ovale: A Case Report and Review of Literature

SESSION TITLE: Student/Resident Case Report Poster - Pulmonary Vascular Disease II SESSION TYPE: Student/Resident Case Report Poster PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM INTRODUCTION: We describe a case of refractory hypoxemia due to acute elevation in pulmonary vascular resistance (PVR) secondary to a pulmonary embolism(PE) with resulting right to left intra-cardiac shunt through a patent foramen ovale (PFO). CASE PRESENTATION: We describe a case of a 44-year-old female COPD, Systolic Heart Failure, and Asthma presenting with sudden onset hypoxemic respiratory failure requiring emergent endotracheal intubation. On arrival, hypoxemia persisted with oxygen saturations 69-73% despite maximal supplemental oxygen and airway pressure release ventilation with a positive end expiratory pressure of 20. The admission vital signs included a blood pressure of 90/54, pulse 87, and temperature of 100.3 degrees F. The cardiopulmonary examination encompassed a sedated female with bilateral rhonchi without wheezing/rales and s1/s2 without additional mummers. The rest of the examination was unremarkable. A computed tomography angiogram revealed a submissive PE to the left lower lobe anterobasal and medial-basal segments with diffuse ground glass opacities throughout the lungs due to infarction. Given her refractory hypoxia and hypotension requiring norepinephrine, a bedside echocardiogram was performed and revealed evidence of right ventricular failure and transesophageal echocardiogram demonstrated a PFO (9mm) with right to left intra-cardiac shunting. Initiating Inhaled NO (INO), epoprostenol, and milrinone facilitated shunt reversal by reducing the PVR. Ultimately, the patient was extubated and discharged with closure of the PFO. DISCUSSION: We present a rare case of an acute right to left intra-cardiac shunt through a PFO secondary to a pulmonary embolism. The acute management of this scenario is not widely reported, yet the death rate of patients with a PFO with right to left shunting has been shown to be twice as high. Nitrous Oxide was used to help reduce right-sided pressures with studies demonstrating decreased right-to-left intra-cardiac shunting in the setting of pulmonary embolism. Due to minimal improvement in patient’s condition on INO, Milrinone and Flolan were initiated. Animal models have shown that INO and Milrinone can provide additional pulmonary vasodilation and inotropic support. Flolan, prostacyclin vasodilator, has a significant survival benefit in people with chronic severe pulmonary hypertension. CONCLUSIONS: Our case suggests the importance of heightened suspicion for significant shunt physiology in the setting of refractory hypoxemia with the benefit of performing a bedside echocardiogram to aid in diagnosis. Thus, a combination of agents from different classes may provide the most benefit in managing the complex physiology of an acute right to left intra-cardiac shunt with hemodynamic instability. Reference #1: De Backer D, Moures JM, Vachiery JL, Leclerc JL, Kahn RJ, Vincent JL: Oxygenation improvement with nitric oxide in right-to-left shunt without significant effects on pulmonary arterial pressure. Chest 1996;110:1361-3. DISCLOSURE: The following authors have nothing to disclose: Bankim Patel, Puneet Singh, Stella Ogake, Samuel Durrett, Frank Lodeserto No Product/Research Disclosure Information

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

IntroductionRespiratory 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.MethodsA cross-sectional survey was developed and tested for content validity and retest reliability by members of the Canadian Critical Care Trials Group. The questionnaire was distributed to all EM and CCM physician members of three national organizations. Using three clinical scenarios (trauma, pneumonia, congestive heart failure), we assessed physician preferences for use and types of fluid and vasopressor medication in pre-EETI resuscitation of critically ill patients.ResultsIn total, 1,758 physicians were surveyed (response rate 50.2%, 882/1,758). Overall, physicians would perform pre-EETI resuscitation using either fluids or vasopressors in 54% (1,193/2,203) of cases. Most physicians would “always/often” administer intravenous fluid pre-EETI in the three clinical scenarios (81%, 1,484/1,830). Crystalloids were the most common fluid physicians would “always/often” administer in congestive heart failure (EM 43%; CCM 44%), pneumonia (EM 97%; CCM 95%) and trauma (EM 96%; CCM 96%). Pre-EETI resuscitation using vasopressors was uncommon (4.9%). Training in CCM was associated with performing pre-EETI resuscitation (odds ratio, 2.20; 95% CI, [1.44–3.36], p<0.001).ConclusionPre-EETI resuscitation is common among Canadian EM and CCM physicians. Most physicians use crystalloids pre-EETI as a resuscitation fluid, while few would give vasopressors. Physicians with CCM training were more likely to perform pre-EETI resuscitation.

Device and Medication Preferences of Canadian Physicians for Emergent Endotracheal Intubation in Critically Ill Patients.

Various medications and devices are available for facilitation of emergent endotracheal intubations (EETIs). The objective of this study was to survey which medications and devices are being utilized for intubation by Canadian physicians. A clinical scenario-based survey was developed to determine which medications physicians would administer to facilitate EETI, their first choice of intubation device, and backup strategy should their first choice fail. The survey was distributed to Canadian emergency medicine (EM) and intensive care unit (ICU) physicians using web-based and postal methods. Physicians were asked questions based on three scenarios (trauma; pneumonia; heart failure) and responded using a 5-point scale ranging from "always" to "never" to capture usual practice. The survey response rate was 50.2% (882/1,758). Most physicians indicated a Macintosh blade with direct laryngoscopy would "always/often" be their first choice of intubation device in the three scenarios (mean 85% [79%-89%]) followed by video laryngoscopy (mean 37% [30%-49%]). The most common backup device chosen was an extraglottic device (mean 59% [56%-60%]). The medications most physicians would "always/often" administer were fentanyl (mean 45% [42%-51%]) and etomidate (mean 38% [25%-50%]). EM physicians were more likely than ICU physicians to paralyze patients for EETI (adjusted odds ratio 3.40; 95% CI 2.90-4.00). Most EM and ICU physicians utilize direct laryngoscopy with a Macintosh blade as a primary device for EETI and an extraglottic device as a backup strategy. This survey highlights variation in Canadian practice patterns for some aspects of intubation in critically ill patients.

Emergency endotracheal intubation under fluoroscopy guidance for patients with acute dyspnea or asphyxia

ObjectiveTo evaluate the feasibility and effectiveness of emergency endotracheal intubation (EEI) under fluoroscopy guidance for patients with acute dyspnea or asphyxia. MethodsFrom October 2011 to October 2014, of 1521 patients with acute dyspnea or asphyxia who required EEI in 6 departments, 43 patients who experienced intubation difficulty or failure were entered into this study. Data on technical success, procedure time, complications, and clinical outcome were collected. The pulse oxygen saturation and Hugh-Jones classification changes were analyzed. ResultsFluoroscopy-guided EEI was technically successful in all patients. Acute dyspnea had resolved in all patients with clinical success rate 100% after the procedure. There were no serious complications during or after the procedure. The pulse oxygen saturation and Hugh-Jones classification showed significant increase after EEI (P < .05). Further treatments, including tracheal stents (n = 21), surgical resection (n = 16), palliative tracheotomy (n = 4), and bronchoscopic treatment (n = 2), were performed 1 to 72 hours after EEI. During a mean follow-up period of 13.2 months, 13 patients had died and 30 patients remained alive without dyspnea. ConclusionsFluoroscopy-guided EEI is a safe and feasible procedure, and may serve as an alternative treatment option for patients when traditional EEI is unsuccessful.