Publications

BACKGROUND: The recommended rocuronium dose for rapid sequence intubation is 1.0 mg/kg; however, the optimal dose for emergency airway management is not clear. We assessed the relationship between rocuronium dose and first-attempt success among emergency department (ED) patients undergoing rapid sequence intubation.

METHODS: This is a secondary analysis of the National Emergency Airway Registry (NEAR), an observational 25-center registry of ED intubations. Ninety percent recording compliance was required from each site for data inclusion. We included all patients > 14 years of age who received rocuronium for rapid sequence intubation from 1 Jan 2016 to 31 Dec 2018. We compared first-attempt success between encounters using alternative rocuronium doses (< 1.0, 1.0-1.1, 1.2-1.3 and ≥1.4 mg/kg). We performed logistic regressions to control for predictors of difficult airways, indication, pre-intubation hemodynamics, operator, body habitus and device. We also performed subgroup analyses stratified by device (direct vs. video laryngoscopy). We calculated univariate descriptive statistics and odds ratios (OR) from multivariable logistic regressions with cluster-adjusted 95% confidence intervals (CI).

RESULTS: 19,071 encounters were recorded during the 3-year period. Of these, 8,034 utilized rocuronium for rapid sequence intubation. Overall, first attempt success was 88.4% for < 1.0 mg/kg, 88.1% for 1.0-1.1 mg/kg, 89.7% for 1.2-1.3 mg/kg, and 92.2% for ≥1.4 mg/kg. Logistic regression demonstrated that when direct laryngoscopy was used and when compared to the standard dosing range of 1.0-1.1 mg/kg, the adjusted odds of a first attempt success was significantly higher in ≥1.4 mg/kg group at 1.9 (95% CI 1.3-2.7) relative to the other dosing ranges, OR 0.9 (95% CI 0.7-1.2) for < 1.0 mg/kg and OR 1.2 (95% CI 0.9-1.7) for the 1.2-1.3 mg/kg group. First-attempt success was similar across all rocuronium doses among patients utilizing video laryngoscopy. Patients who were hypotensive (SBP < 100 mmHg) prior to intubation had higher first-attempt success 94.9% versus 88.6% when higher doses of rocuronium were used. The rates of all peri-intubation adverse events and desaturation were similar between dosing groups, laryngoscope type utilized and varying pre-intubation hemodynamics.

CONCLUSIONS: Rocuronium dosed ≥1.4 mg/kg was associated with higher first attempt success when using direct laryngoscopy and among patients with pre-intubation hypotension with no increase in adverse events. We recommend further prospective evaluation of the dosing of rocuronium prior to offering definitive clinical guidance.

AIM: To determine the incidence of peri-intubation cardiac arrest through analysis of a multi-center Emergency Department (ED) airway registry and to report associated clinical characteristics.

METHODS: This is a secondary analysis of prospectively collected data (National Emergency Airway Registry) comprising ED endotracheal intubations (ETIs) of subjects >14 years old from 2016 to 2018. We excluded those with cardiac arrest prior to intubation. The primary outcome was peri-intubation cardiac arrest. Multivariable logistic regression generated adjusted odds ratios (aOR) of variables associated with this outcome, controlling for clinical features, difficult airway characteristics, and ETI modality.

RESULTS: Of 15,776 subjects who met selection criteria, 157 (1.0%, 95% CI 0.9-1.2%) experienced peri-intubation cardiac arrest. Pre-intubation systolic blood pressure <100 mm Hg (aOR 6.2, 95% CI 2.5-8.5), pre-intubation oxygen saturation <90% (aOR 3.1, 95% CI 2.0-4.8), and clinician-reported need for immediate intubation without time for full preparation (aOR 1.8, 95% CI, 1.2-2.7) were associated with higher likelihood of peri-intubation cardiac arrest. The association between pre-intubation shock and cardiac arrest persisted in additional modeling stratified by ETI indication, induction agent, and oxygenation status.

CONCLUSIONS: Peri-intubation cardiac arrest for patients undergoing ETI in the ED is rare. Higher likelihood of arrest occurs in patients with pre-intubation shock or hypoxemia. Prospective trials are necessary to determine whether a protocol to optimize pre-intubation haemodynamics and oxygenation mitigates the risk of peri-intubation cardiac arrest.

OBJECTIVE: To describe awake intubation practices in the emergency department (ED) and report success, complications, devices used, and rescue techniques using multicenter surveillance.

METHODS: We analyzed data from the National Emergency Airway Registry (NEAR). Patients with an awake intubation attempt between January 1, 2016 and December 31, 2018 were included. We report univariate descriptive data as proportions with cluster-adjusted 95% confidence intervals (CIs).

RESULTS: Of 19,071 discrete patient encounters, an awake technique was used on the first attempt in 82 (0.4%) patients. The majority (91%) of first attempts were performed by emergency medicine physicians. Angioedema (32%) and non-angioedema airway obstruction (31%) were the most common indications for an awake intubation attempt. The most common initial device used was a flexible endoscope (78%). Among all awake intubations first-attempt success was achieved in 85% (95% CI [76%-95%]), and peri-intubation complications occurred in 16% (95% CI [9%-26%]).

CONCLUSION: Awake intubation in this multicenter cohort of emergency department patients was rare and was performed most often in patients with airway edema or obstruction. Emergency physicians performed the majority of first intubation attempts with high first-attempt success. Further studies are needed to determine optimal emergency airway management in this patient population.

STUDY OBJECTIVE: We sought to (1) characterize emergency department (ED) intubations in trauma patients and estimate (2) first-pass success and (3) the association between patient and intubation characteristics and first-pass success.

METHODS: We performed a secondary analysis of a multicenter prospective observational cohort of ED intubations from the National Emergency Airway Registry (NEAR). Descriptive statistics were calculated for all patients who were intubated for trauma at 23 NEAR EDs between 2016 and 2018. We evaluated first-pass success in patients intubated by (1) emergency or pediatric emergency physicians, (2) using rapid sequence intubation or no medications, and (3) either direct laryngoscopy or video laryngoscopy. We used propensity score matching with a generalized linear mixed-effects model to estimate the associations between patient and intubation characteristics and first-pass success.

RESULTS: Of the 19,071 intubations in NEAR, 4,449 (23%) were for trauma, and nearly all (88%) had at least one difficult airway characteristic. Prevalence of first-pass success was 86.8% (95% confidence interval [CI]: 83.3% to 90.3%). Most patients were intubated with video laryngoscopy, and patients were more likely to be intubated on first-pass with video laryngoscopy as compared to direct laryngoscopy (90% versus 79%). After propensity score matching, video laryngoscopy remained associated with first-pass success (adjusted risk difference 11%, 95% CI: 8% to 14%; and OR 2.2, 95% CI: 1.6 to 2.9). Additionally, an initial impression of difficult airway, blood/vomit in the airway, and use of external laryngeal manipulation were all associated with decreased odds of first-pass success.

CONCLUSION: Emergency physicians are successful at intubating patients in the setting of trauma, and video laryngoscopy is associated with twice the odds of first-pass success when compared to direct laryngoscopy.

BACKGROUND: Angioedema, a localized swelling of subcutaneous and submucosal tissues, may involve the upper airway. A subset of patients presenting for emergent evaluation of angioedema will require intubation. Little is known about airway management practices in patients with angioedema requiring intubation in the emergency department (ED).

OBJECTIVE: To describe airway management practices in patients intubated for angioedema in the ED.

METHODS: We analyzed data from the National Emergency Airway Registry. All patients with an intubation attempt for angioedema between January 1, 2016 and December 31, 2018 were included. We report univariate descriptive data as proportions with cluster-adjusted 95% confidence intervals.

RESULTS: Of 19,071 patient encounters, intubation was performed for angioedema in 98 (0.5%). First-attempt success was achieved in 81%, with emergency physicians performing the procedure in 94% of encounters. The most common device used was a flexible endoscope (49%), and 42% of attempts were via a nasal route. Pharmacologic methods included sedation with paralysis (61%), topical anesthesia with or without sedation (13% and 13%, respectively), and sedation only (10%). Among 19 (19%) patients requiring additional attempts, intubation was achieved on second attempt in 10 (53%). The most common adverse events were hypotension (13%) and hypoxemia (12%). Cricothyrotomy occurred in 2 patients (2%). No deaths were observed.

CONCLUSIONS: Angioedema was a rare indication for intubation in the ED setting. Emergency physicians achieved first-attempt success in 81% of encounters and used a broad range of intubation devices and methods, including flexible endoscopic techniques. Cricothyrotomy was rare, and no ED deaths were reported. © 2021 Elsevier Inc.

BACKGROUND: Adequate analgesia is difficult to achieve in patients with an abscess requiring incision and drainage (I&D). There has been a recent increase in regional anesthesia use in the emergency department (ED) to aid in acute musculoskeletal pain relief. Specifically, transgluteal sciatic nerve (TGSN) block has been used as an adjunct treatment for certain chronic lumbar and lower extremity pain syndromes in the ED.

CASE REPORT: A 21-year-old woman presented to the ED with a painful gluteal abscess. The pain was so severe that the patient barely tolerated light palpation to the abscess area. Using dynamic ultrasound guidance, a TGSN block was performed with significant pain reduction. Ultrasonographic confirmation of abscess was obtained followed by definitive I&D. She was discharged from the ED and her incision site was healing well at the time of follow-up. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Abscess I&D is a common procedure in the ED. Procedural analgesia for I&D can be difficult to obtain. We describe the TGSN block as an additional analgesic option to be used for procedural analgesia. The use of regional anesthesia has the potential to decrease unwanted and at times dangerous side effects of opiate use and resource utilization of procedural sedation while optimizing patient comfort.

Shoulder pain is a common and painful patient condition. Unfortunately, diagnostic imaging of shoulder pain in the emergency department (ED) is often limited to radiography. While diagnostic for fractures and dislocations, drawbacks of radiography include time delays and non-diagnostic imaging in the case of rotator cuff pathology. While bedside ultrasound has been incorporated into many procedural and diagnostic applications in the ED, its use for musculoskeletal complaints and specifically shoulder pain is infrequent among ED clinicians. The incorporation of shoulder ultrasound in the ED may improve diagnostic certainty while decreasing time to diagnosis and treatment, yielding patient and health system benefits. Herein, we present the ABSIS (Acromio-clavicular joint, Biceps, Subscapularis, Impingement, Supraspinatus) Protocol for performing bedside ultrasound of the shoulder including the rotator cuff and bony anatomy.

BACKGROUND: Acute pain is one of the most common complaints encountered in the emergency department (ED). Single-injection peripheral nerve blocks are a safe and effective pain management tool when performed in the ED. Dexamethasone has been explored as an adjuvant to prolong duration of analgesia from peripheral nerve blocks in peri- and postoperative settings; however, data surrounding the use of dexamethasone for ED-performed nerve blocks are lacking.

CASE SERIES: In this case series we discuss our experience with adjunctive perineural dexamethasone in ED-performed regional anesthesia. Why Should an Emergency Physician be Aware of This?: Nerve blocks performed with adjuvant perineural dexamethasone may be a safe additive to provide analgesia beyond the expected half-life of local anesthetic alone. Prospective studies exploring the role of adjuvant perineural dexamethasone in ED-performed nerve blocks are needed. © 2021 Elsevier Inc.