Happy New Year!!!
Following on from your feedback from our user survey at the back end of 2015 there seemed to be a thirst for summary podcasts to compliment our papers of the week. So starting from now we’ll be bringing you monthly round ups of the papers that caught our eye. As always don’t just take our interpretation of the papers, go and have a look at them yourself and let us know your thoughts. First off……
Defining the learning curve for endotracheal intubation using direct laryngoscopy: a systematic review. Buis ML. Resuscitation. 2015 Dec 19. pii: S0300-9572(15)00877-1. doi: 10.1016/j.resuscitation.2015.11.005. [Epub ahead of print]
So this is a really relevant paper to many specialties including EM and PHEM, with a limited number of ET intubations being performed in hospitals currently (with a ever growing move towards LMAs wherever possible) the ability to gain experience with ET tubes is relatively spares. The recent joint RCoA and RCEM statement commented;
‘Opportunities for the maintenance of rapid sequence induction and tracheal intubation skills by emergency physicians should be provided within each acute hospital.’
So with a competition for an ever dwindling number of tubes, the question becomes how many is enough to gain and then maintain confidence. This paper looked exclusively at direct, rather than video, laryngoscopy in the adult population by novice intubators (definition not provided). They included 13 studies with a total of over 1,400 students and over 19,000 patients. The students were first year residents, medical students or paramedic students. All of the studies were performed in operating theatres (excluding one). They found that 51-75 of ET intubations needed to be performed to achieve a success of intubation of at least 90%, with 1-43 intubations required to achieve an 80% success rate.
To achieve first pass success rate of at least 90% one paper demonstrated there was a requirement for over 200 ET intubations.
Complication rates were also discussed with one paper demonstrating mucosal and tooth injury decreased from 24% to 0% after 30 patients per student.
So the question of how many intubations you need to perform to be competent for ED RSI with a high risk cohort with abnormal physiology will not be answered by this paper. It does help show crude number of ET intubation and the resultant effect in a lower risk cohort in the operating theatre. The question of ED competency will remain difficult to quantify! There’s a fantastic podcast over at Minh Le Cong’s PHARM about the difference video laryngoscopy can make to a service so make sure you check that out.
Tracheal intubation during pediatric cardiopulmonary resuscitation: A videography-based assessment in an emergency department resuscitation room. Donoghue A. Resuscitation. 2015 Dec 15. pii: S0300-9572(15)00892-8. doi: 10.1016/j.resuscitation.2015.11.019. [Epub ahead of print]
So the recent DAS guidelines have stated that ED’s need to have immediate access to video laryngoscopy as part of their difficult airway plan. Video laryngoscopy has many benefits including improving the view obtained but also others. Having just
started introducing video laryngoscopy (by way of the C-MAC) to Heartlands Resus Room the benefit of affording the team an insight into the views being obtained would seem significant. It allows the team leader to recognise difficulties or complications from the airway management. One of the most revolutionary benefits is allowing the intubator to perform a post hoc analysis of the intubation, reviewing exactly what happened including any unintended change of blade position and the actual time taken to intubation compared with how it may have appeared during the act. This really adds value to every single airway encounter and dramatically increases learning opportunities per event.
This next paper again from Resuscitation, lead author Donoghue, was a observational study in which all resuscitations in the paediatric Emergency Department are video recorded. The study looked at a 15 month period and included only 32 patients and data was extracted from the video recording. First pass success rate was pretty phenomenally low at just under half of attempts and had an overall success rate of 94%. They found a median laryngoscopy time of 47 seconds. They showed a non statistically significant trend towards a lower tracheal intubation success rate if CPR was not interrupted for intubation.
Think about your practice for a moment, how long do you think it takes you to get a ET tube placed correctly, what’s your first pass success rate and what aspects of your airway skills do you need to be concentrating on? If you don’t know the answers to these questions is that acceptable?
Again the limitations of the study need to be appreciated including the fact that this was only a single centre study with a very small patient numbers but what this does mean for me is that with good governance, data gathering and reflection on practice there is a great deal that can be taken from airway management. Whilst we may not be all about to set up a rig of cameras in our resus room video laryngoscopy may be a practical, affordable and acceptable way to do that.
Moving away from airway management and onto another topic that’s never far away form the EM headlines, Stewarts BRIPPED paper (which is an acronym for its constituent parts) from the the American Journal of Emergency Medicine looked at the difference an ultra sound of pulmonary B-lines, RV size, IVC collapsibility, both pleural and pericardial effusions, LVEF and a DVT scan makes on the list of differential diagnoses in patients presenting with shortness of breath, when compared to standard work up.
So this study looked at a convenience sample of adult patients presenting to ED with shortness of breath. The BRIPPED scan was performed by a separate study investigator. Clinicians reviewed patients and completed a differential diagnosis ranking and as per norm ordered treatment and investigations, patients were then randomly assigned BRIPPED or not. The information from the scan was then immediately relayed back to the clinician assessing the patient and a repeat differential list was completed. When BRIPPED was not performed this differential list was completed after all standard investigations were back.
Clinicians performing the BRIPPED scan completed a minimum of 18 hours training and on average took just under 6 minutes to complete. The main outcome they were looking for was a difference in differential diagnosis ranking, which they found was not significantly altered between BRIPPED and standard investigation. They showed a time saving of around 14 minutes to disposition in the ultrasound group as compared to the control arm, however this doesn’t allow for the fact that a further clinician is being tasked to perform and ultrasound meaning further resource implications.
So we’ve previously covered the POCUS trial which showed point of care ultrasound could increase the correct diagnosis in the ED but without any meaningful patient outcomes when used in addition to standard investigation. BRIPPED looks at ultrasound as an alternative to standard work up, and even with a significant amount of training, if it were feasible to perform this in the ED, it doesn’t look at the moment like this is going to help narrow down the differential any more effectively and certainly here we’ve not been looking at any outcomes that are patient entered
Last but one……. with the recent guidelines from the European Resuscitation Council on Traumatic Cardiac Arrest, it would seem that in combination with the European Trauma Course and ATLS (lets not start another argument on the ETC vs ATLS debate) you would hope that trauma care is becoming a universal standard. This paper in Critical Care from Hamada was a questionnaire sent out to Intensive Care physicians involved in trauma across Europe based on the European guidelines on bleeding an coagulopathy following major trauma 2013.
There were 296 responses collected, although it’s unclear from the paper the response rate. Roughly 3 quarters were working in a trauma centre. The questionnaire revealed a wide variety of practice which significantly differed from the guidelines for example with only 38% complying with the goal of a systolic BP between 80-90 mmHg in patients with shock without TBI. There was also a significant difference with respect to fluid resuscitation and vasopressor usage.
The questionnaire did not and could not have accurately reflected differences in the outcomes between the different management strategies but what it does reveal in a period of medicine that is highly evidenced based and guideline driven that this doesn’t necessarily disseminate into united practice. Maybe part of the problem is the vast amount of information out there that we are expected to know and translate to practice, perhaps this is the place for FOAM to help disseminate!
The electrocardiographic characteristics of an acute embolism in the pulmonary trunk and the main pulmonary arteries. Zhang J. Am J Emerg Med. 2015 Oct 24. pii: S0735-6757(15)00914-6. doi: 10.1016/j.ajem.2015.10.028. [Epub ahead of print]
And finally a paper from Zhang, published in the American Journal of Emergency Medicine looked at nearly 150 patients diagnosed with an acute PE as identified by CTPA over a 3 year period ending in April 2014. The authors looked at ECGs performed within 24hours of the onset of the symptoms and reviewed them with regard to the location of the PE, either the main pulmonary artery or lobular artery/remote group.
The paper is worth a full read but the main take home point was the frequency of ECG abnormalities and the difference that this holds to traditional teaching. Ask most clinicians the classic findings of a PE on ECG and you can be sure the S1Q3T3 will be near the top of the list and although this was found in 19% of the study group it was by no means the most common abnormality. New t-wave inversion in the chest leads was found in 41% of patients, new t-wave in version in III and aVF in 28% with ST depression in these leads at 27%. Sinus tachycardia was also found in 30% of patients.
So that’s it for this month. Let us know what you think of this format of paper round up for the month and we’d be hugely grateful if you’d pop over to iTunes and give the podcast a rating. If you want more of these podcasts then we’ll gladly keep them coming and we’ll also be bringing you some of our more standard topic reviews imbetween.
Speak to you soon! Simon