Emergency medicine journal : EMJ
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A short cut review of the literature was carried out to establish whether any risk factors would predict the need for endotracheal intubation in undifferentiated adult patients presenting with poisoning/overdose with unknown substance. Five papers presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated. It is concluded that further robust studies of large cohorts are needed to answer this difficult question.
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Comparative Study
Exploring the characteristics, acuity and management of adult ED patients at night-time.
ED care is required for acutely unwell and injured patients 24 hours a day, 7 days a week. The aim of this study was to compare characteristics and activity of type 1 ED attendances according to whether their time of arrival was during the day (08:00-18:00) or at night (18:00-08:00). ⋯ There is an 'overnight effect' of patients attending EDs. Patients wait longer, leave without being seen, attend with non-urgent problems and are more likely to be admitted for a short stay. Further work is required to identify the potential underlying causes of these differences.
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Prolonged wait times prior to triage outside the emergency department (ED) were a major problem at our institution, compromising patient safety. Patients often waited for hours outside the ED in hot weather leading to exhaustion and clinical deterioration. The aim was to decrease the median waiting time to triage from 50 min outside ED for patients to <30 min over a 4-month period. ⋯ The authors demonstrated that people new to QI could use improvement methods to address a specific problem. It was the commitment of the frontline staff, with the active support of senior leadership in the department that helped this effort succeed.
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Observational Study
Location of arrest and effect of prehospital advanced airway management after emergency medical service-witnessed out-of-hospital cardiac arrest: nationwide observational study.
What is this?
This Korean study investigated 6,620 out-of-hospital cardiac arrests (OHCA) witnessed by emergency medical providers, covering a four year period of the Korean OHCA registry. They looked at outcome among those receiving advanced airway intervention, comparing arrest at scene to arrest in the ambulance.
Why is this interesting?
Past studies have suggested better OHCA outcomes when a supraglottic airway (SGA) is used rather than endotrachial intubation (ETI). We also know that repeated advanced airway attempts are detrimental, and that airway intervention can interrupt CPR.
What was not known is:
- Whether SGA placement is detrimental or beneficial, compared with basic airway support, and;
- Whether there is any difference if the arrest occurs at the scene or in the confines of an ambulance.
And they found:
There was no benefit from advanced airway intervention (SGA or ETI) for EMS witnessed out-of-hospital arrest – and in fact there was an associated worse neurological outcome for in-ambulance OHCA when the airway was instrumented compared to any other group.
Don’t be hasty...
Although the authors reasonably describe the ways in which providing advanced airway interventions in the confines of an ambulance may impede other resuscitation, thus worsening outcomes, it may also be that a patient who still arrests despite receiving EMS care in the back of an ambulance is by definition at risk of worse outcomes despite medical care.
Nevertheless, at worst this retrospective observational study suggests there is no benefit of advanced airways in OHCA.
Bonus...
The authors also provide an interesting overview of the Korean emergency medical system, servicing 50 million people in urban and rural areas. This is an enlightening insight into how one country has structured its EMS service.
summary -
Observational Study
Process conformance is associated with successful first intubation attempt and lower odds of adverse events in a paediatric emergency setting.
Intubation is an essential, life-saving skill but associated with a high risk for adverse outcomes. Intubation protocols have been implemented to increase success and reduce complications, but the impact of protocol conformance is not known. Our study aimed to determine association between conformance with an intubation process model and outcomes. ⋯ Conformance with a task-based expert-derived process model for emergency intubation was associated with a higher rate of success on first intubation attempt when using direct laryngoscopy and a lower odds of associated adverse events. Further evaluation of the impact of human factors, such as teamwork and decision-making, on intubation process conformance and success and outcomes is needed.