Of 6088 patients requiring intubation within the first hour of arrival at a Level 1 trauma centre, 21 (0.3%) required a surgical airway for unanticipated difficult upper airway anatomy. There were no deaths from failed airway management. The authors ascribe their effective airway management to a simple protocol based on rapid sequence induction of anesthesia, judicious use of selected adjunctive devices (bougie, LMA), and the supervision by a small group of experienced anesthesiologists.
The Success of Emergency Endotracheal Intubation in Trauma Patients: A 10-Year Experience at a Major Adult Trauma Referral Center
Anesth Analg. 2009 Sep;109(3):866-72
Category Archives: Resus
Life-saving medicine
'Shock Room' belongs to both ED & ICU
Belgian authors describe a four-bedded ‘shock room’, situated between the ED and the ICU and managed jointly by ED and ICU staff, which is used to stabilise all acutely ill patients in the hospital, whether they are from outside or inside the hospital. 2514 patients were treated in their shock room in 2006, managed by either senior emergency physicians or intensivists, and nurses from both departments. 21.5% were admitted to ED shock room from other wards, and 14.5% were transfers from other hospitals.
Comment: I personally visited this unit in Brussels in 2007 and liked the concept – sick patients in the ED and patients who go off on the wards often have similar needs in terms of skills and equipment. Why not manage them all in the resus room, and have intensivists and emergency physicians working more collaboratively?
A ‘shock room’ for early management of the acutely ill
Anaesth Intensive Care. 2009 May;37(3):426-31
Rectal exam for urethral injury a waste of time?
Of 41 male patients with proven blunt urethral injury over a thirteen year period at a major trauma centre, only one had an abnormal prostate on digital rectal examination (DRE). Meatal blood and haematuria prior to catheterisation were more common findings (8 and 7 patients, respectively). All patients had haematuria after catheter insertion. In blunt urethral injuries, DRE has very low sensitivity.
Traumatic urethral injuries: Does the digital rectal examination really help us?
Injury. 2009 Sep;40(9):984-6
Small infant IJV cannulation tip
Simple taping using Transpore tape of the skin over the internal jugular vein insertion point increased IJV cross sectional area and AP diameter, and shortened to time to successful cannulation in this RCT on 28 infants and neonates undergoing cardiac surgery. Also, the degree of IJV collapse during advancement of the needle was less in the taped group.
The skin over the right IJV (RIJV) was lifted up with several pieces of tape in the cephalad and caudad directions. The skin cephalic to the RIJV was stretched cephalad, whereas the skin caudal to the RIJV was stretched caudad. The other ends of the tape were attached to the metal edge of the operating table.
A Novel Skin-Traction Method Is Effective for Real-Time Ultrasound-Guided Internal Jugular Vein Catheterization in Infants and Neonates Weighing Less Than 5 Kilograms
Anesth Analg. 2009 Sep;109(3):754-9
emergence with ketamine overstated
A prospective study of 746 children sedated in the emergency department with iv or im ketamine revealed 2.1% may have experienced ’emergence delirium’ although the authors concede this was difficult to define. In contrast, 291 (38%) reported pleasant altered perceptions. Follow up revealed at least one nightmare in the following weeks in 3.4% of patients, which may be well under the rate reported in the normal unsedated paediatric population.
What is the nature of the emergence phenomenon when using intravenous or intramuscular ketamine for paediatric procedural sedation?
Emerg Med Australas. 2009 Aug;21(4):315-22
Vasopressin in Pediatric Vasodilatory Shock
This Canadian multi-centre study on 65 children compared vasopressin infusions with placebo in children with vasodilatory shock who had already received fluid resuscitation and catecholamine infusions. No significant difference was observed in the primary endpoint of time to haemodynamic stability or the secondary endpoints of mortality, organ-failure–free days, length of critical care unit stay, and adverse events, although there was a trend toward increased mortality in the vasopressin group.
Vasopressin in Pediatric Vasodilatory Shock
Am J Respir Crit Care Med. 2009 Oct 1;180(7):632-9
Don't ignore hypotension in the emergency department!
Another paper shows hypotension in the ED is an ominous sign. Nonsustained hypotension – even a single episode – was associated with an three-fold increase in mortality in adult patients presenting the ED with sepsis.
The significance of non-sustained hypotension in emergency department patients with sepsis
Intensive Care Med. 2009 Jul;35(7):1261-4
Tracheal deviation in infants
It is common for the infant trachea to deviate to the right, with a frequency of 50% at one year, 25% at two years, 15% at three years and 6% at four years (tending not to occur in the over fives), but it may be missed on inspiratory chest films with the head in extension. In a case report from India, authors point out that anaesthetists are often unaware of this normal variant. Since many tracheal tubes are designed with the bevel facing left, the angled tracheal wall may occlude the distal outlet of the tube, necessitating repositioning of the tube higher in the trachea above the bend.
Anaesth Intensive Care. 2009 Jan;37(1):144-5
Frog leg position for femoral vein cannulation
An ultrasound study of 80 children from 5 pre-determined age groups showed that the femoral veins increased their diameter in the frog-leg compared with straight-leg positions. Left and right femoral veins were the same size. There was significant overlap of the femoral arteries and veins which increased with distance distal to the inguinal ligament.
The Anatomic Relationship between the Common Femoral Artery and Common Femoral Vein in Frog Leg Position Versus Straight Leg Position in Pediatric Patients.
Acad Emerg Med. 2009 Jul;16(7):579-84
Infant CPR – push deeper?
A small study of 6 PICU patients requiring CPR for cardiac arrest due to primary cardiac disease showed that blood pressure as measured by an arterial line increased when the depth of chest compression was increased from one third to one half of the chest wall diameter (using the hand-encircling method). Systolic, mean, and pulse pressures increased significantly whereas diastolic blood pressure (a key determinant of coronary perfusion) did not.
Should the ILCOR guidelines be changed to recommend deeper chest compressions? More data are needed, but the take home message here may be that invasive arterial monitoring is a good guide to the effectiveness of CPR during cardiac arrest resuscitation.
Depth of sternal compression and intra-arterial blood pressure during CPR in
infants following cardiac surgery