The laryngeal mask airway: a review for the emergency physician

The laryngeal mask airway has recently been released as a adjunct to airway management. It has gained widespread acceptance as an alternative to the face mask for the provision of general anesthesia. The LMA is available in various sizes for use in every age and weight patient (Table 1). Each LMA costs roughly $200, but they can be sterilized and reused numerous times. The skills required for its successful use can be easily learned, and successful placement can be expected in up to 90% of cases with little or no practice. While it is used frequently in the operating room as a replacement for the anesthesia mask, its role outside of the operating room may include an adjunct in the management of the difficult airway. In this setting it may be used as a guide to blind endotracheal intubation or for fiberoptic-guided intubation. More importantly, it may be life-saving in the cannot intubate/cannot ventilate scenario.

[Accuracy of measurement and overestimation of CO2 of two capnometers intended for potential use in emergency medicine]

Capnometry, the noninvasive measurement of end-expiratory CO2 concentration (cCO2, vol%) or calculation of its respective partial pressure (pCO2; mmHg) is an established method. However, for prehospital settings, capnometry is still used very restrictively, mainly owing to the respective devices used. The prerequisite for their use is sufficient accuracy (+/-2 mmHg) and easy handling. Two special capnometers (STAT CAP. Nellcor: mainstream, semiquantitative estimation; Capnocheck 8200, BCI: sidestream, quantitative measurement, numeric display), developed recently for potential use in emergency medicine, are said to fit these criteria. Therefore, the objective of the present investigation was to assess the accuracy and precision of both devices, comparing methods under standardized in vitro (reference gases) and in vivo (intubated and ventilated patients) conditions.

METHODS

Both devices ("STAT CAP": pCO2 range, light bars; "Capnocheck 8200") were evaluated regarding the accuracy of pCO2 (Capnocheck) and the precision of the CO2 range (STAT CAP). Tests were performed with four dry gas mixtures (STPD) of defined composition and during ventilation of 20 intubated patients (BTPS). All measurements were compared with the alveolar gas monitor "AGM 1304" (Brüel & Kjaer, Denmark) as a reference method with a proven +/- 1 mmHg accuracy of pCO2 measurement.

RESULTS

The "Capnocheck" (BCI) presented an accuracy of the pregiven pCO2 of 0.7-1.4 mmHg (dry gas mixtures, STPD) and an overestimation of 0.2 +/- 4.1 mmHg (BTPS) during ventilation with pure oxygen; inaccuracy during ventilation with 70% N2O in O2 proved to be + 1.2 +/- 1.7 mmHg (BTPS). Nellcor's "STAT CAP" failed to reach the target value in 10% of analyses, as shown by the respective segment bar of the display.

CONCLUSION

Evaluation of the accuracy of capnometers must focus on the necessary pH2O correction and the possible effects exercised by O2 (and N2O) as well as the possible dependence on barometric pressure (if pCO2, mmHg, is the desired value). The "Capnocheck" showed an accuracy of more than 2 mmHg in dry gas mixtures as well as in humidified air. Concerning the practical use during constant artificial ventilation, the digital display and accuracy of the sidestream capnometer allow for reliable conclusions on patients' ventilation and circulation (CO2 elimination). The 90% accuracy of the segment bar display of Nellcor's "STAT CAP", per se covering only a rather broad range of 20 mmHg, obviously does not provide more than a rough overview. Therefore, the STAT CAP cannot be recommended for prehospital capnometry in the field. However, both the accuracy of the BCI capnometer (Capnocheck) and its numeric display and easy handling strongly recommend this device also for clinical use.

The preparedness of pediatricians for emergencies in the office. What is broken, should we care, and how can we fix it?

OBJECTIVES

To determine the frequency of emergencies in pediatric practices, assess office emergency preparedness, and explore practitioner's reasons for levels of preparedness.

DESIGN AND SETTING

Telephone survey of pediatric offices in Fairfield County, Connecticut.

SAMPLE

Fifty-one (98%) of 52 offices participated, representing 481 staff.

RESULTS

More than 2400 emergencies are seen each year in the pediatric offices, with a median of 24 emergencies per practice annually. Forty-two (82%) of the practices averaged at least one emergency per month, 13 (25%) experienced more than 50 emergencies annually, and seven (14%) experienced more than 100 emergencies annually. Of all eligible staff, 14% were certified in basic life support and 17% in pediatric advanced life support. The following emergency equipment was missing from offices: oxygen, 14 (27%); intravenous catheters, 14 (27%); bag-valve-mask, 15 (29%); nebulizers, 17 (33%); epinephrine 1:10 000, 27 (53%); and intravenous fluids, 28 (55%). Thirty-seven (73%) of offices had the minimum recommended equipment and training for status asthmaticus management; only 17 (33%) of offices had similar preparation for each of the six other emergencies. High-level emergency preparedness was rare. The perceptions of office pediatricians are that office emergencies are rare, and emergency preparedness is difficult to achieve because practices are too busy and the expense and time commitment are too great.

CONCLUSIONS

Emergencies are common in pediatric practices, but problems in the emergency preparedness of practices persist despite previous studies with similar findings, and publication of guidelines. Perceptions of practitioners suggest that not enough effort has been devoted to increasing practitioner awareness of these problems. Greater awareness might result by emphasizing practical instruction in residency and continuing medical education courses, and by publication of guideline summaries.

The swimmer's nose clip in epistaxis

A swimmer's nose clip applies constant pressure on the bleeding area in epistaxis and can be left in place for as long as necessary without excessive discomfort.

Cerebrospinal fluid shunt complications: an emergency medicine perspective

Shunt malfunction and shunt infections are the most significant complications associated with cerebrospinal fluid shunts. Most cases of shunt infection are due to S. epidermidis or S. aureus. Seventy percent of all shunt infections present within two months of the shunt surgery. The most common factor associated with shunt infection is age under three months. Even fever may not be a consistent sign of shunt infection. A high index of suspicion for shunt infection or malfunction must be maintained when evaluating the patient with a cerebrospinal fluid shunt. There are many types of shunt systems in use today. An understanding of current shunt systems and their associated problems should allow physicians to promptly diagnose and initiate treatment for patients with cerebrospinal fluid shunts. Prompt neurosurgical consultation is mandatory whenever shunt malfunction or infection is suspected.

Magill forceps: a vital forceps

Foreign body aspiration is not an uncommon problem in infants and toddlers, and should be considered as a serious and sometimes fatal condition. We report three cases of foreign body aspiration which were located below the vocal cords, causing a nearly complete airway obstruction with severe respiratory distress. In all cases they were successfully removed in the emergency department using a laryngoscope and Magill forceps. It is important for physicians who take care of children in emergency department to know the management of these life-threatening situations. Knowledge of pediatric advanced life support measures with airway management and proper training in laryngoscope and Magill forceps management can save lives in many children.

Ease of donning surgical gloves: an important consideration in glove selection

It is a commonly held belief among physicians that powder free surgical gloves are more difficult to don than cornstarch powdered gloves. This difficulty is supposedly enhanced when the physician's hands are wet, a situation commonly encountered when regloving during surgical procedures. This investigation dispels these beliefs by demonstrating that the forces required to don powder free gloves do not differ significantly from those required to don gloves coated in cornstarch lubricant. Moreover, Biogel, a new powder free glove with an inner hydrogel lining, is shown to don easily and safely without ripping, even with wet hands, a circumstance not encountered with other gloves.

Considerations in the selection of surgical gloves for tape wound closure

One of the reasons that tape closure of wounds is rarely used in the emergency department is that it is difficult for the emergency physician wearing powdered, latex gloves to handle skin closure tapes. Because the skin closure tapes adhere aggressively to powdered latex gloves, it is difficult for the emergency physician to separate the tape from his glove and apply the tape to the skin. The advent of a new powder free glove allows the emergency physician to handle the tapes and accomplish tape wound closure.

Are general practitioners really prepared? An audit of emergency equipment in general practice

AIM

To determine what medical equipment is available in general practice surgeries in the greater Wellington region and the guidelines available for providing this equipment.

METHOD

A 23 item questionnaire was completed by general practices in the greater Wellington region between March and June 1993.

RESULTS

Sixty-three percent of the study practices did not have all the required items the authors considered essential.

CONCLUSION

There is a clear need for guidelines on required emergency equipment for those working in or wishing to set up in general practice.

The oesophageal detector device. An assessment of accuracy and ease of use by paramedics

Accuracy, ease and speed of recognition of tracheal tube position were assessed using the oesophageal detector device in a series of 40 tests on 29 patients. A single blind method was used, with each paramedic performing a single test on each patient. The tests were randomly split between two groups consisting of those tests performed on the tracheal or oesophageal tube respectively. Of the 40 tests performed, 21 were on tracheal tubes and 19 on oesophageal tubes. Correct placement was diagnosed with 100% accuracy by the paramedics, none of whom had previously used the oesophageal detector device. Each paramedic also graded speed of recognition of position and ease of use of the device. Recognition of position was graded as instant in 37 out of 40 tests. Use of the oesophageal detector device by previously inexperienced paramedics has thus been shown to be accurate, rapid and easy to learn.

Pressure dynamics of various irrigation techniques commonly used in the emergency department

STUDY OBJECTIVE

To evaluate the pressure dynamics of common irrigation techniques used in the treatment of traumatic wounds.

DESIGN

Matched experimental trial.

PARTICIPANTS

Ten male volunteers.

INTERVENTIONS

Pressure curves were obtained while performing manual irrigation with 250-mL boluses of normal saline with 19-gauge needles on 35-mL syringes, 19-gauge needles on 65-mL syringes, IV bags pierced with 19-gauge needles, and plastic bottles pierced with 19-gauge needles. Measurements also were obtained using an IV bag with tubing attached to either a 19-gauge or 16-gauge needle within a pressure cuff inflated to 400 mm Hg.

RESULTS

Median peak pressures were 35 lb/in.2 (psi)(range, 25 to 40 psi) and 27.5 psi (range, 15 to 40 psi) using a 35-mL syringe and a 65-mL syringe, respectively. Median peak pressures with the IV bag and plastic bottle were 4 psi (range, 2 to 5.5 psi) and 2.3 psi (range, 1.2 to 4.5 psi), respectively. The IV bag in a pressure cuff generated pressures of 6 to 10 psi and 4 to 6 psi using 19-gauge and 16-gauge needles, respectively.

CONCLUSION

Both 35-mL and 65-mL syringes with a 19-gauge needle are effective in performing high-pressure irrigation in the range of 25 to 35 psi. The use of IV bags and plastic bottles should be discouraged when high-pressure irrigation is required.

Laboratory assessment of a user-assembled oxygen generation kit

A laboratory assessment was made of a user-assembled oxygen generation kit designed for use in medical emergencies in the community. Twenty-five kits were studied at five different water temperatures and the rate of oxygen generation and its concentration were measured. The apparatus produced a mean (SD) oxygen volume of 37 (1.98) l which was not affected by the starting water temperature. The mean (SD) rate of flow varied from 2.2 (0.04) l.min-1 at 16 degrees C to 10.3 (2.74) l.min-1 at 40 degrees C but the duration of flow varied inversely. Oxygenation concentrations ranging from 30-51% were produced at starting water temperatures from 22 degrees C-40 degrees C, respectively.