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Zhang Y, Miller M, Buttfield A, Burns B, Lawrie K, Gaston J, Ferguson I. Alfentanil versus fentanyl for emergency department rapid sequence induction with ketamine: A-FAKT, a pilot randomized trial. Am J Emerg Med 2024; 84:25-32. [PMID: 39059038 DOI: 10.1016/j.ajem.2024.07.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 06/12/2024] [Accepted: 07/14/2024] [Indexed: 07/28/2024] Open
Abstract
BACKGROUND Fentanyl is often administered during rapid sequence induction of anesthesia (RSI) in the emergency department (ED) to ameliorate the hypertensive response that may occur. Due to its more rapid onset, the use of alfentanil may be more consistent with both the onset time of the sedative and the commencement of laryngoscopy. As such, we compared the effect of alfentanil and fentanyl on post-induction hemodynamic changes when administered as part of a standardized induction regimen including ketamine and rocuronium in ED RSI. METHODS This was a double-blind pilot randomized controlled trial of adult patients requiring RSI in the ED of three urban Australian hospitals. Patients were randomized to receive either alfentanil or fentanyl in addition to ketamine and rocuronium for RSI. Non-invasive blood pressure and heart rate were measured immediately before and at two, four, and six minutes after induction. The primary outcome was the occurrence of at least one post-induction systolic blood pressure outside the pre-specified range of 100-160mmHg (with adjustment for patients with baseline hypertension). Secondary outcomes included hypertension, hypotension, hypoxia, first-pass intubation success, 30-day mortality, and the pattern of hemodynamic changes. RESULTS A total of 61 patients were included in the final analysis (31 in the alfentanil group and 30 in the fentanyl group). The primary outcome was met in 58% of the alfentanil group and 50% of the fentanyl group (difference 8%, 95% confidence interval: -17% to 33%). The 30-day mortality rate, first-pass success rate, and incidences of hypertension, hypotension, and hypoxia were similar between the groups. There were no significant differences in systolic blood pressure or heart rate between the groups at any of the measured time-points. CONCLUSION Alfentanil and fentanyl produced comparable post-induction hemodynamic changes when used as adjuncts to ketamine in ED RSI. Future studies could consider comparing different dosages of these opioids.
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Affiliation(s)
- Yichen Zhang
- South Western Sydney Clinical School, University of New South Wales, Warwick Farm, New South Wales, Australia.
| | - Matthew Miller
- Aeromedical Operations, New South Wales Ambulance, Bankstown Aerodrome, New South Wales, Australia; Department of Anaesthesia, St George Hospital, Kogarah, New South Wales, Australia; St George and Sutherland Clinical Schools, University of New South Wales, Kogarah, New South Wales, Australia
| | - Alexander Buttfield
- Emergency Department, Campbelltown Hospital, Campbelltown, New South Wales, Australia; School of Medicine, Western Sydney University, Campbelltown, New South Wales, Australia
| | - Brian Burns
- Aeromedical Operations, New South Wales Ambulance, Bankstown Aerodrome, New South Wales, Australia; Emergency Department, Northern Beaches Hospital, Frenchs Forest, New South Wales, Australia; Faculty of Medicine & Health, University of Sydney, Camperdown, New South Wales, Australia; Macquarie Medical School, Macquarie University, Macquarie Park, New South Wales, Australia
| | - Kimberley Lawrie
- Aeromedical Operations, New South Wales Ambulance, Bankstown Aerodrome, New South Wales, Australia; Emergency Department, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - James Gaston
- Emergency Department, Campbelltown Hospital, Campbelltown, New South Wales, Australia; School of Medicine, Western Sydney University, Campbelltown, New South Wales, Australia
| | - Ian Ferguson
- South Western Sydney Clinical School, University of New South Wales, Warwick Farm, New South Wales, Australia; Aeromedical Operations, New South Wales Ambulance, Bankstown Aerodrome, New South Wales, Australia; Emergency Department, Liverpool Hospital, Liverpool, New South Wales, Australia
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Lousick M, Edwards S, Keijzers G, Pellatt RAF. Utility of computed tomography brain scans in intubated patients with overdose. Emerg Med Australas 2024. [PMID: 39344858 DOI: 10.1111/1742-6723.14510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Accepted: 09/12/2024] [Indexed: 10/01/2024]
Abstract
OBJECTIVE Describe the yield of computed tomography brain (CTB) scans in patients intubated for drug overdose. METHODS Retrospective descriptive study using existing registry data from two Australian EDs between February 2021 and June 2022. RESULTS Two hundred and six patients were intubated; 159 (77%) received a post-intubation CTB scan. Of these, 38 out of 159 (24%) had a documented indication (i.e. head injury and seizure) for their scans, with a yield of 5.3% (95% confidence interval [CI] = 1.5-17%). Of the 121 out of 159 (76%) patients without an indication, the yield of CTB was 0% (95% CI = 0-3%). CONCLUSIONS Routine imaging of patients intubated for overdose without clinical indication is unjustified.
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Affiliation(s)
- Michael Lousick
- Emergency Department, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Serena Edwards
- Emergency Department, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Gerben Keijzers
- Emergency Department, Gold Coast University Hospital, Gold Coast, Queensland, Australia
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
- School of Medicine, Griffith University, Gold Coast, Queensland, Australia
| | - Richard A F Pellatt
- Emergency Department, Gold Coast University Hospital, Gold Coast, Queensland, Australia
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
- School of Medicine, Griffith University, Gold Coast, Queensland, Australia
- LifeFlight Retrieval Medicine, Brisbane, Queensland, Australia
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Endlich Y, Davies EL, Kelly J. The nature of the response to airway management incident reports in high income countries: A scoping review. Anaesth Intensive Care 2024; 52:283-301. [PMID: 39219018 DOI: 10.1177/0310057x241227238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
Adverse events associated with failed airway management may have catastrophic consequences, and despite many advances in knowledge, guidelines and equipment, airway incidents and patient harm continue to occur. Patient safety incident reporting systems have been established to facilitate a reduction in incidents. However, it has been found that corrective actions are inadequate and successful safety improvements scarce. The aim of this scoping review was to assess whether the same is true for airway incidents by exploring academic literature that describes system changes in airway management in high-income countries over the last 30 years, based on findings and recommendations from incident reports and closed claims studies. This review followed the most recent guidance from the Joanna Briggs Institute (JBI). PubMed, Ovid MEDLINE and Embase, the JBI database, SCOPUS, the Cochrane Library and websites for anaesthetic societies were searched for eligible articles. Included articles were analysed and data synthesised to address the review's aim. The initial search yielded 28,492 results, of which 111 articles proceeded to the analysis phase. These included 23 full-text articles, 78 conference abstracts and 10 national guidelines addressing a range of airway initiatives across anaesthesia, intensive care and emergency medicine. While findings and recommendations from airway incident analyses are commonly published, there is a gap in the literature regarding the resulting system changes to reduce the number and severity of adverse airway events. Airway safety management mainly focuses on Safety-I events and thereby does not consider Safety-II principles, potentially missing out on all the information available from situations where airway management went well.
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Affiliation(s)
- Yasmin Endlich
- School of Medicine, The University of Adelaide, Adelaide, Australia
- School of Nursing, The University of Adelaide, Adelaide, Australia
- Royal Adelaide Hospital, Department of Anaesthesia, Adelaide, Australia
| | - Ellen L Davies
- Adelaide Health Simulation, The University of Adelaide, Adelaide, Australia
| | - Janet Kelly
- School of Nursing, The University of Adelaide, Adelaide, Australia
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Hohenstein C, Merz S, Eppler F, Arslan V, Ayvaci BM, Ünlü L. Emergency airway management: an EUSEM statement with regard to the guidelines of the Society of Critical Care Medicine. Eur J Emerg Med 2024; 31:83-85. [PMID: 38100641 PMCID: PMC10901228 DOI: 10.1097/mej.0000000000001114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 11/16/2023] [Indexed: 12/17/2023]
Affiliation(s)
- Christian Hohenstein
- Department of Emergency Medicine, Zentralklinik Bad Berka, University of Marburg, Faculty of Medicine, Bad Berka
| | - Sabine Merz
- Red Cross Villingen-Schwenningen, Villingen-Schwenningen
| | - Fabian Eppler
- Faculty of Medicine, University of Mainz, Mainz, Germany
| | - Volkan Arslan
- Department of Emergency Medicine, Hacettepe University Medicine Faculty, Ankara
| | - Bariş Murat Ayvaci
- Department of Emergency Medicine, University of Health Sciences Prof. Dr. Cemil Taşcioğlu City Hospital, Istanbul, Turkey
| | - Luca Ünlü
- Faculty of Medicine, Karl-Landsteiner University of Health Sciences, Krems a.d. Donau, Austria
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von Hellmann R, Fuhr N, Ward A Maia I, Gerberi D, Pedrollo D, Bellolio F, Oliveira J E Silva L. Effect of Bougie Use on First-Attempt Success in Tracheal Intubations: A Systematic Review and Meta-Analysis. Ann Emerg Med 2024; 83:132-144. [PMID: 37725023 DOI: 10.1016/j.annemergmed.2023.08.484] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 08/16/2023] [Accepted: 08/21/2023] [Indexed: 09/21/2023]
Abstract
The use of a bougie, a flexible endotracheal tube introducer, has been proposed to optimize first-attempt success in emergency department intubations. We aimed to evaluate the available evidence on the association of bougie use in the first attempt and success in tracheal intubations. This was a systematic review and meta-analysis of studies that evaluated first-attempt success between adults intubated with a bougie versus without a bougie (usually with a stylet) in all settings. Manikin and cadaver studies were excluded. A medical librarian searched Ovid Cochrane Central, Ovid Embase, Ovid Medline, Scopus, and Web of Science for randomized controlled trials and comparative observational studies from inception to June 2023. Study selection and data extraction were done in duplicate by 2 independent reviewers. We conducted a meta-analysis with random-effects models, and we used GRADE to assess the certainty of evidence at the outcome level. We screened a total of 2,699 studies, and 133 were selected for full-text review. A total of 18 studies, including 12 randomized controlled trials, underwent quantitative analysis. In the meta-analysis of 18 studies (9,151 patients), bougie use was associated with increased first-attempt intubation success (pooled risk ratio [RR] 1.11, 95% confidence interval [CI] 1.06 to 1.17, low certainty evidence). Bougie use was associated with increased first-attempt success across all analyzed subgroups with similar effect estimates, including in emergency intubations (9 studies; 8,070 patients; RR 1.11, 95% CI 1.05 to 1.16, low certainty). The highest point estimate favoring the use of a bougie was in the subgroup of patients with Cormack-Lehane III or IV (5 studies, 585 patients, RR 1.60, 95% CI 1.40 to 1.84, moderate certainty). In this meta-analysis, the bougie as an aid in the first intubation attempt was associated with increased success. Despite the certainty of evidence being low, these data suggest that a bougie should probably be used first and not as a rescue device in emergency intubations.
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Affiliation(s)
- Rafael von Hellmann
- Department of Emergency Medicine, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
| | - Natalia Fuhr
- Department of Emergency Medicine, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
| | - Ian Ward A Maia
- Department of Emergency Medicine, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | | | - Daniel Pedrollo
- Department of Emergency Medicine, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
| | | | - Lucas Oliveira J E Silva
- Department of Emergency Medicine, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil; Department of Emergency Medicine, Mayo Clinic, Rochester, MN.
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Venner C. Is it time for mandatory airway assessments for emergency medicine trainees? Emerg Med Australas 2023; 35:521-522. [PMID: 37005065 DOI: 10.1111/1742-6723.14210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 03/23/2023] [Indexed: 04/04/2023]
Affiliation(s)
- Caroline Venner
- Gladstone Hospital, Gladstone, Queensland, Australia
- Children's Health Queensland Retrieval Service, Brisbane, Queensland, Australia
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Dean P, Kerrey B. Video screen visualization patterns when using a video laryngoscope for tracheal intubation: A systematic review. J Am Coll Emerg Physicians Open 2022; 3:e12630. [PMID: 35028640 PMCID: PMC8738719 DOI: 10.1002/emp2.12630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Revised: 11/08/2021] [Accepted: 11/23/2021] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE Published studies of video laryngoscopes are often limited by the lack of a clear definition of video laryngoscopy (VL). We performed a systematic review to determine how often published studies of VL report on video screen visualization. METHODS We searched PubMed, EMBASE and Scopus for interventional and observational studies in which a video laryngoscope equipped with a standard geometry blade was used for tracheal intubation. We excluded simulation based studies. Our primary outcome was data on video laryngoscope screen visualization. Secondary outcomes were explicit methodology for screen visualization. RESULTS We screened 4838 unique studies and included 207 (120 interventional and 87 observational). Only 21 studies (10% of 207) included any data on video screen visualization by the proceduralist, 19 in a yes/no fashion only (ie, screened viewed or not) and 2 with detail beyond whether the screen was viewed or not. In 11 more studies, visualization patterns could be inferred based on screen availability and in 16 more studies, the methods section stated how screen visualization was expected to be performed without reporting data collection on how the proceduralist interacted with the video screen. Risk of bias was high in the majority of included studies. CONCLUSIONS Published studies of VL, including many clinical trials, rarely include data on video screen visualization. Given the nuances of using a video laryngoscope, this is a critical deficiency, which largely prevents us from knowing the treatment effect of using a video laryngoscope in clinical practice. Future studies of VL must address this deficiency.
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Affiliation(s)
- Preston Dean
- Division of Emergency MedicineCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
| | - Benjamin Kerrey
- Division of Emergency MedicineCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
- Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
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