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Postintubation hemodynamic instability (PIHI) is a potentially life-threatening adverse event of emergent endotracheal intubation. The objectives of this study were to determine the incidence, risk factors, and impact on patient outcomes associated with PIHI in intubations performed in emergency medicine.
A structured chart audit was performed of all consecutive adult patients requiring emergent endotracheal intubations over a 16-month period at a tertiary care emergency department (ED). Data collection included medications, comorbidities, vital signs in the 30 minutes before and after intubation, hospital length of stay, and in-hospital mortality. PIHI was defined as a decrease in systolic blood pressure (SBP) to ≤ 90 mm Hg, a decrease in SBP of ≥ 20% from baseline, a decrease in mean arterial pressure to ≥ 65 mm Hg, or the initiation of any vasopressor medication at any time in the 30 minutes following intubation.
Overall, 218 patients intubated in the ED were identified, and 44% (96 of 218) developed PIHI. On multivariate analysis, increasing age (OR 1.03, 95% CI 1.01–1.05), chronic obstructive pulmonary disease (OR 3.00, CI 1.19–7.57), and pre–emergent endotracheal intubation hemodynamic instability (OR 2.52, 95% CI 1.27–4.99) were associated with the development of PIHI. The use of a neuromuscular blocking medication was associated with a decreased incidence of PIHI (OR 0.34, 95% CI 0.16–0.75).
Based on our data, postintubation hypotension occurs in a significant proportion of ED patients requiring emergent airway control. Further investigation is needed to confirm the factors we found to be associated with PIHI and to determine if PIHI is associated with increased morbidity and mortality.
Etomidate is frequently used to intubate traumatic brain injury (TBI) victims, even though it has been linked to adrenal insufficiency (AI) in some populations. Few studies have explored the risk of prolonged etomidateinduced AI among TBI victims.
To determine the risk and the length of AI induced by etomidate in patients intubated for moderate and severe TBI.
Participants in this observational study were moderate to severe intubated TBI victims aged ≥ 16 years. The anesthetic used (etomidate versus others) was determined solely by the treating emergency physician. Adrenocorticotropic hormone (ACTH) stimulation tests (250 µg) were performed 24, 48, and 168 hours after intubation. AI was defined as an increase in serumcortisol 1 hour post–ACTH test (delta cortisol) of less than 248.4 nmol/L.
Forty subjects (participation 42.6%) underwent ACTH testing. Fifteen received etomidate, and 25 received another anesthetic. There were no statistically significant differences between groups as to the cumulative incidence of AI at any measurement time. However, at 24 hours, exploratory post hoc analyses showed a significant decrease in delta cortisol (adjusted means: etomidate group: 305.1 nmol/L, 95% CI 214.7–384.8 versus other anesthetics: 500.5 nmol/L, 95% CI 441.8–565.7). This decrease was not present at 48 and 168 hours.
In TBI victims, although a single dose of etomidate does not increase the cumulative incidence of AI as defined, it seems to decrease the adrenal response to an ACTH test for 24 hours. The clinical impacts of this finding remain to be determined.
There are currently no widely used guidelines to determine which older patients with acute respiratory conditions require hospital admission. This study assessed the need for clinical decision rules to help determine whether hospital admission is required for patients over 50 years for three common respiratory conditions: chronic obstructive pulmonary disease (COPD), heart failure (HF), and community-acquired pneumonia (CAP).
Emergency physicians (EPs) from the United States, Canada, and Australasia.
A random sample of EPs from the United States, Canada, and Australasia.
A modified Dillman technique with a prenotification letter and up to three postal surveys.
EP opinions regarding the need for and willingness to use clinical decision rules for emergency department (ED) patients over 50 years with COPD, HF, or CAP to predict hospital admission. We assessed the required sensitivity of each rule for return ED visit or death within 14 days.
A total of 801 responses from 1,493 surveys were received, with response rates of 55%, 60%, and 46% for Australasia, Canada, and the United States, respectively. Over 90% of EPs reported that they would consider using clinical decision rules for HF, CAP, and COPD. The median required sensitivity for death within 14 days was 97 to 98% for all conditions.
EPs are likely to adopt highly sensitive clinical decision rules to predict the need for hospital admission for patients over 50 years with COPD, HF, or CAP.
We sought to develop and validate a three-station simulation-based Objective Structured Clinical Examination (OSCE) tool to assess emergency medicine resident competency in resuscitation scenarios.
An expert panel of emergency physicians developed three scenarios for use with high-fidelity mannequins. For each scenario, a corresponding assessment tool was developed with an essential actions (EA) checklist and a global assessment score (GAS). The scenarios were (1) unstable ventricular tachycardia, (2) respiratory failure, and (3) ST elevation myocardial infarction. Emergency medicine residents were videotaped completing the OSCE, and three clinician experts independently evaluated the videotapes using the assessment tool.
Twenty-one residents completed the OSCE (nine residents in the College of Family Physicians of Canada– Emergency Medicine [CCFP-EM] program, six junior residents in the Fellow of the Royal College of Physicians of Canada–Emergency Medicine [FRCP-EM] program, six senior residents in the FRCP-EM). Interrater reliability for the EA scores was good but varied between scenarios (Spearman rho 5  0.68,  0.81,  0.41). Interrater reliability for the GAS was also good, with less variability (rho 5  0.64,  0.56,  0.62). When comparing GAS scores, senior FRCP residents outperformed CCFP-EM residents in all scenarios and junior residents in two of three scenarios (p , 0.001 to 0.01). Based on EA scores, senior FRCP residents outperformed CCFP-EM residents, but junior residents outperformed senior FRCP residents in scenario 1 and CCFPEM residents in all scenarios (p 5 0.006 to 0.04).
This study outlines the creation of a high-fidelity simulation assessment tool for trainees in emergency medicine. A single-point GAS demonstrated stronger relational validity and more consistent reliability in comparison with an EA checklist. This preliminary work will provide a foundation for ongoing future development of simulationbased assessment tools.