Endotracheal intubation during manual inline cervical ...

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Although the prima- ry method of ventilation in the unconscious patient is the bag-valve- mask (BVM) ventilation, BVM ventilation is not very effective according.
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Correspondence / American Journal of Emergency Medicine 34 (2016) 2440–2460

version and scoring system used, is able to predict early and late ED return, hospitalization, functional decline, and death within 6 months after an ED visit with a low/moderate performance [2-5,8-10]. Our data suggested that the proposed 5-item TRST works better than the original 6-item one. Similarly, the alternative scoring system (a score ≥ 2 independent of the positive items) seems to improve TRST5 performance; therefore, it could allow for a more appropriate selection of older adults in the ED who could benefit from geriatric interventions depending on resource availability. In conclusion, the TRST was confirmed as a moderately useful screening tool for frail elderly adults in the ED, allowing their selection for geriatric interventions on the basis of local organizational and economic resources. We recommend the use of the 5-item version whose result should be considered as positive when the score is ≥2 independent of the positive items. Further studies are warranted to develop and validate new tools with better performance in predicting adverse outcomes after an ED visit.

[7] Fan J, Worster A, Fernandes CM. Predictive validity of the triage risk screening tool for elderly patients in a Canadian emergency department. Am J Emerg Med 2006; 24:540–4. http://dx.doi.org/10.1016/j.ajem.2006.01.015. [8] Braes T, Moons P, Lipkens P, Sterckx W, Sabbe M, Flamaing J, et al. Screening for risk of unplanned readmission in older patients admitted to hospital: predictive accuracy of three instruments. Aging Clin Exp Res 2010;22: 345–51. [9] Cousins G, Bennet Z, Dillon G, Smith SM, Galvin R. Adverse outcomes in older adults attending emergency department: systematic review and meta-analysis of the triage risk stratification tool. Eur J Emerg Med 2013;20:230–9. http://dx.doi.org/10. 1097/MEJ.0b013e3283606ba6. [10] Carpenter CR, Shelton E, Fowler S, Suffoletto B, Platts-Mills TF, Rothman RE, et al. Risk factors and screening instruments to predict adverse outcomes for undifferentiated older emergency department patients: a systematic review and metaanalysis. Acad Emerg Med 2015;22:1–21. http://dx.doi.org/10.1111/acem.12569.

Endotracheal intubation during manual inline ☆ cervical stabilization performed by nurses

Conflicts of interest To the Editor, None. Author contributions F Salvi wrote the manuscript, and collected and analyzed the data; V Morichi collected and managed the data; A Cherubini critically revised the manuscript and gave final approval.

Sponsor's role None. Fabio Salvi, MD* Valeria Morichi, MD Antonio Cherubini, MD, PhD Department of Geriatrics and Geriatric Emergency Care IRCCS–Italian National Research Centres on Aging (I.N.R.C.A.), Ancona, Italy *Corresponding author at: Department of Geriatrics and Geriatric Emergency Care, IRCCS–Italian National Research Centres on Aging (I.N.R.C.A.), Via della Montagnola, 81, 60127, Ancona, Italy Tel.: +39 71 8003818; fax: +39 71 8003543 E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2016.09.029 References [1] Salvi F, Morichi V, Grilli A, Giorgi R, De Tommaso G, Dessì-Fulgheri P. The elderly in the emergency department: a critical review of problems and solutions. Intern Emerg Med 2007;2:292–301. http://dx.doi.org/10.1007/s11739-007-0081-3. [2] Mion LC, Palmer RM, Anetzbeerger GJ, Meldon SW. Establishing a case-finding and referral system for at-risk older individuals in the emergency department setting: the SIGNET model. J Am Geriatr Soc 2001;49:1379–86. [3] Meldon SW, Mion LC, Palmer RM, Drew BL, Connor JT, Lewicki LJ, et al. A brief riskstratification tool to predict repeat emergency department visits and hospitalizations in older patients discharged from the emergency department. Acad Emerg Med 2003;10:224–32. [4] Hustey FM, Mion LC, Connor JT, Emerman CL, Campbell J, Palmer RM. A brief risk stratification tool to predict functional decline in older adults discharged from emergency department. J Am Geriatr Soc 2007;55:1269–74. http://dx.doi.org/10.1111/j. 1532-5415.2007.01272.x. [5] Lee JS, Schwindt G, Langevin M, Moghabghab R, Alibhai SM, Kiss A, et al. Validation of the triage risk stratification tool to identify older persons at risk for hospital admission and returning to the emergency department. J Am Geriatr Soc 2008;56:2112–7. http://dx.doi.org/10.1111/j.1532-5415.2008. 01959.x. [6] Salvi F, Morichi V, Lorenzetti B, Rossi L, Spazzafumo L, Luzi R, et al. Risk stratification of older patients in the emergency department: comparison between the identification of seniors at risk and triage risk screening tool. Rejuvenation Res 2012;15: 288–94. http://dx.doi.org/10.1089/rej.2011.1239.

Securing the airway in an unconscious trauma patient is one of the key procedures that medical personnel working within the emergency medical services (EMS) should be able to perform. Although the primary method of ventilation in the unconscious patient is the bag-valvemask (BVM) ventilation, BVM ventilation is not very effective according to many publications [1,2]. In addition, it is worth to remember that, in the prehospital care, the patient should be treated as a patient with a full stomach, and incompetent BVM ventilation and elevated pressure within the stomach may result in regurgitation and aspiration of gastric contents into the respiratory tract. In Poland, the EMS teams consist of emergency physicians, paramedics, and nurses. In the training process, nurses generally have a much lower level of education in airway management compared with paramedics. As numerous studies show, the efficacy of intubation using standard Macintosh laryngoscope performed by nurses is insufficient [3,4]. The efficacy of intubation during spine cervical stabilization is greatly reduced; therefore, it is worth to consider the use of the alternative intubation techniques, including videolaryngoscopy or videotubes as, for example, the ETView VivaSight SL (ETView; ETView Ltd, Misgav, Israel). As shown by studies carried out on paramedics and physicians, the use of ETView compared with the standard Macintosh laryngoscope and standard endotracheal tube intubation greatly enhances the efficacy, particularly in the difficult airway [5-7]. The aim of this study was to evaluate the efficacy of endotracheal intubation performed by nurses with and without inline cervical stabilization. The study was approved by the Institutional Review Board of the Polish Society of Disaster Medicine (approval: IRB/34/2016). The study involved 26 nurses working in hospital emergency units or EMS. All participants declared their ability to perform endotracheal intubation using a Macintosh laryngoscope. After presenting the objectives of the study, participants had a 10-minute workout on intubation using a standard Macintosh laryngoscope. Then, the instructor presented the correct endotracheal intubation technique using ETView (Figure). After the demonstration, participants performed endotracheal intubation using ETView in 2 scenarios: scenario A, normal airway; scenario B, manual cervical stabilization simulating the spine injury conditions (manual stabilization performed by the independent instructor). The effectiveness of the first attempt of endotracheal intubation was 88.5% in scenario A and 84.6% in scenario B (P = .672). The average intubation time in scenario A and scenario B was, respectively, 21.5 ± 4.5 seconds and 26.4 ± 5.5 seconds (P = .023). The median time to visualize the larynx was 12.5 ± 3.5 seconds in scenario A and 15.5 ± 5 seconds in scenario B (P = .014). ☆ Source of support: no sources of financial and material support to be declared.

Correspondence / American Journal of Emergency Medicine 34 (2016) 2440–2460

Figure. The ETView VivaSight SL videotube.

In our survey, the use of manual stabilization during endotracheal intubation performed by nurses significantly increased the duration of the intubation; however, it did not affect the efficacy of the intubation. Marcin Madziala, MSc, EMT-P Department of Emergency Medicine Medical University of Warsaw, Warsaw, Poland Polish Society of Disaster Medicine, Poland Department of Emergency Medicine, Medical University of Warsaw Lindleya 4 Str, 02-005, Warsaw, Poland. Tel.: +48 519160829 (Mobile) E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2016.09.030 References [1] Szarpak L, Truszewski Z, Madziala M, Evrin T, Smereka J. Comparison of pocket mask vs. bag valve mask ventilation in cardiopulmonary resuscitation. Resuscitation 2016; 106(Supplement 1):e27–8. http://dx.doi.org/10.1016/j.resuscitation.2016.07.061. [2] Adelborg K, Dalgas C, Grove EL, Jørgensen C, Al-Mashhadi RH, Løfgren B. Mouth-tomouth ventilation is superior to mouth-to-pocket mask and bag-valve-mask ventilation during lifeguard CPR: a randomized study. Resuscitation 2011;82(5):618–22. http://dx.doi.org/10.1016/j.resuscitation.2011.01.009. [3] Aleksandrowicz S, Szarpak L. A comparison of GlideScope and Macintosh laryngoscopes for endotracheal intubation performed by nurses. Am J Emerg Med 2016; http://dx.doi.org/10.1016/j.ajem.2016.07.047 [pii: 34(10):2041. S0735–6757(16)30447–8]. [4] Smereka J, Truszewski Z, Madziala M, Szarpak L. Comparison of Macintosh and Intubrite laryngoscopes for orotracheal intubation by nurses during resuscitation: preliminary data of a randomized crossover simulation-based study. Am J Emerg Med 2016;34(8):1724–5. http://dx.doi.org/10.1016/j.ajem.2016.06.040. [5] Kurowski A, Szarpak L, Truszewski Z, Czyzewski L. Can the ETView VivaSight SL rival conventional intubation using the Macintosh laryngoscope during adult resuscitation by novice physicians? A randomized crossover manikin study. Medicine (Baltimore) 2015;94(21):e850. http://dx.doi.org/10.1097/MD.0000000000000850. [6] Szarpak Ł, Truszewski Z, Kurowski A, Czyzewski Ł, Evrin T, Bogdanski Ł. Tracheal intubation with a VivaSight-SL endotracheal tube by paramedics in a cervicalimmobilized manikin. Am J Emerg Med 2016;34(2):309–10. http://dx.doi.org/10. 1016/j.ajem.2015.10.013. [7] Truszewski Z, Szarpak L, Czyzewski L, Evrin T, Kurowski A, Majer J, et al. A comparison of the ETView VivaSight SL against a fiberoptic bronchoscope for nasotracheal intubation of multitrauma patients during resuscitation. A randomized, crossover, manikin study. Am J Emerg Med 2015;33(8):1097–9. http://dx.doi.org/10.1016/j.ajem.2015.04.078.

Superior mesenteric artery dissection does not necessarily mean acute mesenteric ischemia☆

To the Editor, In the study by Ichiba et al [1], it seems that the diagnosis of acute mesenteric ischemia (AMI) and necrosis is made by excess, leading to misdiagnosis. AMI is defined by the association of (1) clinical, biological, and computed tomographic features of acute bowel injury and (2) vascular

☆ Acknowledgments: no conflict of interest.

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splanchnic insufficiency (occlusive or nonocclusive) [2]. As a result, isolated superior mesenteric artery (SMA) dissection should not be considered as an AMI as long as signs of acute bowel injury are absent. Since the diagnosis of AMI was made, a gut- and lifesaving strategy including medical therapy and revascularization was reported to decrease intestinal necrosis resection rates and survival [3]. In this setting and whatever the baseline disease, predictors of intestinal necrosis are still lacking, but we suggested that elevated lactate levels and/or organ failure and/or peritoneal signs would recommend performing an explorative laparotomy [3]. In our experience of 9 patients with SMA dissection, only 2 patients had concomitant AMI and underwent emergency vascular and digestive surgery, whereas 1 had arteriography for ruptured aneurysm and 6 improved with medical therapy alone [4]. Thus, because SMA dissection does not necessarily mean AMI, medical therapy can be sufficient, whereas physicians must be aware of the appearance of signs of bowel injury. Alexandre Nuzzo, MD SURVI (Structure d'URgences Vasculaires Intestinales)–Intestinal Stroke Center Beaujon & Bichat Hospitals, Paris Diderot University Assistance Publique-Hôpitaux de Paris Paris, France Department of Gastroenterology and Intestinal Failure Corresponding author at: SURVI (Structure d'URgences Vasculaires Intestinales)–Intestinal Stroke Center, Beaujon & Bichat Hospitals Paris Diderot University Assistance Publique-Hôpitaux de Paris, INSERM U1148 Laboratory for Vascular Translationnal Science, Bichat Hospital, Paris, France Tel.: +33 140875000 E-mail address: [email protected] Yves Castier, MD, PhD SURVI (Structure d'URgences Vasculaires Intestinales)–Intestinal Stroke Center Beaujon & Bichat Hospitals, Paris Diderot University Assistance Publique-Hôpitaux de Paris, Paris, France Department of Vascular Surgery Olivier Corcos, MD SURVI (Structure d'URgences Vasculaires Intestinales)–Intestinal Stroke Center, Beaujon & Bichat Hospitals, Paris Diderot University Assistance Publique-Hôpitaux de Paris, Paris, France Department of Gastroenterology and Intestinal Failure http://dx.doi.org/10.1016/j.ajem.2016.09.031 References [1] Ichiba T, Hara M, Yunoki K, Urashima M, Harano M, Naitou H, et al. Baseline disease is a more important predictor of intestinal necrosis than computed tomographic findings in patients with acute mesenteric ischemia. Am J Emerg Med 2016;34:2261–5. [2] Corcos O, Nuzzo A. Gastro-intestinal vascular emergencies. Best practice & research clinical gastroenterology, 27(5). Elsevier Ltd; 2013. p. 709–25. [3] Corcos O, Castier Y, Sibert A, Gaujoux S, Ronot M, Joly F, et al. Effects of a multimodal management strategy for acute mesenteric ischemia on survival and intestinal failure. Clinical gastroenterology and Hepatology, 11(2). Elsevier Inc.; 2013. p. 158–165.e2. [4] Roussel A, Pellenc Q, Corcos O, Tresson P, Cerceau P, Francis F, et al. Spontaneous and isolated dissection of the superior mesenteric artery: proposal of a management algorithm. Ann Vasc Surg 2015;29:475–81.

Normal anion gap metabolic acidosis in salicylate overdose To the Editor, I read with great interest the article in this journal by Bauer and Darracq [1] entitled “Salicylate toxicity in the absence of anion gap metabolic acidosis.” The authors described 3 cases of salicylate intoxication with normal anion gap metabolic acidosis resulting from laboratory