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STUDY OBJECTIVE: We sought to determine whether the manner and order in which historical questions used to risk stratify for subarachnoid hemorrhage are asked significantly alter the response/concordance. METHODS: Adult patients complaining of headache in the emergency department were presented with 1 of 2 questionnaires each containing 2 variations of the pertinent question and differing only in their order. Data were primarily analyzed using the kappa statistic to determine whether rates of concordance are greater than would be expected by chance alone. And, as a secondary outcome, a sample of 120 was predetermined to be adequate to achieve 80% power in detecting a difference of 20% to 25% between questionnaires comparing the influence of order on concordance. RESULTS: The agreement corrected for chance for version 2, kappa = 0.51, is higher than the agreement corrected for chance for version 1, kappa = 0.28, a difference of 0.23 with a 95% confidence interval (-0.03 to 0.49; P = .08; SE, 0.13). The percentages of patients who answered the questions concordantly were 60% and 75%, respectively, for versions 1 and 2. The difference is 15% with a 95% confidence interval of (-2% to 32%, P = .08). CONCLUSION: Although not statistically significant, our study indicates that up 38% answer these 2 very similar questions discordantly. Also, there appears to be a higher degree of concordance (15%) when patients are first asked, 'When was the last time you had a headache this bad?'Copyright © 2007 by Elsevier Inc. [ABSTRACT FROM AUTHOR]

Background: The pathophysiology underlying acute mountain sickness (AMS) and excessive hypoxemia at high altitudes is not fully understood. Previous work by our group has demonstrated a significant association between urinary measures of dehydration and bicarbonate retention in subjects developing excessive hypoxemia and AMS at high altitudes. To further characterize these findings, we returned to our original testing site to examine the hypothesis that subjects with lower levels of oxygen saturation and/or AMS would possess higher levels of venous bicarbonate.Methods: Medical history inquiry, clinical examination, Lake Louise scoring, and the collection of venous levels of bicarbonate concentration and base excess were performed on 52 lowland-dwelling persons after they completed a religious pilgrimage in the Nepal Himalayas to approximately 4,250 m.Results: Oxygen saturation levels were strongly and inversely correlated with serum levels of venous bicarbonate and base excess, whereas AMS and Lake Louise scores were not associated with these measures of alkalosis.Conclusions: Our data suggest an association between measures of serum bicarbonate anion retention and decreasing oxygen saturation. Our data do not demonstrate an association between AMS or Lake Louise scores and measures of serum bicarbonate level. We propose that excessive hypoxemia at high altitudes may be associated with a compromised ability of the kidney to metabolically compensate for an altitude-induced hypocapnic alkalosis. [ABSTRACT FROM AUTHOR]

Objectives: This study investigates whether there are differences in the prevalence, risk factors and age of identification of childhood hearing impairment between the minority and majority ethnic populations in the largely urban multi-ethnic health district of South Glamorgan, in which 5% of the total population belong to minority ethnic communities. The minority ethnic population is highly heterogeneous with communities of Indian subcontinent origin being in the minority. Methods: This was a retrospective study of the under 9-year-old population, in which child surveillance and audiology files of all identified children with moderate to severe hearing impairment born between 1988 and 1996 were reviewed. This incorporated 50 children, of whom 20% were from minority ethnic communities. The data were collected using a structured pro-forma to extract information from the records. Results: Hearing impairment was significantly more common in the minority than majority ethnic population (2.27 compared with 0.83 per 1000). With the exception of consanguinity, there were no significant differences in risk factors between the minority and majority ethnic communities. A genetic cause was found in the majority of children from all groups. There was no significant difference in the age of identification of hearing loss between minority and majority ethnic populations, with hearing loss being identified late in both groups (median age of identification = 19 months and 17 months, respectively). There was a strong association of early identification with both neonatal screening and severity of hearing loss. Conclusion: With current screening methods, hearing impairment is identified late in an unacceptable number of children, regardless of ethnic group. The higher prevalence in minority ethnic communities makes a striking impact on the absolute numbers of affected children, even in an area with a low and very mixed minority ethnic population in which communities other than those of Indian subcontinent origin predominate. This has service implications for early counselling and intervention, speech therapy and educational provision, which must be provided in formats accessible and appropriate to these communities. [ABSTRACT FROM AUTHOR]

This article presents a case in which an air medical flight crew encountered a potentially difficult airway when a trauma patient deteriorated in-flight. The crew elected to sedate and paralyze the patient and place a laryngeal mask airway without a prior attempt at direct laryngoscopy and endotracheal intubation. The term Rapid Sequence Airway (RSA) is coined for this novel approach. This article describes and supports this concept and provides definitions of alternative and failed airways. [ABSTRACT FROM AUTHOR]

Background: An ambulance traffic crash not only leads to injuries among emergency medical service (EMS) professionals but also injures patients or their companions during transportation. We aimed to describe the incidence of ambulance crashes, seating location, seatbelt use for casualties (ie, both fatal and nonfatal injuries), ambulance safety efforts, and to identify factors affecting the number of ambulance crashes in Japan., Methods: We conducted a nationwide survey of all fire departments in Japan. The survey queried each fire department about the number of ambulance crashes between January 1, 2017, and December 31, 2019, the number of casualties, their locations, and seatbelt usage. Additionally, the survey collected information on fire department characteristics, including the number of ambulance dispatches, and their safety efforts including emergency vehicle operation training and seatbelt policies. We used regression methods including a zero-inflated negative binomial model to identify factors associated with the number of crashes., Results: Among the 726 fire departments in Japan, 553 (76.2%) responded to the survey, reporting a total of 11,901,210 ambulance dispatches with 1,659 ambulance crashes (13.9 for every 100,000 ambulance dispatches) that resulted in a total of 130 casualties during the 3-year study period (1.1 in every 100,000 dispatches). Among the rear cabin occupants, seatbelt use was limited for both EMS professionals ( n  = 3/29, 10.3%) and patients/companions ( n  = 3/26, 11.5%). Only 46.7% of the fire departments had an internal policy regarding seatbelt use. About three-fourths of fire departments (76.3%) conducted emergency vehicle operation training internally. The output of the regression model revealed that fire departments that conduct internal emergency vehicle operation training had fewer ambulance crashes compared to those that do not (odds of being an excessive zero -2.20, 95% CI: -3.6 to -0.8)., Conclusion: Two-thirds of fire departments experienced at least one crash during the study period. The majority of rear cabin occupants who were injured in ambulance crashes were not wearing a seatbelt. Although efforts to ascertain seatbelt compliance were limited, Japanese fire departments have attempted a variety of methods to reduce ambulance crashes including internal emergency vehicle operation training, which was associated with fewer ambulance crashes.

Background: A multidisciplinary group of stakeholders were used to identify: (1) the core competencies of a training program required to perform in-hospital ECPR initiation (2) additional competencies required to perform pre-hospital ECPR initiation and; (3) the optimal training method and maintenance protocol for delivering an ECPR program., Methods: A modified Delphi process was undertaken utilising two web based survey rounds and one virtual meeting. Experts rated the importance of different aspects of ECPR training, competency and governance on a 9-point Likert scale. A diverse, representative group was targeted. Consensus was achieved when greater than 70% respondents rated a domain as critical (> or = 7 on the 9 point Likert scale)., Results: 35 international ECPR experts from 9 countries formed the expert panel, with a median number of 14 years of ECMO practice (interquartile range 11-38). Participant response rates were 97% (survey round one), 63% (virtual meeting) and 100% (survey round two). After the second round of the survey, 47 consensus statements were formed outlining a core set of competencies required for ECPR provision. We identified key elements required to safely train and perform ECPR including skill pre-requisites, surrogate skill identification, the importance of competency-based assessment over volume of practice and competency requirements for successful ECPR practice and skill maintenance., Conclusions: We present a series of core competencies, training requirements and ongoing governance protocols to guide safe ECPR implementation. These findings can be used to develop training syllabus and guide minimum standards for competency as the growth of ECPR practitioners continues., Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: [Dirk W. Donker is involved in institutional research consultancy to Getinge – Maquet Critical Care AB, Solna, Sweden; institutional research cooperation with Sonion BV, Hoofddorp, The Netherlands; and consultancy to HBOX Therapies GmbH, Aachen, Germany; all fees and financial compensation paid to the University of Twente, no personal fees received. Demetris Yannopoulos has received NIH grants to study ECPR, philanthropic grants to establish ECPR in Minneapolis ST Paul and has received speaker's honoraria from Medtronic Corporation and Getinge to discuss ECPR. Lionel Lamhaut is the president of SAUV life (non profit organization). Drs Kruit, Burrell and Dennis conceived of the study. All authors contributed to the study with data acquisition and interpretation. All authors reviewed and revised the manuscript. All authors approved the final version of the manuscript. All authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted]., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Postpartum hemorrhage is a relatively common and highly morbid complication of the postpartum period that often requires management by specialized providers at tertiary care facilities. Critical care transport teams may be tasked with transporting postpartum patients who are already experiencing postpartum hemorrhage, but they should also be aware that other peripartum patients may be at risk for developing postpartum hemorrhage while in the process of transport. As such, it is imperative that transport providers understand the signs, symptoms, causes, and complications of postpartum hemorrhage as well as the options for intervention and treatment. This article reviews the current clinical evidence regarding resuscitation and medical management strategies that transport teams should be familiar with as well as more advanced and invasive management techniques they may encounter and be expected to monitor during transport, such as balloon tamponade and aortic balloon occlusion., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Air Medical Journal Associates. Published by Elsevier Inc. All rights reserved.)

Objective: Rules and regulations for ambulance operations differ across countries and regions, however, little is known about ambulance crashes outside of the United States. Japan is unique in several aspects, for example, routine use of lights and sirens during response and transport regardless of the urgency of the case and low speed limits for ambulances. The aim of this study was to describe the incidence and characteristics of ambulance crashes in Japan., Methods: We retrospectively analyzed data from the Institute for Traffic Accident Research and Data Analysis (ITARDA) that include all traffic crashes resulting in injury or death in Japan. The study included all ambulance crashes from 2009 to 2018. We compared crashes that occurred during emergency operations with lights and sirens (i.e., when responding to a call or transporting a patient) to those that occurred during non-emergency operations without lights or sirens. We also used data on total number of ambulance dispatches from the Japanese Fire and Disaster Management Agency to calculate ambulance crash risk., Results: During the 10-year period, we identified a total of 486 ambulance crashes out of 59,208,761 ambulance dispatches (0.82 in every 100,000 dispatches or one crash for every 121,829 dispatches) that included two fatal crashes. Among all ambulance crashes, 142 (29.2%) occurred during emergency operations. The incidence of ambulance crashes decreased significantly over the 10-year period. Ambulance crashes at an intersection occurred more frequently during emergency operations than during non-emergency operations (72.5% vs. 58.1%; 14.4% difference, 95% CI 5.0-22.9)., Conclusions: Ambulance crashes occurred infrequently in Japan with crash rates much lower than previously reported crash rates in the United States. Ambulance crashes during emergency operations occurred more frequently at intersections compared to non-emergency operations. Further investigation of the low Japanese ambulance crash rates could provide opportunities to improve ambulance safety in other countries.

The duration of low flow prior to initiation of extracorporeal cardiopulmonary resuscitation (eCPR) appears to influence survival. Strategies to reduce the low-flow interval for out-of-hospital cardiac arrest have been focused on expediting patient transport to the hospital or initiating extracorporeal support in the prehospital setting. To date, a direct comparison of low-flow interval between these strategies has not been made. To attempt this comparison, a model was created to predict low-flow intervals for each strategy at different locations across the city of Albuquerque, New Mexico. The data, specific to Albuquerque, suggest that a prehospital cannulation strategy consistently outperforms an expedited transport strategy, with an estimated difference in low-flow interval of 34.3 to 37.2 minutes, depending on location. There is no location within the city in which an expedited transport strategy results in a shorter low-flow interval than prehospital cannulation. It would be rare to successfully initiate eCPR by either strategy in fewer than 30 minutes from the time of patient collapse. Using a prehospital cannulation strategy, the entire coverage area could be eligible for eCPR within 60 minutes of patient collapse. The use of predictive modeling can be a low-cost solution to assist with strategic deployment of prehospital resources and may have potential for real-time decision support for prehospital clinicians.

For decades, most prehospital clinicians have only been armed with needle thoracostomy to treat a tension pneumothorax, which has a significant failure rate. Following recent changes by the US military, more ground and air transport agencies are adopting simple thoracostomy, also commonly referred to as finger thoracostomy, as a successful alternative. However, surgical procedures performed by prehospital clinicians remain uncommon, intimidating, and challenging. Therefore, it is imperative to adopt a training strategy that is comprehensive, concise, and memorable to best reduce cognitive load on clinicians while in a high-acuity, low-frequency situation. We suggest the following mnemonic to aid in learning and retention of the key procedural steps: FINGER (Find landmarks; Inject lidocaine/pain medicine; No infection allowed; Generous incision; Enter pleural space; Reach in with finger, sweep, reassess). This teaching aid may help develop and maintain competence in the simple thoracostomy procedure, leading to successful treatment of both a tension pneumothorax and hemothorax., (Copyright © 2022 Air Medical Journal Associates. All rights reserved.)

Background: The national hospital-acquired complication programme captures complications arising from patient-related and hospital-related factors, but the proportion of the two is unclear., Aim: Health services are encouraged to evaluate data from the national hospital-acquired complications (HAC) programme and identify strategies to mitigate them., Methods: A retrospective chart review compared HAC extracted from administrative data. The setting was a 430-bed university-affiliated metropolitan hospital. Records from 260 participants with, and 462 without, reported HAC from 2619 multi-day stay adults were reviewed. The main outcome measures were prevalence and positive predictive value (PPV) of HAC methodology., Results: No errors of HAC coding or classification were identified. Four hundred and twenty-three HAC events were reported in 260 records; most commonly delirium (n = 57; 13.4%), pneumonia (n = 46; 10.9%), blood stream infection (n = 39; 9.2%), hypoglycaemia (n = 33; 7.8%) and cardiac arrhythmias (n = 33; 7.8%). One hundred and eight (25.5%) 'HAC' events in 69 separations (95% confidence interval (CI) = 2.05-3.33 per 100 separations) were false positive, and 43 of 462 (95% CI = 6.72-12.22 per 100 separations) were false negative. Prevalence of total (reported plus missing) HAC was 16.06 (95% CI = 14.02-19.52), reported HAC was 9.93 (95% CI = 8.76-11.21), potentially preventable HAC was 1.68 (95% CI = 1.22-2.26) and healthcare errors was 0.31 (95% CI = 0.13-1.30) per 100 separations. PPV of HAC for true clinical events was 0.74 (0.68-0.79), preventable events 0.18 (0.13-0.23) and healthcare error 0.03 (0.01-0.06)., Conclusions: Prevalence of HAC events was higher than expected, but PPV for healthcare errors was low, suggesting provision of care is a less common cause of HAC events than patient factors. HAC may be an indicator of hospital admission complexity rather than HAC., (© 2021 Royal Australasian College of Physicians.)

Purpose: Data on the use of transesophageal echocardiography (TEE) by intensivist physicians (IP) and emergency physicians (EP) are limited. This study aims to characterize the use of TEE by IPs and EPs in critically ill patients at a single center in the United States. Materials and Methods: Retrospective chart review of all critical care TEEs performed from January 1, 2016 to January 31, 2021. The personnel performing the exams, location of the exams, characteristics of exams, complications, and outcome of the patients were reviewed. Results: A total of 396 examinations was reviewed. TEE was performed by IPs (92%) and EPs (9%). The location of TEE included: intensive care unit (87%), emergency department (11%), and prehospital (2%) settings. The most common indications for TEE were: hemodynamic instability/shock (44%), cardiac arrest (23%), and extracorporeal membrane oxygenation (ECMO) facilitation, adjustment, or weaning (21%). The most common diagnosis based on TEE were: normal TEE (25%), left ventricular dysfunction (19%), and vasodilatory shock (15%). A management change resulted from 89% of exams performed. Complications occurred in 2% of critical care TEEs. Conclusion: TEE can be successfully performed by IPs and EPs on critically ill patients in multiple clinical settings. TEE frequently informed management changes with few complications.

Hemorrhage, and particularly noncompressible torso hemorrhage remains a leading cause of potentially preventable prehospital death from trauma in the United States and globally. A subset of severely injured patients either die in the field or develop irreversible hemorrhagic shock before they can receive hospital definitive care, resulting in poor outcomes. The focus of this opinion paper is to delineate (a) the need for existing trauma systems to adapt so that potentially life-saving advanced resuscitation and truncal hemorrhage control interventions can be delivered closer to the point-of-injury in select patients, and (b) a possible mechanism through which some trauma systems can train and incorporate select prehospital advanced resuscitative care teams to deliver those interventions., Competing Interests: No financial conflicts of interest for any author. ZQ is the medical director of the RAPToR course but receives no financial benefit or contribution from this role.

Supraglottic airway (SGA) devices provide effective conduits for oxygenation and ventilation and may offer protection from gastric aspiration. SGA devices are widely used by EMS clinicians as both rescue and primary airway management devices. While in common use for more than four decades, major developments in SGA education, science, and technology have influenced clinical strategies of SGA insertion and use in prehospital airway management for patients of all ages. NAEMSP recommends:SGAs have utility as a primary or secondary EMS airway intervention. EMS agencies should select SGA strategies that best suit available resources and local clinician skillset, as well as the nature of their clinical practice setting.EMS agencies that perform endotracheal intubation must also equip their clinicians with SGA devices and ensure adequate training and competence.In select situations, drug-assisted airway management may be used by properly credentialed EMS clinicians to facilitate SGA insertion.Confirmation of initial and continuous SGA placement using waveform capnography is strongly encouraged as a best practice.When it is functioning properly, EMS clinicians should refrain from converting an SGA to an endotracheal tube. The decision to convert an SGA to an endotracheal tube must consider the patient's condition, the effectiveness of SGA ventilations, and the clinical context and course of initial SGA insertionSGA training, competency, and clinical use must be continuously evaluated by EMS agencies using focused quality management programs.

Background: Post-intensive care syndrome (PICS) affects as many as 50% of intensive care unit (ICU) survivors, and symptoms can persist for months to years. When psychological symptoms are experienced by patients' loved ones, this is termed PICS-family (PICS-F). Patients with these syndromes represent a frequently underrecognised and suboptimally managed cohort., Objective: The aim of this article is to outline the key aspects of screening and primary care management, providing an evidence-based framework for general practitioners (GPs)., Discussion: PICS screening is not well defined. The breadth of symptoms, along with the absence of a national consensus, renders in-depth assessment a significant undertaking. Community management relies on a coordinated effort from the whole multidisciplinary team, spearheaded by the GP, and focuses on three key areas: 'information and education', 'assessment and therapy' and 'personal support'. Collaboration between key stakeholders is needed to improve outcomes in this hitherto underrecognised patient population.

Background: Post-intensive care syndrome (PICS) refers to a constellation of cognitive, psychiatric and physical symptoms experienced by patients during and following a period of critical illness. As many as 50% of intensive care unit (ICU) survivors are affected, and symptoms can persist for months to years. When psychological symptoms are experienced by patients' loved ones, this is termed PICS-family (PICS-F)., Objective: The aim of this article is to summarise the key facets of PICS and PICS-F with a focus on incidence and pathophysiology.  DISCUSSION: The amalgam of symptoms in PICS has a profound impact on the quality of life of affected ICU survivors. The number of patients with PICS is expected to rise considerably as a result of the COVID-19 pandemic. Primary care practitioners are ideally situated to assist in early diagnosis and treatment.

Background: Rapid Sequence Airway (RSA) describes the administration of an induction agent and paralytic followed by the intended primary placement of an extraglottic airway device rather than an endotracheal tube. The purpose of this study was to determine the success rates for prehospital RSA. The secondary goal was to determine aspiration rates among patients managed with RSA., Methods: Adult and pediatric prehospital RSA cases between 2005 and 2017 reported to an airway quality assurance registry from one ground and one air agency were reviewed. Success was defined as the ability to adequately ventilate patients after extraglottic device placement. Aspiration was defined as radiologic evidence (chest x-ray or CT scan) within 48 hours of hospital presentation., Results: 68 patients underwent RSA with a King LTS-D (n = 24), LMA-Supreme (n = 28), Combitube (n = 2), LMA-Unique (n = 8) and iGel (n = 6). Age ranged from 1 year to 73 years with 10 patients less than 18. RSA was successful in 64 (94%) cases; 56 (88%) were successful on first pass and 63 (98%) within 2 attempts. The RSA procedure occurred in an aircraft in 14 (21%) of cases and 71% of patients were in cervical precautions. Duration of EGD insertion prior to hospital arrival ranged from 5 to 102 minutes with an average of 34.5 minutes. Aspiration data was available for 46 patients of whom 4 (8.7%) were found to have evidence of aspiration., Conclusion: Overall and first pass RSA success rates were high and aspiration rates were low in this quality assurance registry despite predictors of airway difficulty. RSA may be a reasonable alternative to RSI for prehospital airway management that merits further research.

Compared to intubation with a cuffed endotracheal tube, extraglottic airway devices (EGDs), such as laryngeal mask airways, are considered less definitive ventilation conduit devices and are therefore often exchanged via endotracheal intubation (ETI) prior to obtaining CT images. With more widespread use and growing comfort among providers, reports have now described use of EGDs for up to 24 h including cases for which clinicians obtained CT scans with an EGD in situ. The term EGD encompasses a wide variety of devices with more complex structure and CT appearance compared to ETI. All EGDs are typically placed without direct visualization and require less training and time for insertion compared to ETI. While blind insertion generally results in functional positioning, numerous studies have reported misplacements of EGDs identified by CT in the emergency department or post-mortem. A CT-based classification system has recently been suggested to categorize these misplacements in six dimensions: depth, size, rotation, device kinking, mechanical blockage of the ventilation opening(s), and injury from EGD placement. Identifying the type of EGD and its correct placement is critically important both to provide prompt feedback to clinicians and prevent inappropriate medicolegal problems. In this review, we introduce the main types of EGDs, demonstrate their appearance on CT images, and describe examples of misplacements.

Objective: Air medical transport of patients with known or suspected coronavirus disease 2019 (COVID-19) likely represents a high-risk exposure to crew members as aircraft cabins are quite small resulting in close personal contact. The actual risk to medical crew members is not known., Methods: We conducted an institutional review board-exempt, retrospective study of air medical transport of patients with known or suspected COVID-19 by 8 programs in the Four Corners Region to determine the number of symptomatic COVID-19 among air medical crew members compared to total exposure time. All programs used similar routine personal protective equipment (PPE), including N-95 masks and eye protection. Total exposure time was considered from time of first patient contact until handoff at a receiving hospital., Results: There were 616 air transports: 62% by fixed-wing and 38% by rotor-wing aircraft between March 15 and September 6, 2020. Among transported patients, 407 (66%) were confirmed COVID+ and 209 (34%) were under investigation. Patient contact time ranged from 38 to 432 minutes with an average of 140 minutes. The total exposure time for medical crew was 2924 hours; exposure time to confirmed COVID+ patients was 2008 hours. Only 30% of patients were intubated, and the remainder had no oxygen (8%), low-flow nasal cannula (42%), mask (11%), high-flow nasal cannula (4.5%), and continuous positive airway pressure or bilevel positive airway pressure (3.5%). Two flight crew members out of 108 developed COVID that was presumed related to work., Conclusions: Air medical transport of patients with known or suspected COVID-19 using routine PPE is considered effective for protecting medical crew members, even when patients are not intubated. This has implications for health care personnel in any setting that involves care of patients with COVID-19 in similarly confined spaces., Competing Interests: All authors have affirmed they have no conflicts of interest to declare., (© 2021 The Authors. JACEP Open published by Wiley Periodicals LLC on behalf of American College of Emergency Physicians.)

Objectives: Health care workers experience an uncertain risk of aerosol exposure during patient oxygenation. To improve our understanding of these risks, we sought to measure aerosol production during various approaches to oxygenation in healthy volunteers in an emergency department., Methods: This was a prospective study conducted in an empty patient room in an academic ED. The room was 10 ft. long x 10 ft. wide x 9 ft. tall (total volume 900 ft 3 ) with positive pressure airflow (1 complete turnover of air every 10 minutes). Five oxygenation conditions were used: humidified high-flow nasal cannula (HFNC) at 3 flow rates [15, 30, and 60 liters per minute (LPM)], non-rebreather mask (NRB) at 1 flow rate (15 LPM), and closed-circuit continuous positive airway pressure (CPAP) using the ED ventilator; in all cases a simple procedural mask was used. The NRB and HFNC at 30 LPM maneuvers were also repeated without the procedural mask, and CPAP was applied both with and without a filter. Each subject then sequentially underwent 8 total oxygenation conditions, always in the same order. Each oxygenation condition was performed with the participant on a standard ED bed. Particles were measured by laser aerosol spectrometer, with the detector sampling port positioned directly over the center of the bed, 0.35 meters away and at a 45-degree angle from the subject's mouth. Each approach to oxygenation was performed for 10 minutes, followed by a 20-minute room washout (≈ 2 complete room air turnovers). Particle counts were summated for 2 size ranges (150-300 nm and 0.5-2.0 μm) and compared before, during, and after each of the 8 oxygenation conditions., Results: Eight adult subjects were enrolled (mean age 42 years, body mass index 25). All subjects completed 8 oxygenation procedures (64 total). Mean particle counts per minute across all oxygenation procedures was 379 ± 112 (mean ± SD) for smaller aerosols (150-300 nm) and 9.3 ± 4.6 for larger aerosols (0.5-2.0 μm). HFNC exhibited a flow-dependent increase in particulate matter (PM) generation-at 60 LPM, HFNC had a substantial generation of small (55% increase) and large particles (70% increase) compared to 15 LPM. CPAP was associated with lowered small and large particle generation (≈ 10-15% below baseline for both sizes of PM). A patient mask limited particle generation with the NRB, where it was associated with a reduction in small and large particulates (average 40% and 20% lower, respectively)., Conclusion: Among 3 standard oxygenation procedures, higher flow rates generally were associated with greater production of both small and large aerosols. A patient mask lowered aerosol counts in the NRB only. Protocol development for oxygenation application should consider these factors to increase health care worker safety., (© 2021 The Authors. JACEP Open published by Wiley Periodicals LLC on behalf of American College of Emergency Physicians.)

Study Objective: Extraglottic airway devices are frequently used during cardiac arrest resuscitations and for failed intubation attempts. Recent literature suggests that many extraglottic airway devices are misplaced. The aim of this study is to create a classification system for extraglottic airway device misplacement and describe its frequency in a cohort of decedents who died with an extraglottic airway device in situ., Methods: We assembled a cohort of all decedents who died with an extraglottic airway device in situ and underwent postmortem computed tomographic (CT) imaging at the state medical examiner's office during a 6-year period, using retrospective data. An expert panel developed a novel extraglottic airway device misplacement classification system. We then applied the schema in reviewing postmortem CT for extraglottic airway device position and potential complications., Results: We identified 341 eligible decedents. The median age was 47.0 years (interquartile range 32 to 59 years). Out-of-hospital personnel placed extraglottic airway devices in 265 patients (77.7%) who subsequently died out of hospital; the remainder died inhospital. The classification system consisted of 6 components: depth, size, rotation, device kinking, mechanical blockage of ventilation opening, and injury. Under the system, extraglottic airway devices were found to be misplaced in 49 cases (14.4%), including 5 (1.5%) that resulted in severe injuries., Conclusion: We created a novel extraglottic airway device misplacement classification system. Misplacement occurred in greater than 14% of cases. Severe traumatic complications occurred rarely. Quality improvement activities should include review of extraglottic airway device placement when CT images are available and use the classification system to describe misplacements., (Copyright © 2020 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Introduction: The use of transesophageal echocardiography (TEE) by intensivist physicians (IPs) and emergency physicians (EPs) in critically ill patients is increasing in the intensive care unit, emergency department, and prehospital environments. Coagulopathy and thrombocytopenia are common in critically ill patients. The risk of performing TEE in these patients is unknown. The goal of this study was to assess whether TEE is safe when performed by IPs or EPs in critically ill patients with high bleeding risk (HBR)., Methods: All TEEs performed by an IP or EP between January 1, 2016, and July 31, 2019, were reviewed as part of a quality assurance database. A TEE performed on a patient was deemed HBR if the patient met at least one of the following criteria: undergoing therapeutic anticoagulation, had an INR > 2, activated partial thromboplastin time >40 seconds, fibrinogen <150 mg/dL, and/or platelet count <50 000/μL. The medical record was reviewed on each patient to determine whether upper esophageal bleeding, oropharyngeal bleeding, esophageal perforation, or dislodgement of an artificial airway occurred during or after the TEE., Results: A total of 228 examinations were reviewed: 80 in the high-risk group and 148 in the low-risk group (LBR). There were complications potentially attributable to TEE in 8 (4%) of the 228 exams. Total complications were not different between groups: 4 (5%) in the HBR group versus 4 (3%) in the LBR group (odds ratio [OR] = 1.89 [0.34-10.44], P =.368). Upper esophageal bleeding occurred in 5 total examinations (2%), which was not different between groups: 3 (4%) in the HBR group and 2 (1%) in the LBR group (OR = 2.84 [0.31-34.55], P = .238). There were no deaths attributable to TEE in either group., Conclusion: Transesophageal echocardiography can be safely performed by IPs and EPs in critically ill patients at high risk of bleeding with minimal complications.

Out-of-hospital cardiac arrest survival continues to be dismal with the only recent improvement being that of extracorporeal cardiopulmonary resuscitation (E-CPR) or cardiopulmonary resuscitation (CPR), augmented by extracorporeal membrane oxygenation (ECMO). Minimizing time until initiation of E-CPR is critical to improve neurologically intact survival. Bringing E-CPR to the patient rather than requiring transport to the emergency department may increase the number of patients eligible for E-CPR and the chances for a good outcome. We developed a out-of-hospital E-CPR (P-ECMO) program that includes the novel use of a hand-crank and emergency medical services (EMS) providers as first assistants. Here, we report the first P-ECMO procedure in North America for refractory ventricular fibrillation involving a 65-year-old male patient who was cannulated in the field within the recommended 60-minute low-flow window and transported to our institution where he underwent coronary stenting. Details of program design and the procedure used may allow other systems to consider implementation of a P-ECMO program., (© 2020 The Authors. JACEP Open published by Wiley Periodicals, Inc. on behalf of the American College of Emergency Physicians.)

Introduction: Bolus-dose phenylephrine (BDPE) is routinely used to treat hypotension in the operating room. BDPE's fast onset of action and ability to be administered peripherally have prompted calls for its use in the Emergency Department (ED). There are few published data on the safety of BDPE use in the ED. Primary concerns include BDPE's potential to cause dangerous hypertension or reflex bradycardia. We hypothesize that BDPE is a safe short-term vasopressor choice for hypotensive ED patients., Methods: We conducted a structured chart review for all patients who received BDPE from preloaded syringes over 42months. We defined an adverse event (AE) as sBP>180, dBP>110, or HR<50 within 30min of receiving BDPE. We defined a serious adverse event (SAE) as an AE with pharmacologic intervention to correct vital sign abnormality. We also compared mean arterial pressure (MAP), sBP, and dBP pre/post BDPE administration to assess effectiveness. We used a two-sample t-test to assess for differences between the mean delta MAP after low versus high-dose BDPE., Results: We identified 181 cases of ED use. 147 cases had complete pre/post vital signs. We identified 5 AEs and no SAEs. Three patients developed sBP>180mmHg. The patients suffered no apparent harm. No patients had dBP>110. Two patients developed bradycardia post-drug. In both cases, MAP improved despite bradycardia., Conclusions: BDPE does not appear to cause reflex bradycardia or hypertension requiring intervention among hypotensive ED patients. The apparent safety of BDPE should be confirmed in prospective trials., (Copyright © 2018 Elsevier Inc. All rights reserved.)