Tag Archives: ED

Emergency Intubation: ED or OR?

Decades ago, intubation of trauma patients only took place in the operating room, and only anesthesiologists performed it. As the discipline of Emergency Medicine came into being in the 1980s, emergency physicians became skilled in this procedure. Occasional trauma intubations had to occur in the ED, and typically anesthesia was called for it.

As the emergency physicians became more comfortable and improved their skills, they also started intubating. I distinctly remember a paper from the time (which I unfortunately do not have a reference to) stating that ED and OR intubation were equally safe if the ED intubation field could be made to look like the OR.  This thinking has become commonplace, and in most trauma centers, intubation is now provided nearly exclusively by emergency physicians. Anesthesia is called only for extremely difficult cases.

But we have all been involved in cases where the patient is severely injured, usually hypotensive, and crashes and burns during or immediately after the procedure. This is likely due to a combination of loss of sympathetic tone due to the drugs administered, increased vagal tone from instrumenting the airway, and hypovolemia.

Authors from the University of Wisconsin, University of Pennsylvania, and Johns Hopkins hypothesized that ED intubation for patients requiring urgent operation for hemorrhage control was associated with adverse outcomes. They performed a three-year registry study from the National Trauma Program Databank of patients requiring laparotomy for hemorrhage control within 60 minutes of arrival. They excluded the dead and nearly dead (DOA, ED thoracotomy) and patients with immediate indications for intubation (head, neck, or facial trauma). They compared mortality, ED dwell time, blood transfusions, and major complications between patients with ED vs. OR intubation.

Here are the factoids:

  • Nearly 10,000 patients from 253 Level I or II trauma centers were included in the study
  • About 20% of patients underwent intubation in the ED, and they were more likely to have blunt trauma mechanism and higher ISS (22 vs. 17)
  • Initial vital signs were not clinically significant between the ED and OR groups
  • Mortality in the ED group was significantly higher (17% vs. 7%), the ED dwell time was significantly longer ( 31 vs. 22 minutes), required significantly more blood transfusion (6 vs. 4 units), and had a significantly higher risk of major complications (specifically cardiac arrest, AKI, and ARDS)
  • There was a wide variation in the rate of ED intubation across all the hospitals. Centers with the highest rate of ED intubations were 5x more likely to intubate than the lowest rate centers. The patient case mix could not explain this difference.
  • The lower ED intubation rate hospitals tended to be nonprofit Level I university hospitals
  • Centers with high levels of hemorrhage control surgery were more likely to intubate in the OR

Bottom line: From a purely technical perspective, the old dogma about patient location not making a difference is basically true. The process of getting an airway safely into the patient and secured is equivalent wherever it is done as long as the lighting, equipment, and skill levels are equivalent. 

But when one considers the physiologic aftermath of this process, things are obviously more nuanced. Actively bleeding patients are extremely challenged, down to their organ and cellular levels. Disrupting their normal compensatory mechanisms is clearly associated with a significant downside. 

We should clearly distinguish the patient who needs an airway for airway’s sake or cerebral protection from one who needs to be in the OR for bleeding control. Other papers have shown that mortality increases as each minute ticks by in the hemorrhaging patient. Trauma programs need to monitor these patients and do a performance improvement deep dive into all trauma patients intubated in the ED to ensure appropriate decision-making.

Reference: Emergency Department Versus Operating Room Intubation of Patients Undergoing Immediate Hemorrhage Control Surgery. Journal of Trauma and Acute Care Surgery, Publish Ahead of Print
DOI: 10.1097/TA.0000000000003907

ED Use of CT – Everyone Does It Differently

There is tremendous variability in ordering imaging in trauma patients. To some degree, this is due to the dearth of standards pertaining to radiographic imaging, at least in trauma. And when standards do exist, trauma professionals are not very good at adhering to them. We’d rather do it our way. Or the way we were trained to do it.

The group at Jamaica Hospital in Queens, NY quantified some of those differences, studying ordering patterns of trauma surgeons (TS), emergency physicians (EP), and surgery chief residents (CR). Unfortunately, they then tried to draw some interesting conclusions, which I’ll discuss at the end.

They reviewed all blunt trauma activations over a 6 month period at their urban trauma center. At the end of each trauma activation, each of the three physician groups wrote imaging orders, but only the trauma surgeons’ were submitted. Missed injuries were defined as any that would not have been found based on each provider group’s orders. Extremity injuries, and those found on physical exam or plain imaging were excluded.

Here are the factoids:

  • The authors do not state how many patients they saw in this period, but by extrapolation it appears to be about 250
  • Trauma surgeons ordered significantly more studies (1,012) than the EPs (882) or CRs (884)
  • This resulted in essentially a “pan-scan” in 78%, 64%, and 69%, respectively
  • Radiation exposure was said to be the same for all groups (18 vs 13 vs 15 mSv) [I’m having a hard time buying this]
  • But cost was higher in the trauma surgeon group ($344 vs $267 vs $292) [Huh? Is this only the electric bill for the CT scanner? Very low, IMHO]
  • And the trauma surgeons had a missed injury rate of only 1%, vs 11% for EPs and 7% for CRs [Wow!]

Bottom line: Sorry, I just can’t believe these results. There are a lot of things left unsaid in this poster. What were all these missed injuries? What magical CT scan that only the trauma surgeons ordered actually picked them up? And probably most importantly, were they clinically significant? A small hematoma somewhere doesn’t make a difference (see the “tree falls in a forest” post below).

It looks to me like the authors wanted to justify their use of pan-scan, and push their emergency physicians to follow suit. Unfortunately, this is a poster presentation, meaning that there will be limited opportunity to question the authors about the specifics.

The debate regarding pan-scan vs selective imaging is an active one. The evidence is definitely not in yet. While we sort it out, the best path is to develop a reasonable imaging practice guideline based on the literature, where available. Some areas such as head and cervical spine CT have been worked out fairly well. Then fill in the blanks and encourage all trauma professionals in your hospital to follow them. There is great value in adhering to good guidelines, even when there are blanks in our knowledge.

Related posts:

Reference: Variability in computed tomography imaging of trauma patients among emergency department physicians and trauma surgeons with respect to missed injuries, radiation exposure and cost. AAST 2016, Poster #75.

Extubating Trauma Patients In The ED

Many patients are intubated in the emergency department who need brief control of their airway or behavior. In some cases, the condition requiring intubation resolves while they are still in the department. Most of the time these patients are admitted, typically to an ICU bed, for extubation. This is expensive and uses valuable resources. Is it possible to safely extubate these patients and possibly send them home?

Maryland Shock Trauma and Mount Sinai Medical Center looked at their experience in extubating selected patients in the ED. They looked at a series of 50 patients who were intubated for combativeness, sedation, or seizures. A specific protocol was followed to gauge whether or not extubation should be attempted.

None of the patients who were extubated per protocol required unplanned reintubation. One patient underwent planned reintubation when taken to the OR for an orthopedic procedure. 16% of patients were able to be discharged home from the ED.

Bottom line: A subset of patients who are intubated in the emergency department can be extubated once the inciting factor has resolved. These factors include sedation for painful procedures and combativeness. Following this protocol can reduce admission rates and reduce the use of scarce intensive care unit resources.

Click here to download a copy of the ED extubation protocol.

Related post: Trauma 20 years ago: ED intubation for head injury

Reference: Trauma patients can be safely extubated in the emergency department. J Emerg Med 40(2):235-239, 2011.

NOTE: The EMCrit blog, written by Scott Weingart, covered this topic in November 2010. He is the first author on the paper and has created a nice podcast on the topic. You can find his blog here, and you can download the podcast here.

How To Decrease Medication Errors In The ED

The ED is a fast-paced environment where things must happen quickly at times. This makes it a ripe environment for errors. A recent study looked at one possible way of decreasing the number of medication errors in a Level I trauma center.

A prospective observational study was carried out in the ED, where pharmacists were on duty and attended all trauma activations for 10 hours each day. No pharmacist was present the rest of the time. The potential errors that were identified consisted of any of the following:

  • medication ordered but not given
  • medication given but not ordered
  • delay in administration

Nearly 700 patient encounters were evaluated, with about one third seen when the pharmacist was present, and two thirds when they were away (makes sense given their coverage hours). The demographics of the patient groups were the same. 

There was a huge difference in the number of medication errors! Only 6 errors (3%) occurred when pharmacists were present, but 137 occurred (30%) when they were not. An odds-ratio calculation showed that medication errors were 13.5 times more likely to occur on shifts when pharmacists were not present in the ED.

Bottom line: It’s helpful to have another set of eyes, not focused on the patient’s injuries, looking after critical medications. The error rate is so much lower with a pharmacist present that it must be cost effective to provide them 24/7. Time for another study!

Reference: On-site pharmacists in the ED improve medical errors. Am J Emerg Med Jun 10, 2011 (epub ahead of print).