Tag Archives: ED

General

Extubation in the Emergency Department

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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 last November. 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.

General

A Shortage of On-call Surgical Specialists to EDs?

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The results of a survey published this month details problems caused by the lack of surgical specialists on call to emergency departments. It was conducted by the Robert Wood Johnson Clinical Scholars program and Yale University. They sent the survey to ED directors at 715 randomly selected hospitals around the country. The response rate was very good, with 62% returning their surveys.

An overwhelming majority (74%) of EDs indicated that they experience inadequate call coverage by surgical specialists. Notable comparisons included:

  • Teaching hospital (68% had problems) vs non-teaching hospital (78%)
  • Level I trauma center (60% had problems) vs Level II trauma center (59%) vs Level III trauma center (77%)

Almost two thirds of respondents said they had lost 24/7 coverage of at least one surgical specialty within the last 4 years. Hospitals in metropolitan areas were more likely to experience this problem, as were hospitals in the Northeast and South, compared to the West and the Midwest.

As you can imagine, coverage issues can cause larger problems. Nearly a quarter of hospitals either lost or downgraded their trauma center level due to lack of surgical specialist coverage. And 27% reported patients leaving before they could be seen by the specialist.

The percentage of hospitals with no coverage or problem coverage by surgical specialty was as follows:

  • General surgery – 36%
  • Trauma surgery – 64%
  • Neurosurgery – 75%
  • Plastics – 81%
  • Hand – 80%
  • Ortho – 50%

It is becoming apparent that there are limits to the amount of on-call specialty coverage that money can buy. Careful coordination and regionalization may offer aid to some centers, but we need to look critically at strategies in use that work and find ways to disseminate them to maintain the best emergency care possible.

Reference: The Shortage of On-call Surgical Specialist Coverage: A National Survey of Emergency Department Directors. Academic Emerg Med 17(12):1374-82, Dec 2010.

General

How Long Do Trauma Patients Need To Be On A Backboard?

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EMS is very good about immobilizing the spine in trauma patients prior to transporting them to the Emergency Department. Healthcare personnel in the ED are not as good about getting people off of those rigid boards.

As always, it boils down to a risk and benefit assessment. What is the risk of keeping someone on a board, especially if they may have a spine injury? There is a well-known downside to spine immobilization: skin breakdown, which can occur in as little as 2 hours. Less appreciated is the fact that it is very uncomfortable lying on one’s back on any type of board, be it a spine board or even a simple plastic slider board.

What is the risk to the spine if it is indeed injured? In a cooperative patient, essentially zero. Think about it this way: what are spine-injured patients placed on once they are admitted to the hospital? A regular bed with a standard hospital mattress! They are kept on logroll precautions until they have an operative procedure or receive a brace.

The bottom line: All patients should be moved off the EMS spine board onto the ED cart unless they are being transferred to another hospital within an hour or less. The ED cart should have a regular mattress, but the patient must be cooperative. If they cannot or will not cooperate, and the probability of spine injury is high, they may need to be chemically restrained. A plastic slider board may be placed under the patient when they are ready to go to diagnostic studies, and should be removed immediately when they are complete. No board of any kind should ever be left under a patient for more than 2 hours.

General

How to Predict the Need for Massive Transfusion in the ED

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Massive transfusion is needed in about 3-5% of trauma patients. All Level I and II trauma centers are required to have a massive transfusion protocol.However, the protocol must be triggered in a timely manner to best benefit the major trauma patient.

Trauma surgeons at Vanderbilt validated a simple scoring system that allows accurate prediction of the need for massive transfusion in patients as they arrived in the ED. The system was called the ABC score (Assessment of Blood Consumption). It consists of the following 4 yes/no parameters:

  • Penetrating mechanism (0=no, 1=yes)
  • ED SBP <= 90 (0=no, 1=yes)
  • ED heart rate >= 120 (0=no, 1=yes)
  • Positive FAST (0=no, 1=yes)

The results of ABC when applied to trauma patients in the ED was as follows:

ABC Score         % requiring massive transfusion
0                                1%
1                               10%
2                               41%
3                               48%
4                             100%

This scoring system is simple, easy to use and easy to remember. No laboratory tests are needed, and the information needed can be gathered quickly.

Bottom Line: This is a simple and accurate prediction system for determining the need for massive transfusion in trauma patients. Recommended!

Reference: Cotton et al. J Trauma 66(2) 346-352, 2009.