CRACKCast E102 – Seizures

This episode of CRACKCast covers Rosen’s Chapter 102, Seizures. This can be a challenging complaint to diagnose without collateral, but recognition and treatment is critical for patient and public safety. This chapter covers the various etiologies of seizure and their management – both acutely and in the community. Shownotes – PDF Here Rosens in Perspective As an ER doc you will see seizures! Bimodal age distribution with vast majority being in infants (febrile ...

The post CRACKCast E102 – Seizures appeared first on CanadiEM and was written by Chris Lipp.

The ENDAO Trial: Is Apneic Oxygenation a Futile Intervention in ED RSI?

Background: One of the most feared complications associated with rapid sequence intubation (RSI) is hypoxemia ultimately leading to cardiac arrest.  The FELLOW Trial, a recent randomized controlled trial demonstrated no difference in hypoxemia rates between patients that received apneic oxygenation and those that did not (i.e. “usual practice”) in the ICU.  What many forget about this trial is 1/3 of the patients were pre-oxygenated with a bag valve mask and another 1/3 of the patients with a BIPAP device, meaning that 2/3rds of these patients were not truly apneic during the period that induction medications were pushed up to laryngoscopy.  Currently, there is a lack of high quality research on the use of apneic oxygenation in the ED setting.  Many still use the intervention as it is cheap, easy to do, with no increase in patient harm, but there are still naysayers that do not feel the intervention is warranted in standard RSI practice.

What They Did:

  • Randomized Controlled Trial in the ED Setting
  • Single Institution
  • Apneic Oxygenation vs Usual Care

Interventions/Definitions:

  • Apneic Oxygenation: Oxygen via Nasal Cannula at flush flow rates ≥15LPM during laryngoscopy
  • Usual Care: No supplemental oxygen during laryngoscopy
  • Pre-Oxygenation: NRB, BiPAP, or BVM connected to flush flow rate with 100% oxygen
  • Apnea Time: Time from first look (defined as insertion of the laryngoscope blade into the patients mouth) to confirmation of ETT placement by waveform capnography (EtCO2) or in failed intubations time to repeated assisted ventilation

Outcomes:

  • Primary Outcome: Lowest Mean Oxygen Saturation during the apnea period or in the two minutes following intubation
  • Secondary Outcomes: First Pass Success Rate, Time to Desaturation SpO2 <90% and <80%, Average Time to Desaturation, Mortality 

Inclusion:

  • All Patients > 18 Years of age, presenting to the ED, Requiring Intubation

Exclusion:

  • Not Pre-Oxygenated to the Standard RSI Protocol of a Goal of 3 Minutes with 100% FiO2 y Means of BVM, BIPAP, and/or NRB
  • Patients with Cardiac or Traumatic Arrest
  • No Apneic Period (i.e. Awake Intubation)

Results:

  • 206 patients enrolled and 200 patients randomized
    • Apneic Oxygenation = 100
    • Usual Care = 100
  • Lowest Mean Oxygen Saturation
    • Apneic Oxygenation: 92% (95% CI 91 – 93)
    • Usual Care: 93% (95% CI 92 – 94)
    • p = 0.11
  • Critical Results:

Strengths:

  • Randomized controlled trial
  • Observers were blinded to study outcomes and not involved in the procedure of intubation
  • Intubation checklist was used on all intubations
  • Determination of accuracy of data collection was confirmed by comparing the data collected from the first 20 consecutively enrolled patients (10% of study population) with the primary investigators data

Limitations:

  • Utilized a real-time data collection form which have been shown to underestimate adverse events and time to intubation
  • Single center study at an academic ED with residents may make this non-generalizable to non-academic centers

Discussion:

  • Over 70% of patients were successfully intubated by 60 seconds, 80% by 80 seconds, 90% by 100seconds, and 100% by 195 seconds
  • About 60% of patients were intubated due to a pulmonary issue which was the most common indication for intubation in both cohorts
  • All patients were pre-oxygenated for 3 minutes with flush 100% O2 prior to intubation and the majority of patients were successfully intubated by 60 seconds. Its no surprise that no difference was found between the two groups and does not mean apneic oxygenation does not work, especially in patients with prolonged apnea times or requiring crash intubations.
  • First pass intubation success was not obtained in 22 patients of which 15 patients in this group had multiple subsequent attempts made without assisted ventilation between attempts. All 15 patients had prolonged apnea times (average 144 seconds) without desaturation, but none of them had pulmonary indications as the need for intubation.
  • Some interesting stats from the paper:

Author Conclusion:

“There was no difference in lowest mean oxygen saturation between the two groups.  The application of AO during RSI did not prevent desaturation of patients in this study population.”

Clinical Take Home Point:

In patients who receive proper pre-oxygenation (3min with flush 100% O2), apneic oxygenation may be a superfluous intervention, however it is important to remember that AO is not a complicated procedure, not expensive, and has not been shown to be  harmful.  Additionally, the absence of benefit here doesn’t mean there is no group who won’t benefit (i.e. prolonged apnea times and crash intubations) but, it is nearly impossible to make accurate prospective predictions as to which patients will benefit the most.

References:

  1. Caputo N et al. EmergeNcy Department use of Apneic Oxygenation Versus Usual Care During Rapid Sequence Intubation: A Randomized Controlled Trial (the ENDAO Trial). Acad Emerg Med 2017. [epub ahead of print]. PMID: 28791755

For More Thoughts on This Topic Checkout:

Post Peer Reviewed By: Anand Swaminathan (Twitter: @EMSwami)

The post The ENDAO Trial: Is Apneic Oxygenation a Futile Intervention in ED RSI? appeared first on R.E.B.E.L. EM - Emergency Medicine Blog.

ALiEM AIR Series: Renal/Genitourinary

air series renalWelcome to the Renal/GU Module! After carefully reviewing all relevant posts from the top 50 sites of the Social Media Index, the ALiEM AIR Team is proud to present the highest quality Renal/GU content. Below we have listed our selection of the 13 highest quality blog posts within the past 12 months (as of May 2017) related to Renal/GU emergencies, curated and approved for residency training by the AIR Series Board. We identified 3 AIRs and 10 Honorable Mentions. We recommend programs give 4 hours (about 20 minutes per article) of III credit for this module. As of June 2017, over 125 residency programs are using the AIR series – that’s over 1,200 residents completing at least one module in the 2016-2017 academic year!

AIR Stamp of Approval and Honorable Mentions

In an effort to truly emphasize the highest quality posts, we have two subsets of recommended resources. The AIR stamp of approval is awarded strictly to posts scoring above a scoring cut-off of ≥30 points (out of 35 total), based on our scoring instrument. The other subset is for “Honorable Mention” posts. These posts have been flagged by and agreed upon by AIR Board members as worthwhile, accurate, unbiased, and appropriately referenced despite an average score.

Take the quiz at ALiEMU
ALiEMU AIR GU/Renal block quiz

Interested in taking the quiz for fun or asynchronous (Individualized Interactive Instruction) credit? Please go to the above link. You will need to create a free, one-time login account if you haven’t already.

Highlighted Quality Posts on Renal/GU Diseases

Article Title Author Date Label
BEEM Cases 2 – Renal Colic Imaging, Analgesia, Fluids & MET Anton Helman, MD 5/23/2016 AIR
First10EM: UTI: More Than You Ever Wanted to Know Justin Morgenstern MD 4/15/2017 AIR
CoreEM: Ureteral Colic  Anand Swaminathan, MD 7/06/2016 AIR
SGEM#154: Here I Go Again, Kidney Stone  Tony Seupaul, MD and Marc Phan, MD 5/12/2016 HM
EMDocs: Contrast-Induced Nephropathy: Confounding Causation Richard Sinert, MD 2/13/2017 HM
Ultrasound Podcast: Renal Ultrasound Mike Mallin, MD, Matt Dawson, MD, Jacob Avila, MD, and Vicki Noble, MD 2016 HM
EMDocs: Foley Catheter Patients: Common ED Presentations / Management / Pearls & Pitfalls Aaron Schnieder, MD, and William Sanderson, MD 11/24/2016 HM
Ultrasound Podcast: Renal Ultrasound 2 Mike Mallin, MD, Matt Dawson, MD, Jacob Avila, MD, and Vicki Noble, MD 2016 HM
RebelEM: Contrast Induced Nephropathy (CIN): Fact or Myth? Salim Rezaie, MD 3/20/2017 HM
EMDocs: Acute Urinary Retention in the ED Candace Johnson, MD 3/1/2017 HM
PedsEMMorsels: Epididymitis in Children Sean Fox, MD 8/24/2016 HM
EMCrit: Is Piperacillin-Tazobactam Nephrotoxic? Josh Farkas, MD 7/9/2016 HM
PEM Playbook: Urine Trouble Tim Horezco, MD 2/1/2017 HM

HM = Honorable Mention

If you have any questions or comments, please contact us!

From the ALiEM AIR Executive Board and ALiEMU Team:

  • Jeremy Branzetti
  • Hari Bhatt
  • Sean Fox
  • Chris Gaafary
  • Andrew Grock
  • Jacob Hennings
  • Nikita Joshi
  • Jay Khadpe
  • Michelle Lin
  • Kasey Mekonnen
  • Allie Min
  • Eric Morley
  • Salim Rezaie
  • Lynn Roppolo
  • Kaushal Shaw
  • Derek Sifford
  • Anand Swaminathan
  • Taku Taira

Author information

Andrew Grock, MD

Andrew Grock, MD

Lead Editor/Co-Founder of ALiEM Approved Instructional Resources (AIR)
Assistant Professor of Emergency Medicine
UCLA Emergency Medicine Department

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