Does that airbag really help?

Sorry for the long hiatus over the holidays. I wish I could say I was doing something fun and exotic, but instead I simply became the curriculum director at my current residency, which changed my workload quite a bit. That being said, back to the wilderness topics.

Since it’s winter, we are going to keep talking about avalanches. Since indications for resuscitation have been discussed before, now we will turn towards prevention. Two main ideas, first, avoid triggering an avalanche, and second, if you find yourself caught in one, try not to get buried. It makes sense, as the data from older studies is pretty clear that people who are buried die at a markedly higher rate than those who are not (52% vs 4%). What’s more, for those that are buried, the quicker they are found decreases their mortality, thus people buried less deep would likely have a higher survival rate.

Source: Hansi Heckmair/ABS

Enter airbags, which were invented to prevent this “critical burial” that causes increased mortality (critical meaning impairment of airways). They do this by basically making you much larger and more buoyant by inflating a large balloon that is strapped to your back. At least, that’s the theory. There wasn’t a lot of strong research devoted to them before implementation, and as they weren’t created by Roche, postmarketing research was lacking as well. Tie observer bias into this (people weren’t reporting near misses that didn’t involve airbags) and you are left with almost nothing of value to base recommendations on.

These authors wanted to fix that, so they did this study to determine the effectiveness of airbags based on preventing critical burial and mortality, as well as documenting frequency and causes of deployment failures. To do this, they looked at prior avalanche accident records from multiple countries, culling only worthwhile data that would show a difference between airbag users and nonusers. Thus, single victim events, small avalanches, or victims who weren’t seriously involved were removed in an attempt to reduce bias.

And once they crunched the numbers, they found out that airbags really do help. If you combine airbag failures with airbag inflations, the absolute risk reduction for critical burial is 29% (56%-27%), and the absolute mortality reduction is 17% (34%-17%). If you combine airbag failures with those not wearing airbags to begin with (why?), then risk reductions for critical burial and mortality are 35% and 23%, respectively. When you combine these values to adjusted mortality, you get a risk reduction of 11%, or a NNT of 9 for mortality with airbag use. Not too shabby.

Deployment failures occurred an alarming 20% of the time. Of these failures, 72% were attributed to operator error (not deploying them appropriately or incorrect maintenance). Slightly concerning, 12% of the failures involved destruction of the airbag during the avalanche. Of course, the absolute failure rate due to destruction or device failure is right at 5%.

So yes, if you’re going anywhere that there’s a risk of avalanches, you should wear an airbag. Also you should carry a beacon. And, like most other life saving measures, be they medical or technical, you’re only as good as what you do. Thus, read the instructions and know how to use it before you go out-of-bounds. However, this study did have a higher mortality of airbag users from prior studies (11% vs 3%), so don’t expect an airbag to make you immortal. Certainly, don’t do stupid things simply because you think you have a safety net (although it’s been shown that this doesn’t really occur). Of note, the usual problems with poor data due to non-standardized reporting as well as a low total number of victims apply to interpretation of this data.

The effectiveness of avalanche airbags
http://www.ncbi.nlm.nih.gov/pubmed/24909367

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Pollster: Delayed Sequence Intubation, what do YOU think?

RSI is the bread and butter technique use to achieve safe and efficient control of the airway and in a majority of cases is very effective. However in the hypoxic patient that is agitated and cannot be appropriately pre-oxygenated, RSI could very well be a death sentence (or at least a round of chest compressions), if it is not successful on first pass. With the increasing use of the dissociative agent ketamine to assist with pre-oxygenating the difficult hypoxic patient, and the ingenuity of Dr. Scott Weingart, delayed sequence intubation has been born. A very recent study published in the Annals of Emergency Medicine is showing very promising results with this innovative airway management technique. 

In light of this recent study, we are interested in taking a peek at the use of DSI in emergency medicine and find out who is using it, if it is successful, and any issues thus far that you have found with the technique.

Our goal  is to use create extremely brief surveys and utilize social media to spread the word and gather as much data as possible! We will then use this data to generate info-graphics to make interpretation of the data easy, fun and lead to generation of new discussions! Check our previous pollster infographics hereThank you for taking the time to help us gather data!


Delayed Sequence Intubation 

Do you support the novel strategy of delayed sequence intubation in the appropriate clinical circumstances? * Have you used DSI in your practice? * What dose (mg/kg) of ketamine are you using for dissociation? (If, yes to Q2) In your personal experience, have you found DSI to be successful? (Defined as significant improvement in pre-intubation oxygen saturation to >92% and without immediate desaturation during apneic period) Do you perform apneic oxygenation with nasal cannula as part of your DSI strategy? Role * Community or academic working environment? *

Thank you!


Previous Infographics from Pollster

Approach to Geriatric Patients: Functional Assessment in the ED

The wave of baby boomers is coming to an ED near you and it’s time to get prepared [1]. ED overcrowding does not seem to be going away anytime soon, and anything we can do to get these patients back to the community is better for everyone.

While not all 80 year olds have multiple medical problems (we have a spectrum bias based on what we see at work) it does not take many geriatric patients to add significantly to our already busy ED workload. The ED is a focal point for access to the health care system for all patients, particularly the elderly, so we need to prepare ourselves better for their needs. With this in mind, there is a movement towards developing a ‘Geriatric ED’ based on population trends and studies that found implementing geriatric friendly strategies successfully reduced the admission rate of geriatric patients [2].

Currently, few ED’s are lucky enough to have a Geriatric ED or even physicians with geriatric expertise within their group. However, excellent training is available online (see Geri-EM.com) that covers the major issues facing geriatric patients in the ED. Additionally, there are usually an excellent array of services for these patients in your community; you just need to know how to access them! It does not take much for certain geriatric patients to fall below the threshold of dependence, and by using the strategies outlined in this post we might be able to get them back to their home.

The Approach to Geriatric Patients in the ED

The overall approach to the geriatric patient must include the functional, social, cognitive, and medical domains [3].

a) Functional assessment

A functional assessment evaluates the patients ability to complete activities of daily living (ADLs) and instrumental ADLs (iADLS). ADLs are the things you do in the first 20 mins of your day (transferring, toileting, bathing, dressing, feeding, and continence) while iADLs are the things you learned to do when you left to go off to university (meals, housecleaning, meds, finances, driving/transport, shopping, phone/technology).

b) Social assessment:

A social assessment focuses on their supports in the community. A good way to assess this is to ask ”If something bad happened, who would you call?”

c) Cognitive assessment

A cognitive assessment includes screens for Delirium (CAM) & Dementia (mini-Cog). The mini-Cog can be done quickly and should be a vital sign for a Geriatric patient. If it is abnormal, it should prompt further assessment with a mini-mental exam.

Confusion Assessment Method

 

 

Mini-Cog

d) Medical assessment

The physical assessment is something that we already do pretty well. It quantifies the reason for their presentation: Why did they faint? What was injured when they fell? etc. We could probably do a better job of checking their medications for appropriateness and interactions, but realistically we often don’t have the time for this in the confines of an ED visit. A topic most certainly worthy of another Boring EM post!

Specific Scenarios

There are also some specific situations which we need to be aware of that require additional assessment in the geriatric patient:

a) Does your patient have impaired mobility?

Often geriatric patients can have impaired mobility after a minor injury or flare of arthritis. Consider performing a “Timed Up and Go” or TUG Test [4]. This test is performed as outlined below and gives you a sense of whether or not a patient requires a mobility aid. If they do, physical therapy (PT) can often see them in the ED and make the necessary arrangements. If they will be discharged and require help at home for a couple of days, an appointment with a community PT for follow-up and mobility aid teaching can often be set up for them at their residence. If larger concerns are identified the community PT can refer them for a Geriatric Assessment.

TUG test

 

b) Is your patient at risk for falls?

Effective decision tools have been developed by Carpenter and Tiedeman [5,6] to predict falls in the elderly. (Editor’s note: For some more #FOAMed on geriatric fall assessment, be sure to check out The SGEM Episode #89: Preventing Falling to Pieces where Dr. Milne reviews Dr. Carpenter’s latest meta-analysis on the topic with him as a guest!)

Carpenter [5]:

Carpenter fall assessment tool

Tiedeman [6]:

ED falls screening tool

If your patient screens positive for as a fall risk, community occupational therapy (OT) can go to their home and see what improvements can be made for reducing their risk (ie shower bars, bath seats, removal of throw rugs, etc.). If larger concerns are identified, community OT can refer them for a Geriatric Assessment.

c) Does your patient have complex geriatric issues?

Patients with multiple medications, dementia, fall risk, etc who do not require admission need referral for a geriatric assessment. Prior to consult, they can often send someone to their home to collect information and to collect their medical records. A full geriatric assessment might include assessment by OT, PT, social work, nursing, physician +/- geriatric psychiatry, pharmacy, recreational therapy, and a dietician.

d) Can future medical events be prevented?

Prevention is the future of the geriatric ED. Tools are being developed to identify seniors who are at risk (the ISAR questionnaire [7]) and determine appropriate interventions (SEISAR [8]):

ISAR questionnaire

A score of 2 or higher on the ISAR questionnaire suggests need for intervention and prompts further assessment with the SEISAR (Systemic Evaluation & Intervention for SRs at Risk) Tool [8] to see which interventions would be of benefit.

The SEISAR Tool

As these assessments are quite in depth, they would require more than just a home care coordinator. Dedicated individuals are needed for these types of geriatric assessment. I suspect that resources for these types of services will increasingly be made available as our population continues to age.

Conclusion

The ED’s geriatric population is going to continue to increase. This population has unique needs that historically, have not been well addressed in the ED. This post outlined a basic approach for the assessment of geriatric patients and some common scenarios that emergency physicians should be prepared to address with evidence-based resources. Emergency medicine trainees and attendings that familiarize themselves with these resources will be better prepared to address the unique needs of our geriatric patients.

Edited / Reviewed by Brent Thoma (@Brent_Thoma)

References

  1. Foot, D. K., & Stoffman, D. (1997). Boom bust and echo: how to profit from the coming demographic shift (1st Edition). Saint Anthony Messenger Press and Franciscan.
  2. Keyes, D. C., Singal, B., Kropf, C. W., & Fisk, A. (2014). Impact of a new senior emergency department on emergency department recidivism, rate of hospital admission, and hospital length of stay. Annals of emergency medicine, 63(5), 517-524.
  3. Retrieved from Geri-EM.com September 8th, 2014.
  4. Bohannon, R. W. (2006). Reference Values for the Timed Up and Go Test: A Descriptive Meta‐Analysis. Journal of geriatric physical therapy, 29(2), 64-68.
  5. Carpenter, C. R., Scheatzle, M. D., D’Antonio, J. A., Ricci, P. T., & Coben, J. H. (2009). Identification of fall risk factors in older adult emergency department patients. Academic emergency medicine, 16(3), 211-219.
  6. Tiedemann, A., Sherrington, C., Orr, T., Hallen, J., Lewis, D., Kelly, A., … & Close, J. C. (2012). Identifying older people at high risk of future falls: development and validation of a screening tool for use in emergency departments. Emergency medicine journal, emermed-2012.
  7. Dendukuri, N., McCusker, J., & Belzile, E. (2004). The identification of seniors at risk screening tool: further evidence of concurrent and predictive validity.Journal of the American Geriatrics Society, 52(2), 290-296.
  8. Retrieved from http://stmarysresearch.ca/en/publications_and_tools/clinical_tools/isar-seisar December 28, 2014

Author information

Rob Woods
Rob Woods
Program Director at University of Saskatchewan
Rob Woods is the Program Director of the University of Saskatchewan Emergency Medicine Residency Program.

The post Approach to Geriatric Patients: Functional Assessment in the ED appeared first on BoringEM and was written by Rob Woods.

(Failing to) Identify Severe Sepsis at Triage

This is the holy grail of predictive health informatics in Emergency Medicine – instant identification of serious morbidity, with the theoretical expectation of outcomes improvement due to early intervention.

And, more than almost any condition, accurate early identification of severe sepsis remains elusive.

This is an observational evaluation of the “Australian Triage Scale” in combination with infectious keywords as a tool to identify and manage patients with severe sepsis.  Patients were enrolled at presentation to the Emergency Department, and ultimately followed from triage through their ICU stay – where a clinical diagnosis of severe sepsis was used as the gold standard for outcomes. However, of the 995 patients triaged through the Emergency Department and ultimately diagnosed with severe sepsis, only 534 were identified at triage.  The authors present various diagnostic characteristics for each level of the ATS with regards to acuity, and the AUCs for sensitivity and specificity range from 0.457 to .567 (where 0.5 is basically a coin-flip).  So, the authors' presented rule-based mechanism is nearly as likely to be incorrect as correct.  I’m not exactly certain how they came to the conclusion “the ATS and its categories is a sensitive and moderately accurate and valid tool”, but I tend to disagree.

These data are consistent with our a priori expectation for these sorts of tools.  The patients who trigger such rules are generally so obviously severe sepsis such rule-based notifications occur after clinician identification, and are simply redundant and alarm fatigue.  Conversely, patients with severe sepsis going undiagnosed upon initial presentation do so because of their atypical nature – and thus tend to fall outside rigid, rule-based constructs.  E.g., computers are not physicians … yet.

“Identification of the severe sepsis patient at triage: a prospective analysis of the Australasian Triage Scale”
http://www.ncbi.nlm.nih.gov/pubmed/25504659

Secuencia de intubación retardada: un estudio observacional prospectivo

Los autores investigaron una nueva técnica para el manejo en emergencias de la vía aérea de pacientes con estado mental alterado que impiden la adecuada pre-oxigenación. Se realizó un estudio prospectivo, observacional, multicéntrico de pacientes cuya condición médica les impedía una preparación óptima para la pre-oxigenación debido al delirio. Se eligió una muestra del departamento […]