Background: Syncope, defined as a transient loss of consciousness with a complete recovery, is a common ED presentation. There are numerous causes of syncope ranging from the relatively benign (eg vasovagal syncope) to the potentially life-threatening (eg dysrhythmia, ectopic pregnancy, aortic dissection). Among the life-threatening diagnoses is pulmonary embolism (PE). PE is a common cause of sudden, unexpected, non-traumatic death and, syncope in the setting of PE portends poor 30-day outcomes (Roncon 2018). What is not well known is how often ED presentations of syncope are the result of PE. A study in 2016 demonstrated a 17.3% rate of PE in first time syncope presenting to the ED but, had numerous significant biases and limitations (Prandoni 2016). Ultimately, this study is unlikely to reflect the reality of ED syncope cases and lacks external validity. Incorporating the PESIT trial data into clinical assessment would lead to a profound increase in PE evaluation without adding significant benefit. Additional clinical data demonstrating the true prevalence of PE in syncope patients is needed to confirm these suspicions. Read more →
Welcome back to REBELCast. In this episode we talked with Jacob Avila about US guided PIVs. Difficult IV access in an already busy department can be a frustrating thing, but it doesn’t have to be. Patients and providers are often frustrated for different reasons. Patients for multiple IV attempts and providers because of the time it can take to perform the procedure, delays in care, or lack of success. If you want to get better at this all-important procedure, read/listen on. Read more →
Take Home Points
- Bed Up Head Elevated (BUHE) position is a simple intervention that can reduce the rate of intubation-related complications.
- The bougie should be considered standard practice in all intubations and has an NNT = 11 for 1st pass success.
- Consider using Suction Assisted Laryngoscopy for Airway Decontamination (SALAD) for all intubations to avoid the failed airway due to contamination.
Background Information: The successful placement of an endotracheal tube (ETT) is a necessary skill all emergency physicians must possess. Performing life-saving interventions are understandably stressful as their failure can lead to morbid consequences and expedited patient death.1,2 The intensive training of emergency physicians, the availability of multiple alternative airway adjuncts and the use of rapid-sequence intubation has helped reduce the intubation complication rate among trauma and medical patients.3-5 Confirmatory methods to ensure the placement of the endotracheal tube are ever changing with no single method being infallible.6. Physical exam findings such as auscultation of the chest and epigastrium, visualization of thoracic movement and fogging of the ETT are not sufficiently reliable to confirm placement.7,8 The use of end-tidal CO2 detection has been shown to have a cumulative false-positive and false-negative failure rate of 10% in accurately confirming the ETT’s location according to the authors of this paper (The paper referenced is a bit dated).6 Furthermore, the usage of these devices may contribute to the complications as they frequently require up to 5 ventilations to obtain an accurate reading.9-11 This puts the patient at risk for aspiration especially if the tube is in the esophagus. No.12 Despite a post-intubation CXR taking time, exposing the patient to more radiation and adding to the cost of treatment, it still continues to remain the standard of care.12-14 The authors of this study wished to better understand the test characteristics of utilizing ultrasound to confirm ETT placement. They conducted a systematic review and meta-analysis to quantify the accuracy of this ETT confirmatory method. Read more →
Diagnosis and management of concussion in children is part of our everyday bread and butter in the Emergency Department. Given the estimated 1.1 million – 1.9 million pediatric concussions we see annually in the United States, it is no wonder why.  We are well aware that pediatric concussions (more accurately termed mild traumatic brain injury, mTBI) occur most commonly from direct blunt head trauma, but they can also occur via indirect forces. Regardless of mechanism, concussions result in temporary neurologic and/or cognitive impairment that can last hours to days, with long-term sequelae potentially lasting weeks to months. Read more →