1710 Correspondence / American Journal of Emergency Medicine 36 (2018) 1693-1715

Fig. 1. Patients with abdominal pain investigated with CT or MRI in the Emergency Department.

Julia McNabb-Baltar* Matthew S. Chang Shadeah L. Suleiman

Peter A. Banks

D. Punyanganie S. de Silva Division of Gastroenterology, Hepatology, and Endoscopy, Center for Pancreatic Disease, Brigham and Women’s Hospital, Harvard Medical

School, Boston, MA, USA

*Corresponding author at: Brigham and Women’s Hospital, 75 Francis

Street, Boston, MA 02115, USA.

E-mail address: [email protected] (J. McNabb-Baltar).

12 October 2017

https://doi.org/10.1016/j.ajem.2018.01.069

in up to 56% of patients [8]. Previous single center reports have doc- umented overutilization of early CT and MRI in patients presenting with AP. In this U.S. nationally representative database, we show that the utilization of MRI and CT imaging is rising in patients pre- senting with acute pancreatitis in the ED. Despite clear recommen- dations that an early CT cannot be used to determine whether a patient has necrotizing pancreatitis [9], and concerns from the American College of Radiology about unnecessary exposure to radiation, CT imaging continues to be performed for this presenta- tion, and the rate is actually increasing. To the best of our knowledge, we are the first to report this trend in a national database. These findings emphasize current trends in the practice of medicine in the U.S., where a predominantly defensive approach to medicine re- mains at the forefront, despite increasing pressures from payers and policy to reduce waste and inappropriate use of medical equipment. Further education and awareness among ED providers regarding these findings are warranted.

Acknowledgements

Ellen P. McCarthy, PhD, MPH, John Ayanian, MD, MPP, and Shimon Shaykevich MSc provided methodologic and conceptual advice and support.

References

1. Peery AF, Dellon ES, Lund J, Crockett SD, McGowan CE, Bulsiewicz WJ, et al. Burden of gastrointestinal disease in the United States: 2012 update. Gastroenterology 2012; 143(5):1179-87 e1-3. [Epub 2012/08/14].
2. Amis Jr ES, Butler PF, Applegate KE, Birnbaum SB, Brateman LF, Hevezi JM, et al. Amer- ican College of Radiology white paper on radiation dose in medicine. J Am Coll Radiol JACR 2007;4(5):272-84 [Epub 2007/05/01].
3. Mortele KJ, Ip IK, Wu BU, Conwell DL, Banks PA, Khorasani R. Acute pancreatitis: im-

   aging utilization practices in an urban teaching hospital-analysis of trends with as- sessment of independent predictors in correlation with patient outcomes. Radiology 2011;258(1):174-81 [Epub 2010/10/29].

   Amis Jr ES, Butler PF. American College of R. ACR white paper on radiation dose in medicine: three years later. J Am Coll Radiol JACR 2010;7(11):865-70 [Epub 2010/ 11/03].

4. American Gastroenterological Association Institute on “Management of Acute Pancreatits” Clinical P, Economics C, Board AGAIG. AGA Institute medical position statement on acute pancreatitis. Gastroenterology 2007;132(5):2019-21 [Epub 2007/05/09].
5. Wu BU, Banks PA. Clinical management of patients with acute pancreatitis. Gastroen- terology 2013;144(6):1272-81 [Epub 2013/04/30].
6. Tenner S, Baillie J, DeWitt J, Vege SS. American College of G. American College of Gastroenterology guideline: management of acute pancreatitis. Am J Gastroenterol 2013;108(9):1400-15 16. [Epub 2013/07/31].
7. Shinagare AB, Ip IK, Raja AS, Sahni VA, Banks P, Khorasani R. Use of CT and MRI in emergency department patients with acute pancreatitis. Abdom Imaging 2015; 40(2):272-7.

   Which option for ventilation is optimal for resuscitation performed by nurses? Pilot data

   Sir,

   We read with great interest the article entitled “A comparison of the McGrath-MAC and Macintosh laryngoscopes for child tracheal intubation during resuscitation by paramedics. A randomized, cross- over, Mannequin study” [1]. Data presented in the article show that paramedics were able to perform endotracheal intubation with the Macintosh laryngoscope with a success rate of 90.5%. Such a high success rate may be a result of learning that procedure early, at the level of university training. However, the success rate of intubation among other professionals e.g. nurses are significantly lower, which was confirmed by Ladny et al. [2] - 46.9% and other authors [3-5]. An alternative for people who cannot perform endotracheal in- tubation may be supraglottic airway devices (SADs). In their latest guidelines update the American Heart Association [6] allowed the usage of SAD during Continuous chest compressions. The blind intu- bation is also possible now due to new SAD such as iGEL or Laryngeal Mask Airway [7].

   The aim of the study was to assess ventilation in conditions of simu- lated cardiopulmonary resuscitation (CPR) using bag-mask-valve (BVM) and laryngeal mask with self-inflating bag performed by nurses. There were 38 nurses (all women) enrolled in the study. All of them participated in Advanced Cardiovascular Life Support course based on American Heart Association 2017 guidelines. All participants declared that they are able to properly ventilate the patient using BVM. In the study to simulate the patient in cardiac arrest, a training phantom Resusci Anne QCPR manikin (Laerdal, Stavanger, Norway) was used. The participants of the study were intended to perform rescue breaths during a 2-minute cycle of resuscitation using two methods: BVM and Ambu(R) AuraGain(TM) Disposable Laryngeal Mask (AMBU) (Fig. 1). Both the method of ventilation and the order of the participants were ran- domized. The study was designed as a randomized crossover study. Re- spiratory volume was assessed based on the SimPad software which

   was attached to the phantom.

   A mean age of participant was 43.5 +- 9.3 years old with a mean work experience of 21.2 +- 11.4 years. The respiratory volume performed with BVM was 340 +- 84 mL and 485 +- 58 mL for the AMBU with self- inflating bag (p = 0.003). The easiness of performing rescue breaths was measured by a five-point scale (1 = easy ventilation; 5 = hard

   Correspondence / American Journal of Emergency Medicine 36 (2018) 1693-1715 1711

   

   Fig. 1. Ventilation with BVM and Ambu(R) AuraGain(TM) Disposable Laryngeal Mask.

   ventilation) and in the case of BVM was 3.5 +- 0.5 points, while for AMBU with self-inflating bag it was 1.5 +- 0.5 points (p b 0.001).

   To conclude the usage of laryngeal mask with self-inflating bag by the nurses during a simulated CPR was associated with better ventila- tion of the patient compared to using a self-inflating bag with a face mask. However additional clinical trials are necessary to confirm the results.

   Source of support

   No sources of financial and material support to be declared.

   References

   Szarpak L, Truszewski Z, Czyzewski L, T4 Gaszynski, Rodriguez-Nunez A. A com- parison of the McGrath-MAC and Macintosh laryngoscopes for child tracheal in- tubation during resuscitation by paramedics. A randomized, crossover, manikin study. Am J Emerg Med 2016;34(8):1338-41. https://doi.org/10.1016/j.ajem. 2015.11.060.

8. Ladny JR, Sierzantowicz R, Kedziora J, Szarpak L. Comparison of direct and optical lar- yngoscopy during simulated cardiopulmonary resuscitation. Am J Emerg Med Mar 2017;35(3):518-9. https://doi.org/10.1016/j.ajem.2016.12.026.
9. Smereka J, Ladny JR, Naylor A, Ruetzler K, Szarpak L. C-MAC compared with direct lar- yngoscopy for intubation in patients with cervical spine immobilization: a manikin trial. Am J Emerg Med Aug 2017;35(8):1142-6. https://doi.org/10.1016/j.ajem.2017. 03.030.
10. Ladny JR, Smereka J, Szarpak L. Comparison of the Trachway video intubating sty- let and Macintosh laryngoscope for endotracheal intubation. Preliminary data. Am J Emerg Med Apr 2017;35(4):574-5. https://doi.org/10.1016/j.ajem.2016. 12.015.
11. Szarpak L, Czyzewski L, Kurowski A. Comparison of the Pentax, Truview, GlideScope, and the Miller laryngoscope for child intubation during resuscitation. Am J Emerg Med Mar 2015;33(3):391-5. https://doi.org/10.1016/j.ajem.2014.12. 020.
12. Atkins DL, de Caen AR, Berger S, Samson RA, Schexnayder SM, Joyner Jr BL, et al. 2017 American Heart Association focused update on pediatric basic life support and cardiopulmonary Resuscitation quality: an update to the American Heart As- sociation Guidelines for Cardiopulmonary Resuscitation and Emergency Cardio- vascular Care. Circulation Jan 2 2018;137(1):e1-6. https://doi.org/10.1161/CIR. 0000000000000540.
13. Ladny JR, Bielski K, Szarpak L, Cieciel M, Konski R, Smereka J. Are nurses able to perform blind intubation? Randomized comparison of I-gel and laryngeal mask airway. Am J Emerg Med May 2017;35(5):786-7. https://doi.org/10.1016/j. ajem.2016.11.046.

    Halla Kaminska, PhD, MD

    Department of Children’s Diabetology, Medical University of Silesia,

    Katowice, Poland

    Wladyslaw B. Gawel, MS

    Student’s Scientific Association of Children’s Diabetology of Medical

    University of Silesia, Poland

    Wojciech Wieczorek, MSc, EMT-P Department of Anaesthesiology, Intensive Care and Emergency Medicine in Zabrze, Medical University of Silesia, Katowice, Poland Corresponding author at: Department of Anaesthesiology and Intensive Therapy, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia, 3 Maja 13/15 Str., 41-800 Zabrze, Poland. E-mail address: [email protected].

    15 January 2018

    https://doi.org/10.1016/j.ajem.2018.01.072

    Airway ultrasound for the confirmation of endotracheal tube placement in cadavers by military flight medic trainees - A pilot study

    Introduction

    endotracheal tube placement serves as definitive airway con- trol in critically ill and injured patients. Confirming correct ETT place- ment is a key component of successful airway management both initially at the time of tube placement as well as during extended pre- and intra-hospital Patient transportation for continued monitoring and troubleshooting. Many methods for confirming correct ETT place- ment exist including capnography, colorimetric CO₂ detection, visuali- zation of chest rise and direct auscultation; however, each of these methods has limitations. Continuous waveform capnography, in addi- tion to clinical assessment, is considered to be the most reliable method in determining ETT placement; however, capnography has limitations in the setting of low cardiac output, low pulmonary blood flow, air way obstruction or epinephrine use [1-3].

    Ultrasound (US) is widely available in emergency room settings and becoming more available in the pre-hospital setting, and several studies have shown promising results for its use in confirming ETT placement [4-8]. Many pre-hospital providers who intubate critically ill patients, including military medics, have also become facile in the use of limited ultrasound [9,10]. The data demonstrating the ability of pre-hospital providers to verify ETT placement with US is limited and none in human models exists.

    We used a cadaver model to investigate the ability of military medics to correctly identify ETT placement. We hypothesized that after a short educational session, military flight medic trainees would be able to ac- curately identify ETT placement in a cadaver model. We also investigat- ed military medics interest in learning this method of verification.

    Methods

    Study design and setting

    This was a prospective randomized trial which evaluated combat medics’ ability to distinguish the difference between endotracheal and Esophageal intubations in a fresh human cadaver model using Transtracheal ultrasound. The study was conducted at the Center for Emergency Health Sciences, an emergency medical services educational and research institute in Bulverde-Spring Branch, TX, from February through October 2015.

    Selection of participants

    Participating subjects were Army Combat Medics, who had previ- ously completed Emergency Medical Technician-Basic certification and were enrolled in the Army’s 34-week flight paramedic training