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192: Who Reads the Electrocardiograms in Emergency Departments in France
ICEM 2008 Scientific Abstract Program significant differences in performance based on level of training of residents or years of experience of attending physicians. Conclusion: In patients who are successfully ventilated using a standard LMA with good placement, an Eschmann stylet might be placed through the LMA into the trachea approximately 60% of the time.
191
The Ability of Emergency Physicians to Differentiate Tracheal Versus Esophageal Placement of an Eschmann Stylet by Tactile Sensation
Miller JA, Levsky ME, Miller MA, Givens ML/Darnall Army Medical Center, Ft. Hood, TX
Study Objectives: The Eschmann stylet (bougie) is a commonly used intubation rescue device, which may be used to guide placement of an endotracheal tube into the trachea where visualization of the glottis is difficult. The general method of use for blind insertion includes feeling the stylet’s deflections off the tracheal cartilage rings in a successful placement. Although previously published success rates for Eschmann stylet-assisted intubation are generally greater than 90%, no data have been published on physicians’ abilities to determine esophageal versus tracheal placement through tactile stimuli only. The objective of this study is to determine whether emergency medicine residents and staff physicians can differentiate tracheal versus esophageal placement of a bougie based solely on tactile stimuli. Methods: Six unembalmed, human cadavers were each randomized twice to either esophageal or tracheal placement. Investigators then placed a 15 Fr reusable, coude-tipped, introducer bougie (Smiths Medical, Watford, UK) into the esophagus or trachea of cadavers under visualization by direct laryngoscopy. Twenty-one emergency medicine residents and attending physicians, who were blinded to the placement, then moved the bougie with their hands and attempted to identify whether the introducer lay in the trachea or esophagus based solely on tactile stimuli. After each attempt, bougie placement was reconfirmed by an investigator using direct laryngoscopy before the next attempt. Results: Of 210 attempts at stylet localization, 122 were correctly identified (58%). The sensitivity and specificity of tactile stimuli for tracheal placement were 50% and 66%, respectively. There were no significant differences in performance based on level of training of residents or years of experience of attending physicians. Performance characteristics were not different across different cadavers, and did not differ with successive number of attempts on each cadaver. Conclusion: In this cadaveric model, emergency physicians using only tactile stimuli performed poorly at determining Eschmann stylet placement.
192
Who Reads the Electrocardiograms in Emergency Departments in France
Sende J, Bongrand C, Campos-Richard AM, Aouate Y, Loppe M, Monribot M, Jaulin C, Combes X, Marty J/Henri Mondor’s Hospital, Creteil, France; Orangerie Private Hospital, Le-Perreux-sur-Marne, France
Study Objectives: The electrocardiograms (ECG) are routinely used in emergency departments (EDs). New recommendations on leads position have been published in 2007. The aim of our study was to know who mainly reads ECGs in EDs, to improve the communication on the recommendations. Methods: In October 2007, we conducted a telephonic questionnaire, concerning 100 EDs (one per department, randomly chosen). We asked who mainly reads ECGs between doctors, residents, nurses, and nursing auxiliaries. We also asked if there were a written protocol on ECG leads position and if nurses, doctors and residents had a repeated theorical formation on the subject. Results: We contacted 70 EDs over 100 screened. The nurses mainly read ECGs in 48 EDs (69%). In 26 EDs (37%), there was a repeated theorical formation. Only 20 EDs (29%) had a written protocol on ECGs leads position. When the ECG is read for chest pain, 17 leads ECG is systematic in 34 EDs, only if suspected acute coronary disease in 28 EDs (89% of all EDs). Conclusion: In EDs in France, nurses mainly read ECGs. To improve the quality of ECG realization, we should not only target doctors, but also emphasis on nurses’ formation, with written protocols, repeated formation on leads positions, including right and posterior leads, and articles in nurses’ journals.
Volume , . : April
193
Bedside Echocardiography Role in Discharge of Patients With Low Risk Unstable Angina
Farsi D, Mofidi M, Zare MA, Abbasi S, Majidinezhad M, Hassani SA/Iran University of Medical Sciences, Tehran, Iran (Islamic Republic of)
Study Objectives: About 30% of patients with cardiovascular disease who come to the emergency department have unstable angina. Low risk patients can be discharged and receive outpatient treatment if clinical and para clinical assays are normal. The recommended pre-discharge evaluations are controversial. Because of availability and safety of bedside echocardiography in emergency department, we decided to perform this study to validate the role of echocardiography in decisionmaking for discharging the patients. Methods: This cohort study was done on 500 patients with low risk unstable angina that admitted to emergency department of Hazrat-e-Rasool hospital. All of them underwent bedside echocardiography before discharge. Then the patients were divided in two groups regarding echocardiographic findings, the first with normal findings and the second with abnormal findings (EF ⬍ 40% and wall motion abnormality). We called the patients after one month and noted their outcomes (death from cardiac arrest, CCU admission rate and emergency department visit because of angina). Finally, the relationship between echocardiographic findings and outcomes of the patients was evaluated. Results: The mean of age was 51.39 (SD ⫽ 10.13) years. 42.1% were female and 57.9% were male. The patients with abnormal echocardiographic findings (EF ⬍ 40% and wall motion abnormality) had more emergency department visit because of cardiac chest pain than others (p ⫽ 0.000). There is no relationship between other outcomes of the patients with abnormal echocardiographic findings. Conclusion: We suggest bedside echocardiography as a pre-discharge evaluation in the patients with low risk unstable angina because of its safety, availability and efficacy.
194
A Retrospective Study of Hospital Delays in Reperfusion for Patients With ST-Elevation Myocardial Infarction (STEMI) in a Japanese Community Hospital
Sumida Y, Ohta B, Yamagami H, Ohfuchi H, Branch J/Shonan Kamakura General Hospital, Kamakura, Japan
Study Objectives: ACC/AHA guidelines 2005 recommend that the interval between arrival at hospital and intracoronary balloon inflation (door to balloon time) for primary percutaneous coronary intervention (PCI) should be 90 minutes or less for treatment of myocardial infarction (MI). We investigated the causes of hospital delays resulting in a prolonged door to balloon time for patients with ST elevation MI (STEMI) and mortality rates. Methods: We retrospectively analysed 184 patients diagnosed with STEMI and hospitalised from Jan 2004 to July 2007 inclusive. All patients had the diagnosis confirmed through PCI. Patients were excluded from this study when referred from other medical centers with suspected or proven MI, and patients who rejected invasive therapy. Our institution’s STEMI protocol directs that patients should have no more than 45 minutes wait before receiving consultation from a cardiologist. We calculated Door to Balloon time by adding the “door to consultation” time to the “consultation to balloon” time and subsequently, investigated the delays in patients with a prolonged door to balloon time of more than 90 minutes. Results: Door to balloon time of less than 90 minutes included 108 “ambulance” patients (82.4 percent) and 33 “walk-in” patients (62.3 percent) respectively (see figures 1 & 2). Patients who presented as “walk-in” were not seen as rapidly as “ambulance” patients, which resulted in delays to their door to balloon time. Overall 17 patients died, 16 (12.2 percent) from the “ambulance” group and one (1.9 percent) from the “walk-in” group respectively. Conclusions: The results show that 37.7 percent of “walk-in” patients had a prolonged door to balloon time of more than 90 minutes. Although patients with STEMI should have ideally been assessed within the first 10 minutes whether from an “ambulance” or “walk-in” presentation, in reality there were significant delays which included 1) “walk-in” patients at night tended to have delayed assessment as they were not triaged by nursing staff and 2) these patients had atypical symptoms resulting in delayed diagnosis. At our institution, the “ambulance” patients are seen expeditiously, as by definition, they are triaged as emergency cases in comparison to most “walk-in” patients. Unsurprisingly, patients brought in by ambulance had a higher mortality rate because their overall conditions were worse. In one of 17 patients who died, door to balloon time exceeded 90 minutes. This study
Annals of Emergency Medicine 529
191
The Ability of Emergency Physicians to Differentiate Tracheal Versus Esophageal Placement of an Eschmann Stylet by Tactile Sensation
Miller JA, Levsky ME, Miller MA, Givens ML/Darnall Army Medical Center, Ft. Hood, TX
Study Objectives: The Eschmann stylet (bougie) is a commonly used intubation rescue device, which may be used to guide placement of an endotracheal tube into the trachea where visualization of the glottis is difficult. The general method of use for blind insertion includes feeling the stylet’s deflections off the tracheal cartilage rings in a successful placement. Although previously published success rates for Eschmann stylet-assisted intubation are generally greater than 90%, no data have been published on physicians’ abilities to determine esophageal versus tracheal placement through tactile stimuli only. The objective of this study is to determine whether emergency medicine residents and staff physicians can differentiate tracheal versus esophageal placement of a bougie based solely on tactile stimuli. Methods: Six unembalmed, human cadavers were each randomized twice to either esophageal or tracheal placement. Investigators then placed a 15 Fr reusable, coude-tipped, introducer bougie (Smiths Medical, Watford, UK) into the esophagus or trachea of cadavers under visualization by direct laryngoscopy. Twenty-one emergency medicine residents and attending physicians, who were blinded to the placement, then moved the bougie with their hands and attempted to identify whether the introducer lay in the trachea or esophagus based solely on tactile stimuli. After each attempt, bougie placement was reconfirmed by an investigator using direct laryngoscopy before the next attempt. Results: Of 210 attempts at stylet localization, 122 were correctly identified (58%). The sensitivity and specificity of tactile stimuli for tracheal placement were 50% and 66%, respectively. There were no significant differences in performance based on level of training of residents or years of experience of attending physicians. Performance characteristics were not different across different cadavers, and did not differ with successive number of attempts on each cadaver. Conclusion: In this cadaveric model, emergency physicians using only tactile stimuli performed poorly at determining Eschmann stylet placement.
192
Who Reads the Electrocardiograms in Emergency Departments in France
Sende J, Bongrand C, Campos-Richard AM, Aouate Y, Loppe M, Monribot M, Jaulin C, Combes X, Marty J/Henri Mondor’s Hospital, Creteil, France; Orangerie Private Hospital, Le-Perreux-sur-Marne, France
Study Objectives: The electrocardiograms (ECG) are routinely used in emergency departments (EDs). New recommendations on leads position have been published in 2007. The aim of our study was to know who mainly reads ECGs in EDs, to improve the communication on the recommendations. Methods: In October 2007, we conducted a telephonic questionnaire, concerning 100 EDs (one per department, randomly chosen). We asked who mainly reads ECGs between doctors, residents, nurses, and nursing auxiliaries. We also asked if there were a written protocol on ECG leads position and if nurses, doctors and residents had a repeated theorical formation on the subject. Results: We contacted 70 EDs over 100 screened. The nurses mainly read ECGs in 48 EDs (69%). In 26 EDs (37%), there was a repeated theorical formation. Only 20 EDs (29%) had a written protocol on ECGs leads position. When the ECG is read for chest pain, 17 leads ECG is systematic in 34 EDs, only if suspected acute coronary disease in 28 EDs (89% of all EDs). Conclusion: In EDs in France, nurses mainly read ECGs. To improve the quality of ECG realization, we should not only target doctors, but also emphasis on nurses’ formation, with written protocols, repeated formation on leads positions, including right and posterior leads, and articles in nurses’ journals.
Volume , . : April
193
Bedside Echocardiography Role in Discharge of Patients With Low Risk Unstable Angina
Farsi D, Mofidi M, Zare MA, Abbasi S, Majidinezhad M, Hassani SA/Iran University of Medical Sciences, Tehran, Iran (Islamic Republic of)
Study Objectives: About 30% of patients with cardiovascular disease who come to the emergency department have unstable angina. Low risk patients can be discharged and receive outpatient treatment if clinical and para clinical assays are normal. The recommended pre-discharge evaluations are controversial. Because of availability and safety of bedside echocardiography in emergency department, we decided to perform this study to validate the role of echocardiography in decisionmaking for discharging the patients. Methods: This cohort study was done on 500 patients with low risk unstable angina that admitted to emergency department of Hazrat-e-Rasool hospital. All of them underwent bedside echocardiography before discharge. Then the patients were divided in two groups regarding echocardiographic findings, the first with normal findings and the second with abnormal findings (EF ⬍ 40% and wall motion abnormality). We called the patients after one month and noted their outcomes (death from cardiac arrest, CCU admission rate and emergency department visit because of angina). Finally, the relationship between echocardiographic findings and outcomes of the patients was evaluated. Results: The mean of age was 51.39 (SD ⫽ 10.13) years. 42.1% were female and 57.9% were male. The patients with abnormal echocardiographic findings (EF ⬍ 40% and wall motion abnormality) had more emergency department visit because of cardiac chest pain than others (p ⫽ 0.000). There is no relationship between other outcomes of the patients with abnormal echocardiographic findings. Conclusion: We suggest bedside echocardiography as a pre-discharge evaluation in the patients with low risk unstable angina because of its safety, availability and efficacy.
194
A Retrospective Study of Hospital Delays in Reperfusion for Patients With ST-Elevation Myocardial Infarction (STEMI) in a Japanese Community Hospital
Sumida Y, Ohta B, Yamagami H, Ohfuchi H, Branch J/Shonan Kamakura General Hospital, Kamakura, Japan
Study Objectives: ACC/AHA guidelines 2005 recommend that the interval between arrival at hospital and intracoronary balloon inflation (door to balloon time) for primary percutaneous coronary intervention (PCI) should be 90 minutes or less for treatment of myocardial infarction (MI). We investigated the causes of hospital delays resulting in a prolonged door to balloon time for patients with ST elevation MI (STEMI) and mortality rates. Methods: We retrospectively analysed 184 patients diagnosed with STEMI and hospitalised from Jan 2004 to July 2007 inclusive. All patients had the diagnosis confirmed through PCI. Patients were excluded from this study when referred from other medical centers with suspected or proven MI, and patients who rejected invasive therapy. Our institution’s STEMI protocol directs that patients should have no more than 45 minutes wait before receiving consultation from a cardiologist. We calculated Door to Balloon time by adding the “door to consultation” time to the “consultation to balloon” time and subsequently, investigated the delays in patients with a prolonged door to balloon time of more than 90 minutes. Results: Door to balloon time of less than 90 minutes included 108 “ambulance” patients (82.4 percent) and 33 “walk-in” patients (62.3 percent) respectively (see figures 1 & 2). Patients who presented as “walk-in” were not seen as rapidly as “ambulance” patients, which resulted in delays to their door to balloon time. Overall 17 patients died, 16 (12.2 percent) from the “ambulance” group and one (1.9 percent) from the “walk-in” group respectively. Conclusions: The results show that 37.7 percent of “walk-in” patients had a prolonged door to balloon time of more than 90 minutes. Although patients with STEMI should have ideally been assessed within the first 10 minutes whether from an “ambulance” or “walk-in” presentation, in reality there were significant delays which included 1) “walk-in” patients at night tended to have delayed assessment as they were not triaged by nursing staff and 2) these patients had atypical symptoms resulting in delayed diagnosis. At our institution, the “ambulance” patients are seen expeditiously, as by definition, they are triaged as emergency cases in comparison to most “walk-in” patients. Unsurprisingly, patients brought in by ambulance had a higher mortality rate because their overall conditions were worse. In one of 17 patients who died, door to balloon time exceeded 90 minutes. This study
Annals of Emergency Medicine 529