- Email: [email protected]
Syringe aspiration technique in emergency medicine: A device ready to be studied
CORRESPONDENCE
8. Phillips G: Checking for endotracheal placement. Anaesth Intens Care 1994;22:498-499 9. Rossi R: Kapnographie im Notarztdienst. Notarzt 1994;10:$19-22 10. Petroianu G, Widjaja B. Bergler WF: Detection of oesophageal intubation. Anaesthesia 1992;47:70-71 11. Petroianu G: 0berprQfung der Tubuslage. Anaesthesist 1993;42:324-325
485
clinical trial to assure ourselves and our patients that there is a role for it in emergency medicine. VINCENT P. VERDILE, MD
Albany Medical College Department of Emergency Medicine Albany, NY PAUL M. PARIS, MD WILLIAM JENKINS, MD
University of Pittsburgh Pittsburgh, PA
SYRINGE ASPIRATION TECHNIQUE IN EMERGENCY MEDICINE: A DEVICE READYTO BE STUDIED References The authors' reply:--We appreciate the opportunity to respond to the comments of Dr Maleck and his colleagues regarding the utility of the syringe aspiration technique (SAT) in emergency medicine. In his letter, Dr. Maleck describes previous work with both the SAT and the bulb aspiration device in a variety of clinical venues.l-4 Although both techniques involve the same general principles, they are not similar enough to combine and compare data. As an example, the bulb aspiration device has demonstrated false-positive results (positive indicating esophageal placement of the endotracheal tube [ETT]) because of airway secretion. ~6 The SAT in our study was not impaired by the presence of airway secretions.7 It is not reasonable to combine the data from both devices in support of one or the other device. It is also of uncertain validity to combine data from several different studies, from both animal and human trials, and analyze them as if they were from a single source. Although the data from studies of the SAT devices suggest that it works reliably, we argue that the sample sizes in the clinical trials to date have been small, and the prevalence of esophageal ETT placement is extremely rare. 2'5'8-11 Most studies, therefore, do not have a reasonable negative predictive value for the SAT, making conclusions about safety and efficacy difficult. We suggest that for emergency physicians to be assured that the SAT is a safe and effective device for their patients, a controlled, prospective, double-blinded study should be performed on emergency department (ED) patients, with a sufficient sample size to assure that the SAT will be able to detect esophageal placement of the ETT more frequently than just as a random event. Likewise, before widespread implementation, prehospital trials are necessary to examine the use of the SAT by prehospital providers. We also believe that the SAT, at least in the setting of urgent airway control, is in fact better than capnometry for detecting esophageal placement, because the SAT provides nearly instantaneous feedback and is also effective in detecting ETT placement in the setting of cardiopulmonary arrest. Patients who are intubated in the ED or prehospital setting can be continuously monitored with a variety of devices, including capnometry, but not the SAT. This is not to say that the SAT would not be useful for reconfirming ETT placement after a patient has been moved or if any change in lung compliance is detected during ventilation. On-line capnometry has no immediate role in prehospital medicine because of concerns regarding the cost, durability, and portability of these devices. The newer, disposable, calorimetric end-tidal CO 2 detectors have proven to be a useful and reliable device for the verification of ETT placement, although there is a decrease in specificity in the setting of prolonged cardiopulmonary arrest.12"13 However, the role of calorimetric end-tidal CO2 detectors in the continuous monitoring of patients who are intubated has not been demonstrated. We are pleased that Dr Maleck and his colleagues enjoyed our publication. We hope we have clarified our position on the issues they have raised. We agree with them that it is essential to continue to address the issue of unrecognized esophageal placement of ETT by developing new techniques and confirming the proper use of old techniques in both the prehospital and ED settings. The time has come to demonstrate the safety and efficacy of the SAT in a large
1. Nunn JF: The oesophageal detector device. Anaesthesia 1988;43:804 2. O'Leary JJ, Pollard BJ, Ryan MJ: A method of detecting oesophageal intubation confirming tracheal intubation. Anaesth Intensive Care 1988;16:299-301 3. Petroianu GA, Maleck WH: Detection of an oesophageal intubation: "State of the art." Anaesth Intens Care 1994;22:744746 5. Wee MYK: The oesophageal detector device. Assessment of a new method to distinguish oesophageal intubation. Anaesthesia 1988;43:27-29 6. Bozeman W, Hexter D, Liang HK, et al: The oesophageal detector device versus end-tidal CO2 detection in emergency intubation. Acad Emerg Med 1994;1 :A77(abstr) 7. Jenkins WA, Verdile VP, Paris PM: The syringe aspiration technique to verify endotracheal tube position. Am J Emerg Med 1994;12:413-416 8. Wee MYK: The Oesophageal detector device. Anaesthesia 1988 ;43:27-29 9. Haynes SR, Morton NS: Use of the oesophageal detector device in children under one year of age. Anaesthesia 1990;45: 1067-1069 10. Zaleski L, Abello D, Gold MI: The oesophageal detector device. Does it work? Anesthesiology 1993;79:244-247 11. Morten NS, Stuart JC, Thomsom MF, et al: The oesophageal detector device: Successful use in children. Anaesthesia 1989 ;44:523-524 12. Goldberg JS, Rawle PR, Zehnder JL, et al: Colorimetric end-tidal carbon dioxide monitoring for tracheal intubation. Anesth Analg 1990;70:191-194 13. Ornato JP, Shipley JB, Racht EM, et al: Multi-center study of a portable hand size, colorimetric end-tidal carbon dioxide detection device. Ann Emerg Med 1992;21:518-523
EQUESTRIAN-RELATEDTRAUMA To the Editor:--ln the United States, equestrian activities are common. It is estimated that 30 million Americans ride horses each year, and approximately 80% of the 8.3 million horses owned in the United States are owned for recreational purposes. 1 Equestrianrelated injury is infrequently encountered on our trauma service, but it is not unusual. In fact, this form of injury may be significant in terms of health care cost, patient morbidity, and mortality. The object of this review was to determine the severity of injury, injury patterns, outcome, and hospital costs in patients with equestrianrelated injury admitted to a regional trauma center. A retrospective chart review augmented by a postdischarge phone survey of a seven-and-one-half-year trauma experience with equestrian-related injury was undertaken. The records of all patients admitted to the trauma service with equestrian-associated injury were reviewed. A concurrently maintained trauma register was used to provide additional information. Hospital costs were estimated at 64% of hospital charges, a number previously determined by outside audit for another reason. 2 A postdischarge telephone survey was conducted to determine these patients' outcomes in terms of recovery and disability, behavioral factors related to injuries, and whether or not behavior was
8. Phillips G: Checking for endotracheal placement. Anaesth Intens Care 1994;22:498-499 9. Rossi R: Kapnographie im Notarztdienst. Notarzt 1994;10:$19-22 10. Petroianu G, Widjaja B. Bergler WF: Detection of oesophageal intubation. Anaesthesia 1992;47:70-71 11. Petroianu G: 0berprQfung der Tubuslage. Anaesthesist 1993;42:324-325
485
clinical trial to assure ourselves and our patients that there is a role for it in emergency medicine. VINCENT P. VERDILE, MD
Albany Medical College Department of Emergency Medicine Albany, NY PAUL M. PARIS, MD WILLIAM JENKINS, MD
University of Pittsburgh Pittsburgh, PA
SYRINGE ASPIRATION TECHNIQUE IN EMERGENCY MEDICINE: A DEVICE READYTO BE STUDIED References The authors' reply:--We appreciate the opportunity to respond to the comments of Dr Maleck and his colleagues regarding the utility of the syringe aspiration technique (SAT) in emergency medicine. In his letter, Dr. Maleck describes previous work with both the SAT and the bulb aspiration device in a variety of clinical venues.l-4 Although both techniques involve the same general principles, they are not similar enough to combine and compare data. As an example, the bulb aspiration device has demonstrated false-positive results (positive indicating esophageal placement of the endotracheal tube [ETT]) because of airway secretion. ~6 The SAT in our study was not impaired by the presence of airway secretions.7 It is not reasonable to combine the data from both devices in support of one or the other device. It is also of uncertain validity to combine data from several different studies, from both animal and human trials, and analyze them as if they were from a single source. Although the data from studies of the SAT devices suggest that it works reliably, we argue that the sample sizes in the clinical trials to date have been small, and the prevalence of esophageal ETT placement is extremely rare. 2'5'8-11 Most studies, therefore, do not have a reasonable negative predictive value for the SAT, making conclusions about safety and efficacy difficult. We suggest that for emergency physicians to be assured that the SAT is a safe and effective device for their patients, a controlled, prospective, double-blinded study should be performed on emergency department (ED) patients, with a sufficient sample size to assure that the SAT will be able to detect esophageal placement of the ETT more frequently than just as a random event. Likewise, before widespread implementation, prehospital trials are necessary to examine the use of the SAT by prehospital providers. We also believe that the SAT, at least in the setting of urgent airway control, is in fact better than capnometry for detecting esophageal placement, because the SAT provides nearly instantaneous feedback and is also effective in detecting ETT placement in the setting of cardiopulmonary arrest. Patients who are intubated in the ED or prehospital setting can be continuously monitored with a variety of devices, including capnometry, but not the SAT. This is not to say that the SAT would not be useful for reconfirming ETT placement after a patient has been moved or if any change in lung compliance is detected during ventilation. On-line capnometry has no immediate role in prehospital medicine because of concerns regarding the cost, durability, and portability of these devices. The newer, disposable, calorimetric end-tidal CO 2 detectors have proven to be a useful and reliable device for the verification of ETT placement, although there is a decrease in specificity in the setting of prolonged cardiopulmonary arrest.12"13 However, the role of calorimetric end-tidal CO2 detectors in the continuous monitoring of patients who are intubated has not been demonstrated. We are pleased that Dr Maleck and his colleagues enjoyed our publication. We hope we have clarified our position on the issues they have raised. We agree with them that it is essential to continue to address the issue of unrecognized esophageal placement of ETT by developing new techniques and confirming the proper use of old techniques in both the prehospital and ED settings. The time has come to demonstrate the safety and efficacy of the SAT in a large
1. Nunn JF: The oesophageal detector device. Anaesthesia 1988;43:804 2. O'Leary JJ, Pollard BJ, Ryan MJ: A method of detecting oesophageal intubation confirming tracheal intubation. Anaesth Intensive Care 1988;16:299-301 3. Petroianu GA, Maleck WH: Detection of an oesophageal intubation: "State of the art." Anaesth Intens Care 1994;22:744746 5. Wee MYK: The oesophageal detector device. Assessment of a new method to distinguish oesophageal intubation. Anaesthesia 1988;43:27-29 6. Bozeman W, Hexter D, Liang HK, et al: The oesophageal detector device versus end-tidal CO2 detection in emergency intubation. Acad Emerg Med 1994;1 :A77(abstr) 7. Jenkins WA, Verdile VP, Paris PM: The syringe aspiration technique to verify endotracheal tube position. Am J Emerg Med 1994;12:413-416 8. Wee MYK: The Oesophageal detector device. Anaesthesia 1988 ;43:27-29 9. Haynes SR, Morton NS: Use of the oesophageal detector device in children under one year of age. Anaesthesia 1990;45: 1067-1069 10. Zaleski L, Abello D, Gold MI: The oesophageal detector device. Does it work? Anesthesiology 1993;79:244-247 11. Morten NS, Stuart JC, Thomsom MF, et al: The oesophageal detector device: Successful use in children. Anaesthesia 1989 ;44:523-524 12. Goldberg JS, Rawle PR, Zehnder JL, et al: Colorimetric end-tidal carbon dioxide monitoring for tracheal intubation. Anesth Analg 1990;70:191-194 13. Ornato JP, Shipley JB, Racht EM, et al: Multi-center study of a portable hand size, colorimetric end-tidal carbon dioxide detection device. Ann Emerg Med 1992;21:518-523
EQUESTRIAN-RELATEDTRAUMA To the Editor:--ln the United States, equestrian activities are common. It is estimated that 30 million Americans ride horses each year, and approximately 80% of the 8.3 million horses owned in the United States are owned for recreational purposes. 1 Equestrianrelated injury is infrequently encountered on our trauma service, but it is not unusual. In fact, this form of injury may be significant in terms of health care cost, patient morbidity, and mortality. The object of this review was to determine the severity of injury, injury patterns, outcome, and hospital costs in patients with equestrianrelated injury admitted to a regional trauma center. A retrospective chart review augmented by a postdischarge phone survey of a seven-and-one-half-year trauma experience with equestrian-related injury was undertaken. The records of all patients admitted to the trauma service with equestrian-associated injury were reviewed. A concurrently maintained trauma register was used to provide additional information. Hospital costs were estimated at 64% of hospital charges, a number previously determined by outside audit for another reason. 2 A postdischarge telephone survey was conducted to determine these patients' outcomes in terms of recovery and disability, behavioral factors related to injuries, and whether or not behavior was