The effectiveness of a short training course for emergency medicine residents to confirm tracheal tube placement by ultrasound


Objective: The present study aimed to evaluate the performance of tracheal ultrasound by novice emergency medicine residents after participating in a short training course.

Methods: This was an observational prospective study conducted between July 2016 and September 2017 at three university-affiliated emergency departments in Tehran, Iran. Adult patients (over 18 years of age) who needed emergency intubation were included. Investigators were emergency medicine residents who did not have prior experience in tracheal ultrasound. Training course consisted of 40 minutes of theoretical education and three days of hands-on training. Immediately after intubation by treating physicians, two investigators evaluated the placement of the tracheal tube simultaneously. One investigator used tracheal ultrasound and the second investigator used quantitative waveform capnography. The registrant was a nurse who was asked to record the results of each investigator in the following format: 1. Correct tracheal intubation, 2. Esophageal intubation, and 3. Time spent to complete the evaluation. Finally, the ultrasound results were compared with those of capnography.

Results: Ninety patients were included in the study. Based on the capnography results, there were three (3.3%) esophageal intubations and 87 (96.6%) tracheal intubations.  Investigators reported the same results by tracheal ultrasound. The mean±SD time spent to complete the evaluation was 32±10 seconds for capnography and 48±15 seconds for tracheal ultrasound (p value of 0.0001).Conclusion: Emergency medicine residents with basic knowledge of ultrasound can learn tracheal ultrasound techniques through a short training course.

Authors: Mohammad Afzalimoghaddam, Kamal Basiri, Seyedhossein Seyedhosseini-Dvarani, Farideh Bagheri, Ehsan Karimialavijeh

Fatal neck necrotizing fasciitis caused by hypermucoviscous Klebsiella pneumoniae


Klebsiella pneumoniae is a gram-negative rod enterobacteria that is notorious for its role as carrier of extended spectrum beta-lactamase (ESBL) and its carbapenem resistant Enterobacteriaceae (CRE) species. However, hypermucoviscous Klebsiella pneumoniae is distinctly different from ESBL and CRE. We report a case of neck necrotizing fasciitis caused by hypermucoviscous Klebsiella pneumoniae in a 56-year-old male who presented to our emergency department (ED) with a swollen neck. His condition deteriorated rapidly requiring emergency intubation to secure his airway. Despite aggressive resuscitation and treatment with broad spectrum antibiotics and cytokine adsorption therapy, the patient succumbed to his disease. This report describes the clinical characteristics of hypermucoviscous Klebsiella pneumoniae and emphasizes the importance of early detection and subsequent aggressive source control interventions in necrotizing fascitiis caused by this particular bacteria.

Authors: U Wen Yeap

Delirium in critically ill patients: incidence, risk factors and outcomes


Objective: To determine the incidence, and evaluate the risk factors and outcomes of delirium in general Intensive Care Unit (ICU).

Design: Prospective cross-sectional observational study.

Setting: Teaching hospital in Kuala Lumpur, Malaysia.

Patients and participants: Patients ages of 18 and above admitted for more than 24 hours in general ICU were recruited into the study.

Measurements and results:The demographic data, predisposing and precipitating factors, and environmental factors were collected. Confusional Assessment Method (CAM-ICU) was done daily to assess delirium, when the patient had a sedation score of above Richmond Agitation and Sedation Scale (RASS) -3. Patients were followed up till discharged from ICU. Length of mechanical ventilation and length of ICU stay were recorded.

A total of 139 patients were recruited with overall incidence of delirium was 42%. Among patients who had delirium, 68% were of hypoactive delirium, 25% of mixed delirium and 7% were hyperactive delirium. The significant predisposing risk factors for developing delirium were age, higher Acute Physiology and Chronic Health Evaluation II (APACHE II) scores, visual or hearing impairment, smoking, renal impairment, diabetes, and hypertension. The factors detected precipitating delirium were sepsis, use of vasopressors, renal replacement therapies, and acute respiratory distress syndrome (ARDS). The presence of catheters, higher Sequential Organ Failure Assessment (SOFA) scores, and abnormal urea and bilirubin levels further significantly increased risk of delirium. Environmental conditions increasing the risk of delirium included absence of daylight exposure and visible clocks, and use of physical restraints. As a result of delirium, patients had longer length of mechanical ventilation and ICU stay.Conclusions: Recognizing predisposing factors and optimizing the modifiable risk factors will improve the length of mechanical ventilation and ICU stay.

Authors: Lavitha Vyveganathan, Azarinah Izaham, Wan Rahiza Wan Mat, Shereen Tang Suet Peng, Raha Abdul Rahman, Norsidah Abdul Manap

Dispatcher-assisted cardiopulmonary resuscitation improves the neurological outcomes of out-of-hospital cardiac arrest victims: a retrospective analysis of prehospitalisation records in Kumamoto City


Background: Dispatcher-assisted cardiopulmonary resuscitation (DA-CPR) is an effective tool for improving the outcome of out-of-hospital cardiac arrest (OHCA) by providing dispatcher assistance (DA) to bystander cardiopulmonary resuscitation (BCPR) and public access defibrillators (PAD). However, it is unclear whether DA-CPR improves the neurological outcomes of OHCA. In this study, we assessed the effectiveness of DA-CPR using prehospitalisation records in Kumamoto City (Japan), which has a population of 730,000, an area of 390 km2, and 25 ambulances. The DA-CPR protocol in Kumamoto City commenced in 2014.

Methods: We retrospectively analysed the prehospitalisation records in Kumamoto City between 2014 and 2016. The cases were divided into two groups according to whether they received DA: DA group and non-DA group. The BCPR and PAD rates were compared between the two groups. The neurological outcomes (Glasgow–Pittsburgh cerebral performance category 1–2) were compared between the two groups by propensity score analysis with inverse probability of treatment weighting.

Results: A total of 1607 prehospitalisation records were identified and divided into the DA (n=1132) and non-DA (n=474) groups. BCPR (72% vs 17%, p<0.001) and PAD (11% vs 5%, p<0.001) rates were greater in the DA group. Propensity score analysis showed that the neurological outcome was significantly better in the DA group (odds ratio 1.718; 95% confidence interval: 1.017-2.902; p=0.0431).Conclusions: DA-CPR was associated with improved BCPR, PAD, and neurological outcomes of OHCA in this analysis of prehospitalisation cases in Kumamoto City.

Authors: Tadashi Kaneko, Hiromichi Tanaka, Keiji Uezono, Ryuichi Karashima, Shinsuke Iwashita, Hiroki Irie, Kazuo Nishioka, Shunji Kasaoka

The successful treatment of severe aspiration pneumonitis with the combination of hydrocortisone, ascorbic acid and thiamine


Aspiration pneumonitis is a neutrophil mediated inflammatory pneumonitis following the aspiration of regurgitated gastric contents. This syndrome occurs most commonly in patients with depressed levels of consciousness such as drug overdose, seizures, and during anesthesia. Aspiration pneumonitis is the most common cause of anesthesia-related deaths. Aspiration pneumonitis may be clinically silent or present as severe acute lung injury (ARDS) progressing to death. The treatment of acid aspiration pneumonitis is largely supportive. We present two cases of severe life threatening ARDS due to acid aspiration who were treated with the combination of hydrocortisone, ascorbic acid, and thiamine (HAT) and made a dramatic recovery. This treatment strategy should be considered in the management of patients with aspiration pneumonitis.

Authors: Margot M. Gurganus, Paul E. Marik, Joseph Varon

The accuracy of SIRS criteria, qSOFA and SOFA for mortality suspected sepsis patient admitted to the Intensive Care Unit Dr. Hasan Sadikin General Hospital Bandung, January-December 2017


Objective: The high mortality rate found on infectious patients in the intensive care unit (ICU) calls for sepsis identification tools. Sepsis consensus introduced Systemic Inflammatory Response Syndrome (SIRS) criteria, quick Sequential Organ Failure Assessment (qSOFA) score, and Sequential Organ Failure Assessment (SOFA) score. This study aimed at comparing the accuracy and quality to discriminate among the SIRS, qSOFA score, and SOFA score for predicting mortality among patients at risk of sepsis admitted to the ICU.

Design: This study used the analytic observational method with retrospective cohort approach to a sample of 73 qualified medical record data. The data regarding the SIRS, qSOFA, and SOFA criteria were applied after 24 hours of ICU admission.

Setting: ICU of Dr. Hasan Sadikin General Hospital, Bandung from January to December 2017.

Measurements and results: The results of this study showed the SOFA score as being the most accurate and having a good quality to discriminate, with the value of area under the receiver operating characteristic (AUROC) 0.866 (95% CI 0.782-0.95; p=0.00); the qSOFA score had AUROC of 0.707 (95% CI 0.588-0.826; p=0.002) while SIRS criteria were not significant.Conclusions: The conclusion of this study is that in patients with suspected sepsis admitted to an ICU, the SOFA score is the most accurate to predict mortality, whereas qSOFA could be considered and the SIRS criteria is not recommended.

Authors: Tinni T. Maskoen, LS Philip, Indriasari, I. Fuadi

Prediction of optimal right internal jugular vein catheter depth: comparison between Peres’ formula and intracavitary ECG


Background: Incorrect central venous catheter (CVC) placement can lead to serious complications. In order to prevent complications, CVC insertion depth can be predicted using Peres’ formula or intracavitary electrocardiography (ECG). The accurate prediction of optimal CVC depth using Peres’ formula and intracavitary ECG on Malay race is unknown.

Objective: To compare the accuracy of Peres’ formula and intracavitary ECG in predicting the optimal depth of right internal jugular venous catheter on adult Malay race.

Methods: This was a comparative analytic observational study with cross sectional design conducted at Cipto Mangunkusumo National General Hospital Jakarta from May to July 2017. After obtaining approval from the local ethical committee, right internal jugular venous catheter insertion was attempted on 111 patients, but 7 subjects were excluded from the study. Statistical analysis was performed on 104 samples to determine the accuracy of CVC depth prediction based on Peres’ formula and intracavitary ECG using McNemar’s test. The CVC depth prediction formula in adult Malay subject was calculated using linear regression based on its correlation with age, height, and body weight.

Results: The accuracy of intracavitary ECG and Peres’ formula to predict the optimal depth of right internal jugular venous catheter was 75% and 11.5%, respectively. The difference between the accuracy of these two methods was statistically significant (p=0.001). Correlation analysis showed a significant relationship between height and the optimal depth of right internal jugular vein catheter. The CVC depth prediction formula obtained in this study was 4.143 + (0.058 x height in cm).Conclusion: Prediction of right internal jugular venous catheter depth using intracavitary ECG is more accurate than the Peres’ formula.

Authors: Aida Rosita Tantri, Aldy Heriwardito, Hana Nur Ramila