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Papers by Michael Witting

The American Journal of Emergency Medicine, 2013

The axillary vein is an easily accessible vessel that can be used for ultrasound-guided central v... more The axillary vein is an easily accessible vessel that can be used for ultrasound-guided central vascular access and offers an alternative to the internal jugular and subclavian veins. The objective of this study was to identify which transducer orientation, longitudinal or transverse, is better for imaging the axillary vein with ultrasound. Methods: Emergency medicine physicians at an inner-city academic medical center were asked to cannulate the axillary vein in a torso phantom model. They were randomized to start with either the longitudinal or transverse approach and completed both sequentially. Participants answered questionnaires before and after the cannulation attempts. Measurements were taken regarding time to completion, success, skin punctures, needle redirections, and complications. Results: Fifty-seven operators with a median experience of 85 ultrasound procedures (interquartile range, 26-120) participated. The frequency of first-attempt success was 39 (0.69) of 57 for the longitudinal method and 21 (0.37) of 57 for the transverse method (difference, 0.32; 95% confidence interval [CI], 0.12-0.51 [P = .001]); this difference was similar regardless of operator experience. The longitudinal method was associated with fewer redirections (difference, 1.8; 95% CI, 0.8-2.7 [P = .0002]) and skin punctures (difference, 0.3; 95% CI, −2 to +0.7 [P = .07]). Arterial puncture occurred in 2 of 57 longitudinal and 7 of 57 transverse attempts; no pleural punctures occurred. For successful attempts, the time spent was 24 seconds less for the longitudinal method (95% CI, 3-45 [P = .02]). Conclusions: The longitudinal method of visualizing the axillary vein during ultrasound-guided venous access is associated with greater first-attempt success, fewer needle redirections, and a trend of fewer arterial punctures compared with the transverse orientation.

The Journal of Emergency Medicine, 2018

The Journal of Emergency Medicine, 2010

Background: Radiocontrast agents are some of the most commonly used medications in the emergency ... more Background: Radiocontrast agents are some of the most commonly used medications in the emergency department. However, both physicians and patients misunderstand the role that allergies play in reactions to radiocontrast media, especially with regards to shellfish and iodine. Objectives: We sought to review the literature describing rates of contrast reactions and risk of contrast administration to patients with iodine allergy, shellfish or seafood allergies, or prior reactions to intravenous iodinated contrast. Method: Both authors independently performed literature reviews, including position statements of stakeholder organizations, to gain perspective on important issues. They subsequently performed a systematic search for articles that estimated the risk of administration of iodinated contrast to those with a prior history of contrast reaction, "iodine allergy," or reaction to seafood or shellfish. Results: The risk of reactions to contrast ranges from 0.2-17%, depending on the type of contrast used, the severity of reaction considered, and the prior history of any allergy. The risk of reaction in patients with a seafood allergy is similar to that in patients with other food allergies or asthma. A history of prior reaction to contrast increases the risk of mild reactions to as high as 7-17%, but has not been shown to increase the rate of severe reactions. Severe reactions occur in 0.02-0.5% and deaths in 0.0006-0.006%; neither have been related to "iodine allergy," seafood allergy, or prior contrast reaction. Lowosmolality contrast media became available in 1988, and many of the higher risk estimates were from the era before it was widely available. Conclusions: Iodine is not an allergen. Atopy, in general, confers an increased risk of reaction to contrast administration, but the risk of contrast administration is low, even in patients with a history of "iodine allergy," seafood allergy, or prior contrast reaction. Allergies to shellfish, in particular, do not increase the risk of reaction to intravenous contrast any more that of other allergies.

The American Journal of Emergency Medicine

The Journal of emergency medicine, 2016

The easy internal jugular (Easy IJ) technique involves placement of a single-lumen catheter in th... more The easy internal jugular (Easy IJ) technique involves placement of a single-lumen catheter in the internal jugular vein using ultrasound guidance. This technique is used in patients who do not have suitable peripheral or external jugular venous access. The efficacy and safety of this procedure are unknown. We aimed to estimate efficacy and safety parameters for the Easy IJ when used in emergency department (ED) settings. We conducted a prospective study of the Easy IJ in stable ED patients with severe intravenous access difficulty. The study was conducted simultaneously at two academic EDs and a community university-affiliated ED. Patients were selected for failure of alternative access, hemodynamic stability, and ability to increase the IJ diameter with the Valsalva maneuver. Emergency physicians prepped the skin and inserted an 18-gauge, 4.8-cm catheter using a limited sterile technique. We collected the following data: patient body mass index, age, procedure time, pain score, in...

Resuscitation

High-quality chest compressions are a critical component of the resuscitation of patients in card... more High-quality chest compressions are a critical component of the resuscitation of patients in cardiopulmonary arrest. Point-of-care ultrasound (POCUS) is used frequently during emergency department (ED) resuscitations, but there has been limited research assessing its benefits and harms during the delivery of cardiopulmonary resuscitation (CPR). We hypothesized that use of POCUS during cardiac arrest resuscitation adversely affects high-quality CPR by lengthening the duration of pulse checks beyond the current cardiopulmonary resuscitation guidelines recommendation of 10s. We conducted a prospective cohort study of adults in cardiac arrest treated in an urban ED between August 2015 and September 2016. Resuscitations were recorded using video equipment in designated resuscitation rooms, and the use of POCUS was documented and timed. A linear mixed-effects model was used to estimate the effect of POCUS on pulse check duration. Twenty-three patients were enrolled in our study. The mean duration of pulse checks with POCUS was 21.0s (95% CI, 18-24) compared with 13.0s (95% CI, 12-15) for those without POCUS. POCUS increased the duration of pulse checks and CPR interruption by 8.4s (95% CI, 6.7-10.0 [p<0.0001]). Age, body mass index (BMI), and procedures did not significantly affect the duration of pulse checks. The use of POCUS during cardiac arrest resuscitation was associated with significantly increased duration of pulse checks, nearly doubling the 10-s maximum duration recommended in current guidelines. It is important for acute care providers to pay close attention to the duration of interruptions in the delivery of chest compressions when using POCUS during cardiac arrest resuscitation.

The Journal of Emergency Medicine

The need for advanced techniques for intravenous access (ATIVA) can lead to delays in care and co... more The need for advanced techniques for intravenous access (ATIVA) can lead to delays in care and contribute to emergency department (ED) crowding. In this article, we estimate the delay and predictors associated with the need for ATIVA. In this case-control study, we collected data from ED cases requiring ATIVA and control patients in whom i.v. access was gained by traditional inspection and palpation. We included two control groups-a random retrospective sample and a prospective limited convenience sample. We collected time and acuity data from all groups and data on predictor variables from cases and prospective controls. We analyzed time data using quartile regression and predictor variable data using contingency table analysis and logistic regression. We collected data from 116 cases (91 of which had time interval data), 98 retrospective controls, and 144 prospective controls. The median time from triage to i.v. line establishment was 199 min for cases vs. 64 min for prospective controls and 81 min for retrospective controls. The need for ATIVA was associated with a 1.1-greater quartile time interval (95% confidence interval [CI] 0.8-1.3). Two variables-i.v. drug use (IVDU; odds ratio 3.7; 95% CI 1.8-7.3) and prior need for ATIVA (odds ratio 5.2; 95% CI 2.7-9.8)-were associated with a need for ATIVA; obesity, renal failure, and diabetes were not. The need for ATIVA increases median time to i.v. line placement by 118 to 135 min compared with traditional inspection and palpation. IVDU and prior need for an advanced technique are associated with a need for ATIVA.

The American Journal of Emergency Medicine, Feb 1, 2008

We sought to determine the distribution of oximetry (SpO 2) values in awake, asymptomatic adults ... more We sought to determine the distribution of oximetry (SpO 2) values in awake, asymptomatic adults and the effect of personal characteristics on these values. Methods: Using a cross-sectional design, we sampled oximetry readings in awake, asymptomatic adults in an emergency department setting. Personal characteristics were analyzed using logistic regression, with lower oximetry readings, defined by the 20th percentile, as the dependent variable. Results: Of 871 eligible subjects, 50 (5.7%) had an SpO 2 value less than 97%, and 13 (1.5%) had an SpO 2 value less than 96%. Lower readings were associated with the following characteristics (odds ratio with 95% confidence interval): male sex, 3.8 (2.5-5.6); age ≥60 years, 2.4 (1.3-4.5); white race, 5.3 (3.6-7.8); obesity, 3.2 (2.1-4.8); history of asthma, 3.2 (1.6-6.2). Smoking was not associated with lower SpO 2 values. Conclusion: Room-air SpO 2 values less than 97% are rare in asymptomatic, awake adults. White race and male sex are associated with lower SpO 2 readings.

This study was designed to determine whether high room-air pulse oximetry can rule out hypoxemia ... more This study was designed to determine whether high room-air pulse oximetry can rule out hypoxemia or moderate hypercapnia. Based on retrospective analysis of 513 arterial blood gas results, oxygen saturation cutpoints were derived. Coincidentally, a room-air oxygen saturation (RAO 2 sat) value of 96% was selected as a cutpoint to screen for both hypoxemia (PaO 2 < 70 mm Hg) and moderate hypercapnia (PaCO 2 > 50 mm Hg). These tests were validated prospectively by using a convenience sample of 213 Emergency Department patients in whom room-air arterial blood gas sampling was ordered. To detect hypoxemia, the sensitivity of RAO 2 sat < 96% was 1.0 [0.95-1.0, 95% confidence interval (CI)] and specificity was 0.54 (0.45-0.64, 95% CI). To detect hypercapnia, the sensitivity of RAO 2 sat < 96% was 1.0 (0.7-1.0) and specificity was 0.31 (0.25-0.38, 95% CI). We concluded that RAO 2 sat > 97% rules out hypoxemia and may also rule out moderate hypercapnia.

The American Journal of Emergency Medicine, 2015

When an intravenous (IV) catheter is needed and the common approach of inspection and palpation f... more When an intravenous (IV) catheter is needed and the common approach of inspection and palpation fails, an advanced access technique becomes necessary. Our objectives were to estimate pain scores, operator times, success rates, and complication rates when advanced techniques are used in a clinical setting. We enrolled patients who had a need for advanced IV access and were able to give informed consent to participate in our study. We collected data on operator type, technique, initial success, number of attempts, skin punctures, operator time, pain scores, and complications. We estimated confidence intervals for proportions using normal binomial approximation or exact calculation. The registry documented 154 attempts in 116 patients. The median time from triage to establishment of an IV line was 203 minutes; multiple advanced attempts were required in 24% of cases. Most attempts (95%) used either ultrasound-guided cannulation of a peripheral vein (PUG) (108) or cannulated the external jugular vein (EJ) (38). These 2 methods yielded similar pain scores (4.3-4.5), but PUG required more skin punctures (1.6 vs 1.2) and longer operator time (17.7 vs 11.9 minutes). The only complication was IV line failure, occurring in 6% (95% confidence interval, 0%-18%) of EJ approaches and 27% (95% confidence interval, 18%-38%) of the PUG scenarios. Most attempts to establish IV access used PUG or the EJ. External jugular vein cannulation was achieved more quickly, with fewer skin punctures and a lower rate of postinsertion failure, than PUG.

Making Order Out of Chaos, 2015

The American Journal of Emergency Medicine, 2015

Guidelines from the American Academy of Neurology recommend laboratory studies or computed tomogr... more Guidelines from the American Academy of Neurology recommend laboratory studies or computed tomography (CT) for children who experience a nonfebrile seizure if anything in their history suggests a clinically significant abnormality. To ascertain if any patient or seizure characteristics are associated with a greater likelihood that laboratory studies or CT scan will yield clinically significant results. This retrospective case series reviewed 93 children with nonfebrile seizure, who were evaluated in an urban pediatric emergency department (ED) between July 2007 and June 2011. Laboratory studies were performed in 87% of the study group; 7% of those tests gave clinically significant results. Computed tomographic scans were obtained in 35% of our patients; 9% showed clinically significant findings. Presence of an active seizure in the ED or a first nonfebrile seizure had an 8% and 11% difference, respectively, for clinically significant laboratory abnormality. Children younger than 2 years showed a 7% difference of clinically significant laboratory abnormality. This study did not identify statistically significant predictors of laboratory or CT abnormalities for children with nonfebrile seizure presenting to the ED. Age less than 2years, having an active seizure in the ED, and experiencing a first-time seizure showed a trend toward an increased yield of laboratory testing. In accordance with the American Academy of Neurology guidelines, we conclude that the history of a child&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s present illness preceding the nonfebrile seizure, not characteristics of the seizure, should be used to determine the need for further testing.

The American Journal of Emergency Medicine, 2015

Infections with Neisseria gonorrhoeae (GC) and Chlamydia trachomatis (CT) are the most commonly r... more Infections with Neisseria gonorrhoeae (GC) and Chlamydia trachomatis (CT) are the most commonly reported sexually transmitted diseases in the United States. The primary objective of this study was to estimate the incidence of overtreatment of GC and CT infections in the emergency department (ED). The secondary objective was to determine if there are clinical variables that predict infection with GC and CT. A retrospective medical record review was performed at 2 inner-city hospitals. Records were obtained from the evaluation of female patients who presented to the ED between January 1, 2012, and December 31, 2012, who were tested for GC and CT infection. A standardized form was used to extract specific information from each medical record. Data were extracted from 538 medical records. Of the 522 ED visits, 32 (6%) yielded test results positive for either GC or CT, including 3 that were positive for both. Treatment was administered to 101 patients (19%) and declined by an additional 9 (2%). Of those receiving antibiotics, 87 of 101 (0.86; 95% confidence interval, 0.77-0.92) had negative test results. Of those not offered antibiotics, 17 of 412 (0.04; 95% confidence interval, 0.02-0.07) had positive test results. The overtreatment proportion was similar at hospitals (55/66 [0.83] and 32/35 [0.91], respectively). Of clinical variables that were considered, only age less than 19 years was statistically associated with a positive test result for GC and CT. The rate of overtreatment for GC and CT was 86%. The practice of empirical treatment should be reconsidered.

Resuscitation, 2014

The use of hands-on defibrillation (HOD) to reduce interruption of chest compression after cardia... more The use of hands-on defibrillation (HOD) to reduce interruption of chest compression after cardiac arrest has been suggested as a means of improving resuscitation outcomes. The potential dangers of this strategy in regard to exposing rescuers to electrical energy are still being debated. This study seeks to determine the plausible worst-case energy-transfer scenario that rescuers might encounter while performing routine resuscitative measures. Six cadavers were acquired and prepared for defibrillation. A custom instrumentation-amplifier circuit was built to measure differential voltages at various points on the bodies. Several skin preparations were used to determine the effects of contact resistance on our voltage measurements. Resistance and exposure voltage data were acquired for a representative number of anatomic landmarks and were used to map rescuers' voltage exposure. A formula for rescuer-received dose (RRD) was derived to represent the proportion of energy the rescuer ...

The American Journal of Emergency Medicine, 2015

In an emergency department (ED), intravenous (IV) access is frequently accomplished by inspection... more In an emergency department (ED), intravenous (IV) access is frequently accomplished by inspection and palpation of peripheral veins. Failure of these methods indicates severe IV access difficulty and necessitates advanced techniques. Here, we estimate the incidence of advanced IV access in 2 urban EDs with varying resident coverage. In this multiple-cohort study, we enrolled data from 2 neighboring urban EDs-a tertiary care ED and a community hospital affiliate. The 2 have similar volumes but the tertiary care ED has more resident coverage (112 vs 20 hours/d). In a prospective data collection (April 2012-2013), we enrolled consecutive patients during hours of scheduled shifts for research assistants. In a retrospective data collection (March 2011-2012), we reviewed charts of a random sample of patients from each ED for similar outcomes. We calculated the incidence of advanced IV access by dividing the number requiring advanced techniques by the number requiring IV access. We determined IV outcomes for 790 patients in the prospective cohort and 669 patients in the retrospective cohort. Between groups, there was no difference in the incidence of advanced IV access in the prospective collection (P = .08) or in the retrospective collection (P = .7). Pooling data from both cohorts and both hospitals, the overall incidence was 3.2 [95% confidence interval, 1.9-5.2] per 100 attempts. Advanced IV access is needed in 3.2% of IV attempts in 2 urban EDs with varying levels of resident coverage. We found similar incidence in both EDs.

Western Journal of Emergency Medicine, 2012

Introduction: Our goal was to evaluate patients' threshold for waiting in an emergency department... more Introduction: Our goal was to evaluate patients' threshold for waiting in an emergency department (ED) waiting room before leaving without being seen (LWBS). We analyzed whether willingness to wait was influenced by perceived illness severity, age, race, triage acuity level, or insurance status. Methods: We conducted this survey-based study from March to July 2010 at an urban academic medical center. After triage, patients were given a multiple-choice questionnaire, designed to ascertain how long they would wait for medical care. We collected data including age, gender, race, insurance status, and triage acuity level. We looked at the association between willingness to wait and these variables, using stratified analysis and logistic regression. Results: Of the 375 patients who were approached, 340 (91%) participated. One hundred seventyone (51%) were willing to wait up to 2 hours before leaving, 58 (17%) would wait 2 to 8 hours, and 110 (32%) would wait indefinitely. No association was found between willingness to wait and race, gender, insurance status, or perceived symptom severity. Patients willing to wait >2 hours tended to be older than 25, have higher acuity, and prefer the study site ED. Conclusion: Many patients have a defined, limited period that they are willing to wait for emergency care. In our study, 50% of patients were willing to wait up to 2 hours before leaving the ED without being seen. This result suggests that efforts to reduce the percentage of patients who LWBS must factor in time limits. [

Journal of critical care, Jan 16, 2015

tion for patients intubated in the ED. We believe the editorial misstates our main conclusion. We... more tion for patients intubated in the ED. We believe the editorial misstates our main conclusion. We primarily found that, in the subset of patients in whom the ARDS developed, initial tidal volumes were higher than the recommended tidal volume of 6 mL/kg of ideal body weight (IBW) [1]. Our study was not designed to show causality between higher initial ventilator settings and the subsequent development of ARDS. Rather, we selected the subset of patients in whom ARDS later developed because they are the patients in whom tidal volumes are felt to be most important. Lung-protective ventilation with a recommended tidal volume of 6 mL/kg has been commonly adopted for all comers since the And Respiratory Management in ARDS (ARMA) trial from the ARDS Network [1] .I n that prospective, randomized trial, the patients seeing a mortality benefit from lung-protective tidal volume ventilation were those who had ARDS. We therefore chose to look at this specific population by including only patients who developed ARDS within 48 hours after intubation. We sought to determine if the ED-initiated ventilator settings in this subset adhered to the goal of 6 mL/kg IBW and found that the volumes were set higher by approximately 1.5 mL/kg of IBW. Importantly, the assertion that the ARMA trial protocol called for an initial tidal volume of 8 mL/kg IBW is somewhat misleading. The protocol does call for an “initial” tidal volume of 8 mL/kg IBW but then states that this tidal volume “will be reduced by 1 mL/kg IBW at intervals of less than or equal to 2 hours until tidal volume equals to 6 mL/kg IBW,” at which point further adjustments would be made for acidosis, hypoxia, and plateau pressures. We did not findthat this titration occurredin our cohort. For patientswho were eventually ventilated at 6 mL/kg IBW, an average of 14 hours passed before they reached this goal. Furthermore, the same protocol states that the tidal volume could be increased above 6 mL/kg only in the setting of severe acidosis (pH b7.15) that persisted despite a respiratory rate of 35

Journal of critical care, Jan 18, 2014

Emergency department (ED) patients are at high risk for the acute respiratory distress syndrome (... more Emergency department (ED) patients are at high risk for the acute respiratory distress syndrome (ARDS). Settings only 1 mL/kg above recommended tidal volumes confers harm for these patients. The purpose of this study was to determine whether ED physicians routinely initiate mechanical ventilation with low tidal volumes in patients at risk for ARDS. We retrospectively reviewed the charts of all adult patients who were intubated in an urban, academic ED. The charts were analyzed to identify patients in whom ARDS developed within 48 hours after ED admission. Patients were eligible for inclusion if they had bilateral infiltrates on imaging, had a Pao2/Fio2 ratio less than 300 mm Hg and did not have heart failure contributing to their presentation. The tidal volumes set in the ED were then compared with the recommended tidal volume of 6 mL/kg of predicted body weight. The initial tidal volumes set in the ED were higher than recommended by an average of 80 mL (95% confidence interval, 60-...

The American Journal of Emergency Medicine, 2013

The axillary vein is an easily accessible vessel that can be used for ultrasound-guided central v... more The axillary vein is an easily accessible vessel that can be used for ultrasound-guided central vascular access and offers an alternative to the internal jugular and subclavian veins. The objective of this study was to identify which transducer orientation, longitudinal or transverse, is better for imaging the axillary vein with ultrasound. Methods: Emergency medicine physicians at an inner-city academic medical center were asked to cannulate the axillary vein in a torso phantom model. They were randomized to start with either the longitudinal or transverse approach and completed both sequentially. Participants answered questionnaires before and after the cannulation attempts. Measurements were taken regarding time to completion, success, skin punctures, needle redirections, and complications. Results: Fifty-seven operators with a median experience of 85 ultrasound procedures (interquartile range, 26-120) participated. The frequency of first-attempt success was 39 (0.69) of 57 for the longitudinal method and 21 (0.37) of 57 for the transverse method (difference, 0.32; 95% confidence interval [CI], 0.12-0.51 [P = .001]); this difference was similar regardless of operator experience. The longitudinal method was associated with fewer redirections (difference, 1.8; 95% CI, 0.8-2.7 [P = .0002]) and skin punctures (difference, 0.3; 95% CI, −2 to +0.7 [P = .07]). Arterial puncture occurred in 2 of 57 longitudinal and 7 of 57 transverse attempts; no pleural punctures occurred. For successful attempts, the time spent was 24 seconds less for the longitudinal method (95% CI, 3-45 [P = .02]). Conclusions: The longitudinal method of visualizing the axillary vein during ultrasound-guided venous access is associated with greater first-attempt success, fewer needle redirections, and a trend of fewer arterial punctures compared with the transverse orientation.

The Journal of Emergency Medicine, 2018

The Journal of Emergency Medicine, 2010

Background: Radiocontrast agents are some of the most commonly used medications in the emergency ... more Background: Radiocontrast agents are some of the most commonly used medications in the emergency department. However, both physicians and patients misunderstand the role that allergies play in reactions to radiocontrast media, especially with regards to shellfish and iodine. Objectives: We sought to review the literature describing rates of contrast reactions and risk of contrast administration to patients with iodine allergy, shellfish or seafood allergies, or prior reactions to intravenous iodinated contrast. Method: Both authors independently performed literature reviews, including position statements of stakeholder organizations, to gain perspective on important issues. They subsequently performed a systematic search for articles that estimated the risk of administration of iodinated contrast to those with a prior history of contrast reaction, "iodine allergy," or reaction to seafood or shellfish. Results: The risk of reactions to contrast ranges from 0.2-17%, depending on the type of contrast used, the severity of reaction considered, and the prior history of any allergy. The risk of reaction in patients with a seafood allergy is similar to that in patients with other food allergies or asthma. A history of prior reaction to contrast increases the risk of mild reactions to as high as 7-17%, but has not been shown to increase the rate of severe reactions. Severe reactions occur in 0.02-0.5% and deaths in 0.0006-0.006%; neither have been related to "iodine allergy," seafood allergy, or prior contrast reaction. Lowosmolality contrast media became available in 1988, and many of the higher risk estimates were from the era before it was widely available. Conclusions: Iodine is not an allergen. Atopy, in general, confers an increased risk of reaction to contrast administration, but the risk of contrast administration is low, even in patients with a history of "iodine allergy," seafood allergy, or prior contrast reaction. Allergies to shellfish, in particular, do not increase the risk of reaction to intravenous contrast any more that of other allergies.

The American Journal of Emergency Medicine

The Journal of emergency medicine, 2016

The easy internal jugular (Easy IJ) technique involves placement of a single-lumen catheter in th... more The easy internal jugular (Easy IJ) technique involves placement of a single-lumen catheter in the internal jugular vein using ultrasound guidance. This technique is used in patients who do not have suitable peripheral or external jugular venous access. The efficacy and safety of this procedure are unknown. We aimed to estimate efficacy and safety parameters for the Easy IJ when used in emergency department (ED) settings. We conducted a prospective study of the Easy IJ in stable ED patients with severe intravenous access difficulty. The study was conducted simultaneously at two academic EDs and a community university-affiliated ED. Patients were selected for failure of alternative access, hemodynamic stability, and ability to increase the IJ diameter with the Valsalva maneuver. Emergency physicians prepped the skin and inserted an 18-gauge, 4.8-cm catheter using a limited sterile technique. We collected the following data: patient body mass index, age, procedure time, pain score, in...

Resuscitation

High-quality chest compressions are a critical component of the resuscitation of patients in card... more High-quality chest compressions are a critical component of the resuscitation of patients in cardiopulmonary arrest. Point-of-care ultrasound (POCUS) is used frequently during emergency department (ED) resuscitations, but there has been limited research assessing its benefits and harms during the delivery of cardiopulmonary resuscitation (CPR). We hypothesized that use of POCUS during cardiac arrest resuscitation adversely affects high-quality CPR by lengthening the duration of pulse checks beyond the current cardiopulmonary resuscitation guidelines recommendation of 10s. We conducted a prospective cohort study of adults in cardiac arrest treated in an urban ED between August 2015 and September 2016. Resuscitations were recorded using video equipment in designated resuscitation rooms, and the use of POCUS was documented and timed. A linear mixed-effects model was used to estimate the effect of POCUS on pulse check duration. Twenty-three patients were enrolled in our study. The mean duration of pulse checks with POCUS was 21.0s (95% CI, 18-24) compared with 13.0s (95% CI, 12-15) for those without POCUS. POCUS increased the duration of pulse checks and CPR interruption by 8.4s (95% CI, 6.7-10.0 [p&lt;0.0001]). Age, body mass index (BMI), and procedures did not significantly affect the duration of pulse checks. The use of POCUS during cardiac arrest resuscitation was associated with significantly increased duration of pulse checks, nearly doubling the 10-s maximum duration recommended in current guidelines. It is important for acute care providers to pay close attention to the duration of interruptions in the delivery of chest compressions when using POCUS during cardiac arrest resuscitation.

The Journal of Emergency Medicine

The need for advanced techniques for intravenous access (ATIVA) can lead to delays in care and co... more The need for advanced techniques for intravenous access (ATIVA) can lead to delays in care and contribute to emergency department (ED) crowding. In this article, we estimate the delay and predictors associated with the need for ATIVA. In this case-control study, we collected data from ED cases requiring ATIVA and control patients in whom i.v. access was gained by traditional inspection and palpation. We included two control groups-a random retrospective sample and a prospective limited convenience sample. We collected time and acuity data from all groups and data on predictor variables from cases and prospective controls. We analyzed time data using quartile regression and predictor variable data using contingency table analysis and logistic regression. We collected data from 116 cases (91 of which had time interval data), 98 retrospective controls, and 144 prospective controls. The median time from triage to i.v. line establishment was 199 min for cases vs. 64 min for prospective controls and 81 min for retrospective controls. The need for ATIVA was associated with a 1.1-greater quartile time interval (95% confidence interval [CI] 0.8-1.3). Two variables-i.v. drug use (IVDU; odds ratio 3.7; 95% CI 1.8-7.3) and prior need for ATIVA (odds ratio 5.2; 95% CI 2.7-9.8)-were associated with a need for ATIVA; obesity, renal failure, and diabetes were not. The need for ATIVA increases median time to i.v. line placement by 118 to 135 min compared with traditional inspection and palpation. IVDU and prior need for an advanced technique are associated with a need for ATIVA.

The American Journal of Emergency Medicine, Feb 1, 2008

We sought to determine the distribution of oximetry (SpO 2) values in awake, asymptomatic adults ... more We sought to determine the distribution of oximetry (SpO 2) values in awake, asymptomatic adults and the effect of personal characteristics on these values. Methods: Using a cross-sectional design, we sampled oximetry readings in awake, asymptomatic adults in an emergency department setting. Personal characteristics were analyzed using logistic regression, with lower oximetry readings, defined by the 20th percentile, as the dependent variable. Results: Of 871 eligible subjects, 50 (5.7%) had an SpO 2 value less than 97%, and 13 (1.5%) had an SpO 2 value less than 96%. Lower readings were associated with the following characteristics (odds ratio with 95% confidence interval): male sex, 3.8 (2.5-5.6); age ≥60 years, 2.4 (1.3-4.5); white race, 5.3 (3.6-7.8); obesity, 3.2 (2.1-4.8); history of asthma, 3.2 (1.6-6.2). Smoking was not associated with lower SpO 2 values. Conclusion: Room-air SpO 2 values less than 97% are rare in asymptomatic, awake adults. White race and male sex are associated with lower SpO 2 readings.

This study was designed to determine whether high room-air pulse oximetry can rule out hypoxemia ... more This study was designed to determine whether high room-air pulse oximetry can rule out hypoxemia or moderate hypercapnia. Based on retrospective analysis of 513 arterial blood gas results, oxygen saturation cutpoints were derived. Coincidentally, a room-air oxygen saturation (RAO 2 sat) value of 96% was selected as a cutpoint to screen for both hypoxemia (PaO 2 < 70 mm Hg) and moderate hypercapnia (PaCO 2 > 50 mm Hg). These tests were validated prospectively by using a convenience sample of 213 Emergency Department patients in whom room-air arterial blood gas sampling was ordered. To detect hypoxemia, the sensitivity of RAO 2 sat < 96% was 1.0 [0.95-1.0, 95% confidence interval (CI)] and specificity was 0.54 (0.45-0.64, 95% CI). To detect hypercapnia, the sensitivity of RAO 2 sat < 96% was 1.0 (0.7-1.0) and specificity was 0.31 (0.25-0.38, 95% CI). We concluded that RAO 2 sat > 97% rules out hypoxemia and may also rule out moderate hypercapnia.

The American Journal of Emergency Medicine, 2015

When an intravenous (IV) catheter is needed and the common approach of inspection and palpation f... more When an intravenous (IV) catheter is needed and the common approach of inspection and palpation fails, an advanced access technique becomes necessary. Our objectives were to estimate pain scores, operator times, success rates, and complication rates when advanced techniques are used in a clinical setting. We enrolled patients who had a need for advanced IV access and were able to give informed consent to participate in our study. We collected data on operator type, technique, initial success, number of attempts, skin punctures, operator time, pain scores, and complications. We estimated confidence intervals for proportions using normal binomial approximation or exact calculation. The registry documented 154 attempts in 116 patients. The median time from triage to establishment of an IV line was 203 minutes; multiple advanced attempts were required in 24% of cases. Most attempts (95%) used either ultrasound-guided cannulation of a peripheral vein (PUG) (108) or cannulated the external jugular vein (EJ) (38). These 2 methods yielded similar pain scores (4.3-4.5), but PUG required more skin punctures (1.6 vs 1.2) and longer operator time (17.7 vs 11.9 minutes). The only complication was IV line failure, occurring in 6% (95% confidence interval, 0%-18%) of EJ approaches and 27% (95% confidence interval, 18%-38%) of the PUG scenarios. Most attempts to establish IV access used PUG or the EJ. External jugular vein cannulation was achieved more quickly, with fewer skin punctures and a lower rate of postinsertion failure, than PUG.

Making Order Out of Chaos, 2015

The American Journal of Emergency Medicine, 2015

Guidelines from the American Academy of Neurology recommend laboratory studies or computed tomogr... more Guidelines from the American Academy of Neurology recommend laboratory studies or computed tomography (CT) for children who experience a nonfebrile seizure if anything in their history suggests a clinically significant abnormality. To ascertain if any patient or seizure characteristics are associated with a greater likelihood that laboratory studies or CT scan will yield clinically significant results. This retrospective case series reviewed 93 children with nonfebrile seizure, who were evaluated in an urban pediatric emergency department (ED) between July 2007 and June 2011. Laboratory studies were performed in 87% of the study group; 7% of those tests gave clinically significant results. Computed tomographic scans were obtained in 35% of our patients; 9% showed clinically significant findings. Presence of an active seizure in the ED or a first nonfebrile seizure had an 8% and 11% difference, respectively, for clinically significant laboratory abnormality. Children younger than 2 years showed a 7% difference of clinically significant laboratory abnormality. This study did not identify statistically significant predictors of laboratory or CT abnormalities for children with nonfebrile seizure presenting to the ED. Age less than 2years, having an active seizure in the ED, and experiencing a first-time seizure showed a trend toward an increased yield of laboratory testing. In accordance with the American Academy of Neurology guidelines, we conclude that the history of a child&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s present illness preceding the nonfebrile seizure, not characteristics of the seizure, should be used to determine the need for further testing.

The American Journal of Emergency Medicine, 2015

Infections with Neisseria gonorrhoeae (GC) and Chlamydia trachomatis (CT) are the most commonly r... more Infections with Neisseria gonorrhoeae (GC) and Chlamydia trachomatis (CT) are the most commonly reported sexually transmitted diseases in the United States. The primary objective of this study was to estimate the incidence of overtreatment of GC and CT infections in the emergency department (ED). The secondary objective was to determine if there are clinical variables that predict infection with GC and CT. A retrospective medical record review was performed at 2 inner-city hospitals. Records were obtained from the evaluation of female patients who presented to the ED between January 1, 2012, and December 31, 2012, who were tested for GC and CT infection. A standardized form was used to extract specific information from each medical record. Data were extracted from 538 medical records. Of the 522 ED visits, 32 (6%) yielded test results positive for either GC or CT, including 3 that were positive for both. Treatment was administered to 101 patients (19%) and declined by an additional 9 (2%). Of those receiving antibiotics, 87 of 101 (0.86; 95% confidence interval, 0.77-0.92) had negative test results. Of those not offered antibiotics, 17 of 412 (0.04; 95% confidence interval, 0.02-0.07) had positive test results. The overtreatment proportion was similar at hospitals (55/66 [0.83] and 32/35 [0.91], respectively). Of clinical variables that were considered, only age less than 19 years was statistically associated with a positive test result for GC and CT. The rate of overtreatment for GC and CT was 86%. The practice of empirical treatment should be reconsidered.

Resuscitation, 2014

The use of hands-on defibrillation (HOD) to reduce interruption of chest compression after cardia... more The use of hands-on defibrillation (HOD) to reduce interruption of chest compression after cardiac arrest has been suggested as a means of improving resuscitation outcomes. The potential dangers of this strategy in regard to exposing rescuers to electrical energy are still being debated. This study seeks to determine the plausible worst-case energy-transfer scenario that rescuers might encounter while performing routine resuscitative measures. Six cadavers were acquired and prepared for defibrillation. A custom instrumentation-amplifier circuit was built to measure differential voltages at various points on the bodies. Several skin preparations were used to determine the effects of contact resistance on our voltage measurements. Resistance and exposure voltage data were acquired for a representative number of anatomic landmarks and were used to map rescuers' voltage exposure. A formula for rescuer-received dose (RRD) was derived to represent the proportion of energy the rescuer ...

The American Journal of Emergency Medicine, 2015

In an emergency department (ED), intravenous (IV) access is frequently accomplished by inspection... more In an emergency department (ED), intravenous (IV) access is frequently accomplished by inspection and palpation of peripheral veins. Failure of these methods indicates severe IV access difficulty and necessitates advanced techniques. Here, we estimate the incidence of advanced IV access in 2 urban EDs with varying resident coverage. In this multiple-cohort study, we enrolled data from 2 neighboring urban EDs-a tertiary care ED and a community hospital affiliate. The 2 have similar volumes but the tertiary care ED has more resident coverage (112 vs 20 hours/d). In a prospective data collection (April 2012-2013), we enrolled consecutive patients during hours of scheduled shifts for research assistants. In a retrospective data collection (March 2011-2012), we reviewed charts of a random sample of patients from each ED for similar outcomes. We calculated the incidence of advanced IV access by dividing the number requiring advanced techniques by the number requiring IV access. We determined IV outcomes for 790 patients in the prospective cohort and 669 patients in the retrospective cohort. Between groups, there was no difference in the incidence of advanced IV access in the prospective collection (P = .08) or in the retrospective collection (P = .7). Pooling data from both cohorts and both hospitals, the overall incidence was 3.2 [95% confidence interval, 1.9-5.2] per 100 attempts. Advanced IV access is needed in 3.2% of IV attempts in 2 urban EDs with varying levels of resident coverage. We found similar incidence in both EDs.

Western Journal of Emergency Medicine, 2012

Introduction: Our goal was to evaluate patients' threshold for waiting in an emergency department... more Introduction: Our goal was to evaluate patients' threshold for waiting in an emergency department (ED) waiting room before leaving without being seen (LWBS). We analyzed whether willingness to wait was influenced by perceived illness severity, age, race, triage acuity level, or insurance status. Methods: We conducted this survey-based study from March to July 2010 at an urban academic medical center. After triage, patients were given a multiple-choice questionnaire, designed to ascertain how long they would wait for medical care. We collected data including age, gender, race, insurance status, and triage acuity level. We looked at the association between willingness to wait and these variables, using stratified analysis and logistic regression. Results: Of the 375 patients who were approached, 340 (91%) participated. One hundred seventyone (51%) were willing to wait up to 2 hours before leaving, 58 (17%) would wait 2 to 8 hours, and 110 (32%) would wait indefinitely. No association was found between willingness to wait and race, gender, insurance status, or perceived symptom severity. Patients willing to wait >2 hours tended to be older than 25, have higher acuity, and prefer the study site ED. Conclusion: Many patients have a defined, limited period that they are willing to wait for emergency care. In our study, 50% of patients were willing to wait up to 2 hours before leaving the ED without being seen. This result suggests that efforts to reduce the percentage of patients who LWBS must factor in time limits. [

Journal of critical care, Jan 16, 2015

tion for patients intubated in the ED. We believe the editorial misstates our main conclusion. We... more tion for patients intubated in the ED. We believe the editorial misstates our main conclusion. We primarily found that, in the subset of patients in whom the ARDS developed, initial tidal volumes were higher than the recommended tidal volume of 6 mL/kg of ideal body weight (IBW) [1]. Our study was not designed to show causality between higher initial ventilator settings and the subsequent development of ARDS. Rather, we selected the subset of patients in whom ARDS later developed because they are the patients in whom tidal volumes are felt to be most important. Lung-protective ventilation with a recommended tidal volume of 6 mL/kg has been commonly adopted for all comers since the And Respiratory Management in ARDS (ARMA) trial from the ARDS Network [1] .I n that prospective, randomized trial, the patients seeing a mortality benefit from lung-protective tidal volume ventilation were those who had ARDS. We therefore chose to look at this specific population by including only patients who developed ARDS within 48 hours after intubation. We sought to determine if the ED-initiated ventilator settings in this subset adhered to the goal of 6 mL/kg IBW and found that the volumes were set higher by approximately 1.5 mL/kg of IBW. Importantly, the assertion that the ARMA trial protocol called for an initial tidal volume of 8 mL/kg IBW is somewhat misleading. The protocol does call for an “initial” tidal volume of 8 mL/kg IBW but then states that this tidal volume “will be reduced by 1 mL/kg IBW at intervals of less than or equal to 2 hours until tidal volume equals to 6 mL/kg IBW,” at which point further adjustments would be made for acidosis, hypoxia, and plateau pressures. We did not findthat this titration occurredin our cohort. For patientswho were eventually ventilated at 6 mL/kg IBW, an average of 14 hours passed before they reached this goal. Furthermore, the same protocol states that the tidal volume could be increased above 6 mL/kg only in the setting of severe acidosis (pH b7.15) that persisted despite a respiratory rate of 35

Journal of critical care, Jan 18, 2014

Emergency department (ED) patients are at high risk for the acute respiratory distress syndrome (... more Emergency department (ED) patients are at high risk for the acute respiratory distress syndrome (ARDS). Settings only 1 mL/kg above recommended tidal volumes confers harm for these patients. The purpose of this study was to determine whether ED physicians routinely initiate mechanical ventilation with low tidal volumes in patients at risk for ARDS. We retrospectively reviewed the charts of all adult patients who were intubated in an urban, academic ED. The charts were analyzed to identify patients in whom ARDS developed within 48 hours after ED admission. Patients were eligible for inclusion if they had bilateral infiltrates on imaging, had a Pao2/Fio2 ratio less than 300 mm Hg and did not have heart failure contributing to their presentation. The tidal volumes set in the ED were then compared with the recommended tidal volume of 6 mL/kg of predicted body weight. The initial tidal volumes set in the ED were higher than recommended by an average of 80 mL (95% confidence interval, 60-...