75: Primary Spontaneous Pneumothorax In the Emergency Department Observation Unit: Utility of the Mini Chest Drain

75: Primary Spontaneous Pneumothorax In the Emergency Department Observation Unit: Utility of the Mini Chest Drain

Research Forum Abstracts 72 A Randomized, Crossover Comparison of C-Mac Dblade, Glidescope, and Conventional Macintosh Laryngoscopy During Routine I...

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Research Forum Abstracts

72

A Randomized, Crossover Comparison of C-Mac Dblade, Glidescope, and Conventional Macintosh Laryngoscopy During Routine Induction of Anesthesia

Cavus E, Neumann T, Doerges V, Bein B, Serocki G/University Hospital Schleswig-Holstein Campus Kiel, Kiel, Germany

Study Objectives: The recently introduced C-MAC® dBlade (Karl Storz, Tuttlingen, Germany) is a new videolaryngoscope blade that adds to the existing CMAC system. The aim of the present study was to compare for the first time the CMAC® dBlade with the GlideScope videolaryngoscope, and conventional direct laryngoscopy during routine induction of anesthesia. Methods: After approval of the institutional review board and written informed consent, 33 patients (ASA I-III) of either sex (24 male) scheduled for routine surgery under general anesthesia, in whom tracheal intubation was mandatory (mean⫾SD [range] age 61⫾16 [18-85], weight 85⫾17 [52-144]), were randomly assigned in a crossover design to direct laryngoscopy with a Macintosh blade (DL group), to videolaryngoscopy with the GlideScope (GS group), or to videolaryngoscopy with the C-MAC dBlade (CM group). Results: With DL, GS, and CM, a Cormack-Lehane class (C/L) 1 view of the glottis was seen in 11, 28, and 30 patients, class 2a view in 10, 4, and 2, class 2b in 5, 1, and 1, class 3 in 6, 0, and 0, and class IV in 1, 0, 0 patients, respectively. In those patients with difficult conventional laryngoscopy (C/L III and IV; n⫽7), view improved with GS and CM to C/L I in 3 and 5 patients, and to C/L IIa in 4 and 2 patients, respectively. For every patient, the median time taken until optimal visualization of the glottis in the DL, GS, and CM groups was 13 sec (range, 4-27 sec), 11 sec (range, 7-18 sec), and 10 sec (range, 6-24 sec), respectively. The median time taken for tracheal intubation in the DL, GS, and CM groups was 9 sec (range, 5-17 sec; n⫽11), 17 sec (range, 9-29 sec; n⫽11), and 14 sec (range, 8-29 sec; n⫽10), respectively. Conclusions: Our preliminary data suggest that both C-MAC dBlade and GlideScope showed comparable visualization of the glottis and intubation success, but improved visualization of the glottis compared with conventional laryngoscopy.

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A Comparison of Successful Eschmann Introducer Placement Through Four Supraglottic Airway Devices

Mitchell C A, Riddle M L, Pearson NM, Tauferner D H/Carl R. Darnall Army Medical Center, Fort Hood, TX

Study Objectives: The aim of this study was to determine if emergency medicine providers could successfully place an Eschmann® tracheal tube introducer (bougie) through an LMA®, LMA Supreme®(LMA-S), I-gel®, or King LT® pharyngeal airway devices. Secondary outcomes evaluated were time to placement of the bougie and a survey of provider confidence that the bougie was correctly placed. We contended that there would be no difference in the time to place or correct bougie position among these 4 devices. Methods: This prospective study was performed by 14 emergency medicine providers, including 11 EM residents and 3 EM attending physicians, using a cadaveric model. All providers received a series of hands-on instruction on use of a bougie and each airway device. Each provider attempted placement of a bougie into the trachea through a proctor-positioned supraglottic airway device. Time to placement was collected and then placement of the bougie for each trial was verified via direct laryngoscopy after careful removal of the airway device. Finally, participants were surveyed on their level of confidence in proper bougie placement using a 5-point Likert scale. Successful placement between devices was compared using Fisher’s exact test. Time to placement and confidence in placement was evaluated using Wilcoxon’s matched-pairs signed-ranks test. Data was analyzed with GraphPad InStat 3. Results: The results of the study showed statistically significant variation in all three parameters (success, time, and confidence of placement). There was no statistical significance between the rates of bougie placement using the I-gel and the LMA Supreme (85.7% versus 92.8%, p-value 0.1527). The I-gel outperformed the King LT (85.7% versus 28.5% successful, p-value 0.0063). The LMA Supreme outperformed both the LMA (92.8% versus 50% successful, p-value 0.0329) and the King LT (92.8% versus 28.5%, p-value 0.0013). The only comparison showing significance in time was the I-gel versus the King LT (13.8 versus 19.3 seconds, pvalue 0.0338). There was no other significant difference in time to bougie placement among the 4 devices (range 13.8 to 19.9 seconds). There was also no significant

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variation in provider confidence in endotracheal bougie placement among the 4 devices, with most providers stating they “agreed” or “neither agreed nor disagreed.” No correlation was found between provider confidence and successful placement using regression analysis. Conclusions: Supraglottic devices are commonly used in the emergency department as rescue airway devices when endotracheal intubation is either not feasible or is unsuccessful. Prior studies have demonstrated that bougie placement through supraglottic devices may facilitate definitive airway placement. It is important to know which supraglottic devices have the best success rate for bougie placement so that the safe transition to a secure airway can occur. The emergency physicians in our study demonstrated that the LMA Supreme and the I-gel may be better choices than the LMA or King LT in which to attempt this maneuver. Additionally, as a caution, successful bougie placement was independent of provider confidence. This study was limited by the use of a cadaveric model.

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Primary Spontaneous Pneumothorax In the Emergency Department Observation Unit: Utility of the Mini Chest Drain

Kuan W, Heng J, Mahadevan M/National University Health System, Singapore, Singapore

Study Objectives: Patients with primary spontaneous pneumothorax (PSP) have been shown to be safely and efficiently managed in an emergency department observation unit (EDOU) for up to 24 hours with oxygen therapy only or after simple needle aspiration of their pneumothoraces. There has been scant data on the management of such patients in the EDOU after the insertion of a mini chest drain (Seldinger 12 French chest drain). This study aims to determine the feasibility and success rate of the mini chest drain in the management of PSP in the EDOU. Methods: The study involves a retrospective observational cohort of all patients age 16 years and above presenting with spontaneous pneumothorax to the emergency department (ED) from 1 January 2008 to 31 December 2008. Patients with traumatic pneumothorax and secondary pneumothorax were excluded from the study. Only patients who presented for the first time in 2008 were included. They were followed up for a period of 3 months to monitor for recurrent episodes. Results: 102 patients presented with PSP and recurrent spontaneous pneumothorax (RSP). The median age was 21 years. 93% were males. 80 patients (78%) had PSP. 40 patients (39%) were managed with the insertion of a mini chest drain. Of those 40 patients, 34 had PSP where 24 were admitted to the EDOU and the remaining 10 were admitted to the inpatient ward. 6 patients who had RSP were eventually admitted to the inpatient ward (including 2 patients initially admitted to the EDOU). Patients with PSP who had undergone a mini chest drain insertion were analyzed. There was no difference (p⫽0.33) between the mean volume of air aspirated from those admitted to the EDOU (1419.5mL; 95% CI, ⫾546.2mL) compared to those admitted to the inpatient ward (1707.5mL; 95% CI, ⫾688.1mL). 50% of patients were successfully discharged from the EDOU. A 37% decrease in the chest tube insertion rate was observed compared to the year before. In total, the success rate of mini chest drain insertion was 71% for PSP. Conclusion: The reduction in the absolute number of chest tube insertions in favor of mini chest drains translates into a decrease in morbidity for patients with PSP. It is safe and cost-effective. Managing patients with small to moderate-sized pneumothorax using the mini chest drain greatly improves the rate of successful discharge of patients from the EDOU. RSP patients with mini chest drain inserted are not suitable candidates for the EDOU as all were invariably admitted. (see table)

Annals of Emergency Medicine S25