BACKGROUND:Recent trends in emergency airway management encourage longer periods of suction, and the use of more powerful suction devices. Whether the intensity of oropharyngeal suction during laryngoscopy causes more rapid desaturation is unknown. STUDY OBJECTIVE:This study aimed to determine whether longer duration of suction leads to more significant desaturation in Emergency Department patients undergoing Rapid Sequence Intubation (RSI). METHODS:A multicenter pilot randomized controlled trial was conducted at 3 academic tertiary care level 1 trauma centers. Emergency Department patients undergoing RSI and laryngoscopy were randomized to either as needed suction or constant suction. The primary outcome was the decrease in oxygen saturation from the time the laryngoscope blade entered the mouth until endotracheal tube confirmation. RESULTS:A total of 76 patients were enrolled (37 in as needed suction, 39 in constant suction). The median absolute drop in saturation was 0% (IQR 0-1) in the as needed suction group and also 0% (IQR 0-0) in the constant group (p = 0.321). CONCLUSION:The study found that constant suctioning during Emergency Department laryngoscopy facilitated by RSI does not cause more rapid desaturation compared to as needed suctioning. However, the reliability of these results is limited by the small sample size and convenience sampling which likely skewed the cohort to patients less likely to develop hypoxia. Further studies are needed to confirm these findings and their implications for emergency airway management.

Study ObjectivesThis study asks whether the use of red lights and sirens while transporting patients identified as out-of-hospital 'sepsis alerts' impacts the time to antibiotic administration. Emergency Medical Services (EMS) personnel use emergent transport—characterized by the use of red lights and sirens (RLS)—for those patients deemed 'critical' or in need of potentially life-saving interventions beyond the scope of the interventions available in the out-of-hospital scenario. Nationally, the use of RLS saves ∼90 seconds in urban EMS settings, which may be the difference between life and death in a cardiac arrest, traumatic hemorrhage or airway emergency. However, the decision to transport with RLS is often at the discretion of the EMS personnel without formal guidelines or evidence-based recommendations. Emergent transport is associated with increased risk of motor vehicle collision (MVC), injuries to EMS personnel and/or patients and property damage. Additionally, RLS in transport may detrimentally impact the patient's physiological and psychologic response to EMS transport. Sepsis is a life-threatening systemic response to infection, leading to shock or death if not treated with antibiotics. After receiving initial resuscitation in the field, it is common for 'sepsis alert' patients to be transported to the hospital emergently with the use of red lights and sirens (RLS). Upon arrival to the hospital, antibiotics may not be given for prolonged periods of time. Out-of-hospital antibiotic administration has shown little to no difference in patient outcomes either. These findings question the value of emergent transport of out-of-hospital sepsis alert patients, particularly when patients transported with lights and sirens have ∼2.4 times higher risk of MVC.MethodsThis is a prospective, non-randomized controlled trial evaluating the clinical impact of emergent transport for patients identified as out-of-hospital sepsis alerts and transported by the Sarasota County Fire Department (SCFD) using either RLS on even days or no RLS on odd days. The time to antibiotic administration was analyzed by the priority of transport. Absolute time to antibiotic administration was calculated in minutes and analyzed using two-tailed T-tests in Excel and SPSS. Patients who tested positive for COVID-19 were removed from the data analysis.ResultsData collection ran from May to October of 2021, with an total sample of 709 patients identified as out-of-hospital sepsis alerts. Preliminary data from June to July 2021 showed an average time to antibiotic administration of 112 minutes for emergent versus 125 minutes for non-emergent (n = 84; p-value = 0.448). The average difference in transport time between emergent and non-emergent transports was only 91 seconds.ConclusionThere was a marked but non-significant difference in time to antibiotic administration for patients identified as out-of-hospital sepsis alerts and transported with or without RLS in our preliminary analysis. This difference cannot be explained by the time saved using emergent transport. Regional prevalence of COVID-19 cases during the study may have increased the variability in time to antibiotic administration. The absolute time of transport cannot account for the observed difference in time to antibiotic administration and hints that other variables determine the expediency of care for out-of-hospital sepsis alerts seen in the emergency department.No, authors do not have interests to disclose Study ObjectivesThis study asks whether the use of red lights and sirens while transporting patients identified as out-of-hospital 'sepsis alerts' impacts the time to antibiotic administration. Emergency Medical Services (EMS) personnel use emergent transport—characterized by the use of red lights and sirens (RLS)—for those patients deemed 'critical' or in need of potentially life-saving interventions beyond the scope of the interventions available in the out-of-hospital scenario. Nationally, the use of RLS saves ∼90 seconds in urban EMS settings, which may be the difference between life and death in a cardiac arrest, traumatic hemorrhage or airway emergency. However, the decision to transport with RLS is often at the discretion of the EMS personnel without formal guidelines or evidence-based recommendations. Emergent transport is associated with increased risk of motor vehicle collision (MVC), injuries to EMS personnel and/or patients and property damage. Additionally, RLS in transport may detrimentally impact the patient's physiological and psychologic response to EMS transport. Sepsis is a life-threatening systemic response to infection, leading to shock or death if not treated with antibiotics. After receiving initial resuscitation in the field, it is common for 'sepsis alert' patients to be transported to the hospital emergently with the use of red lights and sirens (RLS). Upon arrival to the hospital, antibiotics may not be given for prolonged periods of time. Out-of-hospital antibiotic administration has shown little to no difference in patient outcomes either. These findings question the value of emergent transport of out-of-hospital sepsis alert patients, particularly when patients transported with lights and sirens have ∼2.4 times higher risk of MVC. This study asks whether the use of red lights and sirens while transporting patients identified as out-of-hospital 'sepsis alerts' impacts the time to antibiotic administration. Emergency Medical Services (EMS) personnel use emergent transport—characterized by the use of red lights and sirens (RLS)—for those patients deemed 'critical' or in need of potentially life-saving interventions beyond the scope of the interventions available in the out-of-hospital scenario. Nationally, the use of RLS saves ∼90 seconds in urban EMS settings, which may be the difference between life and death in a cardiac arrest, traumatic hemorrhage or airway emergency. However, the decision to transport with RLS is often at the discretion of the EMS personnel without formal guidelines or evidence-based recommendations. Emergent transport is associated with increased risk of motor vehicle collision (MVC), injuries to EMS personnel and/or patients and property damage. Additionally, RLS in transport may detrimentally impact the patient's physiological and psychologic response to EMS transport. Sepsis is a life-threatening systemic response to infection, leading to shock or death if not treated with antibiotics. After receiving initial resuscitation in the field, it is common for 'sepsis alert' patients to be transported to the hospital emergently with the use of red lights and sirens (RLS). Upon arrival to the hospital, antibiotics may not be given for prolonged periods of time. Out-of-hospital antibiotic administration has shown little to no difference in patient outcomes either. These findings question the value of emergent transport of out-of-hospital sepsis alert patients, particularly when patients transported with lights and sirens have ∼2.4 times higher risk of MVC. MethodsThis is a prospective, non-randomized controlled trial evaluating the clinical impact of emergent transport for patients identified as out-of-hospital sepsis alerts and transported by the Sarasota County Fire Department (SCFD) using either RLS on even days or no RLS on odd days. The time to antibiotic administration was analyzed by the priority of transport. Absolute time to antibiotic administration was calculated in minutes and analyzed using two-tailed T-tests in Excel and SPSS. Patients who tested positive for COVID-19 were removed from the data analysis. This is a prospective, non-randomized controlled trial evaluating the clinical impact of emergent transport for patients identified as out-of-hospital sepsis alerts and transported by the Sarasota County Fire Department (SCFD) using either RLS on even days or no RLS on odd days. The time to antibiotic administration was analyzed by the priority of transport. Absolute time to antibiotic administration was calculated in minutes and analyzed using two-tailed T-tests in Excel and SPSS. Patients who tested positive for COVID-19 were removed from the data analysis. ResultsData collection ran from May to October of 2021, with an total sample of 709 patients identified as out-of-hospital sepsis alerts. Preliminary data from June to July 2021 showed an average time to antibiotic administration of 112 minutes for emergent versus 125 minutes for non-emergent (n = 84; p-value = 0.448). The average difference in transport time between emergent and non-emergent transports was only 91 seconds. Data collection ran from May to October of 2021, with an total sample of 709 patients identified as out-of-hospital sepsis alerts. Preliminary data from June to July 2021 showed an average time to antibiotic administration of 112 minutes for emergent versus 125 minutes for non-emergent (n = 84; p-value = 0.448). The average difference in transport time between emergent and non-emergent transports was only 91 seconds. ConclusionThere was a marked but non-significant difference in time to antibiotic administration for patients identified as out-of-hospital sepsis alerts and transported with or without RLS in our preliminary analysis. This difference cannot be explained by the time saved using emergent transport. Regional prevalence of COVID-19 cases during the study may have increased the variability in time to antibiotic administration. The absolute time of transport cannot account for the observed difference in time to antibiotic administration and hints that other variables determine the expediency of care for out-of-hospital sepsis alerts seen in the emergency department.No, authors do not have interests to disclose There was a marked but non-significant difference in time to antibiotic administration for patients identified as out-of-hospital sepsis alerts and transported with or without RLS in our preliminary analysis. This difference cannot be explained by the time saved using emergent transport. Regional prevalence of COVID-19 cases during the study may have increased the variability in time to antibiotic administration. The absolute time of transport cannot account for the observed difference in time to antibiotic administration and hints that other variables determine the expediency of care for out-of-hospital sepsis alerts seen in the emergency department.

INTRODUCTION:Prior to intubation, preoxygenation is performed to denitrogenate the lungs and create an oxygen reservoir. After oxygen is removed, it is unclear whether renitrogenation after preoxygenation occurs faster in the supine vs the sitting position.METHODS:We enrolled 80 healthy volunteers who underwent two preoxygenation and loss of preoxygenation procedures (one while supine and one while sitting) via bag-valve-mask ventilation with spontaneous breathing. End-tidal oxygen (ETO2) measurements were recorded as fraction of expired oxygen prior to preoxygenation, at the time of adequate preoxygenation (ETO2 >85%), and then every five seconds after the oxygen was removed until the ETO2 values reached their recorded baseline.RESULTS:The mean ETO2 at completion of preoxygenation was 86% (95% confidence interval 85-88%). Volunteers in both the supine and upright position lost >50% of their denitrogenation in less than 60 seconds. Within 25 seconds, all subjects had an ETO2 of <70%. Complete renitrogenation, defined as return to baseline ETO2, occurred in less than 160 seconds for all volunteers.CONCLUSION:Preoxygenation loss, or renitrogenation, occurred rapidly after oxygen removal and was not different in the supine and sitting positions. After maximal denitrogenation in healthy volunteers, renitrogenation occurred rapidly after oxygen removal and was not different in the supine and sitting positions.

Rationale: There has been controversy about the timing and safety of intubation and mechanical ventilation in coronavirus disease (COVID-19).Objectives: To determine the effect of intubation and mechanical ventilation on all-cause, in-hospital mortality for COVID-19 patients.Methods: Retrospective cohort study of adult patients who tested positive for COVID-19 in the emergency department and were subsequently admitted to one of 11 New York City municipal hospitals. Patients with do not intubate orders were excluded.Measurements and Main Results: Data from 6591 COVID-19 patients were included;of these, 1633 (25%) were intubated overall and 791 (12%) were intubated within 48 hours of triage. After controlling for likely confounders, intubation rates for COVID-19 patients varied significantly across hospitals and decreased as the pandemic progressed. After nearest neighbor propensity score matching, intubation within 48 hours of triage was associated with higher allcause mortality (hazard ratio = 1.34, 1.09 to 1.65, p = 0.006), as was intubation at any time point (hazard ratio = 1.22, 1.02 to 1.45, p = 0.026). These results remained robust to multiple sensitivity analyses.Conclusions: Intubation and mechanical ventilation was associated with increased mortality in COVID-19 patients. Further caution should be taken in attempting to avoid intubating these patients.

Objectives:. There has been controversy about the timing and indications for intubation and mechanical ventilation in novel coronavirus disease 2019. This study assessed the effect of early intubation and mechanical ventilation on all-cause, inhospital mortality for coronavirus disease 2019 patients. Design:. Multicenter retrospective cohort study. Setting:. Eleven municipal hospitals in New York City from March 1, 2020, to December 1, 2020. Patients:. Adult patients who tested positive for coronavirus disease 2019 in the emergency department were subsequently admitted. Patients with do-not-intubate orders at admission were excluded. Interventions:. Intubation within 48 hours of triage and intubation at any point during hospital stay. Measurements and Main Results:. Data from 7,597 coronavirus disease 2019 patients were included; of these, 1,628 (21%) were intubated overall and 807 (11%) were intubated within 48 hours of triage. After controlling for available confounders, intubation rates for coronavirus disease 2019 patients varied significantly across hospitals and decreased steadily as the pandemic progressed. After nearest neighbor propensity score matching, intubation within 48 hours of triage was associated with higher all-cause mortality (hazard ratio, 1.30 [1.15–1.48]; p < 0.0001), as was intubation at any time point (hazard ratio, 1.62 [1.45–1.80]; p < 0.0001). Among intubated patients, intubation within 48 hours of triage was not significantly associated with differences in mortality (hazard ratio, 1.09 [0.94–1.26]; p = 0.26). These results remained robust to multiple sensitivity analyses. CONCLUSIONS:. Intubation within 48 hours of triage, as well as at any time point in the hospital course, was associated with increased mortality in coronavirus disease 2019 patients in this observational study.

“Is he going to make it, doctor?” The concerned mother leans forward, wringing her hands. Her adult son had come in by ambulance with respiratory distress. I look at the scene around me, an emergency department (ED) filled with critically ill patients. Doctors, nurses, and techs in head-to-toe persona protective equipment (PPE) are running from patient to patient, responding to urgent calls for help, and troubleshooting beeping monitors. There are patients at all stages of the disease, some gasping for air, some dying on ventilators, others sitting in metal chairs in the hallway and taking deep breaths from the nasal cannula connected to oxygen cylinders on the floor next to them. My thoughts turn to the events that brought us to this moment: a public health system overwhelmed, an unexpected surge in patient volume, a pandemic that had turned the sleepless city inside out overnight. However, despite the uncertainty, the grim predictions, and the daily struggle to care for each patient, the last few weeks have taught me the most important lesson I have ever learned. My hospital is in the Mott Haven neighborhood of the Bronx, the poorest congressional district in the country. During business as usual, the ED strains under the weight of its 165,000 visits. Now it is close to collapse. Driving in to work, the city had been eerily quiet. The city itself seems sick. The streets are anemic. The buildings no longer buzz with noise and movement. Neon lights that would announce “we are open for business” are dark. The heart of a city that pumps 8 million humans through her arteries and veins each day is stilled. In contrast to the empty streets outside, the ED is plethoric, feverish, hyperdynamic. The staff and physicians are strained and exhausted but still hypervigilant. There is a constant awareness of the virus: around us, in the air as we ventilate a patient, in the lungs of those coughing and gasping for breath, in the bodies stacking up in the morgue. During the first few days of the pandemic, we were understaffed, underresourced, and woefully ignorant of how the virus worked. The first week was terrifying. We intubated more patients in 1 week than we had in several months. The intensive care units (ICUs) quickly filled up, and the available ventilator counts dwindled. Our PPE stocks were vanishing. The medications used to help keep our intubated patients comfortable were disappearing just as fast. Despair set in. I saw colleagues lose confidence and hope. The news was awash with stories of worsening caseloads, increasing mortality, and physicians losing their jobs for demanding adequate PPE. I felt myself lose hope. Then something incredible happened. I found myself, an emergency physician on the frontlines of the greatest pandemic of our lifetime, not alone. The messages of support started to pour in: text messages, phone calls, e-mails of encouragement and support. I started receiving invitations to forums discussing how to address the pandemic and how to share lessons learned from the frontlines across the world. Researchers began to collect data to look for patterns of illness and effectiveness of treatments. Educators found new ways to keep medical schools and residencies going despite the social distancing measures. Hospital leadership listened and addressed the concerns of the frontline workers. Requests for structural changes, resources, and supplies that we had been making for years finally fell on open ears. When we were out of ventilators, the leadership found more. When ICU space ran out, we upgraded inpatient wards to have ICU capabilities. Almost overnight, telehealth was set up to take care of outpatient visits. Changes that would have been unthinkable a week before were suddenly not just doable but done. The pandemic brought with it more than despair, illness, and death. It brought cohesion, kindness, an acceleration of shared innovation, and a sense of community. It brought a sense of connection with the 8 million residents of New York and with physicians around the world as we have banded together in spirit while we remain apart in space. It brought with it, for me, a sense of hope. “Doctor?” I quickly focused my attention back to the patient’s mother. “I think he’s going to be alright,” I say. Together, I think we all are.

Background: To our knowledge, no study has assessed the correlation of fraction of inspired oxygen (FiO(2)) and end-tidal oxygen (EtO2) values obtained from a gas analyzer during the preoxygenation period of rapid sequence intubation (RSI) to predict partial pressure of oxygen (PaO2) among patients requiring intubation in the emergency department (ED). Objective: The purpose of this study was to determine whether a simple equation using EtO2 and FiO(2) at time of induction could reliably estimate minimal PaO2 in ED patients undergoing RSI. Methods: We conducted an observational pilot study performed in an adult ED utilizing a gas analyzer to obtain EtO2 and FiO(2) values in ED patients undergoing RSI from data collectors blinded to our objective. The Pearson correlation coefficient was calculated between the equation's predicted PaO2 and the PaO2 drawn from an arterial blood gas shortly after intubation. A Bland-Altman plot analysis was performed to identify any additional bias. Results: Seventy-five patients were enrolled. The equation's mean predicted minimal PaO2 and mean PaO2 from an arterial blood gas within 3 min after intubation was 178 mm Hg (95% confidence interval [CI] 145-211 mm Hg) and 209 mm Hg (95% CI 170-258 mm Hg), respectively. The Pearson correlation coefficient between the predicted minimal PaO2 and post-intubation PaO2 demonstrated a strong correlation r(2) = 0.89). The Bland-Altman plot indicated no bias affecting the correlation between the predicted and actual PaO2. Conclusions: Among ED patients undergoing RSI, the use of a gas analyzer to measure EtO2 and FiO(2) can provide a reliable measure of the minimal PaO2 at the time of induction during the RSI phase of preoxygenation. (C) 2019 Elsevier Inc. All rights reserved.

Survival rates after an out-of-hospital cardiac arrest remain low despite notable advances in out-of-hospital care. The 1-year global survival rates are ≈7.7% and increase to 12.6% among patients receiving bystander cardiopulmonary resuscitation (CPR).1 Early initiation of effective compressions with minimal interruptions is essential to maximizing favorable outcomes after out-of-hospital cardiac arrest. Yet effective compressions are subject to a provider's ability to maintain an accurate compression rate, compression depth, and chest recoil allowance. In addition, a provider delivering manual compressions eliminates his or her ability to participate in alternative resuscitation efforts. During the past several decades, mechanical CPR devices have been deployed to improve the quality of compressions delivered. Mechanical compression devices such as the LUCAS alleviate the limitations of manual compressions by serving as an additional "mechanical resource" capable of providing optimized compressions. In resource-limited areas with limited providers or extended emergency medical services transportation times, these mechanical devices are useful in maximizing resuscitative efforts. However, evidence for the superiority over manual compressions is lacking.2 A 2016 meta-analysis found no difference in survivability between mechanical and manual CPR.3 Few studies to date have assessed an important nuance of mechanical chest compression devices—the delicate and difficult transition from manual to mechanical compression devices. This elapsed time includes positioning the patient on the compression device backplate, connecting the compression device to the backplate (and often challenging task for new users), adjusting the device for accurate compression location, and digitally starting the device. In total, this could result in a significant delay and cessation of perfusion. Prior research has noted that this transition can result in chest compression pauses of up to 35 seconds.4 Are these delays harmful? Prior studies have demonstrated worse outcomes with the use of mechanical compressions devices.5 In the AutoPulse Assisted Prehospital International Resuscitation trial, application of the auto-pulse devices resulted in almost 2 minutes of chest compression interruption, potentially explaining the lower out-of-hospital cardiac arrest survival seen associated with mechanical chest compressions in that trial. This paradox presents an important conundrum; any survival benefit from a mechanical chest compression device could be easily undone by the slow application of the device. To date, no rigorous randomized controlled trial has definitively shown the superiority of mechanical CPR—could the manual-to-mechanical transition be the smoking gun? In the study by Levy et al,6 titled “Metrics of Mechanical Chest Compression Device Use in Out-of-Hospital Cardiac Arrest,” the researchers give us hope for the future use of mechanical chest compressions. The authors specifically focused on time to implementation of mechanical CPR as well as the transition time from standard (manual) to mechanical CPR. In this retrospective analysis comparing survivability among 49 patients with out-of-hospital cardiac arrest (ventricular tachycardia/ventricular fibrillation) receiving manual CPR alone versus a combined manual and mechanical CPR, the authors reported a median duration of 6.9 minutes before the transition to a mechanical CPR device. As a result of emergency medical services policy, mechanical CPR could not be initiated sooner than 2 cycles of manual CPR, which prevented earlier initiation. Importantly, the authors reported that the transition from manual to mechanical CPR could be accomplished with impressively minimal interruption (median, 7 seconds; interquartile range, 5–13 seconds). The maximum duration of interruption for any reason was 14 seconds in the manual + mechanical CPR group compared with 10 seconds in the manual compression group. These researchers should be congratulated on their demonstration that practical training on the transition from manual to mechanical CPR can result in a reduced time to implementation (<10 seconds) that could efficiently be completed during a CPR pulse check. There are several other practical yet important lessons to be taken from Levy et al when considering implementing the use of mechanical compression devices during resuscitation. Although the timing of the transition from manual to mechanical compressions is crucial, the steps required to perform that transition in a successful manner that will impact patient outcomes are even more important. One must take into consideration the training, as well as the cost to provide such training, required to familiarize one's team with how to make this transition in a choreographed manner. This requires specific planning with defining of roles for each person involved in the resuscitation. This has implications as adding in the device can complicate already chaotic scenarios; however, as Levy et al have demonstrated, if done correctly, can lead to smoother transitions, ultimately leading to more available resources (ie, frees providers from performing manual compressions) to help deliver care needed. Per the American Heart Association, every effort should be made to minimize the interruptions in high-quality chest compressions to improve the likelihood of return of spontaneous circulation. Given the successful demonstration of a rapid transition between manual and mechanical CPR by Levy et al, we second the author's conclusion that encourages future research comparing manual to mechanical compressions that employ similar transition training to minimize compression interruption. At this time, further research is still needed to determine whether this limited compression interruption can result in improved survival rates in out-of-hospital cardiac arrest or merely a benefit to those providing manual CPR efforts. Nevertheless, training programs similar to those employed by the Anchorage Fire Department should be encouraged to optimize the transition from manual to mechanical CPR. In addition, the use of mechanical CPR in resource-limited efforts with prolonged transportation time should still be promoted as a means to support emergency medical services out-of-hospital care.

The novel coronavirus, or COVID-19, has rapidly become a global pandemic. A major cause of morbidity and mortality due to COVID-19 has been the worsening hypoxia that, if untreated, can progress to acute respiratory distress syndrome (ARDS) and respiratory failure. Past work has found that intubated patients with ARDS experience physiological benefits to the prone position, because it promotes better matching of pulmonary perfusion to ventilation, improved secretion clearance, and recruitment of dependent areas of the lungs. We created a systemwide multi-institutional (New York-Presbyterian Hospital enterprise) protocol for placing awake, nonintubated, emergency department patients with suspected or confirmed COVID-19 in the prone position. In this piece, we describe the background literature and the approach we have taken at our institution as we care for a high burden of COVID-19 cases with respiratory symptoms.

BackgroundEnd-tidal oxygen (ETO2) monitoring is used by anesthesiologists to quantify the efficacy of preoxygenation before intubation but is generally not used in emergency departments (EDs). We have previously published our findings describing preoxygenation practices in the ED during blinded use of ETO2. The purpose of this investigation is to determine whether the unblinded use of ETO2 monitoring led to improvements in preoxygenation during rapid sequence intubation in the ED and also the oxygen device or technique changes that were used to achieve higher ETO2 levels. MethodsWe conducted an interventional study at 2 academic EDs in Sydney, Australia and New York City, New York using ETO2 monitoring to investigate the preoxygenation process and effectiveness. We used data collected during a previous descriptive study for the control group, in which care teams in the same 2 EDs were blinded to the ETO2 value. In the study group, clinicians could utilize ETO2 to improve preoxygenation. Following an education process, clinicians were able to choose the method of preoxygenation and the techniques required to attempt to achieve an ETO2 level >85%. The primary outcome was the difference in ETO2 levels at the time of induction between the control and study group and the secondary outcome included the methods that were attempted to improve preoxygenation. ResultsA convenience sample of 100 patients was enrolled in each group. The median ETO2 level achieved at the time of induction was 80% (interquartile range 61 to 86, overall range 73) in the control group and 90% in the study group (interquartile range 83 to 92, overall range 41); the median difference was 12 (95% confidence interval: 8, 16, P = < 0.001). The majority of oxygen device changes were from non-rebreather mask to bag-valve-mask (BVM) (15%, n = 15) and changes in technique from improvements in mask seal (54%, n = 34). The final device used in the study group was BVM in 87% of cases. ConclusionsIn 2 clinical studies of ETO2 in academic EDs, we have demonstrated that the use of ETO2 is feasible and associated with specific and potentially improved approaches to preoxygenation. A clinical trial is needed to further study the impact of ETO2 on the preoxygenation process and the rate of hypoxemia.

The second largest outbreak of Legionnaires' disease in United States history began in July, 2015 in Bronx County, NY. It was initially described as a single outbreak affecting 138 patients with 16 deaths. Subsequently, additional cases were noted in the same area and time period, officially attributed to different exposures, making the final total 155 patients and 17 deaths before ending in September, 2015. The largest portion of cases was seen at Lincoln Medical and Mental Health Center with 48 patients treated.

A 45-year-old man with no medical history, non-smoker, presented with several days of cough and fever. He became short of breath on the day of presentation. He had a low-grade fever of 100.1°F with normal heart rate (HR) (80s) and respiratory rate (RR) (16–18); however, he was hypoxic on presentation, SpO2 89% on RA. He was started on 4 L nasal cannula and improved to 96%. Chest x-ray is shown (Figure 1). He became tachypneic (RR 20–25) and further hypoxic (SpO2 92%) despite an increase of nasal cannula to 6 LPM. The chest x-ray did not appear to fully explain how this patient had become so hypoxic so a CT chest was done (Figures 2-5). Patient was endotracheally intubated after further decompensation, despite high flow nasal cannula at 50 LPM. The CT scan attached demonstrates a severe example of the novel coronavirus (COVID19), commonly seen in hospitals around the globe. The high oxygen requirement needed by many of these patients and the intense reduction of the pulmonary reserve is leading to more and more endotracheal intubations. Frequently, providers are finding chest x-ray results to be equivocal, thus multiple modalities of imaging must be explored. Although a chest x-ray may be easily obtainable, portable, and rapidly interpretable, frequently patients are poorly positioned and may have confounding previous comorbidities that impact interpretation. CT scan on the other hand has improved specificity and visibility when investigating the lungs. When a CT chest is obtained, providers may fully recognize the severity of lung infiltration. Some major negatives to obtaining CT scans on these patients are time consumption, availability of CT scanners, and isolation cleaning requirements implemented after the patient has obtained their scan. Point-of-care ultrasound has been proposed to be a useful imaging modality when evaluating these patients. Ultrasound, however, is operator dependent and may demonstrate B-lines or subpleural consolidation only in dependent regions of the lung, which in the setting of patients with multiple comorbidities may be non-specific. With this patient, point-of-care ultrasonography was performed and demonstrated only a few B-lines, leading it to be unclear as to the extent of the disease. With COVID19 testing in most hospitals having a turnaround time of 3–5 days, it is important for health care providers to be able to recognize both symptoms and classic imaging of severe COVID19 infections in real time. While many patients have minimal chest x-ray findings, this case shows how hypoxia in the setting of suspected COVID19 can be further explained with CT imaging.

AbstractObjectiveProlonged and unaddressed hypoxia can lead to poor patient outcomes. Proning has become a standard treatment in the management of patients with ARDS who have difficulty achieving adequate oxygen saturation. The purpose of this study was to describe the use of early proning of awake, non‐intubated patients in the emergency department (ED) during the COVID‐19 pandemic.MethodsThis pilot study was carried out in a single urban ED in New York City. We included patients suspected of having COVID‐19 with hypoxia on arrival. A standard pulse oximeter was used to measure SpO2. SpO2 measurements were recorded at triage and after 5 minutes of proning. Supplemental oxygenation methods included non‐rebreather mask (NRB) and nasal cannula. We also characterized post‐proning failure rates of intubation within the first 24 hours of arrival to the ED.ResultsFifty patients were included. Overall, the median SpO2 at triage was 80% (IQR 69 to 85). After application of supplemental oxygen was given to patients on room air it was 84% (IQR 75 to 90). After 5 minutes of proning was added SpO2 improved to 94% (IQR 90 to 95). Comparison of the pre‐ to post‐median by the Wilcoxon Rank‐sum test yielded P = 0.001. Thirteen patients (24%) failed to improve or maintain their oxygen saturations and required endotracheal intubation within 24 hours of arrival to the ED.ConclusionAwake early self‐proning in the emergency department demonstrated improved oxygen saturation in our COVID‐19 positive patients. Further studies are needed to support causality and determine the effect of proning on disease severity and mortality.

Education related to clinical research often focuses on methodology, statistics, ethics, and study design. While knowledge of these conventional skills is essential to the operationalization of research, many "soft" skills related to leadership, communication, and team management are critical to the successful conduct research in the real world. Conducting clinical research in the emergency department is generally a challenging endeavor. Based on our prior experience as clinical researchers and a narrative review of the published literature, we offer nine practical strategies to help junior investigators conduct research. To successfully execute a research study, investigators must know how to motivate their team, create a brand around their study, communicate effectively, maximize clinician and patient engagement, and celebrate victory, among other skills. These skills and strategies are often missing from the formal research education and in peer-reviewed manuscripts but are, in fact, invaluable to the successful development of junior investigators. Thus, we offer the "story behind the study" in an effort to contribute to research education with material that is not typically covered in formal curricula.

Central venous oxygen saturation (ScVO2) is commonly used in clinical practice as a surrogate for cardiac output and delivery of oxygen to tissues. However, ScVO2 is invasive, as it requires central vein cannulation. A non-invasive alternative, such as End-Tidal Oxygen (ETO2), would be beneficial to patients, as it is painless, and without the risks of central vein cannulation. If a strong level of agreement exits and a correlation is present, ETO2 could be used as a non-invasive measure to determine the heart's ability to circulate blood and oxygen to tissues. The objective of this study is to determine in patients requiring hemodynamic support (ie, pressor support or large volume resuscitation) how well ETO2 compares to ScVO2 as a surrogate for cardiac output. We also sought to determine the correlation between the two. This is a prospective observational study of patients in the emergency department in which ETO2 was measured non-invasively at the time of ScVO2 collection from a central line. Approximately 2ml of blood was drawn from a central venous catheter by a nurse at the same time ETO2 measurements were recorded. Blood samples were analyzed immediately by a validated point-of-care blood gas analyzer. ScVO2 and ETO2 measurements were recorded, along with data including vitals signs, lab values, and the patient's diagnosis. Statistical Analysis: Bland-Altman Plot for level of agreement and bias was generated and Pearson correlation was calculated to describe relationship between ScVO2 and EtO2 as well as their ability to measure cardiac output. Demographic data is presented with descriptive statistics. Twenty-seven patients have been enrolled to date. The average lactate for the group was 2.5 (95% CI 1.5 to 3.5) with an average hock index of 0.85 indicating the presence of a hypoperfused state. Pearson correlation was modest (0.63). The mean ScVO2 was 73 (95% CI 68 to 78) and ETO2 was 52 (95% CI 42 to 62). The Bland-Altman Plot demonstrates moderate level of agreement with bias towards ETO2 under measuring compared to ScVO2 (See Graph). We found a modest agreement between EtO2 and ScVO2 with some bias to under measuring for ETO2. ETO2 may offer some benefit in helping clinicians to determine the presence of hypoperfusion.

STUDY OBJECTIVE:Preoxygenation is important to prevent oxygen desaturation during emergency airway management. The purpose of this study is to describe the use of end tidal oxygen (eto2) during rapid sequence intubation in the emergency department. METHODS:This study was carried out in 2 academic centers in Sydney, Australia, and New York City. We included patients undergoing rapid sequence intubation in the emergency department. A standard gas analyzer was used to measure eto2. Preoxygenation methods included nonrebreather mask and bag-valve-mask ventilation. We measured eto2 before preoxygenation and at administration of rapid sequence intubation medications. We also characterized peri-intubation SpO2, identifying instances of SpO2 less than 90%. RESULTS:We included 100 patients during a 6-month period. Median eto2 level before and after preoxygenation was 53% (interquartile range [IQR] 43% to 65%) and 78% (IQR 64% to 86%), respectively. One fourth of patients achieved an eto2 level greater than 85%. Median eto2 level achieved varied with preoxygenation method, ranging from 80% (IQR 60% to 87%) for the nonrebreather mask group to 77% (IQR 65% to 86%) for the bag-valve-mask group. The method with the highest median eto2 level was nonrebreather mask at flush rate (86%; IQR 80% to 90%) and the lowest median eto2 level was nonrebreather mask at 15 L/min (57%; IQR 53% to 60%). Eighteen patients (18%) experienced oxygen desaturation (SpO2 <90%); of these, 14 (78%) did not reach an eto2 level greater than 85% at induction. CONCLUSION:ETO2 varied with different preoxygenation techniques employed in the emergency department. Most patients undergoing rapid sequence intubation did not achieve maximal preoxygenation. Measuring ETO2 in the emergency department may be a valuable adjunct for optimizing preoxygenation during emergency airway management.