Article

A local survey of gastric lavage for gastrointestinal decontamination in a new century: The future marches on

gastric lavage forgast”>1114 Correspondence / American Journal of Emergency Medicine 36 (2018) 10981120

emergency medicine residents at Maimonides Medical Center in Brooklyn, New York. The Maimonides Medical Center institutional review board approved this study. Residents had not received any formal training on how to evaluate for HF/pEF prior to the initiation of this study. Residents’ abilities to diagnosis and characterize HF/ pEF based on sonographic images were assessed with a pre-test, a post-test, and a 4 month follow-up test. These tests included pictures of Tissue Doppler imaging of the mitral valve septal annulus as well as pulse wave Doppler of inflow velocities through the mitral valve. The tests queried the ability of residents to differentiate between normal heart function, heart failure with a reduced left ventricular systolic ejection fraction, and HF/pEF. After taking the pre-test, the residents underwent a training session, which included a lecture on the VALVE protocol. The residents then took a post-test to assess their newfound knowledge. After 4 months, the residents took an- other test to see if their ability to diagnose the presence of and de- gree of heart failure was retained.

Twenty-eight residents were enrolled in this study of varying post- graduate years. The mean for the pre-test was 2.64 +- 1.31 while the mean for the post-test was 7.07 +- 2.65. This finding represented a sig- nificant increase in score (p b 0.001). After four months, the mean for the follow-up test was 4.21 +- 2.41. This mean constituted a significant decline in score between the post-test and follow-up (p b 0.001). How- ever, the mean for the follow-up test was still significantly higher than pre-test scores (p = 0.012).

This study attempted to determine whether emergency medicine residents could be taught to correctly identify HF/pEF by echocardiogra- phy. The most obvious limitation was that this study used still images from echocardiograms obtained by echocardiography-trained ultra- sound technologists. At no point where residents assessed on their abil- ity to obtain adequate images. Furthermore, the testing was done with static images. More comprehensive understanding of HF/pEF, particu- larly with a resident who would be at the bedside obtaining the images would include the need to interpret dynamic clips. However, a basic un- derstanding could be conveyed through the testing of stills and felt ad- equate for this study.

To our knowledge, this study was the first to evaluate emergen- cy medicine residents in their ability to evaluate for HF/pEF. This study demonstrated that emergency medicine residents were able to learn and assess for HF/pEF. Even though there was a signif- icant improvement between the pre-test and post-test score, there was also a significant decrease in scores four months later. Howev- er, the follow-up test scores were significantly higher than the pre- test scores indicating some knowledge retention. The emergency medicine residents were able to significantly improve their test scores, but that does not mean the residents were able to perform well. They were competent, but ideally, the ability to diagnose dia- stolic dysfunction would be closer to 100% such as the percentages obtained by Adhikari et al. [6]. This percentage is a realistic goal for residents although more research would be required to determine how much teaching and how many echocardiograms are necessary to meet this threshold. More research is required to assess whether the image acquisition skill for this particular application can be learned by emergency medicine residents. However, we believe that this skill will ultimately help with diagnostics in the ED. Emer- gency medicine residents should consider assessing for HF/pEF when they perform an echocardiogram as it has the potential to in- fluence treatment and management when caring for acutely ill patients.

Samuel Blake Kluger, MD Thomas Jefferson University, United States Corresponding author at: Department of Emergency Medicine, Thomas Jefferson University, 1020 Samson Street, Philadelphia, PA 19107,

United States.

E-mail address: [email protected]

Eitan Dickman, MD Peter Homel, PhD

Lawrence Haines, MD, MPH, RDMS

Maimonides Medical Center, United States

26 June 2017

https://doi.org/10.1016/j.ajem.2017.10.033

References

  1. Bustam A, et al. Performance of emergency physicians in the point-of-care echocardi- ography following limited training. Emerg Med J 2013;0:1-5.
  2. Moore CL, et al. Determination of the left ventricular function by emergency phy-

sician echocardiography of hypotensive patients. Acad Emerg Med 2002;9: 186-93.

  1. Randazzo MR, et al. Accuracy of emergency physician assessment of left ventricular

ejection fraction and central venous pressure using echocardiography. Acad Emerg Med 2003;10:973-7.

  1. Lindenfeld J, et al. HFSA 2010 comprehensive heart failure practice guideline. J Card Fail 2010;16:e1-194.
  2. Unluer EE, et al. Limited Bedside echocardiography by emergency physicians for diag- nosis of Diastolic heart failure. Emerg Med J 2012;29:280-3.
  3. Adhikari S, et al. Ability of emergency physicians with advanced echocardiographic

experience at a single center to identify complex echocardiographic abnormalities. Amer. J Emerg Med 2014;32:363-6.

A local survey of gastric lavage for gastrointestinal decontamination in a new

century: The future marches on?,??,?,??

In 2013, The American Academy of Clinical Toxicology (AACT) and the European Association of Poison Centres and Clinical Toxicologists (EAPCCT) revised a joint statement summarizing the evidence of using gastric lavage (GL) in the poisoned patient [1]. They admitted evidence supporting GL was weak, but no substantial evidence against use in a potentially lethal exposure, or soon after ingestion. This tone of uncer- tainty left the door open a crack for advocates of GL.

The specific aims of our study were to determine the understanding of GL in our state by surveying emergency medicine physicians, assessing whether GL equipment was available in hospitals, and if man- ufactures still produced GL kits.

Members of the Virginia College of Emergency Physicians (VACEP) were surveyed about their practice patterns regarding GL using a 10- question electronic survey. Hospitals were surveyed by directly calling the central supply or emergency departments. Finally, device manufac- turers were queried regarding sales data for GL kits with phone calls and emails.

A total of 75 (7%) out of the 1060 VACEP members contacted responded to the survey. Half stated they have used a GL kit however, 20% and a 34% of physicians reported having not used a GL kit in the last five or over ten years, respectively.

A third of respondents felt GL was never indicated for gastrointesti-

nal decontamination. Proponents felt it was indicated in high acuity overdose; less than one hour from time of ingestion; type of toxin ingested such as iron, paraquat or verapamil; and if a toxicologist or Poi- son Control instructed them to do so. Twenty percent felt it changed the outcome. Only 5% of respondents felt GL was the standard of care.

In Central Virginia, 42 hospitals were surveyed about GL kits and 38 (90%) responded. Only two (5%) hospitals stated they still stocked GL

? The research was presented as an abstract at the North American Conference of Clinical Toxicology, Boston, MA, September 12, 2016.

?? There was no grant funding for this research.

? There are no reported conflicts of interest.

?? Dr. Maskell reports this manuscript reflects his opinion only and not of the US Army.

Correspondence / American Journal of Emergency Medicine 36 (2018) 10981120 1115

kits but one elaborated it had been more than five years since the last purchase. The remaining 36 (95%) hospitals stated they no longer stock GL kits but five (14%) reported they would use a small-bore naso- gastric tube for GL.

Internet search revealed four companies that in 2015 advertised the sale of GL kits on their websites. Of these, one discontinued the kit. Two of them decided not to disclose sales information. One sold approxi- mately $10,000 of kits in 2015 in the mid-Atlantic region (DE, MD, NJ, PA, SC, and VA).

Our survey suffers from low rate of response from emergency med- icine physicians, which limits conclusions on their General practice with GL. However, regardless of the existing opinions from clinicians about GL, hospitals are not continuing to stock the GL kit and companies are producing far less. Despite this being a local study, GL has become anachronistic, and will soon be relegated to medical museums nation- wide, whether we like it or not.

Rebecka M. Hoffman

Virginia Commonwealth University, School of Medicine, Richmond, VA,

United States

Kevin F. Maskell

Department of Emergency Medicine, Madigan Army Medical Center,

Tacoma, WA, United States

Kirk L. Cumpston

Department of Emergency Medicine, Virginia Commonwealth University

Medical Center, Richmond, VA, United States

Corresponding author at: 830 E. Main St, Suite 300, Richmond, VA

23219, United States.

E-mail address: [email protected].

5 October 2017

https://doi.org/10.1016/j.ajem.2017.10.037

Reference

[1] Bensen B, Hoppu K, Troutman W, et al. Position paper update: gastric lavage for gas- trointestinal decontamination. Clin Toxicol 2013;51:140-6.

Effect of simulation-based sedation training course for dentists on emergency response monitoring

To the Editor,

In 1993, American Society of Anesthesiologists published ‘Practice Guidelines for Sedation and Analgesia by Non-Anesthesiologists (ASA- SED)’ and it was updated in 2002 [1]. This guideline indicates recom- mendations and cautions for non-anesthesiologists including dentists to perform effective and safe sedation and analgesia. High quality and safety sedation needs not only adequate emergency equipment buy also appropriate respiratory monitoring for emergency response.

In 2011, we Japanese Association of Medical Simulation established simulation-based sedation training course (SEDTC). SEDTC is performed for the improvement of sedation and analgesia safety for non-anesthe- siologists. The SEDTC consisted of a practical involving four sections, lec- ture about ASA-SED, discussion about several sedatives and analgesics utilizing card simulation, basic airway management utilizing manikin, and scenario-based training utilizing simulator. The participants were expected to demonstrate not only appropriate preparation for sedation

but also appropriate management of drug-induced hypoxia and/or shock [2,3]. Participants also put nasal capnography or SpO2 monitoring to themselves and evaluated its performance.

The most important step for rescuing the patient is to recognize the respiratory suppression by excessive sedation. However, the ASA-SED does not recommend the best monitoring for detecting respiratory suppression.

Here, we performed a survey for subjective utility of evaluating var- ious monitoring for emergency monitoring to dentists.

We introduced this SEDTC on 23th June to 14 dentists. Both before and at the end of training, participants rated the utility of the various monitors (number of respiration, respiratory pattern, consicousness level, SpO2, capnography) for emergency response on a Visual analog scale , which ranged from 0 mm (not useful at all) to 100 mm (extremely useful) [4]. Results obtained from each trial were compared using one-way re- peated measures analysis of variance or Mann-Whitney U test. Data are presented as mean +- SD. P b 0.05 was considered significant.

The subjective difficulty did not differ among monitoring both

before and after SEDTC. The subjective utility of capnography signif- icantly increased (before 75.7 +- 20.6 mm, after 92.9 +- 12.0 mm, P = 0.018), while it did not in the other four monitoring (number of res- piration P = 0.059, respiratory pattern P = 0.070, consicouness level P = 0.105, SpO2 P = 0.357).

Our results showed that SEDTC participation significantly increased the subjective utility of capnography for emergency response monitor- ing. As excessive sedation often lead to crisis in dental situation, educa- tion of capnography monitoring for early detection of respiratory arrest.

Conflict of interest

None.

Details of author contributions

M.H., N.K. and T.S. performed this survey and wrote the manuscript;

K.A. prepared the manuscript, provided critical comments, and ap- proved the final version.

Masanori Haba

Anesthesiology, Hidaka General Hospital, Japan

Nobuyasu Komasawa Department of Anesthesiology, Osaka Medical College, Japan Corresponding author at: Department of Anesthesiology, Osaka Medical College, Daigaku-machi 2-7, Takatsuki, Osaka 569-8686, Japan.

E-mail address: [email protected]

Takuro Sanuki

Department of Dental Anesthesiology, Nagasaki University, Japan

Kazuaki Atagi

Intensive Care Unit, Nara General Medical Center, Japan

9 October 2017

https://doi.org/10.1016/j.ajem.2017.10.038

References

  1. Practice Guidelines for Sedation and Analgesia by Non-Anesthesiologists. An updated report by the American Society of Anesthesiologists Task Force on sedation and anal- gesia by non-anesthesiologists. Anesthesiology 2002;96:1004-17.
  2. Komasawa N, Fujiwara S, Atagi K, Ueki R, Haba M, Ueshima H, et al. Effects of a sim- ulation-based sedation training course on non-anesthesiologists’ attitudes toward se- dation and analgesia. J Anesth 2014;28:785-9.

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