ultrasonographic lung sliding sign in confirming proper endotracheal intubation during emergency...

752 Abstracts

study specifically were blunt trauma, injury to the brain, andtransfer from or referral to a non-TARN hospital. Regressionanalyses were performed crude and adjusted for age, gender, In-jury Severity Scale, and Glasgow Coma Scale score. Using datafrom January 2000 through December 2009, a total of 3444 pa-tients from 161 hospitals, with a median age of 30.0 years andSBP of 126 mm Hg, were analyzed. The majority of patients(86.9%) were male. Mortality ranged from 1.2% in patientswith an SBP$ 170 mm Hg to 47.7% in patients withSBP < 70 mm Hg (p for linear trend < 0.001). After adjustmentfor confounders, mortality odds doubled at 90–109 mm Hg(odds ratio [OR] 2.22, 95% confidence interval [CI] 1.09–4.50) compared to the reference range of 110–129 mm Hg.Odds were four-fold higher at 70–89 mm Hg (OR 4.01, 95%CI 2.02–7.95), 10-fold higher at < 70 mm Hg (OR 10.3, 95%CI 4.76–22.2), and unchanged for SBP 150–169 mm Hg (OR0.65, 95% CI 0.22–1.91) or SBP$ 1700 mm Hg (OR 0.20,95% CI 0.03–1.17).

[Omeed Saghafi, MD

Denver Health Medical Center, Denver, CO]

Comment: This study was limited principally by its retro-spective design. It also has questionable generalizability, giventhe composition of the patient population within the studygroup. Nonetheless, the finding that mortality increases ata blood pressure cutoff of 110 mm Hg is of interest, as this ishigher than most Emergency Physicians would traditionally as-sociate with such an adverse outcome. Additional research withblunt and more minor trauma would be of special interest, espe-cially if it corroborated this finding.

, PREVALENCE AND INCIDENCE OF LONGERTERMPAIN INSURVIVORSOFPOLYTRAUMA.Gross T,Amsler F. Surgery 2011;150:985–95.

This study sought to better define the prevalence and severityof chronic pain in patients who have suffered polytrauma, and toevaluate the utility of different methods of measuring pain inthese patients. The authors identified 229 consecutive patientsover 4 years who were treated for blunt polytrauma at an aca-demic trauma center in Switzerland. Patients were included ifat least two Abbreviated Injury Severity regions were affectedand the patient had an Injury Severity Score of > 16. Follow-up data were collected by mail surveys at a mean of 2.4 yearsafter injury. However, 23% of patients were not alive at thetime of follow-up, and 43% did not respond. The final cohort in-cluded 102 polytrauma survivors. Patients were asked to ratetheir pre-injury pain and quality of life as well as post-injurypain, quality of life, and functional outcomes using seven previ-ously described scoring systems. At the time of follow-up, 54%of patients were fully rehabilitated. The prevalence and severityof pain differed among the different pain score metrics used, butoverall, the authors found that 46–85% of patients reported painthat they did not have before injury, and the different scores usedin the assessment of longer-term pain correlated well (R = 0.4–0.9). The authors found that the Trauma Outcome Profile (TOP),a recently developed scoring system, was the most sensitive forincidence of pain, and correlated best with objective functionaloutcomes. Several factors were found to be associated withprevalence of long-term pain in polytrauma survivors, including

higher initial Trauma and Injury Severity Score, and blue-collarprofession. Increased severity of long-term pain was associatedwith existence of pre-injury pain, lesser pre-injury quality oflife, and lower educational level.

[Nir Harish, MD

Denver Health Medical Center, Denver, CO]

Comments: This study had several significant limitations, in-cluding a low follow-up rate, potential for significant recall biasin patient assessment of pre-injury pain, and reliance on subjec-tive outcome data. It is also unclear if the length of follow-upwas sufficient, given that only 54% of patients were consideredfully rehabilitated at the time of follow-up. Some confoundingfactors that have been previously described, such as the effectof traumatic brain injury on chronic pain, were not addressed.Nonetheless, the results highlight the heavy disease burden ofchronic pain in survivors of polytrauma. The role of the TOPscore for evaluation of chronic pain in survivors of traumawill need to be studied further, but may prove to be a useful tool.

, ULTRASONOGRAPHIC LUNG SLIDING SIGN INCONFIRMING PROPER ENDOTRACHEAL IN-TUBATION DURING EMERGENCY INTUBATION. SimSS, Liena WC, Chou HC, et al. Resuscitation 2012;83:307–12.

Unrecognized single-lung intubation can lead to hypoventi-lation, atelectasis, barotrauma, and even patient death. This pro-spective, single-center, observational study conducted at theEmergency Department of a national university teaching hospi-tal in Taiwan aimed to assess the utility of ultrasound lung slid-ing sign in confirming proper endotracheal tube placementduring emergency intubation, as previous cadaver studies havenoted the absence of lung sliding in some cases of one-lung in-tubation. One hundred fifteen emergent intubations were in-cluded; 9 (7.8%) had one-lung intubations by chestradiograph. The overall accuracy of ultrasound to confirmproper endotracheal intubation was 88.7% (95% confidence in-terval [CI] 81.6–93.3%). The positive predictive value was94.7% (95% CI 87.1–97.9%) in the non-cardiac-arrest groupand 100% (95% CI 87.1–100.0%) in the cardiac-arrest group.Hence, unilateral absence of lung sliding is not accurate enoughto detect one-lung intubation. However, this study produced re-sults that corroborate the findings of previous studies, and furthersupport the practice of using bilateral lung sliding in identifyingproper endotracheal tube placement, especially in cardiac arrestpatients. Moreover, themedian operating time of ultrasoundwas88 s (interquartile range [IQR] 55.0–193.0), and of chest radiog-raphy was 1349 s (IQR 879.0–2221.0) post intubation.

[Douglas Melzer, MD

Denver Health Medical Center, Denver, CO]

Comments: The principal limitation of this study was its verysmall size and exceedingly small number of true positives. Theresults of the study would not seem to support the enthusiasm ofthe authors in advocating for this test, as chest X-ray study isclearly superior for detecting the rare single-lung intubation.The exception may be in cardiac arrest, although in that situa-tion, it is unclear whether making the determination using ultra-sound, although more rapid, will have any impact on clinicaloutcome.