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Objective: The objective was to determine whether the use of fentanyl with ketamine for emergency department (ED) rapid sequence intubation (RSI) results in fewer patients with systolic blood pressure (SBP) measurements outside the pre‐specified target range of 100–150 mm Hg following the induction of anesthesia. Methods This study was conducted in the ED of five Australian hospitals. A total of 290 participants were randomized to receive either fentanyl or 0.9% saline (placebo) in combination with ketamine and rocuronium, according to a weight‐based dosing schedule. The primary outcome was the proportion of patients in each group with at least one SBP measurement outside the prespecified range of 100–150 mm Hg (with adjustment for baseline abnormality). Secondary outcomes included first‐pass intubation success, hypotension, hypertension and hypoxia, mortality, and ventilator‐free days 30 days following enrollment. Results: A total of 142 in the fentanyl group and 148 in the placebo group commenced the protocol. A total of 66% of patients receiving fentanyl and 65% of patients receiving placebo met the primary outcome (difference = 1%, 95% CI = −10 to 12). Hypotension (SBP ≤ 99 mm Hg) was more common with fentanyl (29% vs. 16%; difference = 13%, 95% CI = 3% to 23%), while hypertension (≥150 mm Hg) occurred more with placebo (69% vs. 55%; difference = 14%, 95% CI = 3 to 24). First‐pass success rate, 30 day mortality, and ventilator‐free days were similar. Conclusions and Relevance: There was no difference in the primary outcome between groups, although lower blood pressures were more common with fentanyl. Clinicians should consider baseline hemodynamics and postinduction targets when deciding whether to use fentanyl as a coinduction agent with ketamine. [ABSTRACT FROM AUTHOR]

Background In critical care medicine, US views of the inferior vena cava ( IVC) and its change with respiration are used to estimate the intravascular volume status of unwell patients and, in particular, to answer the question: 'Is this patient likely to be fluid responsive?' Most commonly in the literature, the subxiphisternal ( SX) window in the longitudinal plane is utilised. To date, no study has specifically assessed interrater agreement in estimating IVC diameter between emergency medicine specialists (experts) and trainees (learners). Objectives To determine the interrater agreement between an expert (senior emergency specialist with US qualifications) and learner (emergency medicine trainee) when measuring IVC diameter ( IVCD) and IVC collapsibility index ( IVCCI) in the SX longitudinal US window in healthy volunteers. Methods Healthy volunteers ( ED staff) were scanned in the supine position using a sector (cardiac) probe of a portable US machine, in the SX longitudinal position. The maximum and minimum diameters of the IVC were measured in each of these positions and the IVCCI calculated. Results were analysed using Bland- Altman plots. Results In the longitudinal SX window, the operators' measurements of maximum IVCD differed by an average of 1.9 mm (95% limits of agreement −9.4 mm to +5.5 mm) and their measurement of IVCCI differed by an average of 4% (95% limits of agreement −30% to 38%). Conclusions The wide 95% limits of agreement demonstrate a poor interrater agreement between the IVC US measurements obtained by expert and learner users in the assessment of fluid status. These ranges are greater than clinically acceptable. [ABSTRACT FROM AUTHOR]

Study Objective: We examine first-look success in emergency pediatric intubation by a physician-staffed helicopter emergency medical service (EMS).Methods: A database analysis of all pediatric (<16 years) intubations during a 64-month period was undertaken, using data from a prospectively enrolled electronic airway registry form. Recorded findings included patient demographics, operator background, airway intervention including intubation attempts, complications, and critical timings.Results: Eighty-two subjects were identified during the 64-month study. All patients were successfully intubated. The overall first-look success rate was 75 of 82 (91%), registrars achieving a first-look success rate of 26 of 26 (100%), consultants 16 of 17 (94%), and paramedics 33 of 39 (85%). Overall complication rate was 14%; 84% of cases were rapid sequence induction, whereas 16% were "cold intubations." Difficult airway indicators were present in 77% of patients.Conclusion: A high first-look success rate for pediatric intubation was achieved by adult helicopter EMS physicians and intensive care paramedics. To our knowledge, this compares favorably with the rate in published literature in pediatric emergency departments and critical care units. [ABSTRACT FROM AUTHOR]

Objective: This article reviews the logistics and safety of extracorporeal membrane oxygenation (ECMO) medical retrieval in New South Wales, Australia., Methods: We describe the logistics involved in ECMO road and rotary-wing retrieval by a multidisciplinary team during the H1N1 influenza epidemic in winter 2009 (i.e., June 1 to August 31, 2009). Basic patient demographics and key retrieval time lines were analyzed., Results: There were 17 patients retrieved on ECMO, with their ages ranging from 22 to 55 years. The median weight was 110 kg. Four critical events were recorded during retrieval, with no adverse outcomes. The retrieval distance varied from 20.8 to 430 km. There were delays in times from retrieval booking to both retrieval tasking and retrieval team departure in 88% of retrievals. The most common reasons cited were "patient not ready" 23.5% (4/17); "vehicle not available," 23.5% (4/17); and "complex retrieval," 41.2% (7/17). The median time (hours:minutes) from booking with the medical retrieval unit (MRU) to tasking was 4:35 (interquartile range [IQR] 3:27-6:15). The median time lag from tasking to departure was 1:00 (IQR 00:10-2:20). The median stabilization time was 1:30 (IQR 1:20-1:55). The median retrieval duration was 7:35 (IQR 5:50-10:15)., Conclusion: The process of development of ECMO retrieval was enabled by the preexistence of a high-volume experienced medical retrieval service. Although ECMO retrieval is not a new concept, we describe an entire process for ECMO retrieval that we believe will benefit other retrieval service providers. The increased workload of ECMO retrieval during the swine flu pandemic has led to refinement in the system and process for the future.