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High Risk Pitfalls in ED

dr Jollis, SpEM


Multiple factors contributing

Patient hospital bed shortages
Insufficient availability of ED examination bed
Shortages in RN staff
Increasing medical acuity
Increasing patient volume

There may be increased risks of harm to

patients resulting from impaired
communication and diminished access to care
Possible increases in morbidity and mortality

ED overcrowding patients leaving ED

without fully evaluated or at least screened
20 years ago, never heard patients call 911
when they were already in ED waiting room
Reports of patients suffering significant injury
secondary to delay of care-or worse dying in
ED waiting room

The manner in which ED handle wait times

and patient's who leave without being seen
can impact liability, patient safety, and
hospital finances

ANY patients who come to ED requesting

examination or treatment for medical
condition must be screen medically for
emergency (TRIAGE)
If emergency, the patient must be stabilized or
transfer to another hospital

Once triage completed, having policy and

procedure that can ensure continued
monitoring of patients who are waiting

Every 2 hours (many hospital used)

Triage and re-triage must be reliable
Vital sign should be reevaluated

Was the triage assessment appropiate based

on chief complaint and vital sign?
Did the wait time exceed standards (national?)
for that triage level?
Were re-assessments performed on a regular

2. Endotracheal tube placement

Verification of correct ETT placement after

intubation is critical to prevent hypoxia and
gastric insufflation
Auscultate epigastrium
Auscultate lateral lung fields

Don't rely on clinical examination alone to

confirm correct ETT placement
Clinical examination is hepful, but IMPERFECT
Air flow into oesophagus can produce similar
sound quality that flow through trachea
Mainstem intubation not compared to
opposite side may caused intubator to assume
esophangeal intubation

Even experienced intubators can be misled

Fog in ETT?
Over reliance on pulse oximetry?

Best Way?
Most common and most reliable method is
Qualitative End Tidal CO2 (ETCO2) capnometry
Producing color change in the presence of
exhaled CO2
Must persists beyond six breaths through ETT

Quantitative or waveform capnography even

Most reliable, but one limitation: cardiac

Esophangeal detector device (EDD)

Used by many EMS agencies
Very effective

Recent studies: role of ultrasonography in

verifying ETT placement
Requires real time use of ultrasound probe
placed over the neck during intubation

All these methods show varying sensitivities

and specificities
Using at least two modalities for any given
intubation will decread likelihood of
unrecognized esophangeal intubation
No method should be used alone
ETCO2 capnography should be used whenever


Obtaining rapid vascular access in critical ill

patient is a key step in resus
Vascular collapse often occurs
Inability to secure iv peripheral line major
challenge for resus team
Chaotic first moments of resus central line?
Even in most skilled hands, still need minutes
during a time when seconds count

Be familiar with Intraosseous

Not a new method
Effective route medications and fluids
Radionucleotide shown IO deliver fluids as
rapidly as IV
Indication: need emergency vascular access
when conventional methods fail

ACLS-ATLS-PALS recommend IO as alternative

means of vascular access when IV delayed or
not feasible
AHA: IO under 6 yo who have had 2 failed IV
attempts or where >2 min have elapsed at
attempting IV access
Eastern Associations of Surgeons of Trauma:
IO in adults trauma when IV access failed 2
attempts or unobtainable

Contraindication: Fracture of bone near access

Complications (RARE): fluid extravasation,

What can go through IO needle?

Any standard IV fluids
Blood products
All drugs administered IV
10 ml/min by gravity until 41 ml/min by
pressurized bags


Do not be Lazy..
Use maximal Barrier Protection
when performing invasive
Catheter related bloodstream infections

CRBSIs high financial costs and significant

health consequences. Prevention is critical
Infections rate from IV peripheral catheters:
0,5 per 1.000 IVD-days (0,1%)
Arterial catheters: 0,4%
CV catheters: 4,4%

Confirmation CRBSI needs standardized techniques to

determine colonization of catheters and isolation
same organism from bloodstream
Most obvious intervention that prevent CRBSI
maximal barrier precautions:
Sterile gloves
Long-sleeved sterile gown
Mask and Cap
Large sterile sheet drape when insert CVC

5 evidence-base procedure
(NEJM, 2007)

Maximal barrier techniques

Hand washing
Use chlorhexidine for skin preparation
Avoiding femoral site if possible
Removal unnecessary catheters