The edition · Emergency & Critical Care
Each extra intubation attempt raised the odds of cardiac arrest in critically ill children
A 70-unit registry ties peri-intubation arrest to attempts, shock and hypoxia; four in ten paramedic STEMI activations turn out to be something else; a liberal transfusion target in septic shock with cancer stopped early for thrombosis; and an ED programme raised outpatient care of low-risk pulmonary embolism.
The edition in brief
In 27,773 intubations across international paediatric ICUs, cardiac arrest within 20 minutes occurred in 1.2%. Odds rose with every extra attempt (aOR 1.70 per attempt), with shock (aOR 4.67) and with pre-intubation oxygenation failure (aOR 2.29); ketamine, propofol, neuromuscular blockade and video laryngoscopy were each associated with lower odds. These are observational associations. In a Victorian ambulance registry of 7,205 paramedic-suspected STEMI patients with a discharge diagnosis, 60% had confirmed STEMI; those with non-cardiac diagnoses had higher long-term mortality (HR 1.75). The French TRANSPORT trial in 187 cancer patients with septic shock found no lactate benefit from a 9 g/dL over a 7 g/dL transfusion threshold and stopped early after more thrombotic events with liberal transfusion (13% vs 1%). A single-centre ED programme raised discharge of low-PESI pulmonary embolism from 5.1% to 33.3% over three years, with no 30-day recurrence or deaths among those discharged.
Four in ten paramedic STEMI activations end with a different diagnosis
Treat a paramedic STEMI alert as a working diagnosis: confirm it fast, and if it is not STEMI, look hard for what it is.
A liberal transfusion target in septic shock with cancer brought no lactate benefit and more thrombosis
In septic shock with cancer, a 9 g/dL transfusion threshold did not improve lactate and was linked to more thrombosis than 7 g/dL.
An ED programme raised discharge of low-risk pulmonary embolism sixfold without 30-day harm
Consider outpatient care for low-PESI pulmonary embolism without Hestia criteria, with anticoagulation and follow-up arranged before discharge.
Resuscitate before you intubate the shocked patient
Correct hypotension and hypoxia as far as possible before inducing a critically ill patient.
Peri-intubation cardiac arrest in children rose with every extra attempt
Aim for first-pass success when intubating a critically ill child, and correct shock and hypoxia first; each further attempt was linked to higher odds of arrest.
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