This case series documents the clinical courses of 4 patients after verapamil overdose and 1 patient after amlodipine-atenolol overdose. All subjects had hypodynamic circulatory shock (hypotension, bradycardia, and acidosis) that was not adequately responsive to conventional treatment. After initiation of insulin-dextrose infusion, the hemodynamic status of all 5 patients stabilized and all patients survived. Plasma drug concentrations are reported for all cases and verapamil levels were extremely high in 2 patients (3710 ng/mL and 3980 ng/mL). However, because patients were not treated according to a standard protocol, each patient received variable other supportive measures and inotropic agents, and the infusion rates of insulin were variable among patients. This report provides preliminary evidence toward a larger trial of insulin-dextrose to treat hypodynamic shock from calcium channel blocker overdose.

Abstract. Objectives: Rapid-sequence intubation (RSI) is an active airway intervention used frequently in emergency medicine (EM). The authors hypothesized that RSI can be performed safely in the setting of an EM training program at a tertiary care center. Methods: Observational study of RSI at an urban ED/Level 1 trauma center with annual census of 100,000 patients. Consecutive patients who underwent RSI during a two-year period were studied. Data included age, gender, type of patient (medical/ trauma), indication for intubation, number of intubation attempts (laryngoscope passes), training level of operator, and major immediate adverse events (clinical deterioration within 10 minutes of RSI). Results: RSI was used in 417 of 596 (70%) critically ill patients requiring emergent intubation. The patient demographic distribution was the following: adults 89.7%, male 58%, and trauma 44%. Primary indications for intubation among RSI patients were as follows: mechanical ventilation 57.4%, airway protection 41.3%, and cardiac arrest 1.3%. Distribution of intubations by level of EM training was PGY1, 5%; PGY2, 52%; PGY3, 40%; and attendings, 3%. Intubations were successfully completed within two attempts in 97% of the patients. Major immediate adverse events were encountered in six patients (1.4%) (hypotention = 2, hypoxemia = 1, dysrhythmia = 3). There was no death attributable to RSI. The rate of intubations requiring two or fewer attempts and without major immediate adverse events was 96%. Three patients required cricothyrotomy. Conclusion: In the setting of an EM residency at a tertiary care ED, RSI can be performed successfully with few major immediate adverse events. Key words: intubation; emergency; RSI; residency; adverse events; success rate. ACADEMIC EMERGENCY MEDICINE 1999; 6:31 -37 R APID-sequence intubation (RSI) continues to garner wide acceptance in the emergency setting.1,2 Advantages, such as decreased risk of aspiration, attenuation of intracranial pressure (ICP), avoidance of cardiovascular compromise, and increased patient comfort, have rendered RSI the method of choice for the emergency airway. 2 -7 In addition, RSI can facilitate the difficult intubation in combative patients.3,8 However, RSI is not without risk, particularly if the airway cannot be readily secured and adequate ventilation cannot be provided.

Soft-tissue US changes physician management in approximately half of patients in the ED with clinical cellulitis. US may guide management of cellulitis by detection of occult abscess, prevention of invasive procedures, and guidance for further imaging or consultation.

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