Resus Today Summer 2019

Volume 6 No. 2 

Summer 2019 

Resuscitation Today 

A Resource for all involved in the Teaching and Practice of Resuscitation 

Illuminating 

Infant CPR 

Illuminating 

Seeing is 

Infant CPR 

believing 

Seeing is 

believing 

CONTACT US TO FIND OUT MORE 

Tel: 01252 344007 | 

braydenbaby@welmedical.com 

www.welmedical.com 


Tel: 01252 344007 | 


www.welmedical.com

CONTENTS 

CONTENTS 

Resuscitation Today 

4 EDITORS COMMENT 

6 CLINICAL PAPER Airway Management in the Emergency 

Department (The OcEAN-Study) - 

a prospective single centre observational 

cohort study 

17 CLINICAL PAPER Repeated vital sign measurements in 

the emergency department predict 

patient deterioration within 72 hours: 

a prospective observational study 

This issue edited by: 

Paul Jones (MRes; BSc; fHEA; Paramedic) 

c/o Media Publishing Company 

Media House 

48 High Street 

SWANLEY, Kent BR8 8BQ 

ADVERTISING & CIRCULATION: 

Media Publishing Company 

Media House, 48 High Street 

SWANLEY, Kent, BR8 8BQ 

Tel: 01322 660434 Fax: 01322 666539 

E: info@mediapublishingcompany.com 

www.MediaPublishingCompany.com 

PUBLISHED: 

Spring, Summer and Autumn 

COVER STORY 

Dear Friends and Colleagues, 

We are delighted to announce the much-anticipated arrival of Brayden Baby, 

the new member of our Brayden family. This is truly a unique baby, having 

The First 

been created and developed by a highly skilled design team with help from 

Illuminating 

leading European experts in the field of resuscitation. 

Infant CPR 

Brayden Baby illuminating infant CPR has been designed to be an ideal 

teaching manikin for Paediatric BLS, EPALS and EPILS. 

Resuscitation professionals are praising it for its many innovative features – 

read more about these in this issue. 

We have more great news for you! 

'Here's 

looking at 

you, Baby!' 

Manikin 


Tel: 01252 344007 | paul.mulvey@welmedical.com 


COPYRIGHT: 

Media Publishing Company 

Media House 

48 High Street 

SWANLEY, Kent, BR8 8BQ 

PUBLISHERS STATEMENT: 

The views and opinions expressed in 

this issue are not necessarily those of 

the Publisher, the Editors or Media 

Publishing Company. 

Next Issue Autumn 2019 

Subscription Information – Summer 2019 

Resuscitation Today is a tri-annual publication 

published in the months of March and 

September. The subscription rates are as 

follows:- 

UK: 

Individuals - £12.00 inc. postage 

Commercial Organisations - £30.00 inc. postage 

Rest of the World: 

Individuals - £60.00 inc. postage 

Commercial Organisations - £72.00 inc. postage 

There are lots more Brayden Babies looking for good homes and if you would like 

to see this little genius in action, please email paul.mulvey@welmedical.com to 

arrange an informal demonstration. 

Best wishes 

Brayden 

P.S Please take a look at a short overview of Brayden Baby ‘in action’ on 

www.welmedical.com/baby-brayden-advanced 

We are also able to process your 

subscriptions via most major credit 

cards. Please ask for details. 

Cheques should be made 

payable to MEDIA PUBLISHING. 

Designed in the UK by me&you creative 

RESUSCITATION TODAY - SUMMER 2019 

3

EDITORS COMMENT 

EDITORS COMMENT 

It’s interesting that this season’s edition relates to both the management of 

the patient’s airway in the Emergency Department, and the recognition of 

deterioration in the most serious of patients in the first place. Failure to manage a 

patient’s airway appropriately is always going to lead to poor prognoses and the 

observation of vital signs is… well, vital. Both of these issues are contentious and 

evolving, considered and developing. They professionally divide colleagues and 

create professional discussion – as well as offering the opportunity for high quality 

studies to develop even higher quality patient care. 


“Resources 

for managing 

patients in an 

emergency 

setting are 

becoming 

more effective, 

and technology 

continues to 

improve patient 

outcomes, 

we find 

ourselves at a 

crossroads…” 

As resources for managing patients in an emergency setting become more effective (when 

they are used well), and technology continues to improve patient outcomes, I suggest we find 

ourselves at a crossroads. There are options – but what direction should we go? Is it towards 

the high-tech intervention that continues to perfuse but offers little hope of positive long-term 

outcome? Do we aim for a back-to-basics approach of doing the simple things well and accept 

that if they are not effective then it was not to be? Is it about taking a true moral and ethical 

approach, with the individual at the centre of all of the decisions we make? Or, should we be 

looking at a combination of all of the above: a resuscitation road-map which allows high quality 

basic care, accompanied by modern technology that can assist with identifying arrest causation, 

but based on real-time, patient-focused decision-making? 

There are so many more aspects of resuscitation to be considered: causes; prevention; 

recognition; management; and decision-making to name but a few. And there are so many 

possibilities within those aspects too: the education; the skills; the tools; the people; the effects; 

the outcomes. Quite rightly, the time is upon us to break the taboo and talk about such topics as 

applying patient choice and dignity in dying alongside the more professionally concerning areas 

of legal and regulatory care. 

Resuscitation Today offers the opportunity to consider all of these aspects and more; and you 

are welcome to submit your own work for publication – I look forward to receiving submissions 

for review that range from ‘simple’ position-pieces to ‘complex’ analytical research papers. From 

novices who may be experimenting with their investigative genes, to experts in the field who can 

offer academic challenge to the ‘norm’. 

Get in touch, submit comments and work at: info@mediapublishingcompany.com 

Paul Jones (MRes; BSc; fHEA; Paramedic) 

4

Resuscitation 

and Emergency 

Care 

A full range of products for 

use in an emergency and 

resuscitation situation. 

• Bag-Valve-Mask (BVM) 

• Pocket Resuscitation Mask 

• Airway Management Devices 

• Video Laryngoscopy 

• Oxygen Therapy Masks 

The complete solution from 

the respiratory care specialists 

To view the full range visit 

www.intersurgical.co.uk/info/emergency 

lnteract with us 

Quality, innovation and choice 

www.intersurgical.co.uk

CLINICAL PAPER 

AIRWAY MANAGEMENT IN THE EMERGENCY 

DEPARTMENT (THE OCEAN-STUDY) - A PROSPECTIVE 

SINGLE CENTRE OBSERVATIONAL COHORT STUDY 

Michael Bernhard 1,2,3† , Sönke Nils Bax 2,7*† , Thomas Hartwig 2 , Maryam Yahiaoui-Doktor 4 , Sirak Petros 5 , Sven 

Bercker 6 , Alexandra Ramshorn-Zimmer 2 and André Gries 2 

Reproduced with permission from the Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. (2019) 27:20 doi: 10.1186/s13049-019-0599-1 

Abstract 

Background 

Emergency airway management (AM) is a major key for successful 

resuscitation of critically ill non-traumatic (CINT) patients. Details of 

the AM of these patients in German emergency departments (ED) are 

unknown. This observational study describes epidemiology, airway 

techniques, success rates and complications of AM in CINT ED patients 

in the resuscitation room (RR). 

Methods 

Data was collected prospectively on adult CINT patients admitted to 

the RR of a single German university ED September 2014 to August 

2015. Patient characteristics, out-of-hospital and in-hospital RR AM, 

complications and success rates were recorded using a self-developed 

airway registry form. 

Results 

During the study period 34,303 patients were admitted to the ED, 

out of those 21,074 patients for non-trauma emergencies. Suffering 

from severe acute life-threatening problems, 532 CINT patients were 

admitted to the RR. 150 (28.2%) CINT patients had received out-ofhospital 

AM. In 16 of these cases (10.7%) the inserted airway needed to 

be changed after RR admission (unrecognized oesophageal intubation: 

n = 2, laryngeal tube exchange: n = 14). 136 (25.6%) CINT patients 

without out-of-hospital AM received RR AM immediately after admission. 

The first-pass and overall success rate in the RR were 71 and 100%, 

respectively, and multiple intubation attempts were necessary in 

29%. A lower Cormack/Lehane (C/L) grade was associated with less 

intubation attempts (C/L1/2 vs. 3/4: 1.2 ± 0.5 vs. 1.8 ± 1.2, p = 0.0002). 

Complication rate was 43%. 

Conclusions 

OcEAN demonstrates the challenges of AM in CINT patients in a 

German ED RR. We propose a nation-wide ED airway registry to better 

track outcomes in the future. 

Keywords 

Airway management, Emergency department, Resuscitation room, Firstpass 

success, Complications 

Background 

Methods 


Critically ill patients frequently require airway management in the field 

or in the Emergency Department (ED) [1]. Several investigations have 

shown that emergency airway management in the field and in the ED 

is associated with adverse events and complications (e.g., hypoxemia, 

oesophageal intubation, hypotension) [2, 3]. However, inadequate 

oxygenation and ventilation will lead to wrong outcome and therefore 

emergency airway management is of priority in resuscitation of critically 

ill patients [4, 5]. 

Studies have demonstrated that the number of intubation attempts 

is associated with increasing complication rates, therefore, the “firstpass 

intubation success” is an important concept in emergency airway 

management [6, 7]. ED Airway registries exist in some countries (e.g., 

Australia [8], North America [9, 10], Korea [11], Japan [12]), however 

data on emergency airway management in German EDs are still 

missing. 

The aim of this study is to evaluate airway management in critically 

ill patients in the resuscitation room (RR) of a German ED in order to 

describe incidence, devices, techniques, success and complication 

rates. 

Study design 

This prospective single centre observational cohort [Observation of 

airway management in Emergency Department (OcEAN)] study was 

carried out from 1 September 2014 to 31 August 2015 in the ED of 

the University Hospital of Leipzig, Germany. The OcEAN study was 

approved by the ethical committee of the Medical Faculty of the 

University of Leipzig, Germany (265–14-25,082,014). 

Setting 

More than 34,000 patients are managed annually in the ED of the 

University Hospital of Leipzig, a level 1 trauma centre. However, 

about 50% of patients suffering from non-traumatic acute problems 

or emergencies. The out-of-hospital emergency care is provided by 

an EMS system staffed with paramedics and EMS physicians. In our 

institution, all non-traumatic critically ill patients in the RR are treated 

by a team of two nurses, one resident and one senior physician with 

emergency and intensive care competency. Patients fulfilling the nontrauma 

RR activation criteria according to Additional file 1: Table S1 

(in the Supplemental material) are admitted to the RR, the others are 

treated in other regions of the ED as the observation unit or one of the 

single cabins. 

6


Study definition and data collection 

All adult non-traumatic critically ill patients needing airway management 

in the ED RR were consecutively included. Paediatric and trauma 

patients were excluded. For further analysis, data were documented 

in a self-developed and implemented airway registry form. The airway 

registry form included the “Utstein airway core variables” established 

in the out-of-hospital airway management, as well as parameters 

implemented in out-of-hospital and ED airway registries in North 

America and Austria, as well as other out-of-hospital studies from 

Germany [4, 5, 8, 9, 13-16]. 

The OcEAN airway registry form was completed in the RR, any missing 

data were followed up through interviews with the staff involved or from 

the medical records. 

The OcEAN airway registry form included the patient’s characteristics 

(age, gender, weight, high, body mass index), out-of-hospital triage score 

using American Society of Anesthesiology (ASA) score [17] at hospital 

admission and National Advisory Committee of Aeronautics (NACA) score 

in order to stratify the patient cohort [18], as well as the chief complaint 

leading to ED admission [cardiac arrest, unconsciousness (Glasgow 

coma scale [19] < 9), respiratory failure, shock]. 

The out-of-hospital airway management records were reviewed by the 

main investigator [airway management technique performed by EMS 

physicians including endotracheal intubation, supraglottic airway device 

(SAD), cricothyroidotomy, success of airway management, use of 

capnography]. 

The ED airway management was recorded, including patient position 

[back-up head elevated (BUHE [20]) or supine position], immobilization, 

and airway device [Macintosh blade, video laryngoscope, SAD 

(laryngeal tube, laryngeal mask airway), cricothyroidotomy, tracheotomy 

tube]. The number of intubation attempts per patient was also recorded. 

An airway management attempt was defined as the insertion of the 

airway device in the mouth (i.e., single passage of a laryngoscopy 

blade behind the lips, insertion of SAD). Multiple intubation attempts 

were defined as more than one insertion attempt. Per our institutional 

safety protocol, physicians had to handover the airway procedure to 

another physician after a second failed attempt at airway management. 

Difficult airway characteristics were described using parameters of the 

LEMON law (look external, evaluate 3–3-2 rule, Mallampati score [21], 

obstruction, immobilisation). Degree of visualization of the vocal cords 

was described using Cormack/Lehane (C/L) grade [22, 23] as assessed 

by direct or video laryngoscopy. The intubations’ difficulty scale (IDS) 


Fig. 1 Study cohort: ED = emergency department, CINT = critically ill non-traumatic, RR = resuscitation room 

7


Table 1 Patient’s characteristics 

out-of-hospital airway management (n = 150) ED airway management (n = 136) p 

Epidemiology 

age (years), MV ± SD, 66 ± 16 65 ± 18 0.730 

Median, min-max 69, 18–94 71, 20–89 

Weight (kg), MV ± SD, 83 ± 27 81 ± 22 0.403 

Median, min-max 80, 42–180 80, 40–150 

Hight (cm), MV ± SD, 170 ± 32 170 ± 9 0.992 

Median, min-max 170, 150–190 170, 140–190 

BMI (kg/m 2 ), MV ± SD, 28 ± 8 28 ± 7 0.419 

Median, min-max 28, 15–58 26, 16–59 

Male Gender [n, (%)] 86 (57.3%) 82 (60.2%) 0.611 

NACA (points), MV ± SD, 5.3 ± 0.8 4.8 ± 0.7 0.001 

Median, min-max 5.5, 3–6 5, 3–6 

ASA (points), MV ± SD, 3.5 ± 1.3 3.2 ± 0.9 0.007 

Median, min-max 4, 1–6 3, 1–5 

Reason for airway management 

Cardiac arrest [n, (%)] 74 (49.3%) 9 (6.6%) < 0.001 

Unconsciousness [n, (%)] 50 (33.3%) 58 (42.6%) 0.105 

Respiratory failure [n, (%)] 18 (12.0%) 50 (36.8%) < 0.001 

Hemodynamic instability [n, (%)] 8 (5.3%) 19 (14.0%) 0.01 


was calculated for each patient [24]. A difficult intubation was defined as 

one that requires more than two attempts or an IDS ≥5 points [24]. 

For ED airway management, intubation conditions (very good = glottis 

open, good = glottis open and less combative patient, poor = glottis 

nearly closed and combative patient, very bad = glottis closed) were 

recorded. Moreover, any complication during RR airway management 

was documented. Complications (e.g. oxygen desaturation, 

hypotension) were defined in accordance to Sakles et al. [6]. 

Statistical analysis 

Data were entered into Microsoft Excel 2014 (Microsoft, Germany) and 

analysed using SPSS (IBM-Statistics, Version 20, IBM Inc., Armonk, NY, 

USA). Descriptive statistics included number or percentages, mean 

(SD), median and minimal to maximal value. Ch i2 -test or, as appropriate, 

Fisher’s exact test were used to compare groups of binary data and 

to test for trends. For all analyses, actual P-values were reported 

and all tests were two-tailed. Statistically significant differences were 

considered at p < 0.05 level. 

Results 

During the 12-month study period, 34,303 patients were admitted to the 

ED. 13,229 patients with 592 treated in the RR were excluded due to 

trauma as leading cause of admission. 21,074 patients were admitted 

for non-traumatic emergencies, with 537 patients directly admitted to 

the RR (2.54%). After excluding five patients due to incomplete datasets, 

286 critically ill non-traumatic patients receiving airway management in 

the RR were further investigated (53.8%). 

In 150 (52.4%) patients, airway management was performed by EMS 

before and in 136 (47.6%) patients by ED staff after admission to the RR 

(Fig. 1). In 11 (7.3%) patients of the EMS group, the airway was secured 

with a laryngeal tube by paramedics. In 7 out of these 11 (63.6%) cases, 

an EMS physician had changed the airway device into an endotracheal 

tube in the out-of-hospital setting. In 16 (10.7%) patients of the EMS 

group, the airway device had to be changed after RR admission due 

to various reasons. The patient characteristics in the EMS and the RR 

management group were comparable (Table 1). However, according 

to the out-of-hospital triage score, patients with out-of-hospital airway 

management had a higher NACA (5.3 ± 0.8 vs. 4.8 ± 0.7, p = 0.001) and 

ASA score (3.5 ± 1.3 vs. 3.2 ± 0.9, p = 0.007) in comparison to patients 

with in-hospital airway management in the RR. The leading indication 

for airway management in the field and the RR setting differ significantly, 

with cardiac arrest in the out-of-hospital setting and unconsciousness as 

well as respiratory failure in the RR setting (Table 1). 

Patients with out-of-hospital airway management in the 

resuscitation room 

Patients who received airway management by EMS physicians (n = 150) 

underwent endotracheal intubation or laryngeal tube insertion in 90.7% 

(n = 136) and 9.3% (n = 14), respectively. Out of hospital capnography 

was used in 82.7%. Oesophageal intubation was detected in two cases 

(1.5%) of the out-of-hospital intubation group. In one of these patients 

capnography had not been used in the field or during transport. Both 

patients were admitted with on-going cardiopulmonary resuscitation and 

ED physicians secured the airway within the first intubation attempt using 

direct laryngoscopy (each C/L grade 1). In both cases, there were no 

predicted or occurred difficult airways using LEMON law and IDS score. 

8


In the 14 patients with out-of-hospital inserted laryngeal tubes, we 

observed insufficient ventilation (e.g. airway leakage) in 8 cases 

(57.1%), in 75% without out-of-hospital use of capnography. During 

the RR period, all 14 patients with laryngeal tube were successfully 

intubated using direct vs. video laryngoscopy (42.9%, n = 6 vs. 57.1%, 

n = 8) within 1.3 ± 0.5 (Median: 1, min-max 1–2) vs. 1.9 ± 1.4 attempts 

(Median: 1.5, min-max 1–5), respectively. We did not observe a 

significant difference according to LEMON law (0.7 ± 0.5 vs. 0.6 ± 0.5 

points) or IDS score (2.7 ± 0.5 vs. 2.0 ± 1.9) comparing direct vs. video 

laryngoscopy, while C/L grades were significantly different (2.3 ± 1.0 vs. 

1.4 ± 0.5, p = 0.04). 

RR patients without out-of-hospital airway management 

In 136 patients, airway management was initiated first after RR 

admission. A tracheotomy tube change was necessary in 2 cases, both 

successful at the first attempt. The other patient had been intubated 

with first-pass, second-pass, and third-pass intubation success rates 

of 70.9% (n = 95), 14.9% (n = 20), and 0.8% (n = 1), respectively. 

Overall, 100% of the intubations were successful in mean after 1.3 ± 0.8 

intubation attempts (Median: 1, min-max: 1–6). Multiple intubation 

attempts were needed in 39 cases (29.1%). The intubation procedure 

was handed over to another physician in 14 cases (10.4%), as required 

by the institutional ED safety protocol. In the cases handed over, 

1.2 ± 0.4 intubations attempts were required for successful intubation by 

the next provider (Median 1, min-max: 1–2). 

Table 2 Difficult airway characteristics (n = 136) 

[n, (%)] 

anticipated difficult airway 32 (23.5%) 

Table 2 Difficult airway characteristics (n = 136) 

LEMON 

[n, (%)] 

0 points 85 (62.5%) 

anticipated difficult airway 32 (23.5%) 

LEMON ≥1 point 51 (37.5%) 

LEMON 

IDS 

0 points 85 (62.5%) 

0 points 39 (28.8%) 

LEMON ≥1 point 51 (37.5%) 

1–5 points 81 (59.6%) 

IDS 

≥ 5 points 16 (11.6%) 

0 points 39 (28.8%) 

Cormack/Lehane I 59 (43.4%) 

1–5 points 81 (59.6%) 

II 40 (29.4%) 

≥ 5 points 16 (11.6%) 

III 23 (16.9%) 

Cormack/Lehane I 59 (43.4%) 

IV 4 (2.9%) 

II 40 (29.4%) 

not documented 10 (7.4%)* 

III 23 (16.9%) 

*including 2 patients with tracheotomy tube exchange 

IV 4 (2.9%) 

not documented 10 (7.4%)* 

desaturation *including 2 (9.3%) patients(Table with tracheotomy 4). The overall tube exchange complication rate was 42.6%. 

The complication rates (and mean number of intubations attempts) 

increased according to the C/L grade 1, 2, 3 and 4 as following 24% 

(1.2 ± 0.5), 25% (1.2 ± 0.4), 24% (1.6 ± 0.8), and 75% (3.3 ± 2.2). 

Direct laryngoscopy and video laryngoscopy was used in 69.9% 

(n = 94) and 30.1% (n = 40), respectively. Overall, the needed mean 

number of intubation attempts in the direct (macintosh blade) and video 

laryngoscopy (macintosh-like blade) group with 1.2 ± 0.5 vs. 1.2 ± 0.4 

were comparable (p = 0.887). 

The percentage of anticipated difficult airways estimated by the acting 

physician was 23.5%. The prediction of difficult airways according to 

patients with at least one positive LEMON criterion and with an IDS ≥5 

points was 37.5 and 11.6%. The difficult airway characteristics of the 

patients are presented in Table 2, and the difficulties contributed to 

problems during RR intubation procedures were shown in Table 3. 

BUHE and supine, as patient positioning for endotracheal intubation, 

were used in 50.7% (n = 68) and 44.8% (n = 60), respectively. In order 

to optimize the first intubation attempt, stylets, NBA, Jackson’s position, 

BURP, and suction units were used in 91.0% (n = 122), 82.1% (n = 110), 

70.9% (n = 95), 26.9% (n = 36), and 14.2% (n = 19). 

The mean number of needed intubation attempts correlated with the 

intubation condition categories “very good/good” and “bad/very bad” with 

1.2 ± 0.5 vs. 2.2 ± 1.4 (p = 0.0001) and C/L grade 1/2 and 3/4 (1.2 ± 0.5 

vs. 1.8 ± 1.2, p = 0.0002) (Fig. 2). First-pass success was associated with 

C/L 1, 2, 3 and 4 with 79.5, 77.5, 56.5, and 25.0%, respectively. Patient 

positioning in BUHE or supine did not affect the C/L grade (BUHE vs. 

supine: C/L grade 1/2: 78.1 vs. 79.3%; C/L grade 3/4: 21.9 vs. 20.7, 

p = 0.873). Direct laryngoscopy compared with video laryngoscopy did 

not lead to better C/L grade 1/2 (81.3 vs. 73.9%, p = 0.334). 

Complications and adverse events were documented in 129 out of 

136 patients (94.9%). The most common complications and adverse 

events during RR airway management were hypotension (20.4%) and 

Discussion 

This prospective single centre study evaluated the out-of-hospital and 

ED initiated airway management in adult non-traumatic critically ill 

patients in an academic German ED during a one-year observational 

period. The primary goal was to evaluate the out-of-hospital airway 

management performed by EMS physicians at hospital arrival and to 

document the airway management in the RR setting in the ED in order to 

describe incidence, airway technique, success and complication rates. 

Several ED airway registries exist worldwide (e.g., Australia [8], North 

America Table[9, 3 Difficulties 10], Korea [11], contributed Japan [12]), to problems however during data on emergency 

resuscitation room intubation procedures (n = 129) 

[n, (%)] 

Table Secretion/blood 3 Difficulties contributed to problems during 21 (16.3%) 

resuscitation room intubation procedures (n = 129) 

Reduced mouth opening 12 (9.3%) 

[n, (%)] 

Short neck 9 (8.5%) 

Secretion/blood 21 (16.3%) 

Immobilisation 7 (5.4%) 

Reduced mouth opening 12 (9.3%) 

Untrained personal 7 (5.4%) 

Short neck 9 (8.5%) 

Retrognathy 4 (3.1%) 

Immobilisation 7 (5.4%) 

Patient positioning 3 (2.3%) 

Untrained personal 7 (5.4%) 

Anatomy pharynx/larynx 3 (2.3%) 

Retrognathy 4 (3.1%) 

Foreign body 1 (1.6%) 

Patient positioning 3 (2.3%) 

Anatomy neck 0 (0.0%) 

Anatomy pharynx/larynx 3 (2.3%) 

Malfunction equipment 0 (0.0%) 

Foreign body 1 (1.6%) 

Anatomy neck 0 (0.0%) 

Malfunction equipment 0 (0.0%) 


9


Fig. 2 Number of mean intubations attempts according to intubations conditions and Cormack/Lehane grade. MV = mean value, 

SD = standard deviation 

Fig. 2 Number of mean intubations attempts according to intubations conditions and Cormack/Lehane grade. MV = mean value, 

SD = standard deviation 

airway management in German EDs are still missing. Thereby, the 

introduction of an airway registry is an important issue for quality 

assurance [25]. To our knowledge, this is the first study investigating RR 

airway management in non- traumatic patients in a German ED setting. 

As described in the study protocol only critically ill non-traumatic 

patients were investigated in this study and patients with trauma were 

excluded. However, this study population may restrict the comparability 

of our results to other airway registries [8, 10, 32, 33]. 


In patients with out-of-hospital airway management admitted to the RR we 

found a low incidence of oesophageal intubation with 1.5% in comparison 

to other studies that reported a rate of 5.1–6.7% in German physicianstaffed 

EMS [26, 27]. Interestingly, 9.3% of the admitted patients were 

treated with a laryngeal tube. According to institutional policy all 14 

patients with SADs were intubated immediately after RR admission. In 

57% of these SAD patients ventilation was insufficient at RR admission. 

Comparable complications and adverse events rates after out-of-hospital 

laryngeal tube insertion were also reported elsewhere [28, 29, 30]. One of 

the major concerns is that only 82.7% of patients received capnography 

in the out-of-hospital setting. Oesophageal intubations, as well as 

insufficient ventilation after insertion of a laryngeal tube would likely be 

recognized during the out-of-hospital airway management if capnography 

would solely have been used [28, 31]. 

Table 4 Complications during airway management in 

resuscitation room (n = 129) 

Hypotension (decrease in SBP to < 90 mmHg) 26 (20.2%) 

Table 4 Complications during airway management in 

desaturation (decrease in oxygen saturation ≥ 10%) 12 (9.3%) 

resuscitation room (n = 129) 

Hypotension 

oesphageal 

(decrease 

intubation 

in SBP to < 90 mmHg) 26 

7 

(20.2%) 

(5.4%) 

desaturation aspiration (decrease in oxygen saturation ≥ 10%) 124 (9.3%) (3.1%) 

oesphageal endobronchial intubation intubation 7 (5.4%) 2 (1.6%) 

aspiration cardiac arrest 4 (3.1%) 4 (3.1%) 

endobronchial complicationsintubation 2 (1.6%) 55 (42.6%) 

SBP systolic blood pressure 

cardiac arrest 4 (3.1%) 

complications 55 (42.6%) 

SBP systolic blood pressure 

In the second part of this investigation, the observed sample size of 

136 ED initiated airway procedures in our ED is comparable with those 

in other large ED airway registries (including 50–90 cases per year) 

[10, 34]. In addition, we investigated RR patients with out-of-hospital 

airway management already performed by EMS physicians. However, 

16 of theses cases with insufficient ventilation and oxygenation needed 

immediate airway management after hospital arrival. The observed 

first-pass success rate of the 134 patients receiving invasive airway 

management after RR admission was 70.9%. These findings were in 

line with previous analysis of ED airway registry reporting a first-pass 

success range of 61–94% [7, 8, 10, 33, 34, 35]. However, the first-pass 

success rate in this study was lower than in the meta-analysis by Park 

et al. [36] founded 84% as an ED benchmark. The aim of improving 

first-pass success should be paramount since it is well known that 

multiple intubation attempts are associated with significant increases 

in complications [6, 7, 12]. The overall airway management success in 

this investigation was 100% and comparable with the results of other 

airway registries and ED studies [7, 10, 32, 34]. Overall, the airway 

of all patients was secured using endotracheal intubation, excluding 

two patients with tracheostomy tube change (1.5%). Contrary to other 

investigations [10, 25, 32], fiberoptic intubation and cricothyroidotomy 

was not performed during the study period. However, with an 

anticipated incidence of cricothyroidotomy of 0.3%, it is likely only a 

question of time for this procedure to also be seen in our institution. 

The intubation procedure was performed in two-thirds of cases using 

direct laryngoscopy with Macintosh blades, and less often using C-MAC 

video laryngoscopes with Macintosh-like blades. Other investigations 

found a comparable rate of video laryngoscopy use in 39–48% [8, 34]. 

10


It is anticipated that the incidence of video laryngoscopy assisted 

intubation will increase in the upcoming years [10, 33]. 

A difficult airway was anticipated in 23.5% of patients receiving RR 

airway management. One-third of airways were predicted as difficult 

per LEMON law, and a moderate to severe intubation situation was 

observed in 11.6% per IDS. These findings were in the range with 

data reported from other airway registries [33]. In line with previous 

investigations, problems associated with difficulties during ED airway 

management were most often secretion or blood in the pharynx, 

reduced mouth opening, short neck and immobilization [4]. In 

contrast to Khandelwal et al. [20] and Turner et al. [37], we did not 

find an association between C/L grade and BUHE or supine position 

in ED airway management. Hossfeld et al. [38] reported an improved 

visualization using video laryngoscopes (with Macintosh-like blade) 

compared to standard Macintosh laryngoscopes. However, in line 

with some investigations [39], we found similar C/L grade 1/2 using 

video laryngoscopes in comparison to direct laryngoscopy with 

standard Macintosh blade. 

Complications associated with the intubation procedures were 

observed in 42.6%. Other studies reported complication rates 

between 10 and 29% [8, 32, 33, 34]. Differences in the reported 

complication rates are at least in part due to varying definitions 

of complications in other airway registries. Hypotension was the 

most common reported complication with 20%, which is in line with 

other investigations reporting an incidence of 7–18% [40, 41]. The 

incidence of immediately detected and corrected oesophageal 

intubations in 5.4% was in line with other ED studies [8, 34]. 

Immediate recognition of oesophageal intubation using capnography 

is imperative to prevent hypoxemia [31]. In the RR, we used 

capnography without exception. Desaturation occurred in this study 

with 9.3% and which is comparable to other out-of-hospital and ED 

airway registries (11–16%) [8, 33, 42]. 

Our study suffers from several limitations. At first, this study was 

carried out at a single institution and so the results cannot be taken 

to be representative of all EDs in Germany, or other places in the 

world. Nevertheless, this study provided detailed information about 

German RR airway management in critically ill non-traumatic patients 

for the very first time. Furthermore, the study was observational in 

nature, neither randomized nor controlled. The team leader was 

required to complete the airway registry form. Reporter bias is difficult 

to exclude, and there may be a tendency to document an improved 

glottis visualisation and underreport complications. The self-developed 

emergency airway registry form was combined with the information 

of medical charts, which has been reported to be beneficial [45]. The 

team leaders were instructed repeatedly and attempts to improve 

accuracy were made by interviewing the ED physicians and by 

reviewing the medical record. 

Due to the fact that in Germany a multi-centre airway registry does not 

exist, we suggest that this should be initiated in order to analyse the 

situation countrywide. Studies identified more than eleven emergency 

airway registries that sometimes widely differed concerning inclusion 

period, inclusion criteria, definition of complications and application of 

newer methods of emergency airway management [47]. Comparability 

of the reported results and first-pass-success rates is only possible 

to a limited extent. Therefore, standardised reporting forms should 

be used in order to make the results comparable. Using the data, 

benchmarking would be possible, with systematic investigation on 

first-pass success, techniques, complications and adverse events. 

Moreover, the effect of new techniques in the ED setting concerning 

emergency airway management over the years will be detectable as 

described by Brown et al. [34]. Using these data, procedural and 

structural optimisation of this important field will be possible. 

Conclusions 

As a limitation of this study, we need to mention that we performed 

but did not document specific procedures for preoxygenation 

(e.g., delayed sequence intubation using non-invasive ventilation 

for preoxygenation [43]) or apnoeic oxygenation [44]. Including 

these procedures to further study protocols seems to be necessary. 

Moreover, the kind of laryngoscopy (video vs. direct laryngoscopy) 

should be documented in further studies. Cardiac arrest as a major 

complication during ED airway management occurred in the present 

investigation at a rate of 3.1%, which was comparable to other outof-hospital 

and ED investigations with a reported range between 

1.5–4.4% [8, 34, 45]. 

Rapid sequence induction using neuromuscular blocking agents was 

performed in 87.5% in the RR setting. These findings are in line with 

other data from ED airway registries described percentages between 

73 and 92% [10, 25, 32, 34]. However, there are other data from 

a Japanese ED airway registry stated a lower rate of RSI use with 

only 20% [35]. Comparable with other investigations [34], the most 

frequent used neuromuscular blocking agent was rocuronium in 85%. 

Taking together, the game changer in out-of-hospital airway 

management are preoxygenation (e.g. delayed sequence intubation), 

using of video laryngoscopy and muscle relaxation [43, 46]. 

In conclusion, RR airway management of critically ill non-traumatic 

patients has substantial challenges. Our study results confirm that 

RR airway management is a high-risk procedure. We propose a 

nation-wide airway registry to better track outcomes of RR airway 

management in the future. 

Abbreviations 

AM: Airway management; ASA: American Society of Anaesthesiology; 

BUHE: Back-up head elevated or supine position; C/L: Cormack/ 

Lehane score; CINT: Critically ill non-traumatic patients; ED: 

Emergency department; EMS: Emergency medical service (in 

Germany with emergency doctors and emergency paramedics); IDS: 

Intubations’ difficulty scale; LEMON: Look external, evaluate 3–2-2 

rule, Malampati score, obstruction, immobilisation; NACA: National 

Advisory Committee of Aeronautics; OcEAN: Observation of airway 

management in Emergency Department; RR: Resuscitation room; 

SAD: Supraglottic airway device 

Acknowledgements 

Not applicable 

Funding 

This study was funded solely by departmental resources. 


11



Availability of data and materials 

The datasets used and/or analysed during the current study are 

available from the corresponding author on reasonable request. 

Authors’ contributions 

MB and SNB contributed equally to the manuscript. MB, SNB, TH, 

AG and ARZ conceived the study, collected the data, and performed 

first and subsequent drafts. MB, SNB, MYD, AG, ARZ performed the 

statistical analysis of the data. SP reviewed and constructively criticised 

the manuscript. All authors read and approved the final manuscript. 

Ethics approval and consent to participate 

The OcEAN study was approved by the ethical committee of the 

Medical Faculty of the University of Leipzig, Germany (265–14- 

25,082,014). 

Consent for publication 

Not applicable. 

Competing interests 

The authors declare that they have no competing interests. 

Publisher’s Note 

Springer Nature remains neutral with regard to jurisdictional claims in 

published maps and institutional affiliations. 

Author details 

† 

Michael Bernhard and Sönke N. Bax contributed equally to the 

manuscript.. * Correspondence: soenke@bax-se.de; soenke.bax@ 

paracelsus-kliniken.de. 1 Emergency Department, University Hospital of 

Düsseldorf, Düsseldorf, Germany. 2 Emergency Department, University 

Hospital of Leipzig, Leipzig, Germany. 3 Working group “Trauma and 

Resuscitation Room Management“, Task Force Emergency Medicine, 

German Society of Anaesthesiology and Intensiv care Medizin, 

Nürnberg, Germany. 4 Institute for Medical Informatics, Statistics and 

Epidemiology (IMISE), University of Leipzig, Leipzig, Germany. 5 Medical 

Intensive Care Unit, University Hospital of Leipzig, Leipzig, Germany. 

6 

Department of Anaesthesiology and Intensive Care Medicine, University 

Hospital of Leipzig, Leipzig, Germany. 7 Emergency Department, 

Paracelsus Hospital of Henstedt-Ulzburg, Wilstedter Straße 134, 

D-24558 Henstedt-Ulzburg, Germany. 

References 

1. Cook TM, Woodall N, Harper J, Benger J. Fourth National Audit 

Project. Major complications of airway management in the UK: 

results of the fourth National Audit Project of the Royal College of 

Anaesthetists and the difficult airway society. Part 2: intensive care 

and emergency departments. Br J Anaesth. 2011;106:632–42. 

2. Cook TM, MacDouglas-Davis SR. Complications and failure of 

airway management. BJA. 2013;109(Suppl 1):I68–85. 

3. Cook TM, Behringer EC, Benger J. Airway management outside the 

operating room: hazardous and incompletely studied. Curr Opin 

Anesthesiol. 2012;25:461–9. 

4. Bernhard M, Mohr S, Weigand MA, Martin E, Walther A. Developing 

the skill of endotracheal intubation: implication for emergency 

medicine. Acta Anaesthesiol Scand. 2012;56:164–71. 

5. Mohr S, Weigand MA, Hofer S, Martin E, Gries A, Walther A, 

Bernhard M. Developing the skill of laryngeal mask insertion - a 

prospective single center study. Anaesthesist. 2013;62:447–52. 

6. Sakles JC, Chiu S, Mosier J, Walker C, Stolz U. The importance of 

the first pass success when performing orotracheal intubation in the 

emergency department. Acad Emerg Med. 2013;20:71–8. 

7. Bernhard M, Becker TK, Gries A, Knapp J, Wenzel V. The first shot 

is often the best shot: first-pass intubation success in emergency 

airway management. Anesth Analg. 2015;121(5):1389–93. 

8. Fogg T, Annesley N, Hitos K, Vassiliadis J. Prospective observational 

study of the practice of endotracheal intubation in the emergency 

department of a tertiary hospital in Sydney, Australia. Emerg Med 

Ausstalas. 2012;24:617–24. 

9. Bair AE, Filbin MR, Kulkarni RG, Walls RM. The failed intubation 

attempt in the emergency department: analysis of the prevalence, 

rescue techniques, and personnel. J Emerg Med. 2002;23(2):131–40. 

10. Sagarin MJ, Barton ED, Chng YM, Walls RM on behalf of the 

National Emergency Airway Registry (NEAR) Investigators. Airway 

management in the US and Canadian emergency medicine 

residents: a multicenter analysis of more than 6000 endotracheal 

intubations attempts. Ann Emerg Med. 2005;46:328–36. 

11. Cho J, Cho YS, You JS, Lee HS, Kim H, Chung HS. Current status 

of emergency airway management for elderly patients in Korea: 

multicentre study using the Korean emergency airway management 

registry. Emerg Med Australas. 2013;25:439–44. 

12. Hasegawa K, Shigemitsu K, Hagiwara Y, Chiba T, Watase H, Brown 

CA, Brwon DF. Japanese emergency medicine research Alliance 

investigators. Association between repeated intubations attempts 

and adverse events in emergency department: an analysis of a 

multicenter prospective observationsal study. Ann Emerg Med. 

2012;60:749–54. 

13. Breckwoldt J, Klemstein S, Brunne B, Schnitzer L, Arnzt HR, 

Mochmann HC. Expertise in prehospital endotracheal intubation 

by emergency medicine physicians – comparing “proficient 

performers” and “experts”. Resuscitation. 2012;83:434–9. 

14. Davis DP. The need for standardized data reporting for prehospital 

airway management. Crit Care. 2011;15:133. 

15. Lossius HM, Sollid SJM, Rehn M, Lockey DJ. Revisiting the value 

of pre-hospital tracheal intubation: an all time systematic literature 

review extracting the Utstein airway core variables. Crit Care. 

2011;15:R26. 

16. Sollid SJM, Lockey D. Lossius HM and pre-hospital advanced 

airway management expert group: a consensus-based template 

for uniform reporting of data from pre-hospital advanced airway 

management. Scand J Trauma Resus Emeg Med. 2009;17:58. 

17. Saklad M. Grading of patients for surgical procedures. 

Anesthesiology. 1941;2:281–4. 

18. Tryba M, Brüggemann H, Echtermeyer V. Klassifizierung von 

Erkrankungen und Verletzungen im Notarztrettungssystemen. 

Notfallmedizin. 1980;6:725–7. 

19. Teasdale G, Jennet B. Assessment of coma and impaired 

consiousness. A practical scale. Lancet. 1974;2:81–4. 

20. Khandelwal N, Khorsand S, Mitchell SH, Joffe AM. Head-elevated 

patient positioning decreases complications of emergent tracheal 

intubation in the Ward and Intensive care unit. Anesth Analg. 

2016;122:1101–7. 

21. Mallampati SR, Gatt SP, Gugino LD, Desai SP, Waraksa B, Freiberger 

D, Liu PL. A clinical sign to predict difficult tracheal intubation: a 

prospective study. Can Anaesth Soc J. 1985;32:429–34. 

22. Cormack RS, Lehane J. Difficult tracheal intubation in obstetrics. 

Anaesthesia. 1984;39:1105–011. 

23. Samsoon GL, Young JR. Diffcult tracheal intubation: a retrospective 

study. Anaesthesia. 1987;42:487–90. 

24. Adnet F, Borron SW, Racine SX, Clemessy JL, Fournier JL, Plaisance 

P, Lapandry C. The intubation difficulty scale (IDS). Anesthesiology. 

1997;87:1290–7. 

12


25. Phelan MP, Glauser J, Yuen HW, Sturges-Smith E, Schrump SE. 

Airway registry: a performance improvement surveillance project 

of emergency department airway management. Am J Med Qual. 

2010;25:346–50. 

26. Gries A, Sikinger M, Hainer C, et al. Time in care of trauma patients 

in the air rescue service: implications for disposition? Anaesthesist. 

2008;57:562–70. 

27. Timmermann A, Russo SG, Eich C, et al. The out-of-hospital 

esophageal and endobronchial intubations performed by 

emergency physicians. Anesth Analg. 2007;104:619–23. 

28. Bernhard M, Beres W, Timmermann A, Stepan R, Greim CA, Kaisers 

UX, Gries A. Prehospital airway management usingthe laryngeal 

tube. An emergency department point of view. Anaesthesist. 

2014;63:589–96. 

29. Bernhard M, Hossfeld B, Kumle B, Becker TK, Böttiger BW, Birkholz 

T. Don’t forget to ventilate during cardiopulmonary resuscitation 

with mechanical chest compression devices. Eur J Anaesthesiol. 

2016;33:553–6. 

30. Schalk R, Seeger FH, Mutlak H, et al. Complications associated with 

the prehospital use of laryngeal tubes – a systematic analysis of risk 

factors and strategies for prevention. Resuscitation. 2014;85:1629–32. 

31. Von Goedecke A, Herff H, Paal P, Dörges V, Wenzel V. Field airway 

management disasters. Anesth Analg. 2007;104:481–3. 

32. Walls RM, et al. Emergency airway management: a multi-center 

report of 8937 emergency department intubations. J Emerg Med. 

2011;41:347–54. 

33. Fogg T, Alkhouri H, Vassiliadis J. The Royal North Shore Hospital 

Emergency Department airway registry: closing the audit loop. 

Emerg Med Australisia. 2016;28:27–33. 

34. Brown CA, et al. Techniques, success and adverse events of 

emergency department adult intubations. Ann Emerg Med. 

2015;65:363–70. 

35. Hasegawa K, et al. Emergency airway management in Japan: 

interim analysis of a multi-center prospective observational study. 

Resuscitation. 2012;83:428–33. 

36. Park L, Zeng I, Brainard A. Systematic review and meta-analysis 

of first-pass success rate in emergency department intubation: 

creating a benchmark for emergency airway care. Emerg Med 

Austral. 2017;29:40–8. 

37. Turner JS, Ellender TJ, Okonkwo ER, et al. Feasibility of upright 

patient positioning and intubation success rates at two academic 

emergency departments. Am J Emerg Med. 2017;35:986–92. 

38. Hossfeld B, Frey K, Doerges V, Lampl L, Helm M. Improvement in 

glottic visualisation by using the C-MAC PM video laryngoscope as 

a first-line device for out-of-hospital emergency tracheal intubation. 

Eur J Anaesthesiol. 2015;32:425–31. 

39. Carlson JN, Crofts J, Walls RM, Brown CA. Direct vs. video 

laryngoscopy for intubating adult patients with gastrointestinal 

bleeding. West J Emerg Med. 2015;16:1052–6. 

40. Newton A, Ratchford A, Khan I. Incidence of adverse events during 

prehospital rapid sequence intubation: a review of one year on 

the London helicopter emergency medical service. J Trauma. 

2008;64:487–92. 

41. Rognas L, Hansen TM, Kirkegaard H, Tonnesen E. Pre-hospital 

advanced airway management by experienced anaesthesiologists: 

a prospective descriptive study. Scand J Trauma Resusc Emerg 

Med. 2013;21:58. 

42. Helm M, Kremers G, Lampl L, Hossfeld B. Incidence of transient 

hypoxia during pre-hospital rapid sequence intubation by 

anaesthesiologists. Acta Anaesthesiol Scand. 2013;57:199–205. 

43. Weingart SD, Trueger S, Wong N, Scofi J, Singh N, Rudolph SS. 

Delayed sequence intubation: a prospective observational study. 

Ann Emerg Med. 2015;65:349–55. 

44. Oliveira LE, Silva L, Cabrera D, Barrionuevo P, et al. Effectiveness 

of apneic oxygenation during intubation: a systematic review and 

meta-analysis. Ann Emerg Med. 2017;70:483–94. 

45. Bloomer R, Burns BJ, Ware S. Improving documentation in 

prehospital rapid sequence induction: investigating the use of a 

dedicated airway registry form. Emerg Med J. 2013;30:324–6. 

46. Hossfeld B, Bein B, Böttiger BW, Bohn A, Fischer M, Gräsner JT, 

Hinkelbein J, Kill C, Lott C, Popp E, Rössler M, Schaumberg A, 

Wenzel A, Bernhard M. Recommended practice for out-of-hospital 

emergency anaesthesia in adults. Statement from the out-of-hospital 

emergency Anaesthesia working Group of the Emergency Medicine 

Research Group of the German Society of Anaesthesiology and 

Intensive Care. Eur J Anaesthesiol. 2016;33:881–97. 

47. Girrbach FF, Hilbig F, Michael M, Bernhard M. Systematic analysis of 

airway registries in emergency medicine. Anaesthesist. 2018;67:664–73. 

WHY NOT WRITE FOR US? 

Resuscitation Today welcomes the submission of 

clinical papers, case reports and articles that you 

feel will be of interest to your colleagues. 

The publication is mailed to all resuscitation, A&E and anaesthetic departments 

plus all intensive care, critical care, coronary care and cardiology units. 

All submissions should be forwarded to info@mediapublishingcompany.com 

If you have any queries please contact the publisher Terry Gardner via: 

info@mediapublishingcompany.com 


13

The new corpuls cpr has redefined the standard for the next generation 

of chest compression devices used by the emergency services and 

hospitals. 

PROTECT YOUR AMBULANCE CREW 

USER FRIENDLY 

The corpuls cpr has the capability of being able to 

supply fully automated chest compressions, ensuring less 

strain on rescue workers, particularly when performed in 

a moving vehicle. The corpuls cpr is able to check its 

position of the compression pad after each ventilation 

break or 100 compressions (in continuous mode) to 

compensate for any impact cpr has on the patient’s 

thorax. 

The corpuls cpr comes with clearly visible colour 

display and easy to access control panel buttons. 

The compression depth and/or rate, can be manually 

adjusted when required. 

LOW RUNNING COSTS 

REUSABLE COMPRESSION PADS 

The compression pads come in two sizes and can be disinfected with all common agents, keeping running costs to a 

minimum. This ensures that the corpuls cpr can be deployed on every CPR job without financial impact.

The Tireless Arm that 

saves lives 

NEW CASE STUDIES AVAILABLE 

corpuls cpr compliant to current ERC/AHA guidelines. 

sales@theortusgroup.com www.theortusgroup.com T: +44 0845 4594705

Introducing 

The first infant manikin that helps you visualise the effects of CPR 

- both for compressions and ventilations. 

Illuminating 

Infant CPR 

Seeing is 

believing 

Developed with the help of 

European infant resuscitation 

experts. Brayden Baby is ideal for 

Paediatric BLS, EPALS and EPILS 

Launched at the 2019 European Paediatric Resuscitation & Emergency 

Medicine Congress (PREM) in Ghent last month, Brayden Baby received a 

great deal of interest as it obviously fulfils and unmet need. 

There were queues to participate in the demonstration workshops over the 

two-day event, run by Liesje Andre, Resuscitation Lead for Great Ormond 

Street Hospital for Children (to 2018) and Dr Jonathan Smart of Innosonian 

Europe. 

Ms Andre stated, ‘It was a privilege to be asked to help with the development 

of the Brayden Baby manikin. Having taught paediatric resuscitation in 

acute NHS hospitals for over 25 years, I wanted a manikin that could provide 

feedback for both effective chest compressions and ventilation. This new 

infant manikin does just that. It provides the student with intuitive lights to 

enable them to visualise the correct technique for quality chest compressions 

as well as ventilation… I do believe the Brayden Baby is a game changer for 

teaching good quality infant CPR’. 

Brayden Baby’s unique features include intuitive lights that provide real-time 

feedback for ventilation training. The lights indicate when ventilations are 

correctly delivered (volume and speed) and there is realistic chest rise. The 

lights also indicate when the value delivered is too large and delivered too 

quickly. 

In addition, the Brayden Baby has lights providing real-time feedback for 

chest compressions (depth, rate, recoil and finger/thumb position). 

The head positioning to open the airway in the correct neutral position, 

jaw thrust open and interconnected mouth and nose, and large occiput 

realistically mimic a baby. The Brayden Baby also has lights to indicate 

chest compression quality and work in the same way as the awardwinning 

Brayden adult manikin. Compression depth, rate, release and 

finger/thumb position are measured and when correct, the head quality 

light illuminates. Both sets of lights help guide the student to perform 

good quality infant CPR. 

In the UK, the response to Brayden Baby has been equally positive. Kevin 

Mackie, Lead Educator, Resuscitation Council (UK), states, ‘In my opinion, 

the Brayden Baby manikin is the best infant BLS Manikin on the market today. 


Tel: 01252 344007 | 



From an educational perspective, the importance of objective feedback 

cannot be underestimated in improving performance of CPR. 

‘The Brayden Baby gives the usual visual feedback on compression rate, depth, 

position and recoil, but also now features additional lights that indicate rate 

and volume of ventilation. The ventilation resistance is the most realistic I have 

felt, and airway positioning is realistic and allows for jaw thrust to be added 

with ease. It is evident that a lot of thought has been put into the development 

of this manikin and it represents a significant contribution to the infant BLS 

training market.’ 

Brayden Baby is now available across Europe and will demonstrated at 

various international educational workshops to help improve the quality 

of infant CPR. 

Jaw thrust manoeuvre 

For more information contact paul.mulvey@welmedical.com 

Correct Ventilation 

See the video at www.welmedical.com/baby-brayden-advanced


REPEATED VITAL SIGN MEASUREMENTS IN 

THE EMERGENCY DEPARTMENT PREDICT 

PATIENT DETERIORATION WITHIN 72 HOURS: 

A PROSPECTIVE OBSERVATIONAL STUDY 

Vincent M. Quinten 1* , Matijs van Meurs 2,3 , Tycho J. Olgers 1 , Judith M. Vonk 4 , Jack J. M. Ligtenberg 1 

and Jan C. ter Maaten 1 

Reproduced with permission from the Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. (2018) 26:57 doi: 10.1186/s13049-018-0525-y 

Abstract 

Background 

More than one in five patients presenting to the emergency department 

(ED) with (suspected) infection or sepsis deteriorate within 72 h from 

admission. Surprisingly little is known about vital signs in relation 

to deterioration, especially in the ED. The aim of our study was to 

determine whether repeated vital sign measurements in the ED can 

differentiate between patients who will deteriorate within 72 h and 

patients who will not deteriorate. 

Methods 

We performed a prospective observational study in patients presenting 

with (suspected) infection or sepsis to the ED of our tertiary care 

teaching hospital. Vital signs (heart rate, mean arterial pressure (MAP), 

respiratory rate and body temperature) were measured in 30-min 

intervals during the first 3 h in the ED. Primary outcome was patient 

deterioration within 72 h from admission, defined as the development 

of acute kidney injury, liver failure, respiratory failure, intensive care unit 

admission or in-hospital mortality. We performed a logistic regression 

analysis using a base model including age, gender and comorbidities. 

Thereafter, we performed separate logistic regression analyses for each 

vital sign using the value at admission, the change over time and its 

variability. For each analysis, the odds ratios (OR) and area under the 

receiver operator curve (AUC) were calculated. 

Results 

In total 106 (29.5%) of the 359 patients deteriorated within 72 h from 

admission. Within this timeframe, 18.3% of the patients with infection and 

32.9% of the patients with sepsis at ED presentation deteriorated. Associated 

with deterioration were: age (OR: 1.02), history of diabetes (OR: 1.90), heart 

rate (OR: 1.01), MAP (OR: 0.96) and respiratory rate (OR: 1.05) at admission, 

changes over time of MAP (OR: 1.04) and respiratory rate (OR: 1.44) as well 

as the variability of the MAP (OR: 1.06). Repeated measurements of heart 

rate and body temperature were not associated with deterioration. 

Conclusions 

Repeated vital sign measurements in the ED are better at identifying 

patients at risk for deterioration within 72 h from admission than single 

vital sign measurements at ED admission. 

Keywords: Accident & emergency medicine; Patient deterioration; 

Sepsis; Vital signs 

Background 

More than one in five patients presenting to the emergency department 

(ED) with (suspected) infection or sepsis deteriorate within 72 h from 

admission, despite treatment [1]. Recent advances in research have 

improved our understanding of the pathophysiology of sepsis [2]. The 

adoption of surviving sepsis campaign (SSC) guidelines, increased 

awareness and early goal-directed therapy dramatically reduced sepsisrelated 

mortality over the past two decades [3, 4]. However, one of the 

main challenges for the physician in the ED remains to determine the 

risk of deterioration for the individual patient [2]. The numerous sepsisrelated 

biomarkers lack sensitivity and specificity for deterioration and 

are not readily available in the ED [5, 6, 7]. Despite the relative ease of 

measurement, surprisingly little is known about vital signs in relation 

to clinical outcomes, especially in the ED setting [8, 9, 10, 11]. There 

is limited evidence that oxygen saturation and consciousness level 

at ED arrival are associated with mortality, and that heart rate and 

Glasgow coma scale (GCS) are associated with intensive care unit 

(ICU) admission [9, 11]. For all other vital signs, insufficient evidence 

is available [9, 11]. The few available studies mostly studied vital 

signs used in triage systems or vital signs obtained at the time of ED 

admission [9, 12]. Almost one third of the medical patients who arrive at 

the ED with normal vital signs show signs of deterioration in vital signs 

within 24 h [13]. Our pilot study in the ED showed that vital signs change 

significantly during the patient’s stay in the ED [7]. However, surprisingly 

little is known on how to monitor and identify deteriorating patients in the 

emergency department [13]. The latest SSC guidelines recommend a 

thorough re-evaluation of routinely measured vital signs as parameter 

for response to treatment [4]. Therefore, the aim of the current study 

was to determine whether repeated vital sign measurements during 

the patient’s stay in the ED can distinguish between patients who will 

deteriorate within 72 h from admission and patients who will not. 


17


Methods 

Study design and setting 

This study is a predefined prospective observational study, part of the 

Sepsis Clinical Pathway Database (SCPD) project in our emergency 

department (ED). The SCPD project is a prospective cohort study of 

medical patients presenting to the ED with fever and/or suspected 

infection or sepsis. Data was collected in the ED of the University 

Medical Center Groningen in The Netherlands, an academic tertiary 

care teaching hospital with over 30,000 ED visits annually. 

oxygen supplementation [7]. The protocol did not change during the 

inclusion period and was not influenced by the patient’s participation 

in the study. For patients arriving at the ED with EMS and (suspected) 

sepsis, treatment with fluid resuscitation and supplementary oxygen was 

started in the ambulance by EMS personnel according to the nationwide 

EMS guidelines for sepsis in The Netherlands [14]. The average time 

from EMS dispatch call to ED arrival is 40 min in The Netherlands, but 

actual dispatch times in this study were not measured [14]. Pre-hospital 

start of treatment was not influenced by the patient’s participation in the 

study. 


This study was carried out in accordance with the Declaration of 

Helsinki, the Dutch Agreement on Medical Treatment Act and the 

Dutch Personal Data Protection Act. The Institutional Review Board of 

the University Medical Center Groningen ruled that the Dutch Medical 

Research Involving Human Subjects Act is not applicable for this study 

and granted a waiver (METc 2015/164). All participants provided written 

informed consent. 

Study population 

Data was collected between March 2016 and February 2017. 

Consecutive medical patients visiting the ED between 8 a.m. and 23 

p.m. were screened for eligibility. Inclusion criteria were: (1) age of 18 

years or older, (2) fever (> = 38 °C) or suspected infection or sepsis, 

(3) able to provide written informed consent. The clinical suspicion 

of infection or sepsis was judged by the coordinating internist acute 

medicine on duty. He/she handles all medical patient announcements 

from general practitioners or the emergency medical services (EMS), 

and medical patients that enter the ED without previous announcement. 

The judgement was based on information provided over the phone 

during the announcement, information obtained at triage and 

immediately after ED admission of the patient. Only patients with at least 

three repeated vital sign measurements during their first 3 h in the ED 

were included in the final analysis. 

Data collection 

The data collected in the SCPD project includes socio-demographic 

information, patient history, prescription drug usage, comorbidity, 

treatment parameters, results from routine blood analysis, 

questionnaires about activities of daily living, follow-up during the 

patient’s stay in the hospital and registration of various endpoints. The 

data was collected by trained members of our research staff during 

the patient’s stay in the ED and combined with data from the patient’s 

medical record for follow-up during the patient’s stay in the hospital. 

For the current study, next to the data collected for all patients included 

in the SCPD project, we repeatedly measured vital signs in 30-min 

intervals during the patient’s stay in de ED. These vital signs included 

heart rate, respiratory rate and blood pressure, measured using a 

Philips MP30 or MX550 bed-side patient monitor (Philips IntelliVue 

System with Multi-Measurement Module; Philips, Eindhoven, The 

Netherlands). Furthermore, the body temperature was measured using 

an electronic tympanic ear thermometer (Genius 2; Mountainside 

Medical Equipment, Marcy, New York, USA). 

All patients received treatment for infection or sepsis as per our 

hospital’s standardized protocol at the treating physician’s discretion. 

This protocol included intravenous antibiotics, fluid resuscitation and 

Endpoints and definitions 

The primary endpoint was patient deterioration within 72 h from ED 

admission. We defined patient deterioration as the development of 

organ dysfunction, ICU admission or death during the patient’s stay in 

the hospital. For organ dysfunction, we distinguished between acute 

kidney failure (AKI), liver failure and respiratory failure. AKI was defined 

using the Kidney Disease Improving Global Outcomes (KDIGO) criteria 

as an increase in serum creatinine by 26.5 μmol/L (0.3 mg/dL) within 

48 h or 1.5 times the baseline (known or presumed to have occurred 

within the prior 7 days) [15]. Liver failure was defined as total bilirubin 

level > 34.2 μmol/L (2.0 mg/dL) and either alkaline phosphatase or a 

transaminase level above twice the normal limit [16]. Respiratory failure 

was defined as the need for mechanical ventilation, or either hypoxemia 

(PaO 2 

< 8.0 kPa) or hypercapnia (PaCO 2 

> 6.5 kPa) in the arterial blood 

gas analysis, or a peripheral oxygen saturation < 90% when breathing 

ambient air or < 95% with at least 2 L/min of oxygen supplementation 

[17]. In-hospital mortality was defined as all-cause mortality during the 

patient’s stay in the hospital. The Sepsis-2 criteria (2001 international 

sepsis definitions conference) were used to define sepsis, severe 

sepsis or septic shock, i.e. two or more systemic inflammatory response 

syndrome criteria and suspected/confirmed infection [18]. 

Statistical analysis 

Continuous data were reported as median with interquartile range (IQR) 

and analysed using the Mann-Whitney U test. Categorical data were 

summarized as counts with percentages and analysed using the Chisquare 

test. 

For each vital sign and for each patient, we used the repeated 

measurements to estimate the linear change and variability over 

time. Linear change over time was estimated using individual linear 

regression analysis separately for each vital sign (heart rate, respiratory 

rate, mean arterial pressure and temperature) with the time of the 

measurement (in minutes) as independent variable. The resulting 

regression estimates for time, indicate the linear change per minute 

for each patient and each vital sign. The variability of each vital sign 

was calculated as the difference between the highest and lowest value 

during the first 3 h in the ED. 

To analyse the added value of the linear change and variability over time 

of each vital sign as predictors for patient deterioration within 72 h, we 

performed multiple logistic regression analysis. First, we constructed a 

base model containing age, gender and comorbidity. The added value 

of each vital sign to the base model was assessed using the following 

logistic regression analyses: (1) base model + vital sign value at 

admission, (2) base model + vital sign value at admission + change of 

the vital sign during the first 3 h in the ED and (3) base model + vital 

18


Fig. 1 Flow chart of patient recruitment. Consecutive adult medical patients visiting the emergency department of the University Medical Center 

Groningen between March 2016 and February 2017 were screened for eligibility 

sign value at admission + variability of the vital sign during the first 3 h 

in the ED. For each model, the area under the receiver operator curve 

(AUC) was calculated using the predicted probabilities. 

All statistical analyses were performed using IBM SPSS Statistics for 

Windows V.23.0 (IBM Corp, Armonk, New York, USA). A two-tailed 

p-value of < 0.05 was considered significant. 

Results 

Patient characteristics 

During the study period 366 patients met the inclusion criteria (Fig. 

1). Seven patients were excluded because they had less than three 

repeated vital sign measurements in the emergency department 

(ED) during the first 3 h from admission. The remaining 359 patients 

were included in the final analysis. Of the 359 patients, 106 (29,5%) 

patients deteriorated within 72 h from admission (Table 1). Patients 

with cardiac disease (p = 0.004), COPD (p = 0.047) or diabetes 

(p = 0.002), deteriorated more often compared to patients without these 

comorbidities. Malignancy (28.4%) and organ transplant (26.7%) were 

the most frequent comorbidities (Table 2). 

Patient deterioration 

Signs of organ failure were observed in 21.2% of the patients at ED 

admission (Table 3). An additional 6.1% of the patients deteriorated 

in the first 24 h after admission. The increase in respiratory failure 

(+ 4.2%) was the largest contributor to this deterioration. In the first 48 

h after admission, 3.1% of the patients deteriorated to multiple organ 

failure. Most deterioration took place within the first 72 h from admission 

(+ 8.3%), with only a small increase (+ 1.7%) during the rest of the 

hospitalization. 


19



Table 1 Patient characteristics 

Overall Not deteriorated Deteriorated p Value 

Number of patients [n (%)] 359 (100) 253 (70.5) 106 (29.5) – 

Demographics 

Age [median (IQR)] 63 (49; 71) 60 (47; 70) 66 (56; 74) .001* 

Male [n (% of the group)] 222 (61.8) 149 (58.9) 73 (68.9) .076 

Comorbidity 

Number of comorbidities [median (IQR)] 1 (0; 2) 1 (0; 2) 1 (1; 2) .001* 

Cardiac disease [n (% of the group)] 66 (18.4) 37 (14.6) 29 (27.4) .004* 

COPD [n (% of the group)] 23 (6.4) 12 (4.7) 11 (10.4) .047* 

Diabetes [n (%of the group)] 63 (17.5) 34 (13.4) 29 (27.4) .002* 

Chronic kidney disease [n (% of the group)] 43 (12.0) 26 (10.3) 17 (16.0) .125 

Chronic liver disease [n (% of the group)] 30 (8.4) 19 (7.5) 11 (10.4) .370 

Organ transplant [n (% of the group)] 96 (26.7) 64 (25.3) 32 (30.2) .339 

Malignancy [n (% of the group)] 102 (28.4) 77 (30.4) 25 (23.6) .189 

None of the above [n (% of the group)] 98 (27.3) 81 (32.0) 17 (16.0) .002* 

Disease severity 

Infection [n (% of overall)] 82 (22.8) 67 (81.7) 15 (18.3) .011* 

Sepsis [n (% of overall)] 277 (77.2) 186 (67.1) 91 (32.9) .011* 

Vital signs at ED admission 

Heart rate (bpm) [median (IQR)] 95 (83.0; 110.0) 95.0 (82.0; 110.0) 95.5 (83.0; 110.0) .262 

Mean arterial pressure (mmHg) [median (IQR)] 91.7 (83.3; 102.9) 94.3 (86.3; 103.3) 85.8 (73.4; 97.3)


Table 2 Study population comorbidity matrix 

N = 359 Cardiac disease COPD Diabetes Chronic Kidney Disease Chronic Liver Disease Organ Transplant Malignancy 

Cardiac disease 66 10 15 13 3 16 17 

Table COPD 2 Study population comorbidity matrix 23 3 1 1 4 5 

Diabetes N = 359 Cardiac disease COPD Diabetes 63 7Chronic Kidney Disease 9Chronic Liver Disease 17 Organ Transplant 11 Malignancy 

Chronic Cardiac disease Kidney Disease 66 10 15 43 13 23 29 16 417 

Chronic COPD Liver Disease 23 3 1 30 1 11 4 35 

Organ Diabetes Transplant 63 7 9 96 17 21 11 

Malignancy Chronic Kidney Disease 43 2 29 102 4 

Chronic Liver Disease 30 11 3 

Organ Transplant 96 21 

Age Malignancy and diabetes associated with higher risk of deterioration 

The logistic regression base model for patient deterioration including 

age, gender and comorbidities yielded an AUC of 0.679 (Table 4). A 

higher age (odds ratio (OR): 1.02 / year) and a history of diabetes (OR: 

of deterioration (Table 4, Fig. 2). A higher MAP at ED admission 102 was 

associated with a lower risk of deterioration (OR: 0.96/mmHg; model 

MAP-M1; AUC .746). The body temperature at ED admission was not 

independently associated with deterioration (model BT-M1; AUC .680). 

1.90) were associated with a higher risk of patient deterioration. Gender 

and comorbidities other than diabetes were not independent predictors 

of deterioration. 

Repeated vital sign measurements improve the prediction of 

deterioration 

Next to the vital signs at ED admission, the change and variability 

Vital signs at ED admission are associated with deterioration 

Patients who deteriorated had a lower MAP (p < 0.001) and a higher 

respiratory frequency (p = 0.03) at ED admission (Table 1). The base 

model extended with the patient’s vital signs at ED admission, showed 

that both a higher heart rate (OR: 1.01/beat per minute; model HRof 

the repeated vital signs measurements in the first 3 h in the 

ED were entered into the base model together with the vital signs 

at ED admission (Table 4, Fig. 2). An increase in MAP over time 

was associated with a lower risk of deterioration (OR: 0.873/unit 

increase; model MAP-M2; AUC .758). An increase in respiratory 

M1; AUC .683) and a higher respiratory rate (OR: 1.05/respiration per rate over time was associated with a higher risk of deterioration 

Table 3 Patient deterioration outcomes in different timeframes during the patient’s stay in-hospital and divided by infection and 

minute; model RR-M1; AUC .663) were associated with a higher risk (OR: 1.441/unit increase; model RR-M2; AUC .686). The changes in 

sepsis on emergency department presentation 

Acute Liver Respiratory Organ failure 

ICU Inhospital 

Deteriorated 

Kidney failure failure 

admission 

Single Multiple 

Table 3 Patient deterioration Injury outcomes in different timeframes during the patient’s stay in-hospital and divided mortality by infection and 

sepsis Total (N on = 359, emergency 100.0%) department presentation 

At ED admission Acute 45 (12.5%) Liver 21 (5.8%) 14 Respiratory (3.9%) 72 Organ (20.1%) failure 4 (1.1%) – ICU – Inhospital 

76 Deteriorated (21.2%) 

Kidney failure failure 

admission 

24 h after ED admission 51 (14.2%) 22 (6.1%) 29 (8.1%) 82 

Single 

(22.8%) 10 

Multiple 

Injury 

(2.8%) 16 (4.5%) 1 mortality (0.3%) 98 (27.3%) 

Total 48 (N h after = 359, ED100.0%) 

admission 57 (15.9%) 23 (6.4%) 33 (9.2%) 83 (23.1%) 15 (4.2%) 18 (5.0%) 1 (0.3%) 102 (28.4%) 

72 At ED h after admission ED admission 60 45 (16.7%) (12.5%) 23 21 (6.4%) (5.8%) 35 14 (9.7%) (3.9%) 87 72 (24.2%) (20.1%) 15 4 (1.1%) (4.2%) x – 18 (5.0%) – 3 (0.8%) 76 106 (21.2%) (29.5%) 

24 Until h after hospital ED admission discharge 51 70 (14.2%) (19.5%) 22 26 (6.1%) (7.2%) 29 43 (8.1%) (12.0%) 82 87 (22.8%) (24.2%) 10 24 (2.8%) (6.7%) xx 16 22 (4.5%) (6.1%) 12 (0.3%) (3.3%) 98 112 (27.3%) (31.2%) 

Infection 48 h after (N = ED82, admission 22.8%) 

72 At ED h after admission ED admission 

57 (15.9%) 

606 (7.3%) (16.7%) 

23 (6.4%) 

23 4 (4.9%) (6.4%) 

33 (9.2%) 

353 (3.7%) (9.7%) 

83 (23.1%) 

87 11 (24.2%) (13.4%) 

15 (4.2%) 

151 (1.2%) (4.2%) x 18 (5.0%) 

– 18 (5.0%) 

1 (0.3%) 

– 3 (0.8%) 

102 (28.4%) 

12 106 (14.6%) (29.5%) 

24 Until h after hospital ED admission discharge 70 (8.5%) (19.5%) 426 (4.9%) (7.2%) 43 (4.9%) (12.0%) 11 87 (13.4%) (24.2%) 24 (2.4%) (6.7%) xx 22 (2.4%) (6.1%) 012 (0.0%) (3.3%) 15 112 (18.3%) (31.2%) 

Infection 48 h after (N = ED82, admission 22.8%) 7 (8.5%) 4 (4.9%) 5 (6.1%) 12 (14.6%) 2 (2.4%) 2 (2.4%) 0 (0.0%) 15 (18.3%) 

72 At ED h after admission ED admission 76 (8.5%) (7.3%) 4 (4.9%) 53 (6.1%) (3.7%) 12 11 (14.6%) (13.4%) 21 (2.4%) (1.2%) 2 – (2.4%) 0 – (0.0%) 15 12 (18.3%) (14.6%) 

Until 24 h after hospital ED admission discharge 10 7 (8.5%) (12.2%) 64 (7.3%) (4.9%) 64 (7.3%) (4.9%) 14 11 (17.1%) (13.4%) 24 (2.4%) (4.9%) 23 (2.4%) (6.7%) 01 (0.0%) (1.2%) 15 18 (18.3%) (22.0%) 

Sepsis 48 h(N after = 277, ED 77.2%) admission 

At 72 ED h after admission ED admission 

7 (8.5%) 

739 (8.5%) (14.1%) 

4 (4.9%) 

417 (4.9%) (6.1%) 

5 (6.1%) 

511 (6.1%) (4.0%) 

12 (14.6%) 

12 61 (14.6%) (22.0%) 

2 (2.4%) 

23 (2.4%) (1.1%) 

2 (2.4%) 

– 2 (2.4%) 

0 (0.0%) 

– 0 (0.0%) 

15 (18.3%) 

64 15 (23.1%) (18.3%) 

24 Until h after hospital ED admission discharge 44 10 (15.9%) (12.2%) 18 6 (7.3%) (6.5%) 25 6 (7.3%) (9.0%) 71 14 (25.6%) (17.1%) 84 (2.9%) (4.9%) 14 3 (6.7%) (5.1%) 1 (0.4%) (1.2%) 83 18 (30.0%) (22.0%) 

Sepsis 48 h(N after = 277, ED 77.2%) admission 50 (18.1%) 19 (6.9%) 28 (10.1%) 71 (25.6%) 13 (4.7%) 16 (5.8%) 1 (0.4%) 87 (31.4%) 

72 At ED h after admission ED admission 53 39 (19.1%) (14.1%) 19 17 (6.9%) (6.1%) 30 11 (10.8%) (4.0%) 75 61 (27.1%) (22.0%) 13 3 (1.1%) (4.7%) x – 16 (5.8%) – 3 (1.1%) 64 91 (23.1%) (32.9%) 

24 Until h after hospital ED admission discharge 44 60 (15.9%) (21.7%) 18 20 (6.5%) (7.2%) 25 37 (9.0%) (13.4%) 71 73 (25.6%) (26.4%) 820 (2.9%) (7.2%) xx 14 19 (5.1%) (6.9%) 11 (0.4%) (4.0%) 83 94 (30.0%) (33.9%) 

ED: 48 emergency h after EDdepartment; admission x of which 50 (18.1%) one patient19 with (6.9%) all three organ 28 (10.1%) systems failing; 71 (25.6%) xx of which four 13 (4.7%) patient with all 16 three (5.8%) organ systems 1 (0.4%) failing 87 (31.4%) 

72 h after ED admission 53 (19.1%) 19 (6.9%) 30 (10.8%) 75 (27.1%) 13 (4.7%) x 16 (5.8%) 3 (1.1%) 91 (32.9%) 

Until hospital discharge 60 (21.7%) 20 (7.2%) 37 (13.4%) 73 (26.4%) 20 (7.2%) xx 19 (6.9%) 11 (4.0%) 94 (33.9%) 

ED: emergency department; x of which one patient with all three organ systems failing; xx of which four patient with all three organ systems failing 


21



Table 4 Logistic regression models for deterioration within 72 h from admission based on repeated vital sign measurements with a 

30-min interval during the first 3 h of ED admission 

heart rate and temperature were not independently associated with 

deterioration. 

Next to the vital signs at ED admission and change over time, a higher 

variability in MAP (i.e. a higher range) was significantly associated with a 

higher risk of deterioration (OR: 1.06/mmHg; model MAP-M3; AUC .800; 

Table 4, Fig. 2). The variability of the other vital signs was not associated 

with the risk of deterioration. 

Sig. Odds Ratio (95% 

CI) 

Discussion 

Model statistics 

Cox & Snell R 2 AUC (95% CI) N a 

Base model for deterioration within 72 h from admission .080 .679 (.619; .739) 359 (100%) 

Age .012* 1.022 (1.005; 1.039) 

Gender (0 = male, 1 = female) .502 0.839 (0.502; 1.402) 

Cardiac disease .158 1.544 (0.845; 2.820) 

COPD .159 1.906 (0.777; 4.676) 

Diabetes .035* 1.902 (1.048; 3.454) 

Chronic kidney disease .308 1.475 (0.699; 3.111) 

Chronic liver disease .345 1.493 (0.650; 3.429) 

Organ transplant .245 1.408 (0.791; 2.509) 

Malignancy .450 0.807 (0.463; 1.407) 

Base model with heart rate 

HR-M1. Heart rate at admission .042* 1.013 (1.000; 1.025) .091 .683 (.623; .742) 359 (100%) 

HR-M2. Heart rate at admission .035* 1.015 (1.001; 1.030) .091 .684 (.624; .743) 358 (99.7%) 

Heart rate change .463 1.039 (0.938; 1.151) 

HR-M3. Heart rate at admission .062 1.013 (0.999; 1.027) .091 .683 (.624; .743) 359 (100%) 

Heart rate variability .884 0.998 (0.977; 1.021) 

Base model with mean arterial pressure 

MAP-M1. MAP at admission


Fig. 2 Receiver operating curves of the logistic regression models for patient deterioration using various repeated vital sign measurements in 30-min 

intervals during the first three hours of the patient’s stay in the emergency department. The base model includes age, gender and comorbidities. 

Model M1 contains the base model combined with the value of the vital sign at admission, model M2 contains model M1 combined with the change 

of the vital sign over time, model M3 contains model M1 combined with the variability of the vital. A) the ROC curve for the base model combined 

with heart rate (HR). B) the ROC curve for the base model combined with mean arterial pressure (MAP). C) the ROC curve for the base model 

combined with respiratory rate (RR). * Base model only including patients with respiratory rate at admission (AUC .638). D) the ROC curve for the base 

model combined with body temperature (BT) 

deterioration. Inclusion of repeated MAP measurements resulted in the 

largest AUC (.800), whereas repeated respiratory rate measurements 

only slightly improved the predictive capabilities of the logistic 

regression model over the base model. Repeated measurements of 

heart rate and body temperature were not associated with patient 

deterioration. 

associated with patient deterioration in ED patients with infection or 

sepsis. This suggests that keeping a close eye on the MAP during the 

patients stay in the ED is important. Our study shows that this not only 

applies to patients with septic shock (only 1.9% of our population), as 

recommended by the surviving sepsis campaign (SSC) guidelines, but 

for all patients with sepsis or infection [4]. 


Our results indicate that changes and variability of the MAP are 

Apart from our earlier pilot study, little is known about repeated vital 

23



sign measurements in patients with infection or sepsis during their 

stay in the ED in relation to clinical outcomes, patient deterioration and 

(early) signs of organ failure. Our pilot study showed that vital signs 

changed significantly during the patient’s stay in the ED, but did not 

analyse patient deterioration [7]. Henriksen et al... retrospectively found 

a deterioration of vital signs from the normal to abnormal range within 

4–13 h after arrival in 31% of patients in the general ED population, 

leading to a four times higher 30-day mortality risk [13]. The available 

studies on vital signs in the ED mostly use only single measurements, 

mainly at triage [9, 12]. Furthermore, these were often retrospective 

studies in contrast to our study. Finally, they often included the general 

ED population and thus a more heterogeneous population. The 

endpoints and cut-off values differ from study to study, most studies 

used mortality endpoints, several studies had ICU admission as an 

endpoint and only a few studies included organ failure [8, 11, 13, 

19, 20, 21, 22]. The single measurements, heterogeneous patient 

populations and different endpoints make a direct comparison of those 

results with our study’s results impossible. Coslovsky et al aimed to 

develop a prediction model for in-hospital mortality using a model with 

age, prolonged capillary refill, blood pressure, mechanical ventilation, 

oxygen saturation index, GSC and the APACHEII diagnostic category 

in a cohort that contained 15% patients with infection among which 

7.3% with sepsis. Their model had an AUC of 0.92, although, it should 

be noted that their model was based on a heterogeneous patient 

population, single measurements and a combination of multiple vital 

signs [23]. Yamamoto et al. found an association between low body 

temperature (< 36 °C) at ED admission and higher 30 day in-hospital 

mortality risk in patients with suspected sepsis [24]. In our study, we did 

not find an association between body temperature and deterioration. 

Furthermore, it should be noted that the in-hospital mortality in our 

study (3.3%) is much lower than in the study of Yamamoto (9.6%). In 

summary, available studies did not specifically investigate ED patients 

with infection or sepsis, mostly used single vital sign measurements (at 

triage) and primarily had mortality or ICU admission endpoints. 

Early warning scores (EWS), like the national early warning score 

(NEWS) and many variants and related scores, are increasingly 

being used throughout healthcare. These EWS commonly contain 

a combination of various vital sign parameters, supplemented with 

laboratory values or other items, where each item is scored at certain 

thresholds. Early warning scores are mostly used as ‘track-and-trigger’ 

systems to trigger the nurse to call the physician or a rapid response 

team, or to predict a high risk of mortality or ICU admission [25, 26]. 

The many different EWS and patient populations, in which they have 

been validated, make it difficult to compare their performance. However, 

a recent review by Nannan Panday et al. showed that the NEWS score 

was the best to predict mortality or ICU admission in the general 

ED population and the modified early warning score was the best in 

patients with suspected infection or sepsis [25]. Their performance 

(AUC) was in the same range as we found for our repeated blood 

pressure measurements (MAP). However, it should be noted that 

we used only a single vital sign repeated measurement and had a 

composite outcome of patient deterioration, which included signs of 

organ dysfunction. Another recent study by Kivipuro et al. showed that 

the NEWS score was significantly higher before ICU admission when 

a patient was transferred from the ward to the ICU, compared to the 

NEWS score of the same patient at the ED [27]. In our hospital, modified 

early warning scores (MEWS) are taken at admission to the ward and 

thereafter three times per day. Deterioration of the MEWS score triggers 

an early response team. Further research is needed to clarify whether 

repeated vital sign measurements in combination with repeated early 

warning scores are useful in the detection of patient deterioration in 

patients with sepsis or infection. 

We have shown that almost 30% of the patients presenting to the ED 

with suspected infection or sepsis deteriorated within 72 h of admission 

and over 28% of the patients showed signs of (multiple) organ failure 

despite treatment. Our results show that 18.3% of the patients with 

infection, 32.9% of the patients with sepsis and in total 29.5% of the 

patients deteriorated within 72 h (Table 4). Glickman et al. showed 

that almost 23% of patients with uncomplicated sepsis progress 

to severe sepsis or septic shock within 72 h from admission [1]. 

Although a direct comparison cannot be made because of a different 

population and different endpoints, these results clearly show that 

a large part of the patients with infection deteriorate in the first days 

in the hospital and develop (severe) sepsis. Therefore, we question 

whether the introduction of the recent Sepsis-3 definitions, in which 

infection or uncomplicated sepsis are no longer part of the sepsis 

severity spectrum, will lead to better patient care [28]. We would like to 

emphasise that it is important to properly monitor and treat all patients 

with infection or sepsis in the ED. Since sepsis-related mortality has 

dramatically reduced over the past two decades, we believe that early 

detection or prevention of organ failure is where the future focus of 

infection/sepsis research should be, since there is a lot to gain [29]. 

The 30-min measurement interval in the current study was arbitrarily 

chosen, since there is no standard on how often vital signs should 

be measured in the ED and only little research has been conducted 

on this topic. Descriptive studies in the general ED population have 

shown that the time between two measurements is between 67 and 

130 min and that a higher illness severity results in more frequent 

measurements [10, 30]. We believe that these measurement intervals 

are not representative for patients with infection or sepsis, however, 

there are no specific guidelines on how often vital signs should be 

measured in these patients [13]. The 30-min measurement interval in 

our study was much more frequent than the median intervals reported 

by Johnson and Lambe [10, 30]. A higher measurement frequency 

might provide even more information about deterioration, although this 

might lead to a higher burden on the patient and staff. Therefore, we 

recommend continuous measurement of vital signs on a beat-to-beat 

level, preferably automated with the use of bed-side patients monitors 

or wearable devices [3]. Our next step, as a follow-up of this study, 

is to shorten the measurement interval to a beat-to-beat interval with 

heart rate variability (HRV) measured using bed-side patient monitors 

in the SepsiVit study [3]. As we have shown, a substantial number of 

patients deteriorate in the first days from admission. In the currently 

running SepsiVit study, we will extend the measurements beyond the 

boundaries of the ED towards the nursing wards during the first 48 h 

of hospitalization. During this period, we will investigate whether the 

combination of HRV with monitoring on the nursing wards can provide 

an early warning of patient deterioration. Such an early warning could 

provide a possible opportunity for intervention in the future. 

Strengths and limitations 

To the best of our knowledge this is the first study that prospectively 

investigated the relation between repeated vital sign measurements 

24


and patient deterioration in the ED in patients with infection or sepsis. 

We did not only use the common mortality and ICU admission 

endpoints, but also included signs of organ failure in our composite 

patient deterioration endpoint. Vital signs can be easily measured 

with equipment readily available in every ED. The repeated vital sign 

measurements in our study were obtained specifically by a trained 

member of our research staff, which minimized the amount of missing 

data. However, in spite of the prospective study design, 92 (25%) 

respiratory rate measurements were not recorded at triage by the 

triage nurse. It is well-known that respiratory rate is the most frequently 

missing vital sign, unfortunately our study is no exception [31]. These 

missing respiratory rate measurements at triage limit the power of our 

logistic regression models that include respiratory rate (RR-Mx; Table 4). 

Another limitation of our study is that it is a single centre study in an 

academic tertiary care teaching hospital. This may limit the generalizability 

to other patient populations, especially since our population contains 

a high number of patients with a history of organ transplantation (Table 

2). However, a history of organ transplantation was not independently 

associated with patient deterioration in our models (Table 4). Therefore, 

we believe that the specific patient population did not have a substantial 

influence on our results. We did not design the study to analyse 

combinations of multiple vital signs in our models, since we were 

interested in identifying which repeated vital sign measurements are 

helpful in predicting patient deterioration and not in the best combination 

of vital signs. We acknowledge that a combination of repeated vital 

signs may provide even more information in future studies, perhaps in 

combination with repeated early warning scores. 

Clinical implications 

We have shown that more than one in four patients presenting to the ED 

with suspected infection or sepsis deteriorated within 72 h of admission 

and showed signs of organ failure. These were not exclusively patients 

with sepsis at admission, but one in five patients that presented to the 

ED with infection only. Although the organ failure generally did not result 

in mortality, organ failure may even be preventable or treatable. Our 

results show that repeated vital sign measurements (especially blood 

pressure) at the ED is a predictor of patient deterioration and might 

result in a reduction of organ failure related morbidity. It is thus important 

to reassess patient at the ED frequently, including measurement of 

vital signs, as is done on the wards with early warning scores [29]. 

Although it is known that patient deterioration is often preceded by 

changes in vital signs several hours before the event, these signs are 

frequently missed on general wards [25, 27, 32]. At this moment, we are 

conducting a subsequent study (SepsiVit study) with 48 h of continuous 

vital sign measurements at the ED and on the general wards to test the 

hypothesis that repeated vital sign measurements at the general ward 

(with high frequency) is better in the prediction of patient deterioration 

than the currently used systems [3]. Until this information from the 

SepsiVit study becomes available, we assess patients at the ED 

frequently, including repeated vital sign measurements. 

Conclusions 

Repeated measurement of vital signs in the ED are better at identifying 

patients at risk for deterioration within 72 h from admission than single 

vital sign measurements at ED admission. Repeated measurements of 

MAP and respiratory rate are associated with patient deterioration. Since 

almost one third of patients presenting with infection or sepsis to the ED 

deteriorate within 72 h, repeated vital sign measurements may be an 

important way to guarantee early identification of deterioration. 

Abbreviations 

AKI: Acute kidney injury; AUC: Area under the receiver operator curve; 

BT: Body temperature; COPD: Chronic obstructive pulmonary disease; 

ED: Emergency department; GCS: Glasgow coma score; HR: Heart 

rate; HRV: Heart rate variability; ICU: Intensive care unit; KDIGO: Kidney 

disease improving global outcomes; MAP: Mean arterial pressure; 

METc: Institutional review board; OR: Odds ratio; RR: Respiratory rate; 

SBP: Systolic blood pressure; SCPD: Sepsis clinical pathway database; 

SpO 2 

: Peripheral oxygen saturation; SSC: Surviving sepsis campaign; 

USA: United States of America 

Acknowledgements 

The authors thank the nurses and physicians in our emergency 

department for their assistance during the acquisition of the data. We 

thank the members of the Sepsis Research Team in our emergency 

department for their efforts in collecting the data. 

Availability of data and material 

The datasets used and/or analysed during the current study are 

available from the corresponding author on reasonable request. 

Funding 

This study is funded by the emergency department of the University 

Medical Center Groningen. VMQ received a MD-PhD scholarship from 

the University of Groningen, University Medical Center Groningen for his 

PhD research. 

Authors’ contributions 

VMQ drafted the study design, assisted with data acquisition, carried 

out data analysis and drafted the manuscript. MvM participated in the 

study design, assisted with data interpretation and critically revised 

the manuscript. TJO participated in the study design, assisted with 

data acquisition, and critically revised the manuscript. JMV carried out 

data analysis, assisted with data interpretation and critically revised the 

manuscript. JJML participated in the study design, assisted with data 

interpretation and critically revised the manuscript. JCtM participated in 

the study design, assisted with data interpretation, critically revised the 

manuscript and has given final approval of the version to be published. 

Ethics approval and consent to participate 

This study was carried out in accordance to the Declaration of Helsinki, 

the Dutch Agreement on Medical Treatment Act and the Dutch Personal 

Data Protection Act. The Institutional Review Board of the University 

Medical Center Groningen ruled that the Dutch Medical Research 

Involving Human Subjects Act is not applicable for this study and 

granted a waiver (METc 2015/164). All participants provided written 

informed consent. 

Consent for publication 

Not applicable. 

Competing interests 

The authors declare that they have no competing interests. 


25



Publisher’s Note 

Springer Nature remains neutral with regard to jurisdictional claims in 

published maps and institutional affiliations. 

Author details 

* 

Correspondence: v.m.quinten@umcg.nl 1 Department of Emergency 

Medicine, University of Groningen, University Medical Center Groningen, 

HPC TA10, PO Box 30001, 9700 RB Groningen, The Netherlands. 

2 

Department of Critical Care, University of Groningen, University 

Medical Center Groningen, Groningen, The Netherlands. 3 Department 

of Pathology and Medical Biology, Medical Biology section, University 

of Groningen, University Medical Center Groningen, Groningen, The 

Netherlands. 4 Department of Epidemiology, University of Groningen, 

University Medical Center Groningen, Groningen, The Netherlands. 

References 

1. Glickman SW, Cairns CB, Otero RM, Woods CW, Tsalik EL, Langley 

RJ, et al. Disease progression in hemodynamically stable patients 

presenting to the emergency department with sepsis. Acad Emerg 

Med Wiley Online Library. 2010;17:383–90. 

2. Buchan CA, Bravi A, Seely AJE. Variability analysis and the 

diagnosis, management, and treatment of sepsis. Curr Infect Dis 

Rep. 2012;14:512–21. 

3. Quinten VM, van Meurs M, Renes MH, Ligtenberg JJM, ter Maaten 

JC. Protocol of the SepsiVit study: a prospective observational study 

to determine whether continuous heart rate variability measurement 

during the first 48 hours of hospitalization provides an early warning 

for deterioration in patients presenting with infec. BMJ Open 

[Internet]. British Medical Journal Publishing Group; 2017 [cited 

2017 Nov 20];7:1–17. Available from: http://www.ncbi.nlm.nih.gov/ 

pubmed/29151053 

4. Rhodes A, Evans LE, Alhazzani W, Levy MM, Antonelli M, Ferrer 

R, et al. Surviving Sepsis Campaign: International Guidelines for 

Management of Sepsis and Septic Shock: 2016. Intensive Care 

Med. [Internet]. Springer Berlin Heidelberg; 2017;43:304–377. 

Available from: https://link.springer.com/article/10.1007/s00134-017- 

4683-6 

5. Samraj RS, Zingarelli B, Wong HR. Role of biomarkers in sepsis 

care. Shock. Cincinnati. Ohio. 2013;40:358–65. 

6. Pierrakos C, Vincent J-L. Sepsis biomarkers: a review. Crit Care. 

2010;14:R15. 

7. Quinten VM, van Meurs M, Ter Maaten JC, Ligtenberg JJ. Trends 

in vital signs and routine biomarkers in patients with sepsis 

during resuscitation in the emergency department: a prospective 

observational pilot study. BMJ Open. 2016;6:9718. 

8. Ljunggren M, Castrén M, Nordberg M, Kurland L. The association 

between vital signs and mortality in a retrospective cohort study 

of an unselected emergency department population. Scand. J. 

Trauma. Resusc. Emerg. Med. [Internet]. BioMed Central; 2016 

[cited 2017 31];24:21. Available from: http://www.sjtrem.com/ 

content/24/1/21 

9. Farrohknia N, Castrén M, Ehrenberg A, Lind L, Oredsson 

S, Jonsson H, et al. Emergency department triage scales 

and their components: a systematic review of the scientific 

evidence. Scand. J. Trauma. Resusc. Emerg. Med. [Internet]. 

2011;19:42. Available from: http://sjtrem.biomedcentral.com/ 

articles/10.1186/1757-7241-19-42 

10. Lambe KR, Currey JR, Considine J. Frequency of vital 

sign assessment and clinical deterioration in an Australian 

emergency department. Australas. Emerg. Nurs. J. [Internet]. 

Elsevier; 2016 [cited 2017 Oct 16];19:217–222. Available 

from: http://www.sciencedirect.com/science/article/pii/ 

S1574626716300398?via%3Dihub 

11. Hong W, Earnest A, Sultana P, Koh Z, Shahidah N, Ong MEH. How 

accurate are vital signs in predicting clinical outcomes in critically 

ill emergency department patients. Eur. J. Emerg. Med. [Internet]. 

Lippincott Williams & Wilkins; 2013 [cited 2017 Oct 31];20:27–32. 

Available from: https://insights.ovid.com/pubmed?pmid=22198158 

12. Bleyer AJ, Vidya S, Russell GB, Jones CM, Sujata L, Daeihagh 

P, et al. Longitudinal analysis of one million vital signs in patients 

in an academic medical center. Resuscitation [Internet]. 

Elsevier; 2011 [cited 2017 Nov 2];82:1387–1392. Available 


S0300957211004096?via%3Dihub 

13. Henriksen DP, Brabrand M, Lassen AT. Prognosis and risk factors 

for deterioration in patients admitted to a medical emergency 

department. Cleary PR, editor. PLoS One [Internet]. Public Library of 

Science; 2014 [cited 2017 Oct 31];9:e94649. Available from: http:// 

dx.plos.org/10.1371/journal.pone.0094649 

14. Alam N, Oskam E, Stassen PM, van EP, van de VPM, Haak HR, et 

al. Prehospital antibiotics in the ambulance for sepsis: a multicentre, 

open label, randomised trial. Lancet Respir. Med. [Internet]. 

2017; Available from: http://linkinghub.elsevier.com/retrieve/pii/ 

S2213260017304691 

15. Global Kidney Disease: Improving Outcomes (KDIGO) Acute Kidney 

Injury Work Group, Kellum J A, Lameire N, Aspelin P, Barsoum RS, 

Burdmann E A, et al. KDIGO clinical practice guideline for acute 

kidney injury. Kidney Inter. Suppl. [Internet]. 2012;2:1–138. Available 

from: http://www.kdigo.org/clinical_practice_guidelines/pdf/ 

KDIGO%20AKI%20Guideline.pdf. 

16. Sands KE, Bates DW, Lanken PN, Graman PS, Hibberd PL, 

Kahn KL, et al. Epidemiology of Sepsis Syndrome in 8 Academic 

Medical Centers. JAMA [Internet]. American Medical Association. 

1997;278:234–40. Available from: http://jama.jamanetwork.com/ 

article.aspx?doi=10.1001/jama.1997.03550030074038 

17. Burt CC, Arrowsmith JE. Respiratory failure. Surg. - Oxford Int. Ed. 

[Internet]. Elsevier; 2009;27:475–479. Available from: http://www. 

surgeryjournal.co.uk/article/S0263-9319(09)00195-1/fulltext. 

18. Levy MM, Fink MP, Marshall JC, Abraham E, Angus D, Cook D, et 

al. 2001 sccm/esicm/accp/ats/sis international sepsis definitions 

conference. Intensive Care Med. Springer. 2003;29:530–8. 

19. Kristensen AKB, Holler JG, Mikkelsen S, Hallas J, Lassen A. 

Systolic blood pressure and short-term mortality in the emergency 

department and prehospital setting: a hospital-based cohort 

study. Crit. Care [Internet]. BioMed Central; 2015 [cited 2017 Oct 

31];19:158. Available from: http://ccforum.com/content/19/1/158 

20. Barfod C, Lauritzen M, Danker J, Sölétormos G, Forberg J, Berlac 

P, et al. Abnormal vital signs are strong predictors for intensive 

care unit admission and in-hospital mortality in adults triaged in 

the emergency department - a prospective cohort study. Scand J 

Trauma Resusc Emerg Med [Internet]. BioMed Central; 2012 [cited 

2017 Oct 31];20:28. Available from: http://sjtrem.biomedcentral. 

com/articles/10.1186/1757-7241-20-28 

21. Walston J, Cabrera D, Bellew S, Olive M, Lohse C, Bellolio F. Vital 

signs predict rapid-response team activation within twelve hours of 

emergency Department Admission. West. J. Emerg. Med. [Internet]. 

2016 [cited 2017 Oct 31];17:324–330. Available from: http:// 

escholarship.org/uc/item/93r2v5j0 

26


22. Henning DJ, Oedorf K, Day DE, Redfield CS, Huguenel CJ, Roberts 

JC, et al. Derivation and validation of predictive factors for clinical 

deterioration after admission in emergency department patients 

presenting with abnormal vital signs without shock. West. J Emerg 

Med [Internet]. California Chapter of the American Academy of 

Emergency Medicine (Cal/AAEM); 2015 [cited 2017] 

23. Oct 31];16:1059–1066. Available from: http://www.ncbi.nlm.nih.gov/ 

pubmed/26759655 

24. Coslovsky M, Takala J, Exadaktylos AK, Martinolli L, Merz TM. A 

clinical prediction model to identify patients at high risk of death 

in the emergency department. Intensive Care Med [Internet]. 

Springer Berlin Heidelberg; 2015 [cited 2017 Oct 31];41:1029–1036. 

Available from: http://link.springer.com/10.1007/s00134-015-3737-x 

25. Yamamoto S, Yamazaki S, Shimizu T, Takeshima T, Fukuma S, 

Yamamoto Y, et al. Body temperature at the emergency department 

as a predictor of mortality in patients with bacterial infection. Med 

(Baltimore). [Internet] . 2016 [cited 2017 Oct 31];95:e3628. Available 

from: https://insights.ovid.com/pubmed?pmid=27227924. 

26. Nannan Panday RS, Minderhoud TC, Alam N, Nanayakkara 

PWB. Prognostic value of early warning scores in the emergency 

department (ED) and acute medical unit (AMU): A narrative review 

[Internet]. Eur. J. Intern. Med. Elsevier; 2017 [cited 2018 Jun 20]. 

p. 20–31. Available from: https://www.sciencedirect.com/science/ 

article/pii/S0953620517303758?via%3Dihub 

27. Kyriacos U, Jelsma J, Jordan S. Monitoring vital signs using early 

warning scoring systems: A review of the literature. J. Nurs. Manag. 

[Internet]. 2011 [cited 2017 Oct 12];19:311–330. Available from: 

http://doi.wiley.com/10.1111/j.1365-2834.2011.01246.x 

28. Kivipuro M, Tirkkonen J, Kontula T, Solin J, Kalliomäki J, Pauniaho 

SL, et al. National early warning score (NEWS) in a Finnish 

multidisciplinary emergency department and direct vs. late 

admission to intensive care. Resuscitation [Internet]. Elsevier; 

2018;128:164–169. Available from: https://doi.org/10.1016/j. 

resuscitation.2018.05.020 

29. Singer M, Deutschman CS, Seymour CW, Shankar-Hari M, Annane 

D, Bauer M, et al. The third international consensus definitions for 

Sepsis and septic shock (Sepsis-3). JAMA [Internet]. American 

Medical Association; 2016 [cited 2017 Oct 5];315:801. Available 

from: http://www.ncbi.nlm.nih.gov/pubmed/26903338 

30. Quinten VM, van Meurs M, Ligtenberg JJM, Ter Maaten JC. 

Prehospital antibiotics for sepsis: beyond mortality? Lancet Resp Med 

[Internet]. 2018 [cited 2018 Feb 28];6. Available from: http://www. 

thelancet.com/pdfs/journals/lanres/PIIS2213-2600(18)30061-4.pdf. 

31. Johnson KD, Winkelman C, Burant CJ, Dolansky M, Totten V. 

The Factors that affect the frequency of vital sign monitoring 

in the emergency department. J. Emerg. Nurs. [Internet]. 

Mosby; 2014 [cited 2017 Oct 31];40:27–35. Available 


S0099176712003923?via%3Dihub 

32. Cretikos MA, Bellomo R, Hillman K, Chen J, Finfer S, Flabouris 

A. Respiratory rate: the neglected vital sign. Med J Aust. 

2008;188:657–9. 

33. Fuhrmann L, Lippert A, Perner A, Østergaard D. Incidence, staff 

awareness and mortality of patients at risk on general wards. 

Resuscitation [Internet]. Elsevier; 2008 [cited 2018 Jun 21];77:325– 

330. Available from: https://www.sciencedirect.com/science/article/ 

pii/S030095720800052X?via%3Dihub 


27

EMMA® Waveform Capnograph 

All Patient use 

Adult/Paediatric 

Infant/Neonate 

EtC02 & Respiratory rate 

End-tidal C0 2 and Respiratory 

Rate values + Waveform 

Tube Placement & ROSC 

Ensures efficacy of intubation 

Early detection of ROSC 

Effectiveness of CPR 

Feedback > effectiveness of 

chest compressions & CPR 

Optimised Power 

8 hrs. continuous use 

2 x AAA batteries 

Configurable Alarms 

High & Low EtC02, Apnoea 

Blocked airway, Battery status 

when every breath counts 

9 Application proven: pre-hospital, hospital, emergency, critical care & resuscitation 

9 Provides compliance to 2015 ERC/UK ALS, & NAP4 waveform capnography guidelines 

9 Monitoring of Intubated patients during recovery, transfers and transportation 

MEDACX LIMITED • ALEXANDER HOUSE • 60-62 STATION ROAD • HAYLING ISLAND • HAMPSHIRE • PO11 0EL 

02392 469737 

info@medacx.co.uk 

www.medacx.co.uk

Resus Today Summer 2019

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?