51
|
Watts J. Rapid sequence induction. Ann Emerg Med 1999; 33:125-6. [PMID: 9867903 DOI: 10.1016/s0196-0644(99)70434-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
|
52
|
Sing RF, Rotondo MF, Zonies DH, Schwab CW, Kauder DR, Ross SE, Brathwaite CC. Rapid sequence induction for intubation by an aeromedical transport team: a critical analysis. Am J Emerg Med 1998; 16:598-602. [PMID: 9786546 DOI: 10.1016/s0735-6757(98)90227-3] [Citation(s) in RCA: 82] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Airway control is the initial priority in the management of the injured patient. The purpose of this investigation was to evaluate the experience of an aeromedical transport team in the utilization of rapid sequence induction (RSI) for endotracheal intubation in the prehospital setting. Records of a consecutive series of injured patients undergoing RSI between June 1988 and July 1992 by a university-based aeromedical transport team were reviewed for demographics, intubation mishaps, and pulmonary complications. The relationship between intubation mishaps and pulmonary complications was analyzed. Eighty-four patients were studied with a mean age of 30.8 +/- 15.3 years. The mean Revised Trauma Score was 11.3 +/- 2.4, and the mean Injury Severity Score (ISS) was 19.6 +/- 11.5. Intubation mishaps occurred in 15 patients (18%), and pulmonary complications developed in 22 (29%) of the 75 patients surviving longer than 24 hours. There was no relationship between intubation mishaps and pulmonary complications. Abbreviated Injury Scale (AIS) face score was significantly higher in patients with intubation mishaps, compared with patients without mishaps (1.1 +/- 1.2 and 0.5 +/- 0.9, respectively, P < .05, Wilcoxon rank-sum). ISS and AIS chest were higher in patients with pulmonary complications, compared with those without (25.7 +/- 12.6 and 17.4 +/- 10.3 and 2.2 +/- 1.8 and 1.0 +/- 1.5, ISS and AIS respectively; P < .05, Wilcoxon rank-sum). Eighty-one patients (96%) underwent successful RSI, 73 (87%) on the first attempt. Failure to intubate occurred in three patients (4%). Performed under strict protocol by appropriately trained aeromedical transport personnel, RSI is an effective means to facilitate endotracheal intubation in the injured patient requiring definitive airway control. Pulmonary complications were related to injury severity and not to intubation mishaps.
Collapse
Affiliation(s)
- R F Sing
- Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | | | | | | | | | | | | |
Collapse
|
53
|
Adnet F, Hennequin B, Lapandry C. [Rapid sequence anesthetic induction via prehospital tracheal intubation]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 1998; 17:688-98. [PMID: 9750807 DOI: 10.1016/s0750-7658(98)80106-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The choice of sedation for emergency intubation remains controversial. This lack of consensus has led to various sedation protocols used in French prehospital care setting. A review of data from the literature suggests that the association etomidate-suxamethonium is probable the best choice for rapid sequence intubations in the prehospital setting. Its benefits include protection against myocardial and cerebral ischaemia, decreased risk of pulmonary aspiration, and a stable haemodynamic profile. Randomized studies are needed to substantiate the advantages of the association etomidate-suxamethonium for rapid sequences intubation in the prehospital setting.
Collapse
Affiliation(s)
- F Adnet
- Samu 93 et département d'anesthésie et de réanimation, CHU Avicenne, université Paris XIII, Bobigny, France
| | | | | |
Collapse
|
54
|
Cantineau JP, Tazarourte K, Merckx P, Martin L, Reynaud P, Berson C, Bertrand C, Aussavy F, Lepresle E, Pentier C, Duvaldestin P. [Tracheal intubation in prehospital resuscitation: importance of rapid-sequence induction anesthesia]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 1998; 16:878-84. [PMID: 9750618 DOI: 10.1016/s0750-7658(97)89837-1] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To investigate complications of emergency endotracheal intubation (EEI), possibly facilitated by rapid-sequence induction, in the prehospital critical care setting: 1) the difficulty of intubation; 2) the cardiorespiratory consequences of intubation; 3) the relationship between the occurrence of complications and prognosis. STUDY DESIGN Prospective non randomized, open study. PATIENTS All patients treated over a 5-month period by a physician-manned ambulance service and requiring EEI. METHODS Patients were allocated either in with cardiac arrest (CA) group or a group with maintained spontaneous circulation (SC). Difficulty of intubation was assessed by the number of attempts. RESULTS Two hundred and twenty-four consecutive EEI were carried out by physicians (46%) and residents (38%) not trained in anaesthesia, anaesthetists (8%), or nurse anaesthetists (7%). Trachea was intubated after a maximum of three attempts in all patients. Success rate at the first attempt was 91%. It was 92% in CA patients (n = 76) and 90% in SC patients (P = 0.59). Anaesthetic induction, with (n = 112) or without (n = 12) succinylcholine, was used to facilitate 84% of intubations in SC patients. Complications occurred in 30 patients (20%). There was no relationship between the latter and hospital mortality, duration of ventilatory support, duration of stay in the intensive care unit. CONCLUSION In this study, EEI in SC patients was frequently facilitated by rapid sequence induction and was associated with a high success rate at the first attempt, as in CA patients. Morbidity was low. All physicians involved in emergency airway management should be skilled in this technique.
Collapse
Affiliation(s)
- J P Cantineau
- CHU Henri-Mondor, Assistance publique-hôpitaux de Paris, Créteil, France
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
55
|
Suominen P, Baillie C, Kivioja A, Korpela R, Rintala R, Silfvast T, Olkkola KT. Prehospital care and survival of pediatric patients with blunt trauma. J Pediatr Surg 1998; 33:1388-92. [PMID: 9766360 DOI: 10.1016/s0022-3468(98)90014-8] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND The aim of this study was to compare the outcome of severe blunt trauma in children receiving prehospital care from either physician-staffed advanced life support (ALS) units, or from basic life support (BLS) units staffed by emergency medical technicians. METHODS The records of 288 children with severe blunt trauma who required intensive care in the regional level 1 trauma center or who died from their injuries were analyzed retrospectively. Patients were excluded if resuscitation at the scene was not attempted, if the level of prehospital care was unspecified, or if arrival at the level 1 trauma center was delayed beyond 150 minutes. Seventy-two patients met the inclusion criteria of BLS-, and 49 the criteria of ALS-prehospital care. RESULTS A reduced mortality rate (22.4% v 31.9%) was seen in the ALS group, which was more apparent in a "salvageable but high-risk" subgroup, characterized by Glasgow Coma of Scale 4 through 8, Pediatric Trauma Score of 0 through 5, and Injury Severity Score (ISS) of 25 through 49. However, a statistically significant difference was only seen when trauma severity was evaluated by the ISS. CONCLUSION An improved outcome in children with severe blunt trauma has been demonstrated when prehospital care is provided by physician-staffed ALS units compared with BLS units.
Collapse
Affiliation(s)
- P Suominen
- Department of Anaesthesia, University of Helsinki, Finland
| | | | | | | | | | | | | |
Collapse
|
56
|
|
57
|
Sakles JC, Laurin EG, Rantapaa AA, Panacek EA. Airway management in the emergency department: a one-year study of 610 tracheal intubations. Ann Emerg Med 1998; 31:325-32. [PMID: 9506489 DOI: 10.1016/s0196-0644(98)70342-7] [Citation(s) in RCA: 301] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
STUDY OBJECTIVE To describe the methods, success rates, and immediate complications of tracheal intubations performed in the emergency department of an urban teaching hospital. METHODS This was an observational, consecutive series undertaken in an urban university hospital with an emergency medicine residency training program and an annual ED census of 60,000 patients. The study population included all patients for whom intubation was attempted in the ED during a 1-year period (July 1, 1995 through June 30, 1996). At the time of each intubation, the intubator filled out an intubation data collection form. If an intubation was performed in the ED but no form was filled out, the data were obtained from the medical record. RESULTS A total of 610 patients required airway control in the ED; 569 (93%) were intubated by emergency medicine residents or attending physicians. Rapid-sequence intubation (RSI) was used in 515 (84%). A total of 603 patients (98.9%) were successfully intubated; 7 patients could not be intubated and underwent cricothyrotomy. In 33 patients, inadvertent placement into the esophagus occurred; all such situations were rapidly recognized and corrected. Eight (24%) of the 33 esophageal intubations resulted in a reported immediate complication. Overall, 49 patients (8.0%; 95% confidence interval [CI], 6% to 11%) experienced a total of 57 immediate complications (9.3%; 95% CI, 7% to 12%). Three patients sustained a cardiac arrest after intubation; two of these patients had agonal rhythms before intubation, and one probably had a succinylcholine-induced hyperkalemic cardiac arrest. CONCLUSION At this institution, the majority of ED intubations were performed by emergency physicians and RSI was the most common method used. Emergency physicians intubated critically ill and injured ED patients with a very high success rate and a low rate of serious complications.
Collapse
Affiliation(s)
- J C Sakles
- Division of Emergency Medicine, University of California, Davis, Medical Center, School of Medicine Sacramento, 95817, USA.
| | | | | | | |
Collapse
|
58
|
Sivilotti MLA, Ducharme J. Randomized, Double-Blind Study on Sedatives and Hemodynamics During Rapid-Sequence Intubation in the Emergency Department: The SHRED Study. Ann Emerg Med 1998; 31:313-324. [DOI: 10.1016/s0196-0644(98)70341-5] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/1996] [Revised: 10/27/1997] [Accepted: 11/11/1997] [Indexed: 11/29/2022]
|
59
|
Ma OJ, Atchley RB, Hatley T, Green M, Young J, Brady W. Intubation success rates improve for an air medical program after implementing the use of neuromuscular blocking agents. Am J Emerg Med 1998; 16:125-7. [PMID: 9517684 DOI: 10.1016/s0735-6757(98)90027-4] [Citation(s) in RCA: 75] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
To determine whether the success rate for endotracheal intubation improves after implementing the use of neuromuscular blocking (NMB) agents in an air medical program, this retrospective study analyzed all patients requiring endotracheal intubation at two air medical programs (nurse/paramedic crews) over a 5-year period. Air medical program A, the control group, had employed NMB agents throughout the entire study period. Air medical program B, which did not use NMB agents from July 1, 1989 through June 30, 1992, implemented their use starting July 1, 1992. For program A, the overall intubation success rate was 93.5% (202 successful intubations in 216 patients) and the successful intubations/total attempts ratio was 0.67 (202 of 301). For program B, the overall intubation success rate improved from 66.7% (46 successful intubations in 69 patients) before NMB agent use to 90.5% (57 in 63) after NMB agent use (P = .001). The successful intubations/total attempts ratio increased from 0.36 (51 of 141) prior to NMB agent use to 0.48 (63 of 132) after NMB agent use (P = NS). In comparing the 92 patients who did not receive NMB agents to the 40 patients who did, the intubation success rate increased from 69.6% (64 of 92) to 97.5% (39 of 40) (P < .001) and the successful intubation/total attempts ratio increased from 0.36 (73 of 202) to 0.58 (41 of 71) (P = .007). With the use of NMB agents, program B's overall intubation success rate increased significantly, matching the results of program A.
Collapse
Affiliation(s)
- O J Ma
- Department of Emergency Medicine and Carolina Air Care, University of North Carolina, Chapel Hill 27599-7594, USA
| | | | | | | | | | | |
Collapse
|
60
|
Adnet F, Borron SW, Finot MA, Lapandry C, Baud FJ. Intubation difficulty in poisoned patients: association with initial Glasgow Coma Scale score. Acad Emerg Med 1998; 5:123-7. [PMID: 9492132 DOI: 10.1111/j.1553-2712.1998.tb02596.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To determine whether the initial Glasgow Coma Scale (GCS) score is predictive of intubation difficulty in out-of-hospital airway management of poisoned patients. METHODS A prospective, observational study was performed in a toxicological intensive care unit of a university hospital and in a physician-based out-of-hospital care system. Subjects included consecutive poisoned patients intubated during their airway management by out-of-hospital medical teams before hospitalization. The intubating operator (emergency physician or nurse anesthetist) completed a 1-page checklist concerning the clinical parameters and circumstances (nature of sedation and difficulty) of endotracheal intubation upon hospital arrival. RESULTS Forms were completed for all 394 consecutive out-of-hospital intubations. The patients ranged from 15 to 95 years of age (median age 38 years). Most (96%) of the intubations were via the oral route. Intubation difficulty was related to GCS values. Intubation difficulty was seen more often in patients with 7 < or = GCS < or = 9 (36%) than in patients with GCS < 7 (15%) or > 9 (10%). Not surprisingly, perceived intubation difficulty was least for those patients undergoing rapid-sequence intubation rather than administration of sedation alone. CONCLUSION Maximum difficulty of intubation is encountered in poisoned patients with 7 < or = GCS < or = 9. Intubation of such patients appears to be facilitated by appropriate sedation and/or neuromuscular blockade.
Collapse
Affiliation(s)
- F Adnet
- Réanimation Toxicologique-INSERM U-26, Hôpital Fernand Widal, Saint-Denis, Paris, France.
| | | | | | | | | |
Collapse
|
61
|
Abstract
Airway management of the multiple trauma patient presents a series of challenges. By definition, many trauma patients present difficult airways that require a different approach and formulation of a planned series of steps before airway management is initiated. Recognition of specific attributes of the difficult airway, knowledge of appropriate techniques, familiarity with various devices, and prompt recognition of failed airway circumstances are necessary for optimal patient outcome. This article reviews the attributes of the difficult airway, the definition of the failed airway, and devices and techniques to be used in the management of difficult and failed airways in the trauma patient.
Collapse
Affiliation(s)
- R M Walls
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| |
Collapse
|
62
|
March JA, Farrow JL, Brown LH, Dunn KA, Perkins PK. A breathing manikin model for teaching nasotracheal intubation to EMS professionals. PREHOSP EMERG CARE 1997; 1:269-72. [PMID: 9709369 DOI: 10.1080/10903129708958822] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE The widespread use of orotracheal intubation with rapid-sequence induction has made it difficult for emergency medical services (EMS) professionals to gain experience in nasotracheal intubation (NTI) in a controlled and supervised setting. The purpose of this study was to determine whether a training session on NTI with a breathing manikin can be used to improve the self-assessed skill level and comfort of EMS professionals. METHODS A prospective trial was conducted with a convenience sample of 33 EMS professionals, previously trained in NTI techniques. For the training session, a Laerdal airway manikin was modified by replacing the lungs with self-inflating resuscitation bag. The bag could then be squeezed to simulate breathing, with an inspiratory and expiratory phase. Following didactic instruction, and with direct supervision, each participant practiced NTI using this breathing manikin. Each participant completed a questionnaire, both before and after the training session, to determine self-assessed comfort and skill level for both oral and nasal intubations (0 = lowest, 10 = highest). The pre- and postintervention scores were compared using the Wilcoxon signed-rank test, alpha = 0.01. RESULTS Following the training session, the comfort level for NTI by the participants increased significantly from a median value of 2 to 7 (p = 0.001). Furthermore, the self-assessed skill level for NTI following the training session increased significantly from a median value of 4 to 8 (p = 0.0001). As expected, there were no significant differences noted in self-assessed skill level for orotracheal intubation following the training session. However, there was statistically significant improvement in self-assessed comfort levels for orotracheal intubation after the skills laboratory, p = 0.0001. CONCLUSION For EMS professionals, a training session for NTI using a relatively inexpensive and easily assembled breathing manikin model increases both comfort and self-assessed skill level.
Collapse
Affiliation(s)
- J A March
- Pitt County Memorial Hospital, East Carolina University School of Medicine, Department of Emergency Medicine, Greenville, North Carolina, USA
| | | | | | | | | |
Collapse
|
63
|
Affiliation(s)
- E S Nadel
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA
| | | | | |
Collapse
|
64
|
Abstract
Despite measures based on the Monro-Kellie principles for ICP reduction and optimization of cerebral perfusion pressure, the outcome from complicated neurologic injuries remains unsatisfactory. Many patients are "pulled through" the acute event only to remain minimally functional or vegetative for the remainder of their lives. Pharmacologic interventions to protect the brain against the toxic and metabolic consequences of neurologic injury seem to be the future of neurotrauma.
Collapse
Affiliation(s)
- J P Gruen
- Department of Neurological Surgery, University of Southern California School of Medicine, Los Angeles, USA
| | | |
Collapse
|
65
|
Mastering Emergency Airway Management. Am J Nurs 1996. [DOI: 10.1097/00000446-199605000-00031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
66
|
Abstract
Traumatic brain injury (TBI) contributes significantly to the mortality and morbidity rates of traumatized patients. This article presents current concepts in the pathophysiology of TBI, including mechanisms of injury, biomolecular mediators of injury, and the occurrence of secondary injury. Emergency management, monitoring, and imaging of TBI also are reviewed.
Collapse
Affiliation(s)
- B J Zink
- Department of Surgery, Section of Emergency Medicine, University of Michigan Medical School, Ann Arbor, USA
| |
Collapse
|
67
|
|
68
|
Abstract
The Core Content for Emergency Medicine (EM) recommends that all emergency physicians be trained to manage the airway, including administering paralytic agents for endotracheal intubation. This study analyzed compliance with the recommendations by reviewing airway management practices at EM residencies. All 96 EM residency directors were sent a 10-item survey characterizing airway management practices at residency-affiliated emergency departments (EDs). The 91 respondents (95%) represented residencies with 120 affiliated hospitals. Paralytic agents routinely were used during intubations in 114 of the EDs (95%). Forty-nine of the Eds (41%) never requested an anesthesiologist for intubations, and 8 Eds (7%) mandated anesthesiology presence during paralytic agent administration. The Department of Anesthesiology never performed quality assurance (QA) evaluations in at least 64 EDs (53%). The Department of Emergency Medicine performed QA checks less than two thirds of the time in at least 44 EDs (36%). The majority of EM residencies are complying with the Core Content recommendations by actively performing intubations using paralytic agents. Anesthesiologists are infrequently consulted in residency-affiliated EDs. Quality assurance of ED intubations is not rigorously monitored by emergency and anesthesiology departments.
Collapse
Affiliation(s)
- O J Ma
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, USA
| | | | | |
Collapse
|
69
|
Zink BJ. Catheter-assisted intubation. Acad Emerg Med 1995; 2:238-40. [PMID: 7497041 DOI: 10.1111/j.1553-2712.1995.tb03209.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
|
70
|
|
71
|
|
72
|
|
73
|
Marx JA. Acute injury care. Acad Emerg Med 1994; 1:161-3. [PMID: 7621175 DOI: 10.1111/j.1553-2712.1994.tb02750.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- J A Marx
- Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC 28232, USA
| |
Collapse
|