Complications of emergency intubation with and without paralysis

Potential cervical spine injury and difficult airway management for emergency intubation of trauma adults in the emergency department--a systematic review

BACKGROUND

Emergency airway management for trauma adults is practised by physicians from a range of training backgrounds and with differing levels of experience. The indications for intubation and technique employed are factors that vary within EDs and between hospitals.

OBJECTIVES

To provide practical evidence based guidance for airway management in trauma resuscitation: first for the trauma adult with potential cervical spine injury and second the management when a difficult airway is encountered at intubation.

SEARCH STRATEGY AND METHODOLOGY

Full literature search for relevant articles in Medline (1966-2003), EMBASE (1980-2003), and the Cochrane Central Register of Controlled Trials. Relevant articles relating to adults and written in English language were appraised. English language abstracts of foreign articles were included. Studies were critically appraised on a standardised data collection sheet to assess validity and quality of evidence. The level of evidence was allocated using the methods of the Australian National Health and Medical Research Council.

Airway management in neurological emergencies

Several neurological conditions may present to the emergency department (ED) with airway compromise or respiratory failure. The severity of respiratory involvement in these patients may not always be obvious. Proper pulmonary management can significantly reduce the respiratory complications associated with the morbidity and mortality of these patients. Rapid sequence intubation (RSI) is the method of choice for definitive airway management in the ED and is used for the majority of intubations. The unique clinical circumstances of each patient dictates which pharmacological agents can be used for RSI. Several precautions must be taken when using these drugs to minimize potentially fatal complications. Noninvasive positive pressure ventilation may obviate the need for intubation in a select population of patients. This article reviews airway management, with a particular emphasis on the use of RSI for common neurological problems presenting to the ED.

Airway management by US and Canadian emergency medicine residents: a multicenter analysis of more than 6,000 endotracheal intubation attempts

STUDY OBJECTIVE

We determine success rates of endotracheal intubation performed in emergency departments (EDs) by North American emergency medicine residents.

METHODS

During 58 months, physicians performing intubations at 31 university-affiliated EDs in 3 nations completed a data form that was entered into the National Emergency Airway Registry 2 database. Included were all patients undergoing endotracheal intubation in the ED. The data form included patients' age, sex, weight, indication for intubation, technique of airway management, names and dosages of all medications used to facilitate intubation, level of training and specialty of the intubator, number of attempts, success or failure, and adverse events. We queried this prospectively gathered, observational data to analyze intubations done by US and Canadian emergency medicine residents.

RESULTS

Enrollment was incomplete (eg, 85% at the main study center), so the study sample did not include all consecutive patients. Emergency medicine residents performed 77% (5768/7498; 95% confidence interval [CI] 76% to 78%) of all initial intubation attempts in the United States and Canada. The first intubator was successful in 90% (5,193/5,757; 95% CI 89% to 91%) of cases, including 83% (4,775/5,757; 95% CI 82% to 84%) on the first attempt. Success rates on the first attempt were as follows: postgraduate year 1 = 72% (498/692; 95% CI 68% to 75%), postgraduate year 2 = 82% (2,081/2,544; 95% CI 80% to 83%), postgraduate year 3 = 88% (1,963/2,238; 95% CI 86% to 89%), postgraduate year 4+ = 82% (233/283; 95% CI 77% to 87%), and attending physician = 89% (689/772; 95% CI 87% to 91%). Success rates by the first intubator were as follows: postgraduate year 1 = 80% (553/692; 95% CI 77% to 83%), postgraduate year 2 = 89% (2,272/2,544; 95% CI 88% to 90%), postgraduate year 3 = 94% (2,105/2,238; 95% CI 93% to 95%), postgraduate year 4+ = 93% (263/283; 95% CI 89% to 96%), and attending physician = 98% (755/772; 95% CI 96% to 99%). Rapid sequence intubation technique was used in 78% (4,513/5,768; 95% CI 77% to 79%) of initial attempts: it resulted in 85% (3,843/4,513; 95% CI 84% to 86%) success on the first attempt and 91% (4,117/4,513; 95% CI 90% to 92%) success by the first intubator. The overall rate of cricothyrotomy for all emergency resident intubations was 0.9% (50/5,757; 95% CI 0.6% to 1.1%). When an initial intubator failed, 40% (385/954; 95% CI 37% to 44%) of rescue attempts were performed by emergency medicine residents. Among emergency medicine residents, success on the first rescue attempt was 80% (297/371; 95% CI 76% to 84%), and success by the first rescue intubator was 88% (328/371; 95% CI 85% to 91%).

CONCLUSION

Success of initial intubation attempts increased over the first 3 years of residency. This large multicenter study demonstrates the success of airway management by emergency medicine residents in North America. Using rapid-sequence intubation predominantly, emergency medicine residents achieved high levels of success.

Controversies in rapid sequence intubation in children

PURPOSE OF REVIEW

Rapid sequence intubation is the method of choice for intubation of the emergency department patient. The purpose of the present review is to address several controversies pertaining to emergency department rapid sequence intubation of children.

RECENT FINDINGS

The topics covered in this review include the determination of the appropriate clinician to perform emergency department intubation, the use of atropine and lidocaine as premedications, the choice of sedative agents depending upon the clinical scenario, and the choice of neuromuscular blockade agent. Concerning these topics: The literature supports that emergency department physicians, with appropriate training, successfully perform intubation in most patients. Limited data exist to determine the appropriate use of atropine and lidocaine for rapid sequence intubation. Etomidate has clearly become a preferred sedative for rapid sequence intubation with a low risk of cardiovascular side effects. Thiopental and propofol may more readily provide adequate sedation as compared with etomidate but both have the potential to reduce blood pressure. Succinylcholine arguably remains the preferred neuromuscular blockade agent for rapid sequence intubation in most children. The side effects of succinylcholine occur in relatively predictable circumstances. Rocuronium is a commonly used nondepolarizing paralytic agent but its prolonged duration of action must be weighed against the risk of side effects associated with succinylcholine.

SUMMARY

Though more research is needed, the available data allow for the development of protocols that will result in a rational, scenario-based approach to rapid sequence intubation in children.

Should etomidate be the induction agent of choice for rapid sequence intubation in the emergency department?

The ideal induction agent for emergency airway management should be rapidly acting, permit optimum intubating conditions, and be devoid of significant side effects. This review was performed to ascertain whether etomidate should be the induction agent of choice for rapid sequence intubation (RSI) in the emergency department, specifically examining its pharmacology, haemodynamic profile, and adrenocortical effects. A search of Medline (1966-2002), Embase (1980-2002), the Cochrane controlled trials register, and CINAHL was performed. In addition, the major emergency medicine and anaesthesia journals were hand searched for relevant material. Altogether 144 papers were identified of which 16 were relevant. Most studies were observational studies or retrospective reviews with only one double blind randomised controlled trial and one un-blinded randomised controlled trial. Appraisal of the available evidence suggests that etomidate is an effective induction agent for emergency department RSI; it has a rapid onset of anaesthesia and results in haemodynamic stability, even in hypovolaemic patients or those with limited cardiac reserve. Important questions regarding the medium to long term effects on adrenocortical function (even after a single dose) remain unanswered.

Midazolam is more likely to cause hypotension than etomidate in emergency department rapid sequence intubation

OBJECTIVE

To compare the haemodynamic effect of low dose midazolam and etomidate as induction agent in emergency department rapid sequence intubation.

METHODS

A prospective observational study in two phases. In phase one, midazolam 2-4 mg was used as induction agent and in phase two, etomidate 0.2-0.3 mg/kg was used. The haemodynamic data were recorded before and after intubation for comparison. Changes in mean systolic blood pressure were analysed with SPSS software.

RESULTS

A 10% decrease in mean systolic blood pressure was observed in the midazolam group (p = 0.001) while there was no significant change in the etomidate group. Some 19.5% of patients had hypotension after being given midazolam while only 3.6% with etomidate (p = 0.002). Patients older than 70 tended to have more hypotension episodes but the difference was not statistically significant.

CONCLUSIONS

Midazolam, even in low dose, was more likely than etomidate to cause significant hypotension when used as an induction agent for rapid sequence intubation. Etomidate is a better alternative.

Advanced airway management in the emergency department: what are the training and skills maintenance needs for UK emergency physicians?

This article reviews the evidence for the training of emergency physicians in advanced airway management.

Limitations of difficult airway prediction in patients intubated in the emergency department

STUDY OBJECTIVE

Physiognomic assessment of difficult laryngoscopy before rapid sequence intubation has been advocated for all emergency department (ED) intubations. The study objectives were to evaluate whether Mallampati scores, thyromental distance, and neck mobility could have been assessed in non-cardiac arrest ED-intubated patients and determine whether such tests would have been feasible in our rapid sequence intubation-associated laryngoscopy failures.

METHODS

We retrospectively reviewed 37 months of ED intubations using prospectively collected data from electronic medical records, critical care flow sheets, and a trauma registry. All non-cardiac arrest ED-intubated patients were included for analysis. Mallampati scoring was deemed unobtainable if patients could not follow simple commands. Neck mobility and thyromental measurement were deemed unobtainable with cervical spine precautions.

RESULTS

Eight hundred fifty intubations met the inclusion criteria, and 838 patients underwent rapid sequence intubation. Laryngoscopy failed in 3 patients who underwent rapid sequence intubation. Eight patients had awake nasal intubation, and 4 oral intubations were done without rapid sequence intubation. Four hundred fifty-two (53%) patients could not follow simple commands, and cervical spine immobilization was present in 370 (44%) patients. Only 32% of patients could follow simple commands and were not cervical spine immobilized. Among the 3 rapid sequence intubation laryngoscopy failures, no patients were following commands.

CONCLUSION

Mallampati scoring, neck mobility testing, and measurement of thyromental distance could have been done in only one third of our non-cardiac arrest ED intubations and in none of the rapid sequence intubation failures. The inability to widely obtain these assessment tools, coupled with the low incidence of failed rapid sequence intubation, indicates limitations to using these screening tests in the ED setting.

Emergency tracheal intubation: complications associated with repeated laryngoscopic attempts

Repeated conventional tracheal intubation attempts may contribute to patient morbidity. Critically-ill patients (n = 2833) suffering from cardiovascular, pulmonary, metabolic, neurologic, or trauma-related deterioration were entered into an emergency intubation quality improvement database. This practice analysis was evaluated for airway and hemodynamic-related complications based on a set of defined variables that were correlated to the number of attempts required to successfully intubate the trachea outside the operating room. There was a significant increase in the rate of airway-related complications as the number of laryngoscopic attempts increased (</=2 versus >2 attempts): hypoxemia (11.8% versus 70%), regurgitation of gastric contents (1.9% versus 22%), aspiration of gastric contents (0.8% versus 13%) bradycardia (1.6% versus 21%), and cardiac arrest (0.7% versus 11%; P < 0.001). Although predictable, this analysis provides data that confirm the number of laryngoscopic attempts is associated with the incidence of airway and hemodynamic adverse events. These data support the recommendation of the ASA Task Force on the Management of the Difficult Airway to limit laryngoscopic attempts to three in lieu of the considerable patient injury that may occur.

Acute airway management in the emergency department by non-anesthesiologists

PURPOSE

The responsibility of acute airway management often falls into the hands of non-anesthesiologists. Emergency physicians now routinely use neuromuscular blockade to facilitate intubation. The literature in support of this practice has almost exclusively been published in emergency medicine (EM) journals. This body of literature is presented and issues of educational support are discussed.

SOURCE

A narrative review of the literature on the practice of airway management by non-anesthesiologists.

PRINCIPAL FINDINGS

A significant proportion of acute airway management occurring outside the operating room is being performed by non-anesthesiologists. Rapid sequence intubation (RSI) is recognized as a core procedure within the domain of EM. RSI is being performed routinely by emergency physicians practicing in larger centres. Anesthesiologist support for the practice of RSI by non-anesthesiologists has been weak. Formal educational support outside of postgraduate training in the form of dedicated programs for advanced airway management are now being offered. The majority of the literature on the use of RSI by non-anesthesiologists represents retrospective case series, observational studies and registry data published in EM journals. The reported success rates for RSI performed by non-anesthesiologists is high. Complication rates are significant, however reporting consistency has been poor.

CONCLUSIONS

The role of non-anesthesiologists in acute airway management is significant. Despite shortcomings in methodology, current evidence and practice supports the use of RSI by trained emergency physicians. Constructive collaborative efforts between anesthesiology and EM need to occur to ensure that educational needs are met and that competent airway management is provided.

Blind Nasotracheal Intubation for Patients With Penetrating Neck Trauma

BACKGROUND

Early airway management is advocated for patients with penetrating neck trauma who have any signs of airway compromise. This study examined the clinical course of patients with penetrating neck trauma who received prehospital blind nasotracheal intubation, including successful intubation rates, and outcomes.

METHODS

A retrospective review of patients admitted to the emergency department for penetrating neck trauma was conducted from January 1, 1993 to July 1, 2001 at the Denver Health Medical Center. Patients were identified from the trauma registry, and data were collected using standardized inclusion and exclusion criteria.

RESULTS

The study identified 240 patients with penetrating neck trauma. Overall mortality was 8.3%. Among the 240 patients, 89 (37%) required airway management, and 40 (17%) underwent prehospital management with blind nasotracheal intubation. The success rate for prehospital intubation using the blind nasotracheal method was 90%. The mean number of attempts was 1.16 (range, 1-4), and the mortality in this group was 5%.

CONCLUSION

The patients managed with blind nasotracheal intubation did not experience complications related to the choice of airway management. Despite prior warnings in the literature, the results of this study suggest that blind nasotracheal intubation may well be a valuable tool for the management of patients with penetrating neck trauma.

Comparison of intubation attempts and completion times before and after the initiation of a rapid sequence intubation protocol in an air medical transport program

The purpose of this study was to test the hypothesis that the initiation of a rapid sequence intubation (RSI) protocol would decrease the number of intubation attempts and completion times. In the summer of 2001, an RSI protocol was implemented using succinylcholine and etomidate. Before the RSI protocol, patients were sedated with versed and fentanyl for intubation and then paralyzed with succinylcholine to complete intubation, if needed. Retrospectively reviewed patient transport charts yielded 70 patients in the pre-RSI group and 70 patients in the RSI group. The number of attempts in the RSI group significantly dropped in the pre-RSI group, and the time from medication administration to intubation statistically decreased. In this study, the implementation of an RSI protocol resulted in fewer intubation attempts and more rapid intubations.

Paediatric intubation in Scottish emergency departments

BACKGROUND

Intubation of children in the emergency department setting is uncommon. This prospective observational study examines the practice of paediatric intubation in Scottish adult/paediatric urban emergency departments.

METHODS

A prospective observational study of every intubation attempt was performed in seven urban Scottish emergency departments in 1999 and 2000. Children were defined as those patients who were less than 13 years of age on the day of presentation. Prehospital intubations were only included if they were performed by a mobile medical team doctor from one of the seven hospitals.

RESULTS

A total of 1713 patients were identified, 44 of whom (2.6%) were children. The median age was 4 years (range 0-12 years), and 57% (25 of 44) of intubations were performed on patients with traumatic injuries. Emergency physicians attempted intubation in 27% (12 of 44) of cases, anaesthetists in 73% (32 of 44); 18% (eight of 44) of patients were intubated in nontraumatic cardiac arrest, 68% (30 of 44) underwent rapid sequence intubation (RSI), one (2%) had inhalational anaesthesia and 13 (30%) were intubated without drugs. Eighty per cent (35 of 44) of patients were intubated at the first attempt; eight patients required two attempts, and one required three attempts. Three children were intubated prehospital by mobile medical teams. Emergency physicians intubated more patients with 'physiological compromise' (100% vs 91%).

CONCLUSIONS

Paediatric intubation in the emergency department is uncommon. Collaboration and appropriate training for doctors in emergency medicine, anaesthesia and paediatrics is essential.

Challenges facing the anesthesiologist in the emergency department

PURPOSE OF REVIEW

This review focuses on developments in airway management and concious sedation/analgesic techniques employed by anesthesiologists in the emergency department.

RECENT FINDINGS

Emergency medicine physicians routinely employ airway devices and techniques that were previously reserved for anesthesiologists. An understanding of the uses and limitations of these devices are essential for successful outcomes. Anesthesiologists responding to the emergency department may be faced with soiled or traumatized airways. The use of newer devices in cervical trauma and the difficult airway is reviewed. Consious sedation in the emergency department is also reviewed. There are no published recommendations demonstrating the advantage of specific agents for sedation in the emergency department. A wide variety of medications and techniques are currently being employed. Studies indicate that the incidence of adverse effects from these agents range from less than 1% to almost 30%. Various organizations have published guidelines detailing the appropriate protocols and equipment that must be present in the emergency department to monitor patients undergoing conscious sedation. These recommendations have not been universally implemented, and several recent studies suggest that a substantial number of emergency departments may have major deficiencies.

SUMMARY

The consultant anesthesiologist responding to a critical airway may face a variety of challenges, including traumatized or soiled airways, patients with cervical spine fractures, and patients who have undergone sedation techniques that may have progressed to deep and general anesthesia. Anesthesiologists may also face the challenge of responding to these emergent situations without all the equipment or adequately trained support staff necessary to handle those emergencies safely.

Evaluation and initial management of the patient in respiratory distress

Evaluation of the patient in acute respiratory distress poses a complex problem to the emergency physician. Because of the heterogeneity of the population of patients presenting in acute respiratory distress, there is a paucity of evidence-based medicine recommendations. Practice habit dictates most of our diagnostic and therapeutic approach. It is of paramount importance to understand the limitations of history, physical examination, and diagnostic screening studies in evaluating and treating patients with respiratory distress. The emergency physician should become aware of the benefits of NPPV in the management of respiratory failure. Essential to the management of these patients is the ability to anticipate difficulty in airway management and the formulation of alternative airway strategies.

Prehospital rapid-sequence intubation: a pilot training program

OBJECTIVE

To develop a training program enabling paramedics to use sedation and paralytic medications to facilitate endotracheal intubation in patients who otherwise could not be successfully intubated.

METHODS

Paramedics underwent a training program consisting of six hours of didactic education, two four-hour mannequin labs, one four-hour animal intubation lab, and operating room experience. Rapid-sequence intubation (RSI) runs were reviewed for appropriateness in patient selection and medication use. Non-RSI runs were reviewed to determine whether appropriate patients were being missed. Intubation success rates continue to be followed. Long-term quality assurance includes monthly run reviews, periodic quizzes, and unannounced on-site practical tests.

RESULTS

101 patients have been intubated using RSI, including medical, trauma, pediatric, and adult cases. Of all patients receiving RSI drugs, 100 of 101 were successfully intubated. There were no undetected esophageal intubations. Paramedics were able to demonstrate proper patient selection and appropriately administer RSI medications. The use of sheep labs was a critical component of this training because it permitted multiple intubations in a live model possessing an airway quite similar to that of the human. The gum elastic bougie was felt to be critical in the intubation of three patients.

CONCLUSION

This RSI training model can serve as a template for other agencies seeking to implement RSI. Limitations of this model include the availability of live animal labs and the expense of conducting the training. Intense medical director involvement has been key to the success of this prehospital RSI program.

Emergency airway management

Airway control is one of the most critical interventions required for saving a life. It is essential that practitioners be as well trained as possible in the numerous techniques available to establish airway control. This article reviews some of the available techniques, though other techniques that are not discussed (such as fiberoptic-assisted endotracheal intubation) may also be useful. Perhaps the most important aspect of advanced airway management is the ability to anticipate and prepare for the difficult airway. This article gives numerous options for the difficult airway situation.

Predicting adverse outcomes in a diagnosis-based protocol system for rapid sequence intubation

Our ED at Louisiana State University developed a unique approach to airway management by having four diagnosis-based protocols for rapid sequence intubation (RSI). This study examines protocol use and outcome from RSI in an academic ED. The study objective was to identify variables that are predictive of adverse outcomes in patients requiring RSI. This was a 4-year prospective, observational, data-gathering study of all intubations in an academic ED setting with >250,000 patient visits per year. Four protocols were established for 1) children <10 years of age, 2) adults with increased intracranial pressure, 3) adults with chronic obstructive pulmonary disease/asthma, and 4) other adults not fitting B or C. A special continuing quality improvement (CQI) committee was established to examine each case of RSI. Prospective data were collected, including age, race, gender, protocol, diagnostic group, intubation indication, and preintubation oxygen saturation. Diagnostic group was categorized as medical, blunt trauma, or penetrating trauma. Adverse outcome was defined as any case with hemodynamic changes, those requiring surgical or bronchoscopic intervention, and those requiring more than three attempts at intubation. Data were analyzed using univariate analysis, logistic regression, and a binomial regression tree analysis with SPSS 9.0 (Chicago, IL) and Answer Tree (SPSS). A total of 1,320 consecutive intubated patients were included. Protocol A was used in 4%, B in 43%, C in 15%, and D in 38%. Significant differences in number of cases with adverse outcome were based on protocol (P =.03) and final diagnosis (P <.03). Protocol C was less likely to be associated with adverse outcome than protocol D (odds ratio [OR] = 0.2, 95% confidence interval [CI] = 0.1-0.7). Penetrating trauma was more likely to be associated with adverse outcome (OR = 1.8, 95%, CI = 1.1-3.2) than blunt trauma. A regression tree analysis yielded the following, all cases using protocol A or C or medical cases using B had an adverse event in 11 of 458 (2.4%), whereas nonmedical cases using protocols B or D and medical cases using D had adverse outcomes in 73 of 862 cases (8.5%). The decision rules lead to a better classification of cases with adverse outcomes (2.4 vs 8.5%, of = 6.1%, 95% CI = 3.7-8.4). Adult trauma patients who fit the protocols B or D or adult medical patients who fit protocol B were at higher risk for adverse outcomes with RSI. This could alert the physician to a population at higher risk for adverse outcomes. Variables available in a diagnosis-based protocol RSI system can be used to predict adverse outcome among patients requiring RSI.

Rapid sequence intubation in Scottish urban emergency departments

OBJECTIVE

Airway care is the cornerstone of resuscitation. In UK emergency department practice, this care is provided by anaesthetists and emergency physicians. The aim of this study was to determine current practice for rapid sequence intubation (RSI) in a sample of emergency departments in Scotland.

METHODS

Two year, multicentre, prospective observational study of endotracheal intubation in the emergency departments of seven Scottish urban teaching hospitals.

RESULTS

1631 patients underwent an intubation attempt in the emergency department and 735 patients satisfied the criteria for RSI. Emergency physicians intubated 377 patients and anaesthetists intubated 355 patients. There was no difference in median age between the groups but there was a significantly greater proportion of men (73.2% versus 65.3%, p=0.024) and trauma patients (48.5% versus 37.4%, p=0.003) in the anaesthetic group. Anaesthetists had a higher initial success rate (91.8% versus 83.8%, p=0.001) and achieved more good (Cormack-Lehane Grade I and II) views at laryngoscopy (94.0% versus 89.3%, p=0.039). There was a non-significant trend to more complications in the group of patients intubated by emergency physicians (8.7% versus 12.7%, p=0.104). Emergency physicians intubated a higher proportion of patients with physiological compromise (91.8% versus 86.1%, p=0.027) and a higher proportion of patients within 15 minutes of arrival (32.6% versus 11.3%, p<0.0001).

CONCLUSION

Anaesthetists achieve more good views at laryngoscopy with higher initial success rates during RSI. Emergency physicians perform RSI on a higher proportion of critically ill patients and a higher proportion of patients within 15 minutes of arrival. Complications may be fewer in the anaesthetists' group, but this could be related to differences in patient populations. Training issues for RSI and emergency airway care are discussed. Complication rates for both groups are in keeping with previous studies.

Role of the physician in prehospital management of trauma: European perspective

Advanced prehospital trauma life support is challenged as a whole. Formerly well-accepted basic principles for stabilizing vital functions of the severely injured patient like volume resuscitation, airway protection, and immobilization have been questioned. In prehospital management of trauma, the role of not only the physician but also the paramedic must be redefined. In the absence of evidence about the effectiveness of advanced trauma life support training for paramedic crews, the needs of trauma victims and capacities of emergency medical systems must be re-evaluated. Assessment of patients' conditions, including mechanism of trauma (blunt vs penetrating), source of hypovolemic shock (controlled vs ongoing hemorrhage), concomitant disease (as in elderly patients), and identification of therapeutic goals (such as for cerebral perfusion pressure or secondary brain damage caused by hypoxia in severe head injury), is a subject of increasing importance. Invasive airway management techniques require skills, expertise, and daily routines available only to experienced in-hospital personnel. The controversial issue of paramedic vs physician-based systems should be abandoned. It is the skill, the technique, the awareness of pitfalls, and the capability to handle complications that makes the difference, not the person in possession of the skill.

Rapid sequence intubation for pediatric emergency airway management

OBJECTIVES

To characterize current practice with respect to pediatric emergency airway management using a multicenter data set.

METHODS

A multicenter collaboration was undertaken to gather data prospectively regarding emergency intubation. Analysis of data on adult emergency department (ED) intubations clearly demonstrated that rapid sequence intubation (RSI) was the method used most often. We then conducted an observational study of the prospectively collected database of pediatric ED intubations (EDIs) using the National Emergency Airway Registry Phase One data, gathered in 11 participating EDs over a 16-month time period. A data form completed at the time of EDI enabled analysis of patients' ages, weights, and indications for EDI; personnel; methods employed to facilitate EDI; success rates; and adverse events. Data forms were analyzed regarding the methods of intubation employed, and frequencies, success rates, and adverse event rates among various intubation modalities were compared.

RESULTS

Of 1288 EDIs, there were 156 documented pediatric patients. Initial intubation attempts were all oral, including rapid sequence intubation in 81%, without medications (NOM) in 13%, and sedation without neuromuscular blockade (SED) in 6%. Older children and trauma patients were more likely to be intubated with RSI compared to younger children and patients presenting with medical illnesses. Intubation using RSI was more successful on the first attempt (78%) compared with either NOM (47%, < 0.01) or SED (44%, < 0.05), though this finding is likely explainable by the age differences among groups. Intubation was successfully performed by the initial intubator in 85% of RSI, 75% of NOM, and 89% of SED attempts ( = NS for both comparisons vs RSI). Overall, successful intubation occurred in 99% of RSI and 97% of non-RSI intubation attempts ( = NS). Only one of 156 patients required surgical airway management. True complications occurred in 1%, 5%, and 0% of RSI, NOM, and SED attempts, respectively ( = NS for both comparisons vs RSI). The majority of initial intubation attempts were by emergency medicine residents (59%), pediatric emergency medicine fellows (17%), and pediatrics residents (10%). These groups were 77%, 77%, and 50% successful, respectively, on the first laryngoscopy attempt, and 89%, 89%, and 69% successful overall.

CONCLUSIONS

A large, prospective, multicenter observational study of pediatric EDIs was conducted at university-affiliated EDs. RSI is the method of choice for the majority of pediatric emergency intubations; it is associated with a high success rate and a low rate of serious adverse events. Pediatric intubation as practiced in academic EDs, with most initial attempts by emergency and pediatrics residents and fellows under attending physician supervision, is safe and highly successful.

The importance of outcomes research in pediatric emergency medicine

Applying the methods and tools of outcomes research, "evaluation of the impact of health care on the health outcomes or 'end results' of patients and populations," to the clinical domain of emergency services for children offers an important strategic opportunity for addressing the questions that confront all health care services: What works? For which patients? At what cost? From whose perspective? Although the important questions to address are extensive, much of the intersection between emergency services and outcomes research remains unexplored. Important challenges for researchers intrigued by the opportunities at this intersection of fields include: 1) clear definition of the scope of emergency services; 2) consideration of the appropriate end-point of emergency services-the entire episode of illness and/or services provided within the emergency setting; 3) selection and development of measures that incorporate children's and families' perspectives; and 4) a clear focus on linking research findings with strategies for improving outcomes and informed decision making. This essay will provide an overview of accomplishments and challenges from the field of outcomes research, suggest important opportunities for applying existing methods to emergency medical services for children, and identify potential career paths for current and future investigators.

Prehospital tracheal intubating conditions during rapid sequence intubation: rocuronium versus vecuronium

INTRODUCTION

The study purpose was to evaluate tracheal intubating conditions and cardiovascular effects of rocuronium (roc) and vecuronium (vec) in the transport setting.

METHODS

A prospective blinded study of adult patients requiring emergency rapid sequence oral tracheal intubation using direct laryngoscopy. Patients received equipotent doses of roc 1.0 mg/kg (n = 44) or vec 0.15 mg/kg (n = 56) on an alternate day basis.

RESULTS

Intubation was successful in 95% of patients in the vec group and 100% in the roc group. The percentage of patients having good or excellent jaw relaxation and vocal cord exposure was similar between groups (vec/79%, roc/77%). Eleven patients (vec/7, roc/4) had difficult intubation as evidenced by Grade III or IV view and more than three attempts. Five patients in the vec group had inadequate neuromuscular blockade versus 1 patient in the roc group (P = 0.17). No cardiovascular differences occurred between groups after intubation.

CONCLUSION

Tracheal intubating conditions and clinical evidence of complete neuromuscular blockade tended to be better after roc than after vec.

Role of the emergency medicine physician in airway management of the trauma patient

BACKGROUND

A Level I trauma center recently underwent a policy change wherein airway management of the trauma patient is under the auspices of Emergency Medicine (EM) rather than Anesthesiology.

METHODS

We prospectively collected data on 11 months of EM intubations (EMI) since this policy change and compared them to the last year of Anesthesia-managed intubations (ANI) to answer the following questions: (1) Is intubation of trauma patients being accomplished effectively by EM? (2) Has there been a change in complication rates since the policy change? (3) How does the complication rate at our trauma center compare with other institutions?

RESULTS

EM residents successfully intubated trauma patients on their first attempt 73.7% of the time compared with 77.2% ANI. The overall success rates, i.e., securing the airway within three attempts, were 97.0% (EMI) and 98.0% (ANI). The airway was successfully secured by EMI 100% of the time while a surgical airway was performed in two ANIs.

CONCLUSION

EM residents and staff can safely manage the airway of trauma patients. There is no statistically significant difference in peri-intubation complications. The complication rate for EDI (33%) and ANI (38%) is higher than reported in the literature, although the populations are not entirely comparable.

The traumatic airway: the anesthesiologist's role in the emergency room

An approach to the airway is addressed in Table 1. A summary of induction/NMB agents and doses is given on Table 2; indications for the different agents are noted on Table 3. The central pharmacological issue is not that any one drug is universally preferred over another. Rather, it is key that one develop a thoughtful rationale for the drugs used, and a plan to get out of trouble if one is suddenly in the sinking situation of a patient with a difficult airway who cannot breathe on his or her own. The backup plan might involve the use of BVM ventilation, blind digital intubation, fiberoptic bronchoscope-aided intubation, retrograde techniques, light wand intubation, laryngeal mask airway techniques, posterior pharyngeal endotracheal tube placement ventilation, or a surgical airway. Most of these approaches are reviewed elsewhere.

Evaluation and management of acutely decompensated chronic heart failure in the emergency department

A wide range of patients with symptomatic heart failure seek treatment in the emergency department. While there is no single approach to the diversity of patients with acutely decompensated heart failure, certain overarching principles apply. For patients with acute pulmonary edema or cardiogenic shock, the first priority must be rapid stabilization and treatment of reversible problems. For patients with less dramatic presentations, a more systematic search for precipitating factors may be required. Therapy, in general, is directed at reversing dyspnea and/or hypoxemia caused by pulmonary edema, improving systemic perfusion, and reducing myocardial oxygen demand. While morphine and diuretics still have their traditional roles, vasodilators and inotropic agents play an increasingly important part in the modern pharmacologic approach to decompensated heart failure in the emergency department. After evaluation and stabilization in the emergency department, most patients will require hospital admission, although a subset of low-risk patients may be appropriate for discharge to home following a period of observation. Strategies to optimize emergency department care are likely to have an impact upon patient outcomes and upon resource utilization. (c)2001 by CHF, Inc.

A prospective multicenter trial testing the SCOTI device for confirmation of endotracheal tube placement

We sought to characterize the Sonomatic Confirmation of Tracheal Intubation (SCOTI) device's ability to confirm endotracheal tube location during real-time intubation in emergency and elective settings. Data were prospectively collected during a multicenter convenience-sample observational trial of emergency and elective intubation cases. In addition to tracheal and inadvertent esophageal intubations in emergency patients, intentional esophageal intubations were also performed to improve specificity calculations in consenting elective surgical patients. Data analysis included descriptive statistics as well as calculations of sensitivity, specificity, and 95% confidence intervals (CI). Data were obtained from 220 tracheal and 103 esophageal intubations, 137 (42%) performed in emergency patients. Fifteen tracheal intubations were incorrectly identified by SCOTI as esophageal and two esophageal intubations incorrectly as tracheal. Sensitivity and specificity were thus 93% (CI 90-97%) and 98% (CI 94-99%), respectively. The two false-positive cases were attributed to gaseous distension of the stomach and esophagus from prolonged bag-valve-mask ventilation. In addition to use in postprocedure tube placement confirmation, SCOTI aided the intubation procedure itself in 45 difficult emergency attempts (33%), 26 of which necessitated blind tube passage. We conclude that the SCOTI device has high sensitivity and specificity for tube placement confirmation during tracheal intubation attempts in both emergency and elective settings. It also facilitates tube placement itself during difficult intubations. As such it may be considered an adjunctive device to minimize the potentially fatal complication of esophageal intubation.

Capnography alone is imperfect for endotracheal tube placement confirmation during emergency intubation

This analysis primarily sought to determine the effectiveness of end-tidal capnography for tube placement confirmation during emergency airway management. Secondary objectives were validation of the rate of unanticipated esophageal placement during emergency intubation and quantification of the portion of intubations performed in patients with cardiac arrest where capnography is not recommended. The study was performed in two phases. For the primary objective, a meta-analysis was performed on all experimental capnography trials enrolling emergency populations. For the secondary objectives, inadvertent esophageal intubation and cardiac arrest rates were calculated from a large prospective multicenter observational study of emergency intubation cases. Data analysis included calculation of descriptive statistics, sensitivity, specificity, and confidence intervals (CI). Based on 2,192 intubations, a meta-analysis of previous capnography trials resulted in an aggregate sensitivity of 93% (95% CI 92-94%) and an aggregate specificity of 97% (CI 93-99%) for emergency tube placement confirmation. Thus, for emergency capnography use, the false-negative failure rate (tube in trachea but capnography reports esophagus) was 7% and the false-positive rate (tube in esophagus but capnography reports trachea) was 3%. This translates to potential harm for one patient in every 10 treated with capnographic confirmation alone (number needed to harm: 14 for false-negative, 33 for false-positive, and 10 for both). A further literature review demonstrated no sole method of tube placement confirmation is completely foolproof. Of 4,602 consecutive intubations reported to the National Emergency Airway Registry, 4% of emergency intubation attempts resulted in accidental esophageal intubation, and 10% occurred in nontraumatic cardiac arrest patients. During tracheal intubation of critically ill patients, it is concluded that the rate of accidental esophageal tube placement warrants continued improvement in emergency airway techniques. Misidentification of esophageal placement in the emergency setting may occur with capnography. Multiple methods of tube placement confirmation are superior to any single method because no single method has perfect accuracy.

New equipment and techniques for airway management in trauma

A patent, unobstructed airway is fundamental in the care of the trauma patient, and is most often obtained by placing a cuffed tube in the trachea. The presence of shock, respiratory distress, a full stomach, maxillofacial trauma, neck hematoma, laryngeal disruption, cervical spine instability, and head injury all combine to increase tracheal intubation difficulty in the trauma patient. Complications resulting from intubation difficulties include brain injury, aspiration, trauma to the airway, and death. The use of devices such as the gum-elastic bougie, McCoy laryngoscope, flexible and rigid fiberscopes, intubating laryngeal mask, light wand, and techniques such as rapid-sequence intubation, manual in-line axial stabilization, retrograde intubation, and cricothyroidotomy, enhance the ability to obtain a definitive airway safely. The management of the failed airway includes calling for assistance, optimal two-person bag-mask ventilation, and the use of the laryngeal mask airway, Combitube, or surgical airway. The simulation of airway management using realistic simulator tools (e.g. full-scale simulators, virtual reality airway simulators) is a promising modality for teaching physicians and advanced life support personnel emergency airway management skills.

Intubating trauma patients before reaching hospital -- revisited

Endotracheal intubation is widely used for airway management in a prehospital setting, despite a lack of controlled trials demonstrating a positive effect on survival or neurological outcome in adult patients. The benefits, in term of outcomes of invasive airway management before reaching hospital, remain controversial. However, inadequate airway management in this patient population is the primary cause of preventable mortality. An increase in intubation failures and in the rate of complications in trauma patients should induce us to improve airway management skills at the scene of trauma. If the addition of emergency physicians to a prehospital setting is to have any influence on outcome, further studies are merited. However, it has been established that sedation with rapid sequence intubation is superior in terms of success, complications and rates of intubation difficulty. Orotracheal intubation with planned neuromuscular blockade and in-line cervical alignment remains the safest and most effective method for airway control in patients who are severely injured.

[Complications of difficult tracheal intubations in a critical care unit]

OBJECTIVES

This study was performed in order to evaluate the frequency of DI, the predictive factors of DI and to list the related complications.

STUDY DESIGN

Prospective non randomized, open study.

PATIENTS AND METHODS

All patients intubated in the critical care unit during the five months of the study were included. The previous history and clinical setting of the patients, the conditions and the complications of intubation were collected. DI was defined when the procedure required more than two laryngoscopies.

RESULTS

The study included 80 patients. The rate of DI was 22.5%. The Mallampati score (p < 0.001) was the only predictive factor. The frequency of complications was 25%. This rate was 55% for DI versus 16% for easy intubations (p < 0.001).

CONCLUSION

This study confirms the high incidence of DI and associated complications in critical care. We suggest the development of airway management protocols in critical care unit in order to reduce the rate of DI.

Emergent airway management. Indications and methods in the face of confounding conditions

Optimal airway management requires an experienced caregiver, attention to detail, and knowledge of the patient's physiology. A variety of pharmacologic agents have proved useful in obtaining a secure airway and minimizing risk to the patient. Depending on the skills of the caregiver, oral intubation has become the preferred means of airway control in most patients. Advances in technique, equipment, and pharmacology have greatly improved the art of airway management; however, there is no substitute for an experienced clinician.

Pulmonary aspiration and lung injury

Lung injury after aspiration, although very rare, is a feared and potentially devastating sequela after anaesthesia. This paper summarizes the most recent studies in aspiration lung injury focusing on its clinical epidemiology, new insights in its pathophysiology and innovative concepts in its prevention and therapy.