[Airway management in preclinical emergency anesthesia with respect to specialty and education]

Machine learning predicts emergency physician specialties from treatment strategies for patients suspected of myocardial infarction

BACKGROUND

Our investigation aimed to determine how the diverse backgrounds and medical specialties of emergency physicians (Eps) influence the accuracy of diagnoses and the subsequent treatment pathways for patients presenting preclinically with MI symptoms. By scrutinizing the relationships between EPs' specialties and their approaches to patient care, we aimed to unveil potential variances in diagnostic accuracy and treatment choices.

METHODS

In this retrospective, monocenter cohort study, we leveraged machine learning techniques to analyze a comprehensive dataset of 2328 patients with suspected MI, encompassing preclinical diagnoses, electrocardiogram (ECG) interpretations, and subsequent treatment strategies by attending EPs.

RESULTS

We demonstrated that diagnosis and treatment patterns of different specialties were distinct enough, that machine learning (ML) was able to differentiate between specialties (maximum area under the receiver operating characteristic = 0.80 for general medicine and 0.80 for surgery). In our study, internist demonstrated the highest accuracy for preclinical identification of STEMI (0.96) whereas surgeons showed the highest accuracy for identifying NSTEMI. Our findings highlight significant correlations between EP specialties and the accuracy of both preclinical diagnoses and subsequent treatment pathways for patients with suspected MI.

CONCLUSIONS

Our results offer valuable insights into how the diverse backgrounds and specialties of EPs can influence the optimization of patient care in emergency settings. Understanding these patterns can help in the development of tailored training programs and protocols to enhance diagnostic accuracy and treatment efficacy in emergency cardiac care, ultimately optimizing patient treatment and improving outcomes.

Airway management in a Helicopter Emergency Medical Service (HEMS): a retrospective observational study of 365 out-of-hospital intubations

Background

Airway management is a key skill in any helicopter emergency medical service (HEMS). Intubation is successful less often than in the hospital, and alternative forms of airway management are more often needed.

Methods

Retrospective observational cohort study in an anaesthesiologist-staffed HEMS in Switzerland. Patient charts were analysed for all calls to the scene (n = 9,035) taking place between June 2016 and May 2017 (12 months). The primary outcome parameter was intubation success rate. Secondary parameters included the number of alternative techniques that eventually secured the airway, and comparison of patients with and without difficulties in airway management.

Results

A total of 365 patients receiving invasive ventilatory support were identified. Difficulties in airway management occurred in 26 patients (7.1%). Severe traumatic brain injury was the most common indication for out-of-hospital Intubation (n = 130, 36%). Airway management was performed by 129 different Rega physicians and 47 different Rega paramedics. Paramedics were involved in out-of-hospital airway manoeuvres significantly more often than physicians: median 7 (IQR 4 to 9) versus 2 (IQR 1 to 4), p < 0.001.

Conclusion

Despite high overall success rates for endotracheal intubation in the physician-staffed service, individual physicians get only limited real-life experience with advanced airway management in the field. This highlights the importance of solid basic competence in a discipline such as anaesthesiology.

Iatrogenic Tracheal Rupture Related to Prehospital Emergency Intubation in Adults: A 15-Year Single Center Experience

OBJECTIVE

Iatrogenic tracheal rupture is an unusual and severe complication that can be caused by tracheal intubation. The frequency, management, and outcome of iatrogenic tracheal rupture due to prehospital emergency intubation in adults by emergency response physicians has not yet been sufficiently explored.

METHODS

Adult patients with iatrogenic tracheal ruptures due to prehospital emergency intubation admitted to an academic referral center over a 15-year period (2004-2018) with consideration of individual risk factors were analyzed.

RESULTS

Thirteen patients (eight female) with a mean age of 67 years met the inclusion criteria and were analyzed. Of these, eight tracheal ruptures (62%) were caused during the airway management of cardiopulmonary resuscitation (CPR). Stylet use and difficult laryngoscopy requiring multiple attempts were documented in eight cases (62%) and four cases (30%), respectively. Seven patients (54%) underwent surgery, while six patients (46%) were treated conservatively. The overall 30-day mortality was 46%; five patients died due to their underlying emergencies and one patient died of tracheal rupture. Three survivors (23%) recovered with severe neurological sequelae and four (30%) were discharged in good neurological condition. Survivors had significantly smaller mean rupture sizes (2.7cm versus 6.3cm; P <.001) and less cutaneous emphysema (n = 2 versus n = 6; P = .021) than nonsurvivors.

CONCLUSIONS

Iatrogenic tracheal rupture due to prehospital emergency intubation is a rare complication. Published risk factors are not consistently present and may not be applicable to identify patients at high risk, especially not in rescue situations. Treatment options depend on individual patient condition, whereas outcome largely depends on the underlying disease and rupture extension.

Higher pre-hospital anaesthesia case volumes result in lower mortality rates: implications for mass casualty care

Senior physicians with a higher pre-hospital anaesthesia case volume have higher first-pass tracheal intubation success rates, shorter on-site times, and lower patient mortality rates than physicians with lower case volumes. A senior physician's skill set includes the basics of management of airway and breathing (ventilating and oxygenating the patient), circulation, disability (anaesthesia), and environment (especially maintaining core temperature). Technical rescue skills may be required to care for patients requiring pre-hospital airway management especially in hazardous environments, such as road traffic accidents, chemical incidents, terror attacks or warfare, and natural disasters. Additional important tactical skills in mass casualty situations include patient triage, prioritising, allocating resources, and making transport decisions.