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Enomoto Y, Tsutsumi Y, Kido T, Nagatomo K, Tsuchiya A, Inoue Y. Association between helicopter medical services for pediatric trauma patients and mortality: Systematic review and meta-analysis. Am J Emerg Med 2024; 85:196-201. [PMID: 39278027 DOI: 10.1016/j.ajem.2024.09.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2024] [Revised: 09/03/2024] [Accepted: 09/08/2024] [Indexed: 09/17/2024] Open
Abstract
BACKGROUND Helicopter emergency medical services (HEMS) have become widespread around the world. However, previous studies of the influence of HEMS on mortality were limited to adult patients only and showed inconsistent and heterogeneous results. This study aimed to examine the association between HEMS and mortality among pediatric emergencies compared to ground emergency medical service (GEMS). METHODS We searched relevant databases (MEDLINE, EMBASE, The Cochrane Central Register of Controlled Trials) and included articles in any language. The most recent search was on January 4th, 2024. We included prospective observational cohort studies or clinical trials that compared HEMS with GEMS in pediatric patients. We excluded any study that did not compare two or more groups of participants. Two pairs of researchers blindly screened studies and evaluated risk of bias using the Risk of Bias in Nonrandomized Studies of Interventions tool. We conducted this systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Data were extracted by four independent reviewers. We calculated the odds ratio using the random-effects model. The primary outcome was mortality. RESULTS Our search strategy yielded 1454 results. Of these, seven observational studies met our eligibility criteria; no RCT met the criteria. All studies targeted trauma patients only. HEMS was associated with lower mortality (Odds ratio 0.66, 95 % CI 0.59 to 0.74). Inconsistency between trials was determined to be low due to low heterogeneity (I2 = 0 %). In a subgroup analysis conducted with and without physicians on the HEMS staff, we found no significant differences (I2 = 0 %, p = 0.71). CONCLUSION Our systematic review and meta-analysis, which was limited to trauma pediatric trauma patients, revealed that HEMS deployment correlated with decreased mortality. Further research is necessary to more effectively measure the potential influence and applicability of HEMS for pediatric emergencies.
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Affiliation(s)
- Yuki Enomoto
- Department of Emergency and Critical Care Medicine, University of Tsukuba, Ibaraki, Japan; Department of Pediatrics, University of Tsukuba hospital, Ibaraki, Japan
| | - Yusuke Tsutsumi
- Department of Emergency and Critical Care Medicine, National Hospital Organization Mito Medical Center, Ibaraki, Japan; Human Health Science, Kyoto University Graduate School of Medicine, Kyoto, Japan.
| | - Takahiro Kido
- Department of Pediatrics, University of Tsukuba hospital, Ibaraki, Japan
| | - Kazuki Nagatomo
- Department of Emergency and Critical Care Medicine, University of Tsukuba, Ibaraki, Japan
| | - Asuka Tsuchiya
- Department of Emergency and Critical Care Medicine, Tokai University School of Medicine, Kanagawa, Japan; Department of Clinical Epidemiology and Health Economics, School of Public Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yoshiaki Inoue
- Department of Emergency and Critical Care Medicine, University of Tsukuba, Ibaraki, Japan
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Lorenzen U, Marung H, Eimer C, Köser A, Seewald S, Rudolph M, Reifferscheid F. Quality and safety in prehospital airway management - retrospective analysis of 18,000 cases from an air rescue database in Germany. BMC Emerg Med 2024; 24:157. [PMID: 39218873 PMCID: PMC11368010 DOI: 10.1186/s12873-024-01075-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2024] [Accepted: 08/20/2024] [Indexed: 09/04/2024] Open
Abstract
BACKGROUND Prehospital airway management remains crucial with regard to the quality and safety of emergency medical service (EMS) systems worldwide. In 2007, the benchmark study by Timmermann et al. hit the German EMS community hard by revealing a significant rate of undetected oesophageal intubations leading to an often-fatal outcome. Since then, much attention has been given to guideline development and training. This study evaluated the incidence and special circumstances of tube misplacement as an adverse peri-intubation event from a Helicopter Emergency Medical Services perspective. METHODS This was a retrospective analysis of a German helicopter-based EMS database from January 1, 2012, to December 31, 2020. All registered patients were included in the primary analysis. The results were analysed using SPSS 27.0.1.0. RESULTS Out of 227,459 emergency medical responses overall, a total of 18,087 (8.0%) involved invasive airway management. In 8141 (45.0%) of these patients, airway management devices were used by ground-based EMS staff, with an intubation rate of 96.6% (n = 7861), and alternative airways were used in 3.2% (n = 285). Overall, the rate of endotracheal intubation success was 94.7%, while adverse events in the form of tube misplacement were present in 5.3%, with a 1.2% rate of undetected oesophageal intubation. Overall tube misplacement and undetected oesophageal intubation occurred more often after intubation was carried out by paramedics (10.4% and 3.6%, respectively). In view of special circumstances, those errors occurred more often in the presence of trauma or cardiopulmonary resuscitation, with rates of 5.6% and 6.4%, respectively. Difficult airways with a Cormack 4 status were present in 2.1% (n = 213) of HEMS patients, accompanied by three or more intubation attempts in 5.2% (n = 11). CONCLUSIONS Prehospital airway management success has improved significantly in recent years. However, adverse peri-intubation events such as undetected oesophageal intubation remain a persistent threat to patient safety. TRIAL REGISTRATION The study was registered in the German Register for Clinical Studies (number DRKS00028068).
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Affiliation(s)
- Ulf Lorenzen
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Hartwig Marung
- Faculty of Health Sciences, Institute for Safety of Patients and Health Professionals (ISPP), MSH Medical School Hamburg, Am Kaiserkai 1, 20457, Hamburg, Germany.
| | - Christine Eimer
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Andrea Köser
- Department of Emergency Medicine, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Stephan Seewald
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
- Institute for Emergency Medicine, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Marcus Rudolph
- Department of Anesthesiology and Intensive Care Medicine, University Medical Centre Mannheim, Mannheim, Germany
- German Air Rescue "DRF Stiftung Luftrettung gAG", Filderstadt, Germany
| | - Florian Reifferscheid
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
- German Air Rescue "DRF Stiftung Luftrettung gAG", Filderstadt, Germany
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3
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Hayes-Bradley C, McCreery M, Delorenzo A, Bendall J, Lewis A, Bowles KA. Predictive and protective factors for failing first pass intubation in prehospital rapid sequence intubation: an aetiology and risk systematic review with meta-analysis. Br J Anaesth 2024; 132:918-935. [PMID: 38508943 DOI: 10.1016/j.bja.2024.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 01/15/2024] [Accepted: 02/01/2024] [Indexed: 03/22/2024] Open
Abstract
BACKGROUND Prehospital rapid sequence intubation first pass success rates vary between 59% and 98%. Patient morbidity is associated with repeat intubation attempts. Understanding what influences first pass success can guide improvements in practice. We performed an aetiology and risk systematic review to answer the research question 'what factors are associated with success or failure at first attempt laryngoscopy in prehospital rapid sequence intubation?'. METHODS MEDLINE, EMBASE, CINAHL, and Cochrane Library were searched on March 3, 2023 for studies examining first pass success rates for rapid sequence intubation of prehospital live patients. Screening was performed via Covidence, and data synthesised by meta-analysis. The review was registered with PROSPERO and performed and reported as per Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. RESULTS Reasonable evidence was discovered for predictive and protective factors for failure of first pass intubation. Predictive factors included age younger than 1 yr, the presence of blood or fluid in the airway, restricted jaw or neck movement, trauma patients, nighttime procedures, chronic or acute distortions of normal face/upper airway anatomy, and equipment issues. Protective factors included an experienced intubator, adequate training, use of certain videolaryngoscopes, elevating the patient on a stretcher in an inclined position, use of a bougie, and laryngeal manoeuvres. CONCLUSIONS Managing bloody airways, positioning well, using videolaryngoscopes with bougies, and appropriate training should be further explored as opportunities for prehospital services to increase first pass success. Heterogeneity of studies limits stronger conclusions. SYSTEMATIC REVIEW PROTOCOL PROSPERO (CRD42022353609).
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Affiliation(s)
- Clare Hayes-Bradley
- Department of Paramedicine, Monash University, Frankston, VIC, Australia; NSW Ambulance Aeromedical Operations, Sydney, NSW, Australia.
| | | | - Ashleigh Delorenzo
- Department of Paramedicine, Monash University, Frankston, VIC, Australia
| | | | | | - Kelly-Ann Bowles
- Department of Paramedicine, Monash University, Frankston, VIC, Australia
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AlGhamdi FA, AlJoaib NA, Saati AM, Abu Melha MA, Alkhofi MA. Paramedics' Success and Complications in Prehospital Pediatric Intubation: A Meta-Analysis. Prehosp Disaster Med 2024; 39:184-194. [PMID: 38531631 DOI: 10.1017/s1049023x24000244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/28/2024]
Abstract
BACKGROUND Prehospital pediatric intubation is a potentially life-saving procedure in which paramedics are relied upon. However, due to the anatomical nature of pediatrics and associated adverse events, it is more challenging compared to adult intubation. In this study, the knowledge and attitude of paramedics was assessed by measuring their overall success rate and associated complications. METHODS An online search using PubMed, Scopus, Web of Science, and Cochrane CENTRAL was conducted using relevant keywords to include studies that assess success rates and associated complications. Studies for eligibility were screened. Data were extracted from eligible studies and pooled as risk ratio (RR) with a 95% confidence interval (CI). RESULTS Thirty-eight studies involving 14,207 pediatrics undergoing intubation by paramedics were included in this study. The prevalence of success rate was 82.5% (95% CI, 0.745-0.832) for overall trials and 77.2% (95% CI, 0.713-0.832) success rate after the first attempt. By subgrouping the patients according to using muscle relaxants during intubation, the group that used muscle relaxants showed a high overall successful rate of 92.5% (95% CI, 0.877-0.973) and 79.9% (95% CI, 0.715-0.994) success rate after the first attempt, more than the group without muscle relaxant which represent 78.9% (95% CI, 0.745-0.832) overall success rate and 73.3% (95% CI, 0.616-0.950) success rate after first attempt. CONCLUSION Paramedics have a good overall successful rate of pediatric intubation with a lower complication rate, especially when using muscle relaxants.
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Affiliation(s)
- Faisal A AlGhamdi
- College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Nasser A AlJoaib
- College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Abdulaziz M Saati
- College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Mishal A Abu Melha
- College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Mohammad A Alkhofi
- Department of Pediatrics, King Fahad University Hospital, Imam Abdulrahman bin Faisal's University, Khobar, Saudi Arabia
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Morton S, Keane S, O'Meara M. Pediatric Intubations in a Semiurban Helicopter Emergency Medicine Service: A Retrospective Review. Air Med J 2024; 43:106-110. [PMID: 38490772 DOI: 10.1016/j.amj.2023.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 10/06/2023] [Accepted: 10/17/2023] [Indexed: 03/17/2024]
Abstract
OBJECTIVE Although a small proportion of helicopter emergency medical service (HEMS) missions are for pediatric patients, it is recognized that children do present unique challenges. This case series aims to evaluate the intubation first-pass success rate in HEMS pediatric patients for both medical and trauma patients in a UK semiurban environment. METHODS A retrospective review of the computerized records system was performed from January 1, 2015, to July 31, 2022, at 1 UK HEMS. Anonymous data relating to advanced airway interventions in patients < 16 years of age were extracted. Primary analysis related to the first-pass success rate was performed; secondary analysis relating to the initial Glasgow Coma Scale (GCS) of the pediatric patients requiring prehospital anesthesia (rapid sequence induction with drugs) and first-pass success rates by clinician group was also performed. RESULTS Of the pediatric patients, 15.8% required intubation. The overall first-pass success rate for intubation (including in cardiac arrest) was 83.5%; for prehospital anesthesia (drugs administered), it was 98.4%. First-pass success rates were lowest for those under 2 years of age (45.2% without drugs and 87.5% with drugs). There was no difference between physician background in the first-pass success rate. The median GCS for pediatric prehospital anesthesia was 7 versus 5 for adults (P = .012). No children with an initial GCS of 15 had prehospital anesthesia. CONCLUSION The overall intubation first-pass success rates for pediatric patients is high at 83.5% and higher still for prehospital anesthesia (98.4%). However, it remains a rare intervention for clinicians, and children under 2 years of age require special consideration.
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Affiliation(s)
- Sarah Morton
- Essex and Herts Air Ambulance, Colchester, Essex, United Kingdom; Department of Surgery, Imperial College, London, United Kingdom.
| | - Sinead Keane
- Essex and Herts Air Ambulance, Colchester, Essex, United Kingdom
| | - Matt O'Meara
- Essex and Herts Air Ambulance, Colchester, Essex, United Kingdom
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Kaisler M, Pichette C, Popieluszko P, Tift F, Tanaka K. The Value of Physicians as Part of a Helicopter Emergency Medical Services Crew: A Review. Air Med J 2023; 42:477-482. [PMID: 37996186 DOI: 10.1016/j.amj.2023.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 06/30/2023] [Accepted: 07/03/2023] [Indexed: 11/25/2023]
Abstract
OBJECTIVE The benefit and utility of a physician on a US-based air ambulance is an often-debated topic in the prehospital setting. There remains the question of what, if any, effect a physician crewmember has on patient outcome. Our goal was to assess the literature to date and determine if there exists a benefit to staffing air ambulances with physicians. METHODS PubMed and Cochrane databases were searched for English language studies from 1980 to 2020 using the terms "flight physician" and "physician-staffed helicopter." Studies were chosen for inclusion based on the presence of a comparison of physician-staffed crews with non-physician-staffed crews. The included studies had their references reviewed for additional studies meeting the inclusion criteria. RESULTS A total of 19 articles were included, and their overall opinion of the benefit of a physician was assessed. Ten studies demonstrated a benefit, 8 showed no benefit or favored a nonphysician crew, and 1 was equivocal. CONCLUSIONS Although some studies showed a benefit to having physicians staff an air ambulance, some showed no benefit, leaving our findings inconclusive. More data are needed to determine if the inclusion of these crewmembers has a positive effect on patient outcomes.
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Affiliation(s)
- Maria Kaisler
- University at Buffalo Department of Emergency Medicine, Buffalo, NY
| | | | - Patrick Popieluszko
- Department of Emergency Medicine, University of Tennessee Health Science Center College of Medicine Chattanooga, Chattanooga, TN.
| | - Frank Tift
- Department of Emergency Medicine, University of Tennessee Health Science Center College of Medicine Chattanooga, Chattanooga, TN
| | - Kaori Tanaka
- University at Buffalo Department of Emergency Medicine, Buffalo, NY
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Mockler S, Metelmann C, Metelmann B, Thies KC. Prevalence and severity of pediatric emergencies in a German helicopter emergency service: implications for training and service configuration. Eur J Pediatr 2023; 182:5057-5065. [PMID: 37656240 PMCID: PMC10640406 DOI: 10.1007/s00431-023-05178-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 08/15/2023] [Accepted: 08/23/2023] [Indexed: 09/02/2023]
Abstract
This study primarily aims to determine the frequency of life-threatening conditions among pediatric patients served by the DRF, a German helicopter emergency service (HEMS) provider. It also seeks to explore the necessity of invasive procedures in this population, discussing the implications for HEMS crew training and service configuration based on current literature. We analyzed the mission registry from 31 DRF helicopter bases in Germany, focusing on 7954 children aged 10 or younger over a 5-year period (2014-2018). Out of 7954 identified children (6.2% of all primary missions), 2081 (26.2%) had critical conditions. Endotracheal intubation was needed in 6.5% of cases, while alternative airway management methods were rare (n = 14). Half of the children required intravenous access, and 3.6% needed intraosseous access. Thoracostomy thoracentesis and sonography were only performed in isolated cases. Conclusions: Critically ill or injured children are infrequent in German HEMS operations. Our findings suggest that the likelihood of HEMS teams encountering such cases is remarkably low. Besides endotracheal intubation, life-saving invasive procedures are seldom necessary. Consequently, we conclude that on-the-job training and mission experience alone are insufficient for acquiring and maintaining the competencies needed to care for critically ill or injured children. What is Known: • Pediatric emergencies are relatively rare in the prehospital setting, but their incidence is higher in helicopter emergency medical services (HEMS) compared to ground-based emergency services. What is New: • On average, HEMS doctors in Germany encounter a critically ill or injured child approximately every 1.5 years in their practice, establish an IV or IO access in infants or toddlers every 2 years, and intubate an infant every 46 years. • This low frequency highlights the insufficiency of on-the-job training alone to develop and maintain pediatric skills among HEMS crews. Specific interdisciplinary training for HEMS crews is needed to ensure effective care for critically unwell pediatric patients.
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Affiliation(s)
- Stefan Mockler
- Department of Anesthesiology, University Hospital Greifswald, Sauerbruchstr, 17475, Greifswald, Germany.
| | - Camilla Metelmann
- Department of Anesthesiology, University Hospital Greifswald, Sauerbruchstr, 17475, Greifswald, Germany
| | - Bibiana Metelmann
- Department of Anesthesiology, University Hospital Greifswald, Sauerbruchstr, 17475, Greifswald, Germany
| | - Karl Christian Thies
- Department of Anaesthesiology and Critical Care, EvKB, OWL University Medical Center, Campus Bielefeld Bethel, Burgsteig 13, 33617, Bielefeld, Germany
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Miller M, Storey H, Andrew J, Christian E, Hayes-Bradley C. Out-of-Hospital Pediatric Video Laryngoscopy With an Adult Device: A Case Series Presented With a Contemporary Group Intubated With Direct Laryngoscopy. Pediatr Emerg Care 2023; 39:666-671. [PMID: 36790879 DOI: 10.1097/pec.0000000000002909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
OBJECTIVES After introducing an adult video laryngoscope (VL) in our physician-paramedic prehospital and retrieval medical service, our quality assurance process identified this blade being used during pediatric intubations. We present a case series of pediatric intubations using this oversized adult VL alongside a contemporaneous group of direct laryngoscopy (DL) intubations. METHODS We performed a retrospective review of intubated patients 15 years or younger in our electronic quality assurance registry from January 1, 2017, to December 31, 2020. Data collected were demographic details, intubation equipment, drug doses, the number of intubation attempts, and complications. Results are presented according to those intubated with C-MAC4 VL (Karl Storz) alongside age-appropriate DL sizes. RESULTS Ninety-nine pediatric patients were intubated, 67 (67%) by CMAC4 and 32 (33%) by DL. Video laryngoscopy had a first-attempt success rate of 96% and DL 91%. A Cormach and Lehane view 1 or 2 was found in 66 VL (99%) and 29 DL patients (91%). Desaturation was reported in two VL and 1 DL patient. CONCLUSIONS Adult VL became the most common method of intubation in patients older than 1 year during the study period. An adult C-MAC4 VL could be considered for clinicians who prefer VL when a pediatric VL is unavailable or as a second-line device if a pediatric VL is not present when intubating children older than 1 year.
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Affiliation(s)
| | - Heather Storey
- Department of Anaesthesia, Great Ormond Street Hospital, London, United Kingdom
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Tracheal Tube Misplacement after Emergency Intubation in Pediatric Trauma Patients: A Retrospective, Exploratory Study. CHILDREN 2022; 9:children9020289. [PMID: 35205009 PMCID: PMC8870798 DOI: 10.3390/children9020289] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 02/14/2022] [Accepted: 02/16/2022] [Indexed: 02/07/2023]
Abstract
Inadvertent tracheal tube misplacement and particularly endobronchial intubation are well-known complications of emergency endotracheal intubation (ETI) in pediatric trauma patients, which require repositioning of the tube to avoid impairment of gas exchange. The main aim of study was to identify the frequency of tube misplacement and associated factors of pediatric trauma patients who received ETI either by prehospital physician-staffed emergency medical service (EMS), or at emergency department (ED) admission to a single level-1 trauma center. Sixty-five patients (median age 14 years and median injury severity score 29) were included. Of these, 30 underwent helicopter EMS ETI, 29 ground EMS ETI, and 6 ED ETI. Seventeen cases (26%) of tracheal tube misplacement were recognized. After multivariable analysis, tracheal tube misplacement was independently negatively associated with body weight (OR 0.86; 95% CI, 0.76–0.99; p = 0.032) and helicopter EMS ETI (OR 0.20; 95% CI, 0.04–0.97; p = 0.036). Two of nineteen patients received tube thoracostomy due to endobronchial intubation. Mortality and length of stay were comparable in patients with misplaced tubes and correctly placed tubes. The results suggest that particularly small children require attention to avoid tracheal tube misplacement, which emphasizes the need for special training. Helicopter EMS physicians’ expertise might be beneficial in prehospital pediatric trauma patients requiring advanced airway management.
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Funakoshi H, Kunitani Y, Goto T, Okamoto H, Hagiwara Y, Watase H, Hasegawa K. Association Between Repeated Tracheal Intubation Attempts and Adverse Events in Children in the Emergency Department. Pediatr Emerg Care 2022; 38:e563-e568. [PMID: 35100759 DOI: 10.1097/pec.0000000000002356] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
STUDY OBJECTIVES Studies have shown that multiple intubation attempts are associated with a higher risk of intubation-related adverse events. However, little is known about the relationship in children in the emergency department (ED). METHODS This is an analysis of the data from 2 prospective, observational, multicenter registries of emergency airway management. The data were collected from consecutive patients who underwent emergency airway management in 19 EDs across Japan from March 2010 to November 2017. We included children 18 years or younger who underwent tracheal intubation in the ED. The primary exposure was the number of intubation attempts (1 vs ≥2). The primary outcome was an adverse event during or immediately after the intubation. RESULTS A total of 439 children were eligible for the analysis. Of 279 children with first-pass success, 24 children (9%) had an adverse event. By contrast, of 160 children with ≥2 intubation attempts, 50 children patients (31%) had an adverse event. In the unadjusted model, multiple intubation attempts were significantly associated with a higher rate of adverse events (unadjusted odds ratio, 4.83; 95% confidence interval, 2.57-9.06; P < 0.001). This association remained significant after adjusting for 7 potential confounders and patient clustering within the hospital (adjusted odds ratio, 4.49; 95% confidence interval, 2.36-8.53; P < 0.001). Similar associations were found across different age groups and among children without cardiac arrest (all, P < 0.05). CONCLUSIONS In this analysis of large prospective multicenter data, multiple intubation attempts were associated with a significantly higher rate of intubation-related adverse events in children in the ED.
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Affiliation(s)
- Hiraku Funakoshi
- From the Department of Emergency and Critical Care Medicine, Tokyobay Urayasu Ichikawa Medical Center, Chiba
| | - Yuri Kunitani
- From the Department of Emergency and Critical Care Medicine, Tokyobay Urayasu Ichikawa Medical Center, Chiba
| | - Tadahiro Goto
- Graduate School of Medical Sciences, University of Fukui, Fukui
| | - Hiroshi Okamoto
- Department of Critical Care Medicine, St. Luke's International Hospital
| | - Yusuke Hagiwara
- Department of Pediatric Emergency and Critical Care Medicine, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Hiroko Watase
- Department of Surgery, University of Washington, Seattle, WA
| | - Kohei Hasegawa
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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11
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Kelly GS, Deanehan JK, Dalesio NM. Pediatric Difficult Airway Response Team Utilization in the Emergency Department: A Case Series. Pediatr Emerg Care 2021; 37:e1462-e1467. [PMID: 32195976 DOI: 10.1097/pec.0000000000002073] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES A multidisciplinary pediatric difficult airway team was created at our institution to respond to hospital-wide airway emergencies. We report the characteristics, indications, and outcomes of these activations that occur in the pediatric emergency department (PED). METHODS Retrospective, single-center cohort study comprised all difficult airway team activations occurring in the PED from the program's inception in 2008 to 2018. Ages of ≤18 years were included. For each case, detailed information was abstracted, including patient factors, PED context and milieu, airway interventions, and airway outcomes. RESULTS There were 15 difficult airway response team activations in the PED during the study period, or 1.4 activations per year. The most common indications for activation were contaminated airways (n = 7; 47%) and history of difficult intubation (n = 4; 27%). Definitive airway management was successful in all cases, except for a single case where intervention was unnecessary. The most commonly performed definitive airway intervention was direct laryngoscopy (n = 6; 40%). There were no instances of emergency front-of-neck access. CONCLUSIONS Difficult airways in the PED were uncommon. Most cases were resolved with familiar equipment including direct laryngoscopy, video laryngoscopy, and supraglottic airways.
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Affiliation(s)
| | | | - Nicholas M Dalesio
- Anesthesiology and Critical Care Medicine and Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
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12
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Pediatric Prehospital Advanced Airway Management by Anesthesiologist and Nurse Anesthetist Staffed Critical Care Teams. Prehosp Disaster Med 2021; 36:547-552. [PMID: 34254579 DOI: 10.1017/s1049023x21000637] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
INTRODUCTION Prehospital pediatric tracheal intubation (TI) is a possible life-saving intervention that requires adequate experience to mitigate associated complications. The pediatric airway and respiratory physiology present challenges in addition to a relatively rare incidence of prehospital pediatric TI. STUDY OBJECTIVE The aim of this study was to describe characteristics and outcomes of prehospital TI in pediatric patients treated by critical care teams. METHODS This is a sub-group analysis of all pediatric (<16 years old) patients from a prospective, observational, multi-center study on prehospital advanced airway management in the Nordic countries from May 2015 through November 2016. The TIs were performed by anesthesiologists and nurse anesthetists staffing six helicopter and six Rapid Response Car (RRC) prehospital critical care teams. RESULTS In the study, 74 children were tracheal intubated, which corresponds to 3.7% (74/2,027) of the total number of patients. The pediatric patients were intubated by very experienced providers, of which 80% had performed ≥2,500 TIs. The overall TI success rate, first pass success rate, and airway complication rate were in all children (<16 years) 98%, 82%, and 12%. The corresponding rates among infants (<2 years) were 94%, 67%, and 11%. The median time on scene was 30 minutes. CONCLUSION This study observed a high overall prehospital TI success rate in children with relatively few associated complications and short time on scene, despite the challenges presented by the pediatric prehospital TI.
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Nicol T, Gil-Jardiné C, Jabre P, Adnet F, Ecollan P, Guihard B, Ferdynus C, Combes X. Incidence, Complications, and Factors Associated with Out-of-Hospital First Attempt Intubation Failure in Adult Patients: A Secondary Analysis of the CURASMUR Trial Data. PREHOSP EMERG CARE 2021; 26:280-285. [PMID: 33595420 DOI: 10.1080/10903127.2021.1891357] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Objectives: The objectives of this study were to evaluate first attempt intubation failure rate, its associated factors, and its related complications in out-of-hospital emergency setting, when emergency physicians perform standardized airway management using rapid sequence intubation in adult patients. Material and methods: The present study was a substudy of the Succinylcholine versus Rocuronium for out-of-hospital Emergency Intubation (CURASMUR) Trial, which compared Succinylcholine and Rocuronium used for Rapid sequence intubation. First attempt Intubation failure rate and early intubation related complications were recorded. We used multivariable logistic regression analysis to determine first intubation failure associated factors. Results: A total of 1230 patients were included with mean age of 55.9 +/- 19 years. First attempt intubation failure was recorded in 285 (23.2%) patients. The occurrence of a first attempt intubation failure was independently associated with history of ear, nose, and throat neoplasia (OR 2.20, CI 95% 1.06-4.60). Early intubation related complications were more frequent in case of first attempt intubation failure: 80 of 285 (28.4%) in patients with first attempt intubation failure and 185 of 945 (19.6%) in patients with successful first attempt intubation [OR 1.44; CI 95%, 1.11-1.87]. Conclusion: Based on a large multicenter study on out-of-hospital tracheal intubation of adult patients, we found that first attempt intubation failure rate was high and that history of ear, nose, and throat (ENT) neoplasia was an independent associated factor. Failure in first intubation attempt was associated with significantly more intubation related complications.
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Curtis K, Kennedy B, Lam MK, Mitchell RJ, Black D, Burns B, Loudfoot A, Tall G, Dinh M, Beech C, Holland AJA. Prehospital care and transport costs of severely injured children in NSW Australia. Injury 2020; 51:2581-2587. [PMID: 32843148 DOI: 10.1016/j.injury.2020.08.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 08/05/2020] [Accepted: 08/17/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Injury is the leading cause of childhood death and disability in Australia. Prehospital emergency services in New South Wales (NSW) are provided by NSW Ambulance. The incidence, pre-hospital care provided and outcomes of children suffering major injury in NSW has not previously been described. METHODS This retrospective study was conducted between July 2015 and September 2016 and included children <16 years with an injury severity score (ISS) >9, or requiring intensive care admission, or deceased following injury and treated in NSW. Children were identified through the three NSW Paediatric Trauma Centres, the NSW Trauma Registry, NSW Medical Retrieval Registry (AirMaestro, Avinet, Australia). RESULTS There were 359 majorly injured children treated by NSW-based emergency service providers, the majority were male (73.3%) with a mean (SD) age of 8.0 (5.2) years. The median (IQR) injury severity score (ISS) for those transported via NSW emergency medical services was 10 (9-17), with almost half (44.1%) treated prehospital having an ISS >12. The most common documented interventions were intravenous access (44.1%) and oxygen therapy (39.6%). Intubation and chest decompression were recorded in 15.3% and 3.1% of cases respectively. The calculated median (IQR) transport charges for NSW Emergency Services was AUD $942 ($841.3-$1184.6). CONCLUSION Critical interventions are performed infrequently in children with major injuries in the pre-hospital environment. The monitoring of the incidence and success rates for staff performing these interventions is not readily available from all prehospital emergency medical services operating in NSW. The capacity and processes to monitor and audit all critical interventions in the paediatric population should be resourced and clearly defined.
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Affiliation(s)
- Kate Curtis
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, The University of Sydney, MO2 88 Mallett St, NSW 2006, Australia
| | - Belinda Kennedy
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, The University of Sydney, MO2 88 Mallett St, NSW 2006, Australia.
| | - Mary K Lam
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, The University of Sydney, MO2 88 Mallett St, NSW 2006, Australia
| | - Rebecca J Mitchell
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, 75 Talavera Rd, North Ryde NSW 2113, Australia
| | - Deborah Black
- Faculty of Medicine and Health, The University of Sydney, Science Rd, Camperdown NSW 2006, Australia
| | - Brian Burns
- Greater Sydney Area HEMS, NSW Ambulance, 33 Nancy Ellis Leebold Drive, Bankstown Airport NSW 2200, Australia
| | - Allan Loudfoot
- NSW Ambulance, Locked bag 105, Rozelle NSW 2039, Australia
| | - Gary Tall
- Greater Sydney Area HEMS, NSW Ambulance, 33 Nancy Ellis Leebold Drive, Bankstown Airport NSW 2200, Australia
| | - Michael Dinh
- NSW Institute of Trauma and Injury Management (ITIM), Agency for Clinical Innovation, Level 4/67 Albert Ave, Chatswood NSW 2067, Australia
| | - Clare Beech
- NSW Ambulance, Locked bag 105, Rozelle NSW 2039, Australia
| | - Andrew J A Holland
- The Children's Hospital at Westmead, Locked Bag 4001, Westmead NSW 2145, Australia
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Masterson S, Deasy C, Doyle M, Hennelly D, Knox S, Sorensen J. What clinical crew competencies and qualifications are required for helicopter emergency medical services? A review of the literature. Scand J Trauma Resusc Emerg Med 2020; 28:28. [PMID: 32299448 PMCID: PMC7164232 DOI: 10.1186/s13049-020-00722-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 04/06/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Patients served by Helicopter Emergency Medical Services (HEMS) tend to be acutely injured or unwell and in need of stabilisation followed by rapid and safe transport. It is therefore hypothesised that a particular clinical crew composition is required to provide appropriate HEMS patient care. A literature review was performed to test this hypothesis. METHODS MEDLINE, EMBASE, Web of Science and the Cochrane Database of Systematic Reviews were systematically searched from 1 January 2009 to 30 August 2019 to identify peer-reviewed articles of relevance. All HEMS studies that mentioned 'staffing', 'configuration', 'competencies' or 'qualifications' in the title or abstract were selected for full-text review. RESULTS Four hundred one studies were identified. Thirty-eight studies, including one systematic review and one randomised controlled trial, were included. All remaining studies were of an observational design. The vast majority of studies described clinical crews that were primarily doctor-staffed. Descriptions of non-doctor staff competencies were limited, with the exception of one paramedic-staffed model. CONCLUSIONS HEMS clinical crews tended to have a wider range of competencies and experience than ground-based crews, and most studies suggested a patient outcome benefit to HEMS provision. The conclusions that can be drawn are limited due to study quality and the possibility that the literature reviewed was weighted towards particular crewing models (i.e. primarily doctor-staffed) and countries. There is a need for trial-based studies that directly compare patient outcomes between different HEMS crews with different competencies and qualifications.
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Affiliation(s)
- Siobhán Masterson
- Medical Directorate, National Ambulance Service, Dooradoyle House, Dooradoyle Road, Limerick, V94 HW6E, Ireland.
| | - Conor Deasy
- Medical Directorate, National Ambulance Service, Dooradoyle House, Dooradoyle Road, Limerick, V94 HW6E, Ireland.,Emergency Department, Cork University Hospital, Cork, Ireland
| | - Mark Doyle
- Retired Emergency Medicine Consultant, Waterford, Ireland
| | - David Hennelly
- Medical Directorate, National Ambulance Service, Dooradoyle House, Dooradoyle Road, Limerick, V94 HW6E, Ireland
| | - Shane Knox
- National Ambulance Service College, Dublin, Ireland
| | - Jan Sorensen
- Healthcare Outcomes Research Centre, Royal College of Surgeons in Ireland, Dublin, Ireland
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Garner AA, Bennett N, Weatherall A, Lee A. Success and complications by team composition for prehospital paediatric intubation: a systematic review and meta-analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:149. [PMID: 32295610 PMCID: PMC7161251 DOI: 10.1186/s13054-020-02865-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Accepted: 03/31/2020] [Indexed: 12/18/2022]
Abstract
Background Clinical team composition for prehospital paediatric intubation may affect success and complication rates. We performed a systematic review and meta-analysis to determine the success and complication rates by type of clinical team. Methods We searched MEDLINE, EMBASE, and CINAHL for interventional and observational studies describing prehospital intubation attempts in children with overall success, first-pass success, and complication rates. Eligible studies, data extraction, and assessment of risk of bias were assessed independently by two reviewers. We performed a random-effects meta-analysis of proportions. Results Forty studies (1989 to 2019) described three types of clinical teams: non-physician teams with no relaxants (22 studies, n = 7602), non-physician teams with relaxants (12 studies, n = 2185), and physician teams with relaxants (12 studies, n = 1780). Twenty-two (n = 3747) and 18 (n = 7820) studies were at low and moderate risk of bias, respectively. Non-physician teams without relaxants had lower overall intubation success rate (72%, 95% CI 67–76%) than non-physician teams with relaxants (95%, 95% CI 93–98%) and physician teams (99%, 95% CI 97–100%). Physician teams had higher first-pass success rate (91%, 95% CI 86–95%) than non-physicians with (75%, 95% CI 69–81%) and without (55%, 95% CI 48–63%) relaxants. Overall airway complication rate was lower in physician teams (10%, 95% CI 3–22%) than non-physicians with (30%, 95% CI 23–38%) and without (39%, 95% CI 28–51%) relaxants. Conclusion Physician teams had higher rates of intubation success and lower rates of overall airway complications than other team types. Physician prehospital teams should be utilised wherever practicable for critically ill children requiring prehospital intubation.
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Affiliation(s)
- Alan A Garner
- CareFlight Australia, 4 Barden St, Northmead, NSW, 2152, Australia. .,The University of Sydney, Sydney, Australia.
| | | | - Andrew Weatherall
- CareFlight Australia, 4 Barden St, Northmead, NSW, 2152, Australia.,Division of Paediatrics and Child Health, The University of Sydney, Sydney, Australia
| | - Anna Lee
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Shatin, Hong Kong.,Hong Kong Branch of The Chinese Cochrane Centre, The Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong
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17
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Ramgopal S, Button SE, Owusu-Ansah S, Manole MD, Saladino RA, Guyette FX, Martin-Gill C. Success of Pediatric Intubations Performed by a Critical Care Transport Service. PREHOSP EMERG CARE 2020; 24:683-692. [PMID: 31800336 DOI: 10.1080/10903127.2019.1699212] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Background: Prehospital pediatric endotracheal intubation (ETI) is rarely performed. Previous research has suggested that pediatric prehospital ETI, when performed by ground advanced life support crews, is associated with poor outcomes. In this study, we aim to evaluate the first-attempt success rate, overall success rate and complications of pediatric prehospital ETI performed by critical care transport (CCT) personnel.Methods: We conducted a retrospective observational study in a multi-state CCT service performing rotor wing, ground, and fixed wing missions. We included pediatric patients (<18 years) for whom ETI was performed by CCT personnel (flight nurse or flight paramedic).Our primary outcome of interest was rate of first-attempt ETI. Secondary outcomes were overall rates of successful ETI, complications encountered, and outcomes of patients with unsuccessful intubation.Results: 993 patients were included (63.2% male, median age 12 years, IQR 4-16 years). 807/993 (81.3%) patients were intubated on the first attempt. Lower rates of successful first-attempt intubation were seen in younger ages (42.9% in infants ≤30 days of age). In multivariable logistic regression, lower odds (adjusted odds ratio, 95% confidence interval) of successful first-attempt ETI were associated with ages >30 days to <1 year (0.33, 0.18-0.61) and 2 to <6 years (0.60, 0.39-0.94) compared to patients 12 to <18 years. Patients given an induction agent and neuromuscular blockade (NMB) had a higher odds of first-attempt ETI success (1.53, 1.06-2.15). 13 (1.3%) had immediately recognized esophageal intubation and 33 (3.3%) had vomiting. No episodes of pneumothorax were reported. 962/993 (96.9%) patients were successfully intubated after all attempts. In patients without successful ETI (n = 31), supraglottic airways were used in 24, bag-valve mask ventilation in 5, and surgical cricothyroidotomy in 2, with an overall advanced airway success rate of 988/993 (99.5%).Conclusion: Critical care flight nurses and paramedics performed successful intubations in pediatric patients at a high rate of success. Younger age was associated with lower success rates. Improved ETI training for younger patients and use of an induction agent and NMB may improve airway management in critically ill children.
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18
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Garner AA, Bennett N, Weatherall A, Lee A. Physician-staffed helicopter emergency medical services augment ground ambulance paediatric airway management in urban areas: a retrospective cohort study. Emerg Med J 2019; 36:678-683. [DOI: 10.1136/emermed-2019-208421] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Revised: 08/09/2019] [Accepted: 08/25/2019] [Indexed: 01/07/2023]
Abstract
ObjectivesPaediatric intubation is a high-risk procedure for ground emergency medical services (GEMS). Physician-staffed helicopter EMS (PS-HEMS) may bring additional skills, drugs and equipment to the scene including advanced airway management beyond the scope of GEMS even in urban areas with short transport times. This study aimed to evaluate prehospital paediatric intubation performed by a PS-HEMS when dispatched to assist GEMS in a large urban area and examine how often PS-HEMS provided airway intervention that was not or could not be provided by GEMS.MethodsWe performed a retrospective observational study from July 2011 to December 2016 of a PS-HEMS in a large urban area (Sydney, Australia), which responds in parallel to GEMS. GEMS intubate without adjuvant neuromuscular blockade, whereas the PS-HEMS use neuromuscular blockade and anaesthetic agents. We examined endotracheal intubation success rate, first-look success rate and complications for the PS-HEMS and contrasted this with the advanced airway interventions provided by GEMS prior to PS-HEMS arrival.ResultsOverall intubation success rate was 62/62 (100%) and first-look success was 59/62 (95%) in the PS-HEMS-treated group, whereas the overall success rate was 2/7 (29%) for the GEMS group. Peri-intubation hypoxia was documented in 5/65 (8%) of the PS-HEMS intubation attempts but no other complications were reported. However, 3/7 (43%) of the attempted intubations by GEMS were oesophageal intubations, two of which were unrecognised.ConclusionsPS-HEMS have high success with low complication rates in paediatric prehospital intubation. Even in urban areas with rapid GEMS response, PS-HEMS activated in parallel can provide safe and timely advanced prehospital airway management for seriously ill and injured children beyond the scope of GEMS practice. Review of GEMS airway management protocols and the PS-HEMS case identification and dispatch system in Sydney is warranted.
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19
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Glasheen J, Holmes P, Rampersad N, Raman S. Endotracheal intubation by a specialised paediatric retrieval team. Emerg Med Australas 2019; 32:75-79. [PMID: 31264388 DOI: 10.1111/1742-6723.13341] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 06/02/2019] [Accepted: 06/04/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Intubation of critically ill children is an infrequent procedure, and is associated with significant risk. We set out to describe intubations carried out by the Children's Health Queensland Retrieval Service (CHQRS), with the intention to identify areas for improvement in the performance of intubation in the retrieval setting. METHODS Paediatric patients undergoing transport while intubated were identified, and cases where intubation occurred after the arrival of the CHQRS team were examined. RESULTS Over the study period of January 2015 to September 2018, 498 intubated retrievals were undertaken; 85 patients were intubated after the arrival of CHQRS; the age range was 1 day to 16.5 years (median 0.5, interquartile range [IQR] 0.11-3 years). The median weight was 6.2 kg (IQR 3.7-16.5 kg). The pathology requiring intubation included respiratory 36 (42.3%), sepsis 21 (24.7%), neurological 11 (12.9%) and trauma 7 (8.2%). A total of 470 of 498 (94.4%) of intubated patients were from regional referral or tertiary hospitals, 28 of 498 (5.6%) were from rural and remote facilities. Of 85 patients, 57 (67.1%) were intubated by CHQRS and 28 (32.9%) were intubated by a doctor from the referring facility. The CHQRS team was more likely to perform the intubation in smaller children (median weight 5.0 vs 9.9 kg, P = 0.03). The mean scene time was 2.8 h. The scene time was shorter if the intubation was performed by CHQRS (mean 2.6 h, median 2.5, IQR 1.8-3.3; median 3, IQR 2.2-3.9; P = 0.048). The scene time was shorter when the intubation was predicted from tasking information (2.6 vs 3.1 h; P = 0.03). CONCLUSION Paediatric endotracheal intubation is an infrequent procedure in our service. An airway registry could improve documentation and gather information to identify specific training requirements and areas for practice improvement.
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Affiliation(s)
- John Glasheen
- Children's Health Queensland Retrieval Service, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Paul Holmes
- Children's Health Queensland Retrieval Service, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Neeta Rampersad
- Children's Health Queensland Retrieval Service, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Sainath Raman
- Children's Health Queensland Retrieval Service, Queensland Children's Hospital, Brisbane, Queensland, Australia
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20
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Comparison of blind intubation with different supraglottic airway devices by inexperienced physicians in several airway scenarios: a manikin study. Eur J Pediatr 2019; 178:871-882. [PMID: 30903306 PMCID: PMC6511343 DOI: 10.1007/s00431-019-03345-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 02/09/2019] [Accepted: 02/12/2019] [Indexed: 10/31/2022]
Abstract
Endotracheal intubation is the gold standard for airway management. Supraglottic airway devices (SADs) are useful in airway abnormalities. SAD blind intubation enables airway management with better ventilation and a reduced risk of gastric content aspiration. The aim was to compare various SADs in blind intubation performed by inexperienced physicians in several pediatric airway scenarios. One hundred sixteen physicians with no previous experience with SAD performed blind endotracheal intubations with (1) iGEL, (2) Air-Q intubating laryngeal airway, and (3) Ambu AuraGain disposable laryngeal mask in a pediatric manikin in three airway scenarios: (A) normal airway without chest compressions, (B) normal airway with continuous chest compressions with the CORPULS CPR system, and (C) difficult airway with continuous chest compressions with the CORPULS CPR system. Intubation tube with 5.0 internal diameter was used for all blind intubation attempts. First intubation success rate, median time to SAD placement, time to endotracheal intubation with SAD, and ease to perform the intubation were investigated in this study. All these parameters were better or non-inferior for iGEL in all investigated scenarios.Conclusion: Our manikin study demonstrated that iGEL was the most effective device for blind intubation by inexperienced physicians in different pediatric airway scenarios. What is Known: • For pediatric resuscitation, bag-mask ventilation is the first-line method for airway control and ventilation. • Endotracheal intubation is considered by many scientific societies the gold standard for airway management. • Supraglottic airway devices are particularly useful when bag-mask ventilation is difficult or impossible but can be also used for blind intubation. What is New: • The iGEL laryngeal mask turns out the most effective device for blind intubation by inexperienced physicians in different pediatric airway scenarios. • It may be a reasonable first emergency blind intubation technique for inexperienced physicians in pediatric patients in normal airway with and without continuous chest compressions, as well as in difficult airway with continuous chest compressions.
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21
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Driver BE, Dodd KW, Klein LR, Robinson A, McGill JW, Reardon RF, Buckley R, Prekker ME. In reply. Ann Emerg Med 2018; 71:434-435. [PMID: 29458810 DOI: 10.1016/j.annemergmed.2017.10.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Brian E Driver
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN
| | - Kenneth W Dodd
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN
| | - Lauren R Klein
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN
| | - Aaron Robinson
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN
| | - John W McGill
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN
| | - Robert F Reardon
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN
| | - Ryan Buckley
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT
| | - Matthew E Prekker
- Division of Pulmonary/Critical Care, Department of Medicine, Hennepin County Medical Center, Minneapolis, MN; Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN
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22
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Kendall MC. Can Successful Intubation Be Attributed to the Specific Use of Neuromuscular Agent? Ann Emerg Med 2018; 72:506-507. [DOI: 10.1016/j.annemergmed.2018.06.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Indexed: 10/28/2022]
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23
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Sunde GA, Kottmann A, Heltne JK, Sandberg M, Gellerfors M, Krüger A, Lockey D, Sollid SJM. Standardised data reporting from pre-hospital advanced airway management - a nominal group technique update of the Utstein-style airway template. Scand J Trauma Resusc Emerg Med 2018; 26:46. [PMID: 29866144 PMCID: PMC5987657 DOI: 10.1186/s13049-018-0509-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Accepted: 05/09/2018] [Indexed: 12/31/2022] Open
Abstract
Background Pre-hospital advanced airway management with oxygenation and ventilation may be vital for managing critically ill or injured patients. To improve pre-hospital critical care and develop evidence-based guidelines, research on standardised high-quality data is important. We aimed to identify which airway data were most important to report today and to revise and update a previously reported Utstein-style airway management dataset. Methods We recruited sixteen international experts in pre-hospital airway management from Australia, United States of America, and Europe. We used a five-step modified nominal group technique to revise the dataset, and clinical study results from the original template were used to guide the process. Results The experts agreed on a key dataset of thirty-two operational variables with six additional system variables, organised in time, patient, airway management and system sections. Of the original variables, one remained unchanged, while nineteen were modified in name, category, definition or value. Sixteen new variables were added. The updated dataset covers risk factors for difficult intubation, checklist and standard operating procedure use, pre-oxygenation strategies, the use of drugs in airway management, airway currency training, developments in airway devices, airway management strategies, and patient safety issues not previously described. Conclusions Using a modified nominal group technique with international airway management experts, we have updated the Utstein-style dataset to report standardised data from pre-hospital advanced airway management. The dataset enables future airway management research to produce comparable high-quality data across emergency medical systems. We believe this approach will promote research and improve treatment strategies and outcomes for patients receiving pre-hospital advanced airway management. Trial registration The Regional Committee for Medical and Health Research Ethics in Western Norway exempted this study from ethical review (Reference: REK-Vest/2017/260). Electronic supplementary material The online version of this article (10.1186/s13049-018-0509-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- G A Sunde
- Norwegian Air Ambulance Foundation, Drøbak, Norway. .,Dept. of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway. .,Faculty of Health Sciences, University of Stavanger, Stavanger, Norway.
| | - A Kottmann
- Norwegian Air Ambulance Foundation, Drøbak, Norway.,Faculty of Health Sciences, University of Stavanger, Stavanger, Norway.,Emergency Dept., University Hospital of Lausanne, Lausanne, Switzerland.,Swiss Air Ambulance - Rega, Zürich, Switzerland
| | - J K Heltne
- Dept. of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway.,Dept. of Medical Sciences, University of Bergen, Bergen, Norway
| | - M Sandberg
- Air Ambulance Dept., Oslo University Hospital, Oslo, Norway.,Faculty of Medicine, University of Oslo, Oslo, Norway
| | - M Gellerfors
- Karolinska Institutet, Dept. of Clinical Science and Education, Section of Anaesthesiology and Intensive Care, Stockholm, Sweden.,Swedish Air Ambulance (SLA), Mora, Sweden.,Dept. of Anaesthesiology and Intensive Care, Södersjukhuset, Stockholm, Sweden
| | - A Krüger
- Norwegian Air Ambulance Foundation, Drøbak, Norway.,Dept. of Emergency Medicine and Pre-hospital Services, St. Olavs Hospital, Trondheim, Norway
| | - D Lockey
- Faculty of Health Sciences, University of Stavanger, Stavanger, Norway.,London's Air Ambulance, Bartshealth NHS Trust, London, UK
| | - S J M Sollid
- Norwegian Air Ambulance Foundation, Drøbak, Norway.,Faculty of Health Sciences, University of Stavanger, Stavanger, Norway.,Air Ambulance Dept., Oslo University Hospital, Oslo, Norway
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Watterson JB, Reid C, Burns BJ, Regan L. Pre-hospital advanced airway management in children: a challenge that training can handle. Scand J Trauma Resusc Emerg Med 2017; 25:117. [PMID: 29202774 PMCID: PMC5715618 DOI: 10.1186/s13049-017-0432-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Accepted: 08/23/2017] [Indexed: 12/03/2022] Open
Abstract
We respond to the Tarpgaard et al. article reporting on pre-hospital endotracheal intubation (PHETI) success and complications by Danish critical care teams including critical care anaesthetists. We compare the authors' results with previously published results from our service's experience with PHETI in a similar patient population, also with physician and paramedic medical teams. From 25 children <16 years of age, the Danish study reports overall success, and first-pass success, and complication rates of 96, 75 and 20%, respectively. A recently published study of 82 patients that we completed revealed the following results: 100, 91 and 14%, respectively. We propose training and operating protocols we believe contribute to this relative success in paediatric PHETI.
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Affiliation(s)
- Joanna B. Watterson
- Greater Sydney Area Helicopter Emergency Medical Service (GSA-HEMS), New South Wales Ambulance, Sydney, NSW Australia
- New York University School of Medicine, New York, NY USA
| | - Cliff Reid
- Greater Sydney Area Helicopter Emergency Medical Service (GSA-HEMS), New South Wales Ambulance, Sydney, NSW Australia
- Discipline of Emergency Medicine, Sydney Medical School, University of Sydney, Camperdown, NSW Australia
| | - Brian J. Burns
- Greater Sydney Area Helicopter Emergency Medical Service (GSA-HEMS), New South Wales Ambulance, Sydney, NSW Australia
- Discipline of Emergency Medicine, Sydney Medical School, University of Sydney, Camperdown, NSW Australia
| | - Luke Regan
- Emergency Department, Raigmore Hospital, Inverness, Scotland UK
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