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Davis DP, Chandran K, Noce J. A Descriptive Analysis of Air Medical Pediatric Rapid Sequence Intubation: Successes and Opportunities. Air Med J 2024; 43:210-215. [PMID: 38821700 DOI: 10.1016/j.amj.2024.02.001] [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: 12/13/2023] [Revised: 02/10/2024] [Accepted: 02/14/2024] [Indexed: 06/02/2024]
Abstract
OBJECTIVE Advanced airway management, including the use of rapid sequence intubation (RSI), is fundamental in resuscitation. However, the reported experience with pediatric airway management is limited because of the relatively low number of emergency RSI procedures in children. The aim of this study was to document the experience with pediatric RSI in a large air medical database and explore opportunities for improvement. METHODS All pediatric patients (age < 18 years) undergoing RSI by air medical crews between 2015 and 2019 were included in this analysis. Subjects were divided a priori into 3 age subgroups (0-2 years, 3-8 years, and 9-17 years). The primary variables of interest included overall intubation success, first-attempt intubation success, and first-attempt intubation success without desaturation. The rates of positive-pressure ventilation (PPV) use for preoxygenation and oxygen desaturation were also explored. RESULTS A total of 1,091 pediatric RSI patients were included. The overall intubation success rate was 98% (0-2 years = 96%, 3-8 years = 97%, and 9-17 years = 98%), with 91% intubated on the first attempt (0-2 years = 86%, 3-8 years = 90%, and 9-17 years = 92%) and 87% intubated on the first attempt without oxygen desaturation (0-2 years = 80%, 3-8 years = 88%, and 9-17 years = 90%). A sharp decline in intubation success was observed with preoxygenation SpO2 values < 97% across all patients. Younger patients (0-2 years) had lower initial SpO2 values and decreased first-attempt success rates with and without desaturation. These patients were less likely to receive PPV during preoxygenation attempts and had lower use of video laryngoscopy or a bougie on the initial intubation attempt. CONCLUSION In this study, we documented high success rates for air medical pediatric RSI. Higher target SpO2 values may be justified during preoxygenation. Intubation success, PPV use for preoxygenation, video laryngoscopy, and the use of a bougie were lower for younger patients.
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Affiliation(s)
- Daniel P Davis
- Logan Health, Division of EMS, Kalispell, MT; Air Methods Corporation, Greenwood Village, CO.
| | - Kira Chandran
- Georgetown School of Medicine, Georgetown, Washington DC; Harvard Affiliated Emergency Medicine Program, Boston, MA
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Thompson G, Miller B, Lenz TJ. Comparing Intubation Success Between Flight Nurses and Flight Paramedics in Helicopter Emergency Medical Services. Air Med J 2023; 42:436-439. [PMID: 37996178 DOI: 10.1016/j.amj.2023.07.004] [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: 02/01/2023] [Revised: 07/05/2023] [Accepted: 07/12/2023] [Indexed: 11/25/2023]
Abstract
OBJECTIVE Intubation is a vital skill performed by flight nurses and paramedics. Before flight training, nurses do not routinely intubate and must be trained in proper techniques. Flight paramedics universally train in intubation before flight training and are the primary managers of in-flight airways. The aim of this study was to determine if a difference exists in intubation attempts and success rates between flight nurses and flight paramedics. METHODS A 5-year retrospective chart review was performed from a regional helicopter emergency medical service. Intubation attempts and the success of flight nurses compared with flight paramedics were the primary outcomes. RESULTS Three hundred three of 322 cases in which intubation was attempted were successful. Three hundred forty-four total intubation attempts were made. Two hundred seventy-one (88.9%) patients were intubated by paramedics, and 32 (10.5%) were intubated by nurses. Of the 19 unsuccessfully intubated patients, 14 (73.7%) were attempted by a paramedic and 5 (26.3%) by a nurse. Two hundred seventy-seven intubations were successful on the first attempt, 250 (90.3%) of which were performed by a paramedic and 27 (9.7%) by a nurse. CONCLUSION Flight paramedics performed more intubations with greater success than flight nurses.
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Affiliation(s)
- Gregory Thompson
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Blake Miller
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Timothy J Lenz
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI.
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3
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Phillips JP, Anger DJ, Rogerson MC, Myers LA, McCoy RG. Transitioning from Direct to Video Laryngoscopy during the COVID-19 Pandemic Was Associated with a Higher Endotracheal Intubation Success Rate. PREHOSP EMERG CARE 2023; 28:200-208. [PMID: 36730082 DOI: 10.1080/10903127.2023.2175087] [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: 05/13/2022] [Revised: 12/02/2022] [Accepted: 01/03/2023] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The objective of this study was to determine the effect of transitioning from direct laryngoscopy (DL) to video laryngoscopy (VL) on endotracheal intubation success overall and with enhanced precautions implemented during the COVID-19 pandemic. METHODS We examined electronic transport records from Mayo Clinic Ambulance Service, a large advanced life support (ALS) provider serving rural, suburban, and urban areas in Minnesota and Wisconsin, USA. We determined the success of intubation attempts when using DL (March 10, 2018 to December 19, 2019), VL (December 20, 2019 to September 29, 2021), and VL with an enhanced COVID-19 guideline that restricted intubation to one attempt, performed by the most experienced clinician, who wore enhanced personal protective equipment (April 1 to December 18, 2020). Success rates at first attempt and after any attempt were assessed for association with type of laryngoscopy (VL vs DL) after adjusting for patient age group, patient weight, use of enhanced COVID-19 guideline, medical vs trauma patient, and ALS vs critical care clinician. A secondary analysis further adjusted for degree of glottic visualization. RESULTS We identified 895 intubation attempts using DL and 893 intubation attempts using VL, which included 382 VL intubation attempts using the enhanced COVID-19 guideline. Success on first intubation attempt was 69.2% for encounters with DL, 82.9% overall with VL, and 83.2% with VL and enhanced COVID-19 protocols (DL vs overall VL: p < 0.001; COVID-19 vs non-COVID VL: p = 0.86). In multivariable analysis, use of VL was associate with higher odds of successful intubation on first attempt (odds ratio, 2.28; 95%CI, 1.73-3.01; p < 0.001) and on any attempt (odds ratio, 2.16; 95%CI, 1.58-2.96; p < 0.001) compared with DL. Inclusion of glottic visualization in the model resulted in a nonsignificant association between laryngoscopy type and successful first intubation (p = 0.41) and a significant association with the degree of glottic visualization (p < 0.001). CONCLUSIONS VL is designed to improve glottic visualization. The use of VL by a large, U.S. multistate ALS ambulance service was associated with increased odds of successful first-pass and overall attempted intubation, which was mediated by better visualization of the glottis. COVID-19 protocols were not associated with success rates.
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Affiliation(s)
| | - Daniel J Anger
- Mayo Clinic Ambulance Service, Mayo Clinic, Rochester, Minnesota
| | | | - Lucas A Myers
- Mayo Clinic Ambulance Service, Mayo Clinic, Rochester, Minnesota
| | - Rozalina G McCoy
- Mayo Clinic Ambulance Service, Mayo Clinic, Rochester, Minnesota
- Division of Community Internal Medicine, Geriatrics, and Palliative Care, Mayo Clinic, Rochester, Minnesota
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
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Cavanagh N, Blanchard IE, Weiss D, Tavares W. Looking back to inform the future: a review of published paramedicine research. BMC Health Serv Res 2023; 23:108. [PMID: 36732779 PMCID: PMC9893690 DOI: 10.1186/s12913-022-08893-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 11/28/2022] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE Paramedicine has evolved in ways that may outpace the science informing these changes. Examining the scholarly pursuits of paramedicine may provide insights into the historical academic focus, which may inform future endeavors and evolution of paramedicine. The objective of this study was to explore the existing discourse in paramedicine research to reflect on the academic pursuits of this community. METHODS We searched Medline, Embase, CINAHL, Google Scholar and Web of Science from January, 2006 to April, 2019. We further refined the yield using a ranking formula that prioritized journals most relevant to paramedicine, then sampled randomly in two-year clusters for full text review. We extracted literature type, study topic and context, then used elements of qualitative content, thematic, and discourse analysis to further describe the sample. RESULTS The initial search yielded 99,124 citations, leaving 54,638 after removing duplicates and 7084 relevant articles from nine journals after ranking. Subsequently, 2058 articles were included for topic categorization, and 241 papers were included for full text analysis after random sampling. Overall, this literature reveals: 1) a relatively narrow topic focus, given the majority of research has concentrated on general operational activities and specific clinical conditions and interventions (e.g., resuscitation, airway management, etc.); 2) a limited methodological (and possibly philosophical) focus, given that most were observational studies (e.g., cohort, case control, and case series) or editorial/commentary; 3) a variety of observed trajectories of academic attention, indicating where the evolution of paramedicine is evident, areas where scope of practice is uncertain, and areas that aim to improve skills historically considered core to paramedic clinical practice. CONCLUSIONS Included articles suggest a relatively narrow topic focus, a limited methodological focus, and observed trajectories of academic attention indicating where research pursuits and priorities are shifting. We have highlighted that the academic focus may require an alignment with aspirational and direction setting documents aimed at developing paramedicine. This review may be a snapshot of scholarly activity that reflects a young medically directed profession and systems focusing on a few high acuity conditions, with aspirations of professional autonomy contributing to the health and social well-being of communities.
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Affiliation(s)
- N. Cavanagh
- grid.413574.00000 0001 0693 8815Alberta Health Services, Emergency Medical Services, Edmonton, Alberta Canada ,grid.22072.350000 0004 1936 7697Department of Community Health Sciences, University of Calgary, Cumming School of Medicine, Calgary, Alberta Canada
| | - I. E. Blanchard
- grid.413574.00000 0001 0693 8815Alberta Health Services, Emergency Medical Services, Edmonton, Alberta Canada ,grid.22072.350000 0004 1936 7697Department of Community Health Sciences, University of Calgary, Cumming School of Medicine, Calgary, Alberta Canada
| | - D. Weiss
- grid.413574.00000 0001 0693 8815Alberta Health Services, Emergency Medical Services, Edmonton, Alberta Canada
| | - W. Tavares
- grid.512795.dThe Wilson Centre, Department of Medicine, University of Toronto/University Health Network, Toronto, Ontario Canada ,grid.17063.330000 0001 2157 2938Department of Health and Society, University of Toronto, Toronto, Ontario Canada ,York Region Paramedic and Senior Services, Community Health Services Department, Regional Municipality of York, Newmarket, Ontario Canada
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Boccio E. Letter to editor in response to Vlatten et al. study Randomized trial of three airway management techniques for restricted access in a simulated pediatric scenario. Am J Emerg Med 2022; 60:179-180. [PMID: 36031483 DOI: 10.1016/j.ajem.2022.08.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 08/14/2022] [Indexed: 10/15/2022] Open
Affiliation(s)
- Eric Boccio
- Department of Emergency Medicine, UMass Chan Medical School - Baystate, Springfield, MA, USA; Department of Healthcare Delivery & Population Sciences, UMass Chan Medical School - Baystate, Springfield, MA, USA.
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A retrospective descriptive analysis of non-physician-performed prehospital endotracheal intubation practices and performance in South Africa. BMC Emerg Med 2022; 22:129. [PMID: 35842578 PMCID: PMC9287876 DOI: 10.1186/s12873-022-00688-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 07/04/2022] [Indexed: 11/25/2022] Open
Abstract
Introduction Prehospital advanced airway management, including endotracheal intubation (ETI), is one of the most commonly performed advanced life support skills. In South Africa, prehospital ETI is performed by non-physician prehospital providers. This practice has recently come under scrutiny due to lower first pass (FPS) and overall success rates, a high incidence of adverse events (AEs), and limited evidence regarding the impact of ETI on mortality. The aim of this study was to describe non-physician ETI in a South African national sample in terms of patient demographics, indications for intubation, means of intubation and success rates. A secondary aim was to determine what factors were predictive of first pass success. Methods This study was a retrospective chart review of prehospital ETIs performed by non-physician prehospital providers, between 01 January 2017 and 31 December 2017. Two national private Emergency Medical Services (EMS) and one provincial public EMS were sampled. Data were analysed descriptively and summarised. Logistic regression was performed to evaluate factors that affect the likelihood of FPS. Results A total of 926 cases were included. The majority of cases were adults (n = 781, 84.3%) and male (n = 553, 57.6%). The most common pathologies requiring emergency treatment were head injury, including traumatic brain injury (n = 328, 35.4%), followed by cardiac arrest (n = 204, 22.0%). The mean time on scene was 46 minutes (SD = 28.3). The most cited indication for intubation was decreased level of consciousness (n = 515, 55.6%), followed by cardiac arrest (n = 242, 26.9%) and ineffective ventilation (n = 96, 10.4%). Rapid sequence intubation (RSI, n = 344, 37.2%) was the most common approach. The FPS rate was 75.3%, with an overall success rate of 95.7%. Intubation failed in 33 (3.6%) patients. The need for ventilation was inversely associated with FPS (OR = 0.42, 95% CI: 0.20–0.88, p = 0.02); while deep sedation (OR = 0.56, 95% CI: 0.36–0.88, p = 0.13) and no drugs (OR = 0.47, 95% CI: 0.25–0.90, p = 0.02) compared to RSI was less likely to result in FPS. Increased scene time (OR = 0.99, 95% CI: 0.985–0.997, p < 0.01) was inversely associated FPS. Conclusion This is one of the first and largest studies evaluating prehospital ETI in Africa. In this sample of ground-based EMS non-physician ETI, we found success rates similar to those reported in the literature. More research is needed to determine AE rates and the impact of ETI on patient outcome. There is an urgent need to standardise prehospital ETI reporting in South Africa to facilitate future research. Supplementary Information The online version contains supplementary material available at 10.1186/s12873-022-00688-4.
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Nichols M, Fouche PF, Bendall JC. Video versus direct laryngoscopy by specialist paramedics in New South Wales: Preliminary results from a new airway registry. Emerg Med Australas 2022; 34:984-988. [PMID: 35717028 DOI: 10.1111/1742-6723.14033] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 04/18/2022] [Accepted: 05/25/2022] [Indexed: 12/01/2022]
Abstract
OBJECTIVES Video laryngoscopy (VL) is increasingly used as an alternative to direct laryngoscopy (DL) to improve airway visualisation and endotracheal intubation (ETI) success. Intensive Care Paramedics in New South Wales Ambulance, Australia started using VL in 2020, and recorded success in a new advanced airway registry. We used this registry to compare VL to DL. METHODS The present study was a retrospective analysis of out-of-hospital data for ETI by specialist paramedics using an airway registry. We calculated overall and first-pass success for VL versus DL, and compared success using a Χ2 test. RESULTS The DL overall success was 61 out of 78 (78.2%) and VL was 233 out of 246 (94.7%); difference of 16.5% (P < 0.001). First-pass for DL was successful for 49 out of 78 (62.8%) and for VL in 195 out of 246 (79.3%); difference of 16.5% (P = 0.003). There were five (1.6%) patients where both VL and DL were used and in all instances, DL was used first. CONCLUSIONS This analysis of a new airway registry used by specialist paramedics in New South Wales shows a substantial increase in overall and first-pass intubation success with the use of VL when compared to DL.
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Affiliation(s)
- Martin Nichols
- Clinical Systems, New South Wales Ambulance, Sydney, New South Wales, Australia
| | - Pieter F Fouche
- Clinical Systems, New South Wales Ambulance, Sydney, New South Wales, Australia
| | - Jason C Bendall
- Clinical Systems, New South Wales Ambulance, Sydney, New South Wales, Australia
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Impact of Operator Medical Specialty on Endotracheal Intubation Rates in Prehospital Emergency Medicine—A Retrospective Cohort Study. J Clin Med 2022; 11:jcm11071992. [PMID: 35407600 PMCID: PMC8999662 DOI: 10.3390/jcm11071992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 03/10/2022] [Accepted: 03/28/2022] [Indexed: 02/01/2023] Open
Abstract
Prehospital endotracheal intubation (ETI) can be challenging, and the risk of complications is higher than in the operating room. The goal of this study was to compare prehospital ETI rates between anaesthesiologists and non-anaesthesiologists. This retrospective cohort study compared prehospital interventions performed by either physicians from the anaesthesiology department (ADP) or physicians from another department (NADP, for non-anaesthesiology department physicians). The primary outcome was the prehospital ETI rate. Overall, 42,190 interventions were included in the analysis, of whom 68.5% were performed by NADP. Intubation was attempted on 2797 (6.6%) patients, without any difference between NADPs and ADPs (6.5 versus 6.7%, p = 0.555). However, ADPs were more likely to proceed to an intubation when patients were not in cardiac arrest (3.4 versus 3.0%, p = 0.026), whereas no difference was found regarding cardiac arrest patients (65.2 versus 67.7%, p = 0.243) (p for homogeneity = 0.005). In a prehospital physician-staffed emergency medical service, overall ETI rates did not depend on the frontline operator’s medical specialty background. ADPs were, however, more likely to proceed with ETI than NADPs when patients were not in cardiac arrest. Further studies should help to understand the reasons for this difference.
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Galinski M, Simonnet B, Catoire P, Tellier E, Revel P, Pradeau C, Gil-Jardiné C, Combes X. Le mandrin long béquillé : est-ce systématique ? ANNALES FRANCAISES DE MEDECINE D URGENCE 2022. [DOI: 10.3166/afmu-2022-0433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
L’intubation trachéale (IT) est un geste fréquent en médecine d’urgence extra-hospitalière (MUEH) mais elle est associée à un taux élevé d’échec de la première tentative et à certaines complications graves. Le taux de ces dernières augmente avec le nombre de tentative d’IT. La Société française d’anesthésie et de réanimation (SFAR) et la Société de réanimation de langue française (SRLF) avec la collaboration de la Société française de médecine d’urgence (SFMU) ont publié en 2016 des recommandations formalisées d’experts (RFE) sur l’intubation du patient de réanimation. La question qui se pose est la pertinence de ces recommandations pour la MUEH. En effet, la mesure du risque de difficulté est basée sur le score de MACOCHA et en cas de difficulté prévue les outils à utiliser d’emblée sont le vidéo-laryngoscope ou le mandrin long béquillé en laryngoscopie directe. Or il apparait que le score de MACOCHA n’est pas adapté à la MUEH et de façon plus générale, il est complexe de mesurer le risque d’intubation difficile (ID) dans ce contexte. La vidéolaryngoscopie n’a pas encore fait la preuve de sa supériorité par rapport à la laryngoscopie directe en MUEH. Par contre des travaux récents en médecine d’urgence ont démontré que l’utilisation en première intention du mandrin long béquillé augmente significativement le taux de succès de la première tentative de l’IT, même en l’absence de facteur de risque d’ID. Au total, on pourrait considérer chaque IT en MUEH comme a priori à risque de difficulté ce qui justifierait une utilisation d’emblée du mandrin long béquillé. Il semble nécessaire de proposer des recommandations spécifiques à la médecine d’urgence.
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Botha JC, Lourens A, Stassen W. Rapid sequence intubation: a survey of current practice in the South African pre-hospital setting. Int J Emerg Med 2021; 14:45. [PMID: 34404352 PMCID: PMC8369626 DOI: 10.1186/s12245-021-00368-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 07/27/2021] [Indexed: 11/24/2022] Open
Abstract
Background Rapid sequence intubation (RSI) is an advanced airway skill commonly performed in the pre-hospital setting globally. In South Africa, pre-hospital RSI was first approved for non-physician providers by the Health Professions Council of South Africa in 2009 and introduced as part of the scope of practice of degree qualified Emergency Care Practitioners (ECPs) only. The research study aimed to investigate and describe, based on the components of the minimum standards of pre-hospital RSI in South Africa, specific areas of interest related to current pre-hospital RSI practice. Methods An online descriptive cross-sectional survey was conducted amongst operational ECPs in the pre-hospital setting of South Africa, using convenience and snowball sampling strategies. Results A total of 87 participants agreed to partake. Eleven (12.6%) incomplete survey responses were excluded while 76 (87.4%) were included in the data analysis. The survey response rate could not be calculated. Most participants were operational in Gauteng (n = 27, 35.5%) and the Western Cape (n = 25, 32.9%). Overall participants reported that their education and training were perceived as being of good quality. The majority of participants (n = 69, 90.8%) did not participate in an internship programme before commencing duties as an independent practitioner. Most RSI and post-intubation equipment were reported to be available; however, our results found that introducer stylets and/or bougies and end-tidal carbon dioxide devices are not available to some participants. Only 50 (65.8%) participants reported the existence of a clinical governance system within their organisation. Furthermore, our results indicate a lack of clinical feedback, deficiency of an RSI database, infrequent clinical review meetings and a shortage of formal consultation frameworks. Conclusion The practice of safe and effective pre-hospital RSI, performed by non-physician providers or ECPs, relies on comprehensive implementation and adherence to all the components of the minimum standards. Although there is largely an apparent alignment with the minimum standards, recurrent revision of practice needs to occur to ensure alignment with recommendations. Additionally, some areas may benefit from further research to improve current practice. Supplementary Information The online version contains supplementary material available at 10.1186/s12245-021-00368-3.
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Affiliation(s)
- Johanna Catharina Botha
- Division of Emergency Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
| | - Andrit Lourens
- Division of Emergency Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.,School of Nursing, Midwifery and Health, Faculty of Health and Life Sciences, Coventry University, Coventry, UK
| | - Willem Stassen
- Division of Emergency Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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Heyne G, Ewens S, Kirsten H, Fakler JKM, Özkurtul O, Hempel G, Krämer S, Struck MF. Risk factors and outcomes of unrecognised endobronchial intubation in major trauma patients. Emerg Med J 2021; 39:534-539. [PMID: 34376465 PMCID: PMC9234407 DOI: 10.1136/emermed-2021-211786] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 07/31/2021] [Indexed: 12/23/2022]
Abstract
Background Emergency tracheal intubation during major trauma resuscitation may be associated with unrecognised endobronchial intubation. The risk factors and outcomes associated with this issue have not previously been fully defined. Methods We retrospectively analysed adult patients admitted directly from the scene to the ED of a single level 1 trauma centre, who received either prehospital or ED tracheal intubation prior to initial whole-body CT from January 2008 to December 2019. Our objectives were to describe tube-to-carina distances (TCDs) via CT and to assess the risk factors and outcomes (mortality, length of intensive care unit stay and mechanical ventilation) of patients with endobronchial intubation (TCD <0 cm) using a multivariable model. Results We included 616 patients and discovered 26 (4.2%) cases of endobronchial intubation identified on CT. Factors associated with an increased risk of endobronchial intubations were short body height (OR per 1 cm increase 0.89; 95% CI 0.84 to 0.94; p≤0.001), a high body mass index (OR 1.14; 95% CI 1.04 to 1.25; p=0.005) and ED intubation (OR 3.62; 95% CI 1.39 to 8.90; p=0.006). Eight of 26 cases underwent tube thoracostomy, four of whom had no evidence of underlying chest injury on CT. There was no statistically significant difference in mortality or length of stay although the absolute number of endobronchial intubations was small. Conclusions Short body height and high body mass index were associated with endobronchial intubation. Before considering tube thoracostomy in intubated major trauma patients suspected of pneumothorax, the possibility of unrecognised endobronchial intubation should be considered.
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Affiliation(s)
- Guido Heyne
- Department of Anesthesiology and Intensive Care Medicine, Universitätsklinikum Leipzig, Leipzig, Sachsen, Germany.,Department of Anesthesiology, Intensive Care, and Emergency Medicine, BG Klinikum Bergmannstrost Halle, Halle, Sachsen-Anhalt, Germany
| | - Sebastian Ewens
- Department of Diagnostic and Interventional Radiology, Universitätsklinikum Leipzig, Leipzig, Sachsen, Germany
| | - Holger Kirsten
- Institute for Medical Informatics, Statistics and Epidemiology, Universität Leipzig Medizinische Fakultät, Leipzig, Sachsen, Germany
| | - Johannes Karl Maria Fakler
- Division of Traumatology, Department of Orthopedics, Traumatology and Plastic Surgery, Universitätsklinikum Leipzig, Leipzig, Sachsen, Germany
| | - Orkun Özkurtul
- Division of Traumatology, Department of Orthopedics, Traumatology and Plastic Surgery, Universitätsklinikum Leipzig, Leipzig, Sachsen, Germany
| | - Gunther Hempel
- Department of Anesthesiology and Intensive Care Medicine, Universitätsklinikum Leipzig, Leipzig, Sachsen, Germany
| | - Sebastian Krämer
- Division of Thoracic Surgery, Department of Visceral, Transplant, Thoracic and Vascular Surgery, Universitätsklinikum Leipzig, Leipzig, Sachsen, Germany
| | - Manuel Florian Struck
- Department of Anesthesiology and Intensive Care Medicine, Universitätsklinikum Leipzig, Leipzig, Sachsen, Germany
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Fouche PF, Meadley B, StClair T, Winnall A, Stein C, Jennings PA, Bernard S, Smith K. Temporal changes in blood pressure following prehospital rapid sequence intubation. Emerg Med J 2021; 39:451-456. [PMID: 34272210 DOI: 10.1136/emermed-2020-210887] [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: 11/04/2020] [Accepted: 07/09/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND Rapid Sequence intubation (RSI) is an airway procedure that uses sedative and paralytic drugs to facilitate endotracheal intubation. It is known that RSI could impact blood pressure in the peri-intubation period. However, little is known about blood pressure changes in longer time frames. Therefore, this analysis aims to describe the changes in systolic blood pressure in a large cohort of paramedic-led RSI cases over the whole prehospital timespan. METHODS Intensive Care Paramedics in Victoria, Australia, are authorised to use RSI in medical or trauma patients with a Glasgow Coma Scale <10. This retrospective cohort study analysed data from patientcare records for patients aged 12 years and above that had received RSI, from 1 January 2008 to 31 December 2019. This study quantifies the systolic blood pressure changes using regression with fractional polynomial terms. The analysis is further stratified by high versus Low Shock Index (LSI). The shock index is calculated by dividing pulse rate by systolic blood pressure. RESULTS During the study period RSI was used in 8613 patients. The median number of blood pressure measurements was 5 (IQR 3-8). Systolic blood pressure rose significantly by 3.4 mm Hg (p<0.001) and then returned to baseline in the first 5 min after intubation for LSI cases. No initial rise in blood pressure is apparent in High Shock Index (HSI) cases. Across the whole cohort, systolic blood pressure decreased by 7.1 mm Hg (95% CI 7.9 to 6.3 mm Hg; p<0.001) from the first to the last blood pressure measured. CONCLUSIONS Our study shows that in RSI patients a small transient elevation in systolic blood pressure in the immediate postintubation period is found in LSI, but this elevation is not apparent in HSI. Blood pressure decreased over the prehospital phase in RSI patients with LSI, but increased for HSI cases.
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Affiliation(s)
- Pieter Francsois Fouche
- Department of Paramedicine, Monash University Faculty of Medicine Nursing and Health Sciences, Clayton, Victoria, Australia
| | - Ben Meadley
- Paramedicine, Monash University Faculty of Medicine Nursing and Health Sciences, Frankston, Victoria, Australia.,Air Ambulance, Ambulance Victoria, Doncaster, Victoria, Australia
| | - Toby StClair
- Ambulance Victoria, Melbourne, Victoria, Australia.,Department of Paramedicine, Monash University, Melbourne, Victoria, Australia
| | | | - Christopher Stein
- Emergency Medical Care, University of Johannesburg, Johannesburg, Gauteng, South Africa
| | - Paul Andrew Jennings
- Department of Paramedicine, Monash University, Melbourne, Victoria, Australia.,Ambulance Victoria, Doncaster, Victoria, Australia
| | | | - Karen Smith
- Ambulance Victoria, Doncaster, Victoria, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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13
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Avery P, Morton S, Raitt J, Lossius HM, Lockey D. Rapid sequence induction: where did the consensus go? Scand J Trauma Resusc Emerg Med 2021; 29:64. [PMID: 33985541 PMCID: PMC8116824 DOI: 10.1186/s13049-021-00883-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 04/28/2021] [Indexed: 12/15/2022] Open
Abstract
Background Rapid Sequence Induction (RSI) was introduced to minimise the risk of aspiration of gastric contents during emergency tracheal intubation. It consisted of induction with the use of thiopentone and suxamethonium with the application of cricoid pressure. This narrative review describes how traditional RSI has been modified in the UK and elsewhere, aiming to deliver safe and effective emergency anaesthesia outside the operating room environment. Most of the key aspects of traditional RSI – training, technique, drugs and equipment have been challenged and often significantly changed since the procedure was first described. Alterations have been made to improve the safety and quality of the intervention while retaining the principles of rapidly securing a definitive airway and avoiding gastric aspiration. RSI is no longer achieved by an anaesthetist alone and can be delivered safely in a variety of settings, including in the pre-hospital environment. Conclusion The conduct of RSI in current emergency practice is far removed from the original descriptions of the procedure. Despite this, the principles – rapid delivery of a definitive airway and avoiding aspiration, are still highly relevant and the indications for RSI remain relatively unchanged.
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Affiliation(s)
- Pascale Avery
- Southmead Hospital, North Bristol NHS Trust, Bristol, BS10 5NB, UK.
| | - Sarah Morton
- Essex & Herts Air Ambulance, Flight House, Earls Colne, Colchester, Essex, CO6 2NS, UK
| | - James Raitt
- Thames Valley Air Ambulance Stokenchurch House, Oxford Rd, Stokenchurch, High Wycombe, HP14 3SX, UK
| | | | - David Lockey
- Southmead Hospital, North Bristol NHS Trust, Bristol, BS10 5NB, UK.,Blizard Institute, Queen Mary University, Whitechapel, London, E1 2AT, UK
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14
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Assessment of the Thyromental Height Test as an Effective Airway Evaluation Tool. Ann Emerg Med 2021; 77:305-314. [PMID: 33618808 DOI: 10.1016/j.annemergmed.2020.10.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Indexed: 11/22/2022]
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15
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Lesnick JA, Moore JX, Zhang Y, Jarvis J, Nichol G, Daya MR, Idris AH, Klug C, Dennis D, Carlson JN, Doshi P, Sopko G, Schmicker RH, Wang HE. Airway insertion first pass success and patient outcomes in adult out-of-hospital cardiac arrest: The Pragmatic Airway Resuscitation Trial. Resuscitation 2021; 158:151-156. [PMID: 33278521 PMCID: PMC7855546 DOI: 10.1016/j.resuscitation.2020.11.030] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 11/03/2020] [Accepted: 11/17/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE While emphasized in clinical practice, the association between advanced airway insertion first-pass success (FPS) and patient outcomes is incompletely understood. We sought to determine the association of airway insertion FPS with adult out-of-hospital cardiac arrest (OHCA) outcomes in the Pragmatic Airway Resuscitation Trial (PART). METHODS We performed a secondary analysis of PART, a multicenter clinical trial comparing LT and ETI upon adult OHCA outcomes. We defined FPS as successful LT insertion or ETI on the first attempt as reported by EMS personnel. We examined the outcomes return of spontaneous circulation (ROSC), 72-h survival, hospital survival, and hospital survival with favorable neurologic status (Modified Rankin Scale ≤3). Using multivariable GEE (generalized estimating equations), we determined the association between FPS and OHCA outcomes, adjusting for age, sex, witnessed arrest, bystander CPR, initial rhythm, and initial airway type. RESULTS Of 3004 patients enrolled in the trial, 1423 received LT, 1227 received ETI, 354 received bag-valve-mask ventilation only. FPS was: LT 86.2% and ETI 46.7%. FPS was associated with increased ROSC (aOR 1.23; 95%CI: 1.07-1.41)), but not 72-h survival (1.22; 0.94-1.58), hospital survival (0.90; 0.68-1.19) or hospital survival with favorable neurologic status (0.66; 0.37-1.19). CONCLUSION In adult OHCA, airway insertion FPS was associated with increased ROSC but not other OHCA outcomes. The influence of airway insertion FPS upon OHCA outcomes is unclear.
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Affiliation(s)
- Jason A Lesnick
- Department of Emergency Medicine, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Justin X Moore
- Division of Epidemiology, Department of Population Health Sciences, Augusta University, Augusta, GA, USA
| | - Yefei Zhang
- Department of Biostatistics and Data Science, School of Public Health, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Jeffrey Jarvis
- Williamson County Emergency Medical Services, Georgetown, TX, USA; Texas A&M Health Science Center, Temple, TX, USA
| | - Graham Nichol
- University of Washington[HYPHEN]Harborview Center for Prehospital Emergency Care, Departments of Medicine and Emergency Medicine, University of Washington, Seattle, WA, USA
| | - Mohamud R Daya
- Department of Emergency Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Ahamed H Idris
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Cameron Klug
- Legacy Meridian Park Medical Center. Tualatin, OR, USA
| | | | - Jestin N Carlson
- University of Pittsburgh, Pittsburgh, PA, USA; Department of Emergency Medicine, Saint Vincent Hospital, Allegheny Health Network, Erie, PA, USA
| | - Pratik Doshi
- Department of Emergency Medicine, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - George Sopko
- National Institutes of Health, Bethesda, MD, USA
| | - Robert H Schmicker
- Department of Biostatistics, School of Public Health, University of Washington, Seattle, WA, USA
| | - Henry E Wang
- Department of Emergency Medicine, The University of Texas Health Science Center at Houston, Houston, TX, USA.
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16
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Braude D, Dixon D, Torres M, Martinez JP, O'Brien S, Bajema T. Brief Research Report: Prehospital Rapid Sequence Airway. PREHOSP EMERG CARE 2020; 25:583-587. [PMID: 32628568 DOI: 10.1080/10903127.2020.1792015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Rapid Sequence Airway (RSA) describes the administration of an induction agent and paralytic followed by the intended primary placement of an extraglottic airway device rather than an endotracheal tube. The purpose of this study was to determine the success rates for prehospital RSA. The secondary goal was to determine aspiration rates among patients managed with RSA. METHODS Adult and pediatric prehospital RSA cases between 2005 and 2017 reported to an airway quality assurance registry from one ground and one air agency were reviewed. Success was defined as the ability to adequately ventilate patients after extraglottic device placement. Aspiration was defined as radiologic evidence (chest x-ray or CT scan) within 48 hours of hospital presentation. RESULTS 68 patients underwent RSA with a King LTS-D (n = 24), LMA-Supreme (n = 28), Combitube (n = 2), LMA-Unique (n = 8) and iGel (n = 6). Age ranged from 1 year to 73 years with 10 patients less than 18. RSA was successful in 64 (94%) cases; 56 (88%) were successful on first pass and 63 (98%) within 2 attempts. The RSA procedure occurred in an aircraft in 14 (21%) of cases and 71% of patients were in cervical precautions. Duration of EGD insertion prior to hospital arrival ranged from 5 to 102 minutes with an average of 34.5 minutes. Aspiration data was available for 46 patients of whom 4 (8.7%) were found to have evidence of aspiration. CONCLUSION Overall and first pass RSA success rates were high and aspiration rates were low in this quality assurance registry despite predictors of airway difficulty. RSA may be a reasonable alternative to RSI for prehospital airway management that merits further research.
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17
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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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18
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Endotracheal Intubation Success Rate in an Urban, Supervised, Resident-Staffed Emergency Mobile System: An 11-Year Retrospective Cohort Study. J Clin Med 2020; 9:jcm9010238. [PMID: 31963162 PMCID: PMC7019886 DOI: 10.3390/jcm9010238] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Revised: 01/09/2020] [Accepted: 01/12/2020] [Indexed: 12/22/2022] Open
Abstract
Objectives: In the prehospital setting, endotracheal intubation (ETI) is sometimes required to secure a patient’s airways. Emergency ETI in the field can be particularly challenging, and success rates differ widely depending on the provider’s training, background, and experience. Our aim was to evaluate the ETI success rate in a resident-staffed and specialist-physician-supervised emergency prehospital system. Methods: This retrospective study was conducted on data extracted from the Geneva University Hospitals’ institutional database. In this city, the prehospital emergency response system has three levels of expertise: the first is an advanced life-support ambulance staffed by two paramedics, the second is a mobile unit staffed by an advanced paramedic and a resident physician, and the third is a senior emergency physician acting as a supervisor, who can be dispatched either as backup for the resident physician or when a regular Mobile Emergency and Resuscitation unit (Service Mobile d’Urgence et de Réanimation, SMUR) is not available. For this study, records of all adult patients taken care of by a second- and/or third-level prehospital medical team between 2008 and 2018 were screened for intubation attempts. The primary outcome was the success rate of the ETI attempts. The secondary outcomes were the number of ETI attempts, the rate of ETI success at the first attempt, and the rate of ETIs performed by a supervisor. Results: A total of 3275 patients were included in the study, 55.1% of whom were in cardiac arrest. The overall ETI success rate was 96.8%, with 74.4% success at the first attempt. Supervisors oversaw 1167 ETI procedures onsite (35.6%) and performed the ETI themselves in only 488 cases (14.9%). Conclusion: A resident-staffed and specialist-physician-supervised urban emergency prehospital system can reach ETI success rates similar to those reported for a specialist-staffed system.
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19
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Hudson IL, Blackburn MB, Staudt AM, Ryan KL, Mann-Salinas EA. Analysis of Casualties That Underwent Airway Management Before Reaching Role 2 Facilities in the Afghanistan Conflict 2008-2014. Mil Med 2020; 185:10-18. [PMID: 32074383 DOI: 10.1093/milmed/usz383] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION Airway compromise is the second leading cause of potentially survivable death on the battlefield. The purpose of this study was to better understand wartime prehospital airway patients. MATERIALS AND METHODS The Role 2 Database (R2D) was retrospectively reviewed for adult patients injured in Afghanistan between February 2008 and September 2014. Of primary interest were prehospital airway interventions and mortality. Prehospital combat mortality index (CMI-PH), hemodynamic interventions, injury mechanism, and demographic data were also included in various statistical analyses. RESULTS A total of 12,780 trauma patients were recorded in the R2D of whom 890 (7.0%) received prehospital airway intervention. Airway intervention was more common in patients who ultimately died (25.3% vs. 5.6%); however, no statistical association was found in a multivariable logistic regression model (OR 1.28, 95% CI 0.98-1.68). Compared with U.S. military personnel, other military patients were more likely to receive airway intervention after adjusting for CMI-PH (OR 1.33, 95% CI 1.07-1.64). CONCLUSIONS In the R2D, airway intervention was associated with increased odds of mortality, although this was not statistically significant. Other patients had higher odds of undergoing an airway intervention than U.S. military. Awareness of these findings will facilitate training and equipment for future management of prehospital/prolonged field care airway interventions.
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Affiliation(s)
- Ian L Hudson
- US Army Institute of Surgical Research is United States of America (USA), 3698 Chambers Pass, San Antonio TX 78234, USA
| | - Megan B Blackburn
- US Army Institute of Surgical Research is United States of America (USA), 3698 Chambers Pass, San Antonio TX 78234, USA
| | - Amanda M Staudt
- US Army Institute of Surgical Research is United States of America (USA), 3698 Chambers Pass, San Antonio TX 78234, USA
| | - Kathy L Ryan
- US Army Institute of Surgical Research is United States of America (USA), 3698 Chambers Pass, San Antonio TX 78234, USA
| | - Elizabeth A Mann-Salinas
- US Army Institute of Surgical Research is United States of America (USA), 3698 Chambers Pass, San Antonio TX 78234, USA
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20
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Maignan M, Viglino D, Collomb Muret R, Vejux N, Wiel E, Jacquin L, Laribi S, N-Gueye P, Joly LM, Dumas F, Beaune S. Intensity of care delivered by prehospital emergency medical service physicians to patients with deliberate self-poisoning: results from a 2-day cross-sectional study in France. Intern Emerg Med 2019; 14:981-988. [PMID: 31104303 DOI: 10.1007/s11739-019-02108-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 05/08/2019] [Indexed: 10/26/2022]
Abstract
Emergency management of deliberate self-poisoning (DSP) by drug overdose is common in emergency medicine. There is a paucity of data about the prehospital care of these patients. The principal aim was to describe the intensity of care received by patients with DSP who were managed by prehospital emergency medical service (EMS) physicians. A 48-h cross-sectional study was conducted in 319 EMS and emergency units in France. Patient and poisoning characteristics and treatments administered were recorded. Complications of poisoning, hospitalization, intensive care unit admission and death were recorded until day 30. The primary endpoint was the probability of receiving prehospital intensive care, including fluid resuscitation, vasopressor therapy, invasive ventilation, or antidotal treatments, depending whether prehospital treatment was carried out by an EMS physician or not. Data from 703 patients (median age was 43 [30-52] years, 288 (40%) men) were analyzed. One hundred and fifteen (16%) patients were attended by an EMS physician. Patients attended by EMS physicians were more likely to receive intensive treatment in the prehospital setting [odds ratio (OR) 7.4, 95% confidence interval 4.3-12.9]. These patients had more severe poisoning as suggested mainly by a lower Glasgow Coma Score (13 [8-15] vs. 15 [15-15]; p < 0.001) and a higher rate of admission to an intensive care unit [29 (25%) vs. 15 (2%), p < 0.001]. Patients with DSP attended by prehospital EMS physicians frequently received intensive care. The level of care seemed appropriate for the severity of the poisoning.
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Affiliation(s)
- Maxime Maignan
- Emergency Department, CHU Grenoble Alpes University Hospital, HP2 INSERM U1042, CS 10217, 38043, Grenoble cedex 9, France.
| | - Damien Viglino
- Emergency Department, CHU Grenoble Alpes University Hospital, HP2 INSERM U1042, CS 10217, 38043, Grenoble cedex 9, France
| | - Roselyne Collomb Muret
- Emergency Department, CHU Grenoble Alpes University Hospital, HP2 INSERM U1042, CS 10217, 38043, Grenoble cedex 9, France
| | - Nathan Vejux
- Emergency Department, CHU Grenoble Alpes University Hospital, HP2 INSERM U1042, CS 10217, 38043, Grenoble cedex 9, France
| | - Eric Wiel
- Emergency Department and SAMU 59, Lille University Hospital, Inserm UMR1011 and UDSL, Institut Pasteur de Lille, EGID, Lille, France
| | - Laurent Jacquin
- Emergency Department, Hospices Civiles de Lyon, Lyon, France
| | - Said Laribi
- Emergency Department, Tours University Hospital, 37044, Tours, France
- INSERM, U942, BIOmarkers in CArdioNeuroVAScular Diseases, Paris, France
| | - Papa N-Gueye
- Emergency Department, APHP Hôpital Lariboisière, Paris, France
| | - Luc-Marie Joly
- Emergency Department, Charles Nicolle Hospital, Rouen, France
| | - Florence Dumas
- Emergency Department, APHP Hôpital Cochin, Sudden Death Expertise Center, Paris Cardiovascular Research Center, INSERM Unit 970, Paris, France
| | - Sebastien Beaune
- Department of Emergency Medicine, Ambroise Paré Hospital, APHP, University Paris Diderot, INSERM UMR-S 1144, Paris, France
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21
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Jarvis JL, Wampler D, Wang HE. Association of patient age with first pass success in out-of-hospital advanced airway management. Resuscitation 2019; 141:136-143. [DOI: 10.1016/j.resuscitation.2019.06.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Revised: 05/28/2019] [Accepted: 06/03/2019] [Indexed: 12/16/2022]
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22
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Hernandez Padilla AC, Trampont T, Lafon T, Daix T, Cailloce D, Barraud O, Dalmay F, Vignon P, François B. Is prehospital endobronchial intubation a risk factor for subsequent ventilator associated pneumonia? A retrospective analysis. PLoS One 2019; 14:e0217466. [PMID: 31120987 PMCID: PMC6532927 DOI: 10.1371/journal.pone.0217466] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 05/13/2019] [Indexed: 02/04/2023] Open
Abstract
More than half of patients under mechanical ventilation in the intensive care unit (ICU) are field-intubated, which is a known risk factor for ventilator associated pneumonia (VAP). We assessed whether field endobronchial intubation (EBI) is associated with the development of subsequent VAP during the ICU stay. This retrospective, nested case-control study was conducted in a cohort of field-intubated patients admitted to an ICU of a teaching hospital during a three-year period. Cases were defined as field-intubated patients with EBI and controls corresponded to field-intubated patients with proper position of the tracheal tube on admission chest X-ray. Primary endpoint was the development of early VAP. Secondary endpoints included the development of early ventilator associated tracheo-bronchitis, late VAP, duration of mechanical ventilation, length of stay and mortality in the ICU. A total of 145 patients were studied (mean age: 54 ± 19 years; men: 74%). Reasons for field intubation were predominantly multiple trauma (49%) and cardiorespiratory arrest (38%). EBI was identified in 33 patients (23%). Fifty-three patients (37%) developed early or late VAP. EBI after field intubation was associated with a nearly two-fold increase of early VAP, though not statistically significant (30% vs. 17%: p = 0.09). No statistically significant difference was found regarding secondary outcomes. The present study suggests that inadvertent prehospital EBI could be associated with a higher incidence of early-onset VAP. Larger studies are required to confirm this hypothesis. Whether strategies aimed at decreasing the incidence and duration of EBI could reduce the incidence of subsequent VAP remains to be determined.
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Affiliation(s)
| | | | - Thomas Lafon
- INSERM CIC 1435, CHU Dupuytren, Limoges, France
- Service d’Accueil des Urgences, CHU Dupuytren, Limoges, France
| | - Thomas Daix
- INSERM CIC 1435, CHU Dupuytren, Limoges, France
- Réanimation polyvalente, CHU Dupuytren, Limoges, France
- INSERM UMR 1092, Université Limoges, Limoges, France
| | | | - Olivier Barraud
- INSERM UMR 1092, Université Limoges, Limoges, France
- Laboratoire de Bactériologie–Virologie–Hygiène, CHU Dupuytren, Limoges, France
| | | | - Philippe Vignon
- INSERM CIC 1435, CHU Dupuytren, Limoges, France
- Réanimation polyvalente, CHU Dupuytren, Limoges, France
| | - Bruno François
- INSERM CIC 1435, CHU Dupuytren, Limoges, France
- Réanimation polyvalente, CHU Dupuytren, Limoges, France
- INSERM UMR 1092, Université Limoges, Limoges, France
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23
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Fouche PF, Stein C, Jennings PA, Boyle M, Bernard S, Smith K. Review article: Emergency endotracheal intubation in non-traumatic brain pathologies: A systematic review and meta-analysis. Emerg Med Australas 2019; 31:533-541. [PMID: 31041848 DOI: 10.1111/1742-6723.13304] [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: 12/29/2018] [Revised: 04/03/2019] [Accepted: 04/05/2019] [Indexed: 12/30/2022]
Abstract
Endotracheal intubation is an advanced airway procedure performed in the ED and the out-of-hospital setting for acquired brain injuries that include non-traumatic brain pathologies such as stroke, encephalopathies, seizures and toxidromes. Controlled trial evidence supports intubation in traumatic brain injuries, but it is not clear that this evidence can be applied to non-traumatic brain pathologies. We sought to analyse the impact of emergency intubation on survival in non-traumatic brain pathologies and also to quantify the prevalence of intubation in these pathologies. We conducted a systematic literature search of Medline, Embase and the Cochrane Library. Eligibility, data extraction and assessment of risk of bias were assessed independently by two reviewers. A bias-adjusted meta-analysis using a quality-effects model pooled prevalence of intubation in non-traumatic brain pathologies. Forty-six studies were included in this systematic review. No studies were suitable for meta-analysis the primary outcome of survival. Thirty-nine studies reported the prevalence of intubation in non-traumatic brain pathologies and a meta-analysis showed that emergency intubation was used in 12% (95% CI 0-33) of pathologies. Endotracheal intubation was used commonly in haemorrhagic stroke 79% (95% CI 47-100) and to a lesser extent for seizures 18% (95% CI 10-27) and toxidromes 25% (95% CI 6-48). This systematic review shows that there is no high-quality clinical evidence to support or refute emergency intubation in non-traumatic brain pathologies. Our analysis shows that intubation is commonly used in non-traumatic brain pathologies, and the need for rigorous evidence is apparent.
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Affiliation(s)
- Pieter F Fouche
- Department of Community Emergency Health and Paramedic Practice, Monash University, Melbourne, Victoria, Australia
| | - Christopher Stein
- Department of Emergency Medical Care, University of Johannesburg, Johannesburg, South Africa
| | | | - Malcolm Boyle
- School of Medicine, Griffith University, Griffith, Queensland, Australia
| | - Stephen Bernard
- Research and Evaluation, Ambulance Victoria, Melbourne, Victoria, Australia
| | - Karen Smith
- Research and Evaluation, Ambulance Victoria, Melbourne, Victoria, Australia
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Glasheen J, Wall B, Keogh S. A BRILL idea? The benefits, risks, insights, learning and limitations of an emergency airway registry in pre-hospital and retrieval medicine. Emerg Med Australas 2019; 31:483-486. [PMID: 30924314 DOI: 10.1111/1742-6723.13283] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 02/04/2019] [Accepted: 02/24/2019] [Indexed: 12/31/2022]
Abstract
Airway management is a cornerstone of emergency care. Development of a robust evidence base to support the practice of pre-hospital emergency anaesthesia is key to the safety and evolution of this common but high-risk procedure. This paper discusses the benefits, risks, insights, learning and limitations of the use of an airway registry in pre-hospital and retrieval medicine, for both research and quality improvement purposes.
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Affiliation(s)
- John Glasheen
- LifeFlight Retrieval Medicine, Brisbane, Queensland, Australia.,Anaesthesia Trauma and Critical Care, Lancashire, UK
| | - Brigid Wall
- Anaesthesia Trauma and Critical Care, Lancashire, UK.,Queensland Ambulance Service, Brisbane, Queensland, Australia
| | - Sean Keogh
- Faculty of Science, Health, Education and Engineering, University of the Sunshine Coast, Sunshine Coast, Queensland, Australia
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25
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What is the impact of physicians in prehospital treatment for patients in need of acute critical care? - An overview of reviews. Int J Technol Assess Health Care 2019; 35:27-35. [PMID: 30722802 DOI: 10.1017/s0266462318003616] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVES The aim of this overview was to systematically identify and synthesize existing evidence from systematic reviews on the impact of prehospital physician involvement. METHODS The Medline, Embase, and Cochrane library were searched from 1 January 2000 to 17 November 2017. We included systematic reviews comparing physician-based with non-physician-based prehospital treatment in patients with one of five critical conditions requiring a rapid response. RESULTS Ten reviews published from 2009 to 2017 were included. Physician treatment was associated with increased survival in patients with out-of-hospital cardiac arrest and patients with severe trauma; in the latter group, the result was based on more limited evidence. The success rate of prehospital endotracheal intubation (ETI) has improved over the years, but ETI by physicians is still associated with higher success rates than intubation by paramedics. In patients with severe traumatic brain injury, intubation by paramedics who were not well skilled to do so markedly increased mortality. CONCLUSIONS Current evidence is hinting at a benefit of physicians in selected aspects of prehospital emergency services, including treatment of patients with out-of-hospital cardiac arrest and critically ill or injured patients in need of prehospital intubation. Evidence is, however, limited by confounding and bias, and comparison is hampered by differences in case mix and the organization of emergency medical services. Future research should strive to design studies that enable appropriate control of baseline confounding and obtain follow-up data for the proportion of patients who die in the prehospital setting.
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Stassen W, Lithgow A, Wylie C, Stein C. A descriptive analysis of endotracheal intubation in a South African Helicopter Emergency Medical Service. Afr J Emerg Med 2018; 8:140-144. [PMID: 30534517 PMCID: PMC6277604 DOI: 10.1016/j.afjem.2018.07.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Revised: 05/04/2018] [Accepted: 07/03/2018] [Indexed: 11/26/2022] Open
Abstract
Introduction Helicopter Emergency Medical Services (HEMS) exists to supplement the operations of ground-based emergency care providers, mainly in high acuity cases. One of the important procedures frequently carried out by HEMS personnel is endotracheal intubation. Several HEMS providers exist in South Africa, with a mix of advanced life support personnel, however intubation success rates and adverse events have not been described in any local HEMS operation. Methods This was a retrospective chart review of intubation-related data collected by a HEMS operation based in Johannesburg over a 16-month period. First-pass and overall success rates were described, in addition to perceived airway difficulty, adverse events and other data. Results Of the 49 cases recorded in the study period, one was excluded leaving 48 cases for analysis. Most cases (n = 34, 71%) involved young male trauma patients who were intubated with rapid sequence intubation. The first pass success rate was 79% (n = 38) with an overall success rate of 98% (n = 47). At least one factor suggesting airway difficulty was present in 29% (n = 14) of cases, with most perceived airway difficulty related to the high prevalence of trauma cases. At least one adverse event occurred in 27% (n = 13) of cases with hypoxaemia, hypotension and bradycardia most prevalent. Discussion In this small sample of South African HEMS intubation cases, we found overall and first-pass success rates comparable to those reported in similar contexts.
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27
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Murphy DL, Latimer AJ, Utarnachitt RB. Resuscitative Airway Management for Massive Gastrointestinal Hemorrhage. Air Med J 2018; 37:380-382. [PMID: 30424857 DOI: 10.1016/j.amj.2018.07.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Accepted: 07/03/2018] [Indexed: 10/28/2022]
Abstract
Massive upper gastrointestinal hemorrhage represents a highly morbid, resource intensive disease entity that requires rapid diagnostic and therapeutic delivery in parallel with mobilization of in-hospital providers for definitive intervention. This report details a unique case demonstrating exceptional collaboration spanning multiple healthcare systems, a novel use of resuscitative endovascular balloon occlusion of the aorta, and a discussion on resuscitative airway management in the setting of massive upper gastrointestinal hemorrhage.
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Affiliation(s)
- David L Murphy
- Department of Emergency Medicine, University of Washington, Seattle, WA
| | - Andrew J Latimer
- Department of Emergency Medicine, University of Washington, Seattle, WA; Airlift Northwest, University of Washington, Seattle, WA
| | - Richard B Utarnachitt
- Department of Emergency Medicine, University of Washington, Seattle, WA; Airlift Northwest, University of Washington, Seattle, WA
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28
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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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Jarvis JL, Gonzales J, Johns D, Sager L. Implementation of a Clinical Bundle to Reduce Out-of-Hospital Peri-intubation Hypoxia. Ann Emerg Med 2018. [PMID: 29530653 DOI: 10.1016/j.annemergmed.2018.01.044] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
STUDY OBJECTIVE Peri-intubation hypoxia is an important adverse event of out-of-hospital rapid sequence intubation. The aim of this project is to determine whether a clinical bundle encompassing positioning, apneic oxygenation, delayed sequence intubation, and goal-directed preoxygenation is associated with decreased peri-intubation hypoxia compared with standard out-of-hospital rapid sequence intubation. METHODS We conducted a retrospective, before-after study using data from a suburban emergency medical services (EMS) system in central Texas. The study population included all adults undergoing out-of-hospital intubation efforts, excluding those in cardiac arrest. The before-period intervention was standard rapid sequence intubation using apneic oxygenation at flush flow, ketamine, and a paralytic. The after-period intervention was a care bundle including patient positioning (elevated head, sniffing position), apneic oxygenation, delayed sequence intubation (administration of ketamine to facilitate patient relaxation and preoxygenation with a delayed administration of paralytics), and goal-directed preoxygenation. The primary outcome was the rate of peri-intubation hypoxia, defined as the percentage of patients with a saturation less than 90% during the intubation attempt. RESULTS The before group (October 2, 2013, to December 13, 2015) included 104 patients and the after group (August 8, 2015, to July 14, 2017) included 87 patients. The 2 groups were similar in regard to sex, age, weight, ethnicity, rate of trauma, initial oxygen saturation, rates of initial hypoxia, peri-intubation peak SpO2, preintubation pulse rate and systolic blood pressure, peri-intubation cardiac arrest, and first-pass and overall success rates. Compared with the before group, the after group experienced less peri-intubation hypoxia (44.2% versus 3.5%; difference -40.7% [95% confidence interval -49.5% to -32.1%]) and higher peri-intubation nadir SpO2 values (100% versus 93%; difference 5% [95% confidence interval 2% to 10%]). CONCLUSION In this single EMS system, a care bundle encompassing patient positioning, apneic oxygenation, delayed sequence intubation, and goal-directed preoxygenation was associated with lower rates of peri-intubation hypoxia than standard out-of-hospital rapid sequence intubation.
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Affiliation(s)
- Jeffrey L Jarvis
- Williamson County EMS, Georgetown, TX; Department of Emergency Medicine, Baylor Scott & White Healthcare, Temple, TX.
| | | | | | - Lauren Sager
- Department of Biostatistics, Baylor Scott & White Healthcare, Temple, TX
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Delorenzo A, St Clair T, Andrew E, Bernard S, Smith K. Prehospital Rapid Sequence Intubation by Intensive Care Flight Paramedics. PREHOSP EMERG CARE 2018; 22:595-601. [PMID: 29405803 DOI: 10.1080/10903127.2018.1426666] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Rapid sequence intubation (RSI) is an advanced airway procedure for critically ill or injured patients. Paramedic-performed RSI in the prehospital setting remains controversial, as unsuccessful or poorly conducted RSI is known to result in significant complications. In Victoria, intensive care flight paramedics (ICFPs) have a broad scope of practice including RSI in both the adult and pediatric population. We sought to describe the success rates and characteristics of patients undergoing RSI by ICFPs in Victoria, Australia. METHODS A retrospective data review was conducted of adult (≥ 16 years) patients who underwent RSI by an ICFP between January 1, 2011, and December 31, 2016. Data were sourced from the Ambulance Victoria data warehouse. RESULTS A total of 795 cases were included in analyses, with a mean age of 45 (standard deviation = 19.6) years. The majority of cases involved trauma (71.7%), and most patients were male (70.1%). Neurological pathologies were the most common clinical indication for RSI (68.3%). The first pass success rate of intubation was 89.4%, and the overall success rate was 99.4%. Of the 5 failed intubations (0.6%), all patients were safely returned to spontaneous respiration. Two patients were returned via bag/valve/mask (BVM) support alone, two with BVM and oropharyngeal airway, and one via supraglottic airway. No surgical airways were required. Overall, we observed transient cases of hypotension (5.2%), hypoxemia (1.3%), or both (0.1%) in 6.6% of cases during the RSI procedure. CONCLUSION A very high RSI procedural success rate was observed across the study period. This supports the growing recognition that appropriately trained paramedics can perform RSI safely in the prehospital environment.
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31
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Fouche PF, Stein C, Simpson P, Carlson JN, Zverinova KM, Doi SA. Flight Versus Ground Out-of-hospital Rapid Sequence Intubation Success: a Systematic Review and Meta-analysis. PREHOSP EMERG CARE 2018; 22:578-587. [PMID: 29377753 DOI: 10.1080/10903127.2017.1423139] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Endotracheal intubation (ETI) is a critical procedure performed by both air medical and ground based emergency medical services (EMS). Previous work has suggested that ETI success rates are greater for air medical providers. However, air medical providers may have greater airway experience, enhanced airway education, and access to alternative ETI options such as rapid sequence intubation (RSI). We sought to analyze the impact of the type of EMS on RSI success. METHODS A systematic literature search of Medline, Embase, and the Cochrane Library was conducted and eligibility, data extraction, and assessment of risk of bias were assessed independently by two reviewers. A bias-adjusted meta-analysis using a quality-effects model was conducted for the primary outcomes of overall intubation success and first-pass intubation success. RESULTS Forty-nine studies were included in the meta-analysis. There was no difference in the overall success between flight and ground based EMS; 97% (95% CI 96-98) vs. 98% (95% CI 91-100), and no difference in first-pass success for flight compared to ground based RSI; 82% (95% CI 73-89) vs. 82% (95% CI 70-93). Compared to flight non-physicians, flight physicians have higher overall success 99% (95% CI 98-100) vs. 96% (95% CI 94-97) and first-pass success 89% (95% CI 77-98) vs. 71% (95% CI 57-84). Ground-based physicians and non-physicians have a similar overall success 98% (95% CI 88-100) vs. 98% (95% CI 95-100), but no analysis for physician ground first pass was possible. CONCLUSIONS Both overall and first-pass success of RSI did not differ between flight and road based EMS. Flight physicians have a higher overall and first-pass success compared to flight non-physicians and all ground based EMS, but no such differences are seen for ground EMS. Our results suggest that ground EMS can use RSI with similar outcomes compared to their flight counterparts.
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Tsuchida RE, Meurer WJ. More questions than answers - ALS interventions for out of hospital cardiac arrest. Am J Emerg Med 2017; 36:498-500. [PMID: 29217179 DOI: 10.1016/j.ajem.2017.11.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 11/27/2017] [Indexed: 11/18/2022] Open
Affiliation(s)
- Ryan E Tsuchida
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, United States.
| | - William J Meurer
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, United States; Department of Neurology, University of Michigan, Ann Arbor, MI, United States; Stroke Program, University of Michigan, Ann Arbor, MI, United States; Michigan Center for Integrative Research on Critical Care, University of Michigan, Ann Arbor, MI, United States; Frankel Cardiovascular Center, University of Michigan, United States.
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Wang HE. The (Continued) Challenges of Out-of-Hospital Rapid Sequence Intubation. Ann Emerg Med 2017; 70:460-462. [DOI: 10.1016/j.annemergmed.2017.04.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2017] [Indexed: 11/28/2022]
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