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Nikolla DA, Carlson JN, Jimenez Stuart PM, Asar I, April MD, Kaji AH, Brown C. Comparing postinduction hypoxemia between ramped and supine position endotracheal intubations with apneic oxygenation in the emergency department. Acad Emerg Med 2022; 29:317-325. [PMID: 34757633 DOI: 10.1111/acem.14415] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 11/05/2021] [Accepted: 11/08/2021] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Ramped position and apneic oxygenation are strategies to mitigate hypoxemia; however, the benefits of these strategies when utilized together remain unclear. Therefore, we compared first-attempt, postinduction hypoxemia between adult emergency department (ED) endotracheal intubations performed with apneic oxygenation in the ramped versus supine positions. METHODS We used the National Emergency Airway Registry (NEAR), a multicenter registry of data on ED intubations from 25 academic and community sites. We included first-attempt intubations with direct (DL) and video (VL) laryngoscopy in subjects ≥ 18 years old with nontrauma indications receiving apneic oxygenation. We examined patient characteristics (e.g., sex, obesity) and key intubation outcomes, including hypoxemia (primary outcome), first-pass success, and other adverse events (e.g., bradycardia). In addition, we examined unadjusted odds ratios (OR) and adjusted ORs (aOR) for key variables and stratified by laryngoscope type. RESULTS We included 210 ramped cases and 1,820 supine cases in the DL cohort and 202 ramped and 1,626 supine cases in the VL cohort. Rates of postinduction hypoxemia were similar between supine and ramped position in both the DL cohort (supine 6.5% and ramped 7.6%, aOR [95% CI] = 0.96 [0.55 to 1.67]) and the VL cohort (supine 10.1% and ramped 12.4%, aOR [95% CI] = 0.97 [0.60 to 1.56]). Other outcomes were also similar between groups. CONCLUSION Using this large national data set, we did not identify a difference in postinduction hypoxemia between ramped and supine positions in this cohort of ED intubations with apneic oxygenation.
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Affiliation(s)
- Dhimitri A. Nikolla
- Department of Emergency Medicine Allegheny Health Network–Saint Vincent Erie Pennsylvania USA
| | - Jestin N. Carlson
- Department of Emergency Medicine Allegheny Health Network–Saint Vincent Erie Pennsylvania USA
| | - Paul M. Jimenez Stuart
- Department of Emergency Medicine Allegheny Health Network–Saint Vincent Erie Pennsylvania USA
| | - Irtaza Asar
- Department of Emergency Medicine Allegheny Health Network–Saint Vincent Erie Pennsylvania USA
| | - Michael D. April
- 40th Forward Resuscitative Surgical Detachment 627th Hospital Center Fort Carson Colorado USA
- Department of Military and Emergency Medicine Uniformed Services University of the Health Sciences Bethesda Maryland USA
| | - Amy H. Kaji
- Department of Emergency Medicine Harbor–UCLA Torrance California USA
| | - Calvin A. Brown
- Department of Emergency Medicine Brigham and Women’s Hospital Boston Massachusetts USA
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Jarvis JL, Lyng JW, Miller BL, Perlmutter MC, Abraham H, Sahni R. Prehospital Drug Assisted Airway Management: An NAEMSP Position Statement and Resource Document. PREHOSP EMERG CARE 2022; 26:42-53. [PMID: 35001829 DOI: 10.1080/10903127.2021.1990447] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Airway management is a critical intervention for patients with airway compromise, respiratory failure, and cardiac arrest. Many EMS agencies use drug-assisted airway management (DAAM) - the administration of sedatives alone or in combination with neuromuscular blockers - to facilitate advanced airway placement in patients with airway compromise or impending respiratory failure who also have altered mental status, agitation, or intact protective airway reflexes. While DAAM provides several benefits including improving laryngoscopy and making insertion of endotracheal tubes and supraglottic airways easier, DAAM also carries important risks. NAEMSP recommends:DAAM is an appropriate tool for EMS clinicians in systems with clear guidelines, sufficient training, and close EMS physician oversight. DAAM should not be used in settings without adequate resources.EMS physicians should develop clinical guidelines informed by evidence and oversee the training and credentialing for safe and effective DAAM.DAAM programs should include best practices of airway management including patient selection, assessmenct and positioning, preoxygenation strategies including apneic oxygenation, monitoring and management of physiologic abnormalities, selection of medications, post-intubation analgesia and sedation, equipment selection, airway confirmation and monitoring, and rescue airway techniques.Post-DAAM airway placement must be confirmed and continually monitored with waveform capnography.EMS clinicians must have the necessary equipment and training to manage patients with failed DAAM, including bag mask ventilation, supraglottic airway devices and surgical airway approaches.Continuous quality improvement for DAAM must include assessment of individual and aggregate performance metrics. Where available for review, continuous physiologic recordings (vital signs, pulse oximetry, and capnography), audio and video recordings, and assessment of patient outcomes should be part of DAAM continuous quality improvement.
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April MD, Arana A, Reynolds JC, Carlson JN, Davis WT, Schauer SG, Oliver JJ, Summers SM, Long B, Walls RM, Brown CA. Peri-intubation cardiac arrest in the Emergency Department: A National Emergency Airway Registry (NEAR) study. Resuscitation 2021; 162:403-411. [PMID: 33684505 DOI: 10.1016/j.resuscitation.2021.02.039] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 02/10/2021] [Accepted: 02/18/2021] [Indexed: 01/21/2023]
Abstract
AIM To determine the incidence of peri-intubation cardiac arrest through analysis of a multi-center Emergency Department (ED) airway registry and to report associated clinical characteristics. METHODS This is a secondary analysis of prospectively collected data (National Emergency Airway Registry) comprising ED endotracheal intubations (ETIs) of subjects >14 years old from 2016 to 2018. We excluded those with cardiac arrest prior to intubation. The primary outcome was peri-intubation cardiac arrest. Multivariable logistic regression generated adjusted odds ratios (aOR) of variables associated with this outcome, controlling for clinical features, difficult airway characteristics, and ETI modality. RESULTS Of 15,776 subjects who met selection criteria, 157 (1.0%, 95% CI 0.9-1.2%) experienced peri-intubation cardiac arrest. Pre-intubation systolic blood pressure <100 mm Hg (aOR 6.2, 95% CI 2.5-8.5), pre-intubation oxygen saturation <90% (aOR 3.1, 95% CI 2.0-4.8), and clinician-reported need for immediate intubation without time for full preparation (aOR 1.8, 95% CI, 1.2-2.7) were associated with higher likelihood of peri-intubation cardiac arrest. The association between pre-intubation shock and cardiac arrest persisted in additional modeling stratified by ETI indication, induction agent, and oxygenation status. CONCLUSIONS Peri-intubation cardiac arrest for patients undergoing ETI in the ED is rare. Higher likelihood of arrest occurs in patients with pre-intubation shock or hypoxemia. Prospective trials are necessary to determine whether a protocol to optimize pre-intubation haemodynamics and oxygenation mitigates the risk of peri-intubation cardiac arrest.
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Affiliation(s)
- Michael D April
- From the 40th Forward Resuscitative Surgical Detachment, 627th Hospital Center, Fort Carson, CO, USA; Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.
| | - Allyson Arana
- United States Army Institute of Surgical Research, San Antonio, TX, USA
| | - Joshua C Reynolds
- Department of Emergency Medicine, Michigan State University College of Human Medicine, Grand Rapids, MI, USA
| | - Jestin N Carlson
- Department of Emergency Medicine, Saint Vincent Hospital, Allegheny Health Network, Erie, PA, USA
| | - William T Davis
- Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA; United States Army Institute of Surgical Research, San Antonio, TX, USA; Department of Emergency Medicine, San Antonio Military Medical Center, San Antonio, TX, USA
| | - Steven G Schauer
- Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA; United States Army Institute of Surgical Research, San Antonio, TX, USA; Department of Emergency Medicine, San Antonio Military Medical Center, San Antonio, TX, USA
| | - Joshua J Oliver
- Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA; Department of Emergency Medicine, Madigan Army Medical Center, Fort Lewis, WA, USA
| | - Shane M Summers
- Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA; Department of Emergency Medicine, Ryder Trauma Center, Miami, FL, USA
| | - Brit Long
- Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA; Department of Emergency Medicine, San Antonio Military Medical Center, San Antonio, TX, USA
| | - Ron M Walls
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Calvin A Brown
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
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