Does an advanced life support course give non-anaesthetists adequate skills to manage an airway?

Validity Evidence for a Novel, Comprehensive Bag-Mask Ventilation Assessment Tool

OBJECTIVE

To develop a comprehensive competency assessment tool for pediatric bag-mask ventilation (pBMV) and demonstrate multidimensional validity evidence for this tool.

STUDY DESIGN

A novel pBMV assessment tool was developed consisting of 3 components: a 22-item-based checklist (trichotomized response), global rating scale (GRS, 5-point), and entrustment assessment (4-point). Participants' performance in a realistic simulation scenario was video-recorded and assessed by blinded raters. Multidimensional validity evidence for procedural assessment, including evidence for content, response-process, internal structure, and relation to other variables, was assessed. The scores of each scale were compared with training level. Item-based checklist scores also were correlated with GRS and entrustment scores.

RESULTS

Fifty-eight participants (9 medical students, 10 pediatric residents, 18 critical care/neonatology fellows, 21 critical care/neonatology attendings) were evaluated. The pBMV tool was supported by high internal consistency (Cronbach α = 0.867). Inter-rater reliability for the item-based checklist component was acceptable (r = 0.65, P < .0001). The item-based checklist scores differentiated between medical students and other providers (P < .0001), but not by other trainee level. GRS and entrustment scores significantly differentiated between training levels (P < .001). Correlation between skill item-based checklist and GRS was r = 0.489 (P = .0001) and between item-based checklist and entrustment score was r = 0.52 (P < .001). This moderate correlation suggested each component measures pBMV skills differently. The GRS and entrustment scores demonstrated moderate inter-rater reliability (0.42 and 0.46).

CONCLUSIONS

We established evidence of multidimensional validity for a novel entrustment-based pBMV competence assessment tool, incorporating global and entrustment-based assessments. This comprehensive tool can provide learner feedback and aid in entrustment decisions as learners progress through training.

Influence of prehospital physician presence on survival after severe trauma: Systematic review and meta-analysis

BACKGROUND

As trauma is one of the leading causes of death worldwide, there is great potential for reducing mortality in trauma patients. However, there is continuing controversy over the benefit of deploying emergency medical systems (EMS) physicians in the prehospital setting. The objective of this systematic review and meta-analysis is to assess how out-of-hospital hospital management of severely injured patients by EMS teams with and without physicians affects mortality.

METHODS

PubMed and Google Scholar were searched for relevant articles, and the search was supplemented by a hand search. Injury severity in the group of patients treated by an EMS team including a physician had to be comparable to the group treated without a physician. Primary outcome parameter was mortality. Helicopter transport as a confounder was accounted for by subgroup analyses including only the studies with comparable modes of transport. Quality of all included studies was assessed according to the Cochrane handbook.

RESULTS

There were 2,249 publications found, 71 full-text articles assessed, and 22 studies included. Nine of these studies were matched or adjusted for injury severity. The odds ratio (OR) of mortality was significantly lower in the EMS physician-treated group of patients: 0.81; 95% confidence interval (CI): 0.71-0.92. When analysis was limited to the studies that were adjusted or matched for injury severity, the OR was 0.86 (95% CI, 0.73-1.01). Analyzing only studies published after 2005 yielded an OR for mortality of 0.75 (95% CI, 0.64-0.88) in the overall analysis and 0.81 (95% CI, 0.67-0.97) in the analysis of adjusted or matched studies. The OR was 0.80 (95% CI, 0.65-1.00) in the subgroup of studies with comparable modes of transport and 0.74 (95% CI, 0.53-1.03) in the more recent studies.

CONCLUSION

Prehospital management of severely injured patients by EMS teams including a physician seems to be associated with lower mortality. After excluding the confounder of helicopter transport we have shown a nonsignificant trend toward lower mortality.

LEVEL OF EVIDENCE

Systematic review and meta-analysis, level III.

An Anesthesiologist's Perspective on the History of Basic Airway Management: The "Modern" Era, 1960 to Present

This fourth and last installment of my history of basic airway management discusses the current (i.e., "modern") era of anesthesia and resuscitation, from 1960 to the present. These years were notable for the implementation of intermittent positive pressure ventilation inside and outside the operating room. Basic airway management in cardiopulmonary resuscitation (i.e., expired air ventilation) was de-emphasized, as the "A-B-C" (airway-breathing-circulation) protocol was replaced with the "C-A-B" (circulation-airway-breathing) intervention sequence. Basic airway management in the operating room (i.e., face-mask ventilation) lost its predominant position to advanced airway management, as balanced anesthesia replaced inhalation anesthesia. The one-hand, generic face-mask ventilation technique was inherited from the progressive era. In the new context of providing intermittent positive pressure ventilation, the generic technique generated an underpowered grip with a less effective seal and an unspecified airway maneuver. The significant advancement that had been made in understanding the pathophysiology of upper airway obstruction was thus poorly translated into practice. In contrast to consistent progress in advanced airway management, progress in basic airway techniques and devices stagnated.

CPR Guidance by an Emergency Physician via Video Call: A Simulation Study

Background

In South Korea, the prehospital treatment of cardiac arrest is generally led by an emergency medical technician-paramedic (EMT-P), and defibrillation is delivered by the automatic external defibrillator (AED). This study aimed at examining the effects of direct medical guidance by an emergency physician through a video call that enabled prompt manual defibrillation.

Methods

Two-hundred eighty-eight paramedics based in Gyeonggi Province were studied for four months, from July to November 2015. The participants were divided into 96 teams, and the teams were randomly divided into either a conventional group that was to use the AED or a video call guidance group which was to use the manual defibrillators, with 48 teams in each group. The time to first defibrillation, total hands-off time, and hands-off ratio were compared between the two groups.

Results

The median value of the time to the first defibrillation was significantly shorter in the video call guidance group (56 s) than in the conventional group (73 s) (p<0.001). The median value of the total hands-off time was also significantly shorter (228 vs. 285.5 s) (p<0.001), and the hands-off ratio, defined as the proportion of hands-off time out of the total CPR time, was significantly shorter in the video call guidance group (0.32 vs. 0.41) (p<0.001).

Conclusion

Physician-guided CPR with a video call enabled prompt manual defibrillation and significantly shortened the time required for first defibrillation, hands-off time, and hands-off ratio in simulated cases of prehospital cardiac arrest.

Cumulative evaluation data: pediatric airway management simulation courses for pediatric residents

Objectives

To utilize cumulative evaluation data of the pediatric airway management simulation-based learning course on knowledge and practical skills of residents in the Saudi Commission for Health Speciality (SCFHS) in order to measure its efficacy and areas for improvement.

Methods

The evaluation is a retrospective cohort study that compares pre- and post-test (knowledge and skills) of a pediatric airway management simulation course. The 2-day course has been conducted four times annually at CRESENT and is comprised of interactive lectures on airway management and crew resource management, a demonstration of fundamentals of intubation, three skill stations, and six case scenarios with debriefing. Our evaluation data includes all pediatric residents who attended the course between January and December 2015.

Results

Forty-six residents participated, of whom 30 (65.2%) are male and 16 (34.78%) are female. Overall, there is statistically significant improvement between the pre-test and post-test knowledge and practical skill scores. The pre-test scores are significantly different between the four different resident levels with p values of 0.003 and <0.001 respectively. However, there are no statistically significant differences in the post-test scores among the four different resident levels with p values of 0.372 and 0.133 respectively. The practical skill assessment covers four main domains. Improvements were noted in pharmacology (811%), equipment setup (250%), intubation steps (200%), and patient positioning (130%). The post-test scores are similar in all practical skill categories for the four different residency levels.

Discussion

Our outcome-based evaluation strategy demonstrated that residents met the course learning objectives. The pediatric airway management simulation course at CRESENT is effective in improving the knowledge and practical skills of pediatric residents. Although the greatest improvement is noted among junior residents, learners from different residency levels have comparable knowledge and practical skills at the end of the course. Things that can be improved based on our study results include stressing more the type and dosages of the medications used in airway management and mandating the course for all junior pediatric residents. Although residents scored well, specific knowledge and skill elements still led us to targeted areas for course excellence. Similar courses need to be integrated in the pediatric residency curriculum. Further research is needed to study skill retention and more importantly its impact on patients' care. Although resource-intensive, the use of cumulative evaluation data helped to focus quality improvement in our courses.

The novel video-assisted intubating laryngeal mask Totaltrack compared to the intubating laryngeal mask Fastrach - a controlled randomized manikin study

BACKGROUND

The novel Totaltrack combines a supraglottic airway device with video laryngoscopic tracheal intubation. The intubation laryngeal mask Fastrach is an established device without visual control of intubation. We hypothesized that supraglottic ventilation success with Totaltrack would be similar to Fastrach, but intubation would be performed faster due to visual control of the procedure.

METHODS

Fifty-five anaesthesiologists were randomized into one of two study arms: Fastrach Totaltrack. After a standardized introduction, six consecutive attempts of supraglottic ventilation and intubation attempts with each of one of the devices were performed on an airway manikin. The combined primary outcome was: time to supraglottic ventilation and time to ventilation after intubation. Additionally, success rate and learning curves were evaluated.

RESULTS

Supraglottic time to ventilation was shorter when using the Fastrach compared to the Totaltrack (median: 7.8 s [confidence interval [CI]: 7.0-8.6 s] vs. 11 s [CI: 7.8-14.2 s], P < 0.001). Intubation was faster using the Fastrach compared to Totaltrack (median: 12.5 s, [CI: 10.1-14.9 s] vs. 23.3 s [CI: 21.5-25.1 s], P < 0.001). Success rate for supraglottic ventilation was comparable between Fastrach and Totaltrack (86-96%). Successful intubation via the device was 100% in Fastrach and ranged from 61% to 93% in Totaltrack, with a higher probability of successful intubation after four applications.

CONCLUSION

In this manikin-based study the novel Totaltrack did not prove superior to Fastrach despite a similar design. Video laryngoscopic control of supraglottic ventilation and endotracheal intubation was prolonged using the Totaltrack. Clinical trials are mandatory to evaluate the role of the Totaltrack in airway management.

Insertion Success of the Laryngeal Tube in Emergency Airway Management

Background. Emergency airway management (AM) is a priority when resuscitating critically ill or severely injured patients. The goal of this study was to determine the success rates of LT insertion during AM. Methods. Studies that included LT first-pass insertion (FPI) and overall-pass insertion (OPI) success by emergency medical services and in-hospital providers performing AM for emergency situations as well as for scheduled surgery published until July 2014 were searched systematically in Medline. Results. Data of 36 studies (n = 1,897) reported a LT FPI success by physicians of 82.5% with an OPI success of 93.6% (p < 0.001). A cumulative analysis of all 53 studies (n = 3,600) led to FPI and OPI success of 80.1% and 92.6% (p < 0.001), respectively. The results of 26 studies (n = 2,159) comparing the LT with the laryngeal mask airway (LMA) demonstrated a FPI success of 77.0 versus 78.7% (p = 0.36) and an OPI success of 92.2 versus 97.7% (p < 0.001). Conclusion. LT insertion failed in the first attempt in one out of five patients, with an overall failure rate in one out of 14 patients. When compared with the LT, the LMA had a cumulative 5.5% better OPI success rate.

Influence of EMS-physician presence on survival after out-of-hospital cardiopulmonary resuscitation: systematic review and meta-analysis

BACKGROUND

Evidence suggests that EMS-physician-guided cardiopulmonary resuscitation (CPR) in out-of-hospital cardiac arrest (OOHCA) may be associated with improved outcomes, yet randomized controlled trials are not available. The goal of this meta-analysis was to determine the association between EMS-physician- versus paramedic-guided CPR and survival after OOHCA.

METHODS AND RESULTS

Studies that compared EMS-physician- versus paramedic-guided CPR in OOHCA published until June 2014 were systematically searched in MEDLINE, EMBASE and Cochrane databases. All studies were required to contain survival data. Data on study characteristics, methods, and as well as survival outcomes were extracted. A random-effects model was used for the meta-analysis due to a high degree of heterogeneity among the studies (I(2) = 44%). Return of spontaneous circulation [ROSC], survival to hospital admission, and survival to hospital discharge were the outcome measures. Out of 3,385 potentially eligible studies, 14 met the inclusion criteria. In the pooled analysis (n = 126,829), EMS-physician-guided CPR was associated with significantly improved outcomes compared to paramedic-guided CPR: ROSC 36.2% (95% confidence interval [CI] 31.0 - 41.7%) vs. 23.4% (95% CI 18.5 - 29.2%) (pooled odds ratio [OR] 1.89, 95% CI 1.36 - 2.63, p < 0.001); survival to hospital admission 30.1 % (95% CI 24.2 - 36.7%) vs. 19.2% (95% CI 12.7 - 28.1%) (pooled OR 1.78, 95% CI 0.97 - 3.28, p = 0.06); and survival to discharge 15.1% (95% CI 14.6 - 15.7%) vs. 8.4% (95% CI 8.2 - 8.5%) (pooled OR 2.03, 95% CI 1.48 - 2.79, p < 0.001).

CONCLUSIONS

This systematic review suggests that EMS-physician-guided CPR in out-of-hospital cardiac arrest is associated with improved survival outcomes.

[Supraglottic airway devices in emergency medicine : impact of gastric drainage]

This case report describes a life-saving use of a supraglottic airway device (LT-D™-Larynxtubus, VBM Medizintechnik, Sulz, Germany) in an out-of-hospital emergency patient suffering from severe traumatic brain injury. Mechanical ventilation with the laryngeal tube was complicated by repeated airway obstructions and pronounced gastric distension with air as a consequence of oropharyngeal leakage. In this situation pulmonary ventilation of the patient was compromised so that emergency endotracheal intubation became necessary in the resuscitation area with vital indications. In this context the status of supraglottic airway devices in emergency medicine is discussed as well as the reasons for the gastric distension. Besides the immediate drastic consequences of gastric distension with respect to pulmonary ventilation, potential deleterious non-pulmonary consequences of this complication are highlighted. The clinical relevance of the described complications as well as the associated possibility of an optimized position control necessitate the recommendation only to use second generation supraglottic airway devices with integrated gastric access in (out-of-hospital) emergency medicine.

[Emergency anesthesia, airway management and ventilation in major trauma. Background and key messages of the interdisciplinary S3 guidelines for major trauma patients]

Patients with multiple trauma presenting with apnea or a gasping breathing pattern (respiratory rate  < 6/min) require prehospital endotracheal intubation (ETI) and ventilation. Additional indications are hypoxia (S(p)O(2)  < 90% despite oxygen insufflation and after exclusion of tension pneumothorax), severe traumatic brain injury [Glasgow Coma Scale (GCS)  < 9], trauma-associated hemodynamic instability [systolic blood pressure (SBP)  < 90 mmHg] and severe chest trauma with respiratory insufficiency (respiratory rate  > 29/min). The induction of anesthesia after preoxygenation is conducted as rapid sequence induction (analgesic, hypnotic drug, neuromuscular blocking agent). With the availability of ketamine as a viable alternative, the use of etomidate is not encouraged due to its side effects on adrenal function. An electrocardiogram (ECG), blood pressure measurement and pulse oximetry are needed to monitor the emergency anesthesia and the secured airway. Capnography is absolutely mandatory to confirm correct placement of the endotracheal tube and to monitor tube dislocations as well as ventilation in the prehospital and hospital setting. Because airway management is often complicated in trauma patients, alternative devices need to be available preclinical and a fiber-optic endoscope should be available within the hospital. Use of these alternative measures for airway management and ventilation should be considered at the latest after a maximum of three unsuccessful endotracheal intubation attempts. Emergency medical service (EMS) physicians should to be trained in emergency anesthesia, ETI and alternative methods of airway management on a regular basis. Within hospitals ETI, emergency anesthesia and ventilation are to be conducted by trained and experienced anesthesiologists. When a difficult airway or induction of anesthesia is expected, endotracheal intubation should be supervised or conducted by an anesthesiologist. Normoventilation should be the goal of mechanical ventilation. After arrival in the resuscitation room the ventilation will be controlled and guided with the help of arterial blood gas analyses. After temporary removal of a cervical collar, the cervical spine needs to be immobilized by means of manual in-line stabilization when securing the airway.

[Emergency anesthesia, airway management and ventilation in major trauma. Background and key messages of the interdisciplinary S3 guidelines for major trauma patients]

Patients with multiple trauma presenting with apnea or a gasping breathing pattern (respiratory rate <6/min) require prehospital endotracheal intubation (ETI) and ventilation. Additional indications are hypoxia (S(p)O(2)<90% despite oxygen insufflation and after exclusion of tension pneumothorax), severe traumatic brain injury [Glasgow Coma Scale (GCS)<9], trauma-associated hemodynamic instability [systolic blood pressure (SBP)<90 mmHg] and severe chest trauma with respiratory insufficiency (respiratory rate >29/min). The induction of anesthesia after preoxygenation is conducted as rapid sequence induction (analgesic, hypnotic drug, neuromuscular blocking agent). With the availability of ketamine as a viable alternative, the use of etomidate is not encouraged due to its side effects on adrenal function. An electrocardiogram (ECG), blood pressure measurement and pulse oximetry are needed to monitor the emergency anesthesia and the secured airway. Capnography is absolutely mandatory to confirm correct placement of the endotracheal tube and to monitor tube dislocations as well as ventilation and oxygenation in the prehospital and hospital setting. Because airway management is often complicated in trauma patients, alternative devices and a fiber-optic endoscope need to be available within the hospital. Use of these alternative measures for airway management and ventilation should be considered at the latest after a maximum of three unsuccessful intubation attempts. Emergency medical service (EMS) physicians should to be trained in emergency anesthesia, ETI and alternative methods of airway management on a regular basis. Within hospitals ETI, emergency anesthesia and ventilation are to be conducted by trained and experienced anesthesiologists. When a difficult airway or induction of anesthesia is expected, endotracheal intubation should be supervised or conducted by an anesthesiologist. Normoventilation should be the goal of mechanical ventilation. After arrival in the resuscitation room the ventilation will be controlled and guided with the help of arterial blood gas analyses. After temporary removal of a cervical collar, the cervical spine needs to be immobilized by means of manual in-line stabilization when securing the airway.

Developing the skill of endotracheal intubation: implication for emergency medicine

BACKGROUND

Securing the airway by means of endotracheal intubation (ETI) represents a fundamental skill for anaesthesiologists in emergency situations. This study aimed to evaluate the time needed by first-year anaesthesiology residents to perform 200 ETIs and assessed the associated success rates and number of attempts until successful ETI.

METHODS

This prospective single centre study evaluated the number of working days, the success rate, the attempts needed until successful ETI in consecutive blocks of 25 ETI procedures and the related difficulties and complications.

RESULTS

From 2007 to 2010, 21 residents were evaluated consecutively. These residents needed a mean (mean ± standard deviation) of 15.6 ± 3.0 days for 25 ETIs. Out of all residents 52% reached the target value of 200 ETIs after 50.2 ± 14.8 weeks of total working time. The ETI success rate after the first 25 ETIs increased steadily to the results after 200 ETIs (ETI success rate within one ETI attempt: 67% vs. 83%, P = 0.0001; ETI success rate within all ETI attempts: 82% vs. 92%, P = 0.0001). The number of attempts required until successful ETI decreased from 1.6 ± 0.8 after the first 25 ETIs to 1.3 ± 0.6 after 200 ETIs (P = 0.0001).

CONCLUSION

The increasing rate of relative ETI success and the decreasing rate of necessary attempts for successful airway management suggest a steadily increasing gain in ETI experience. The complications that developed during the first 200 ETI procedures justify supervision by a specialist in the field or a senior physician. Moreover, these results may influence the minimum requirement for qualification in anaesthesiology and emergency medicine.

Fatores que afetam a ventilação com o reanimador manual autoinflável: uma revisão sistemática

OBJETIVO: O reanimador manual autoinflável é um dispositivo que fornece ventilação com pressão positiva. Pesquisas mostram que, apesar da padronização dos reanimadores manuais autoinfláveis pela American Society for Testing and Materials, diversos fatores afetam o desempenho da ventilação, porém, os resultados são conflitantes. O objetivo desse estudo foi verificar as evidências dos fatores que influenciam a ventilação pulmonar com reanimadores manuais infantil/adulto por meio de uma revisão sistemática da literatura. FONTES DE DADOS: Foram incluídos artigos indexados nas bases Medline, Lilacs e SciELO publicados entre janeiro de 1986 e março de 2011. Utilizaram-se as palavras-chaves: "reanimador manual", "ressuscitador manual", "ventilação manual", "ventilação com pressão positiva", em inglês e português, além de "bag-valve". SÍNTESE DOS DADOS: Foram selecionados 45 artigos, sendo a maioria experimental. Os trabalhos compararam os reanimadores manuais por marcas, modelos e analisaram as características dos profissionais que os utilizam. Estudos verificaram que a eficácia da ventilação com os reanimadores manuais depende da marca, modelo e características funcionais do aparelho utilizado, assim como formação, treinamento e experiência do profissional que os manipula. Outros fatores que podem influenciar são a forma de compressão dos reanimadores manuais, o uso da válvula limitadora de pressão e o fluxo de oxigênio fornecido aos aparelhos. CONCLUSÕES: A variabilidade nos parâmetros ventilatórios fornecidos durante a ventilação com reanimadores manuais não permite uniformizar a técnica, o que prejudica a reanimação cardiopulmonar. Apesar da maioria dos reanimadores manuais parecer estar de acordo com padrões internacionais, os equipamentos devem ser avaliados antes de utilizados no ambiente clínico. Pouco se sabe sobre os modelos pediátricos e neonatais.