Incidence of transient hypoxia and pulse rate reactivity during paramedic rapid sequence intubation

A Descriptive Analysis of Air Medical Pediatric Rapid Sequence Intubation: Successes and Opportunities

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.

Peri-Intubation Hypoxia After Delayed Versus Rapid Sequence Intubation in Critically Injured Patients on Arrival to Trauma Triage: A Randomized Controlled Trial

BACKGROUND

Critically injured patients who are agitated and delirious on arrival do not allow optimal preoxygenation in the emergency area. We investigated whether the administration of intravenous (IV) ketamine 3 minutes before administration of a muscle relaxant is associated with better oxygen saturation levels while intubating these patients.

METHODS

Two hundred critically injured patients who required definitive airway management on arrival were recruited. The subjects were randomized as delayed sequence intubation (group DSI) or rapid sequence intubation (group RSI). In group DSI, patients received a dissociative dose of ketamine followed by 3 minutes of preoxygenation and paralysis using IV succinylcholine for intubation. In group RSI, a 3-minute preoxygenation was performed before induction and paralysis using the same drugs, as described conventionally. The primary outcome was incidence of peri-intubation hypoxia. Secondary outcomes were first-attempt success rate, use of adjuncts, airway injuries, and hemodynamic parameters.

RESULTS

Peri-intubation hypoxia was significantly lower in group DSI (8 [8%]) compared to group RSI (35 [35%]; P = .001). First-attempt success rate was higher in group DSI (83% vs 69%; P = .02). A significant improvement in mean oxygen saturation levels from baseline values was seen in group DSI only. There was no incidence of hemodynamic instability. There was no statistically significant difference in airway-related adverse events.

CONCLUSIONS

DSI appears promising in critically injured trauma patients who do not allow adequate preoxygenation due to agitation and delirium and require definitive airway on arrival.

I like what you are saying, but only if i feel safe: Psychological safety moderates the relationship between voice and perceived contribution to healthcare team effectiveness

Introduction

Are nurses who voice work-related concerns viewed as positive contributors to a team? We propose that the extent to which healthcare professionals consider voice by nurses as helpful for the team depends on how psychologically safe they feel. Specifically, we hypothesized that psychological safety moderates the relationship between voice of a lower ranking team member (i.e., a nurse) and perceived contribution by others, such that voice is more likely to be seen as valuable for team decision-making when psychological safety is high but not when it is low.

Methods

We tested our hypotheses with a randomized between-subjects experiment using a sample of emergency medicine nurses and physicians. Participants evaluated a nurse who either did or did not speak up with alternative suggestions during emergency patient treatment.

Results

Results confirmed our hypotheses: At higher levels of psychological safety the nurse's voice was considered as more helpful than withholding of voice for team decision-making. This was not the case at lower levels of psychological safety. This effect was stable when including important control variables (i.e., hierarchical position, work experience, gender).

Discussion

Our results shed light on how evaluations of voice are contingent on perceptions of a psychologically safe team context.

Difficult Laryngoscopy Prediction Score for Intubation in Emergency Departments: A Retrospective Cohort Study

Objective

Difficult laryngoscopy is associated with difficult intubation, an increasing number of endotracheal intubation attempts, and adverse events. Clinical prediction of difficult airways in an emergency setting was limited in sensitivity and specificity. This study developed a new model for predicting difficult laryngoscopy in the emergency department.

Methods

This retrospective cohort study was conducted using an exploratory model at the Emergency Medicine of Ramathibodi Hospital. The study was conducted from June 2018 to July 2020. The eligibility criteria were an age of ≥15 years who undergo intubation in the emergency department. Difficult laryngoscopy was defined as a Cormack-Lehane grade 3 and above. The predictive model and score were developed by multivariable logistic regression analysis.

Results

A total of 617 patients met the eligibility criteria; 83 (13.45%) had difficult laryngoscopy. Five independent factors were predictive of difficult laryngoscopy. Significant factors were M: limited mouth opening, O: presence of obstructed airway, N: poor neck mobility, T: large tongue, and H: short hypo-mental distance. The difficult laryngoscopy score had an accuracy of 89%. A score of >4 increased the likelihood ratio of difficult laryngoscopy by 7.62 times.

Conclusion

The MONTH Difficult Laryngoscopy Score of >4 was associated with difficult laryngoscopy.

Use of HEAVEN criteria for predicting difficult intubation in the emergency department

Objective

Most airway prediction tools only consider anatomical factors. The HEAVEN criteria incorporate both anatomical and physiological elements, but have never been studied in the emergency department. This study aimed to evaluate the association between HEAVEN criteria and intubation difficulty.

Methods

We conducted a prospective cross-sectional study from April 1, 2020 to January 31, 2021 in the emergency department of a tertiary public hospital. All patients requiring rapid-sequence or delayed-sequence intubation were included. Patients intubated during cardiopulmonary resuscitation were excluded. We enrolled 174 patients. Study endpoints were first pass success and intubation complications.

Results

The presence of any HEAVEN criteria was associated with a decrease in the first pass success rate (odds ratio [OR], 0.10; 95% confidence interval [CI], 0.02–0.43; P < 0.01). The anatomical challenge was the only criterion associated with first pass sucess (OR, 0.13; 95% CI, 0.05– 0.29; P < 0.01), whilst other criteria (hypoxemia, extremes of size, vomit/blood/fluid, exsanguination, and neck mobility) were not (P > 0.05). All anatomical factor criteria were associated with difficult airway view (P < 0.05). Intubation complications occurred more in the presence of hypoxemia (OR, 7.44; 95% CI, 2.82–19.63; P < 0.01) and vomit/blood/fluid (OR, 5.55; 95% CI, 2.39–12.92; P < 0.01).

Conclusion

Anatomical challenge in HEAVEN criteria can predict first pass success. All anatomical factors in HEAVEN criteria could predict difficult airway view and peri-intubation hypoxemia could be used to anticipate intubation complications. More validation studies are still needed to evaluate the use of HEAVEN criteria as a predictor tool for difficult airway.

Association Between Repeated Tracheal Intubation Attempts and Adverse Events in Children in the Emergency Department

STUDY OBJECTIVES

Studies have shown that multiple intubation attempts are associated with a higher risk of intubation-related adverse events. However, little is known about the relationship in children in the emergency department (ED).

METHODS

This is an analysis of the data from 2 prospective, observational, multicenter registries of emergency airway management. The data were collected from consecutive patients who underwent emergency airway management in 19 EDs across Japan from March 2010 to November 2017. We included children 18 years or younger who underwent tracheal intubation in the ED. The primary exposure was the number of intubation attempts (1 vs ≥2). The primary outcome was an adverse event during or immediately after the intubation.

RESULTS

A total of 439 children were eligible for the analysis. Of 279 children with first-pass success, 24 children (9%) had an adverse event. By contrast, of 160 children with ≥2 intubation attempts, 50 children patients (31%) had an adverse event. In the unadjusted model, multiple intubation attempts were significantly associated with a higher rate of adverse events (unadjusted odds ratio, 4.83; 95% confidence interval, 2.57-9.06; P < 0.001). This association remained significant after adjusting for 7 potential confounders and patient clustering within the hospital (adjusted odds ratio, 4.49; 95% confidence interval, 2.36-8.53; P < 0.001). Similar associations were found across different age groups and among children without cardiac arrest (all, P < 0.05).

CONCLUSIONS

In this analysis of large prospective multicenter data, multiple intubation attempts were associated with a significantly higher rate of intubation-related adverse events in children in the ED.

Quality Management of Prehospital Airway Programs: An NAEMSP Position Statement and Resource Document

Prehospital airway management encompasses a multitude of complex decision-making processes, techniques, and interventions. Quality management (encompassing quality assurance and quality improvement activities) in EMS is dynamic, evidence-based, and most of all, patient-centric. Long a mainstay of the EMS clinician skillset, airway management deserves specific focus and attention and dedicated quality management processes to ensure the delivery of high-quality clinical care.It is the position of NAEMSP that:All EMS agencies should dedicate sufficient resources to patient-centric, comprehensive prehospital airway quality management program. These quality management programs should consist of prospective, concurrent, and retrospective activities. Quality management programs should be developed and operated with the close involvement of the medical director.Quality improvement and quality assurance efforts should operate in an educational, non-disciplinary, non-punitive, evidence-based medicine culture focused on patient safety. The highest quality of care is only achieved when the quality management program rewards those who identify and seek to prevent errors before they occur.Information evaluated in prehospital airway quality management programs should include both subjective and objective data elements with uniform reporting and operational definitions.EMS systems should regularly measure and report process, outcome, and balancing airway management measures.Quality management activities require large-scale bidirectional information sharing between EMS agencies and receiving facilities. Hospital outcome information should be shared with agencies and the involved EMS clinicians.Findings from quality management programs should be used to guide and develop initial education and continued training.Quality improvement programs must continually undergo evaluation and assessment to identify strengths and shortcomings with a focus on continuous improvement.

Prehospital Supraglottic Airways: An NAEMSP Position Statement and Resource Document

Supraglottic airway (SGA) devices provide effective conduits for oxygenation and ventilation and may offer protection from gastric aspiration. SGA devices are widely used by EMS clinicians as both rescue and primary airway management devices. While in common use for more than four decades, major developments in SGA education, science, and technology have influenced clinical strategies of SGA insertion and use in prehospital airway management for patients of all ages. NAEMSP recommends:SGAs have utility as a primary or secondary EMS airway intervention. EMS agencies should select SGA strategies that best suit available resources and local clinician skillset, as well as the nature of their clinical practice setting.EMS agencies that perform endotracheal intubation must also equip their clinicians with SGA devices and ensure adequate training and competence.In select situations, drug-assisted airway management may be used by properly credentialed EMS clinicians to facilitate SGA insertion.Confirmation of initial and continuous SGA placement using waveform capnography is strongly encouraged as a best practice.When it is functioning properly, EMS clinicians should refrain from converting an SGA to an endotracheal tube. The decision to convert an SGA to an endotracheal tube must consider the patient's condition, the effectiveness of SGA ventilations, and the clinical context and course of initial SGA insertionSGA training, competency, and clinical use must be continuously evaluated by EMS agencies using focused quality management programs.

Prehospital Trauma Airway Management: An NAEMSP Position Statement and Resource Document

Definitive management of trauma is not possible in the out-of-hospital environment. Rapid treatment and transport of trauma casualties to a trauma center are vital to improve survival and outcomes. Prioritization and management of airway, oxygenation, ventilation, protection from gross aspiration, and physiologic optimization must be balanced against timely patient delivery to definitive care. The optimal prehospital airway management strategy for trauma has not been clearly defined; the best choice should be patient-specific. NAEMSP recommends:The approach to airway management and the choice of airway interventions in a trauma patient requires an iterative, individualized assessment that considers patient, clinician, and environmental factors.Optimal trauma airway management should focus on meeting the goals of adequate oxygenation and ventilation rather than on specific interventions. Emergency medical services (EMS) clinicians should perform frequent reassessments to determine if there is a need to escalate from basic to advanced airway interventions.Management of immediately life-threatening injuries should take priority over advanced airway insertion.Drug-assisted airway management should be considered within a comprehensive algorithm incorporating failed airway options and balanced management of pain, agitation, and delirium.EMS medical directors must be highly engaged in assuring clinician competence in trauma airway assessment, management, and interventions.

Optimizing Physiology During Prehospital Airway Management: An NAEMSP Position Statement and Resource Document

Airway management is a critical component of resuscitation but also carries the potential to disrupt perfusion, oxygenation, and ventilation as a consequence of airway insertion efforts, the use of medications, and the conversion to positive-pressure ventilation. NAEMSP recommends:Airway management should be approached as an organized system of care, incorporating principles of teamwork and operational awareness.EMS clinicians should prevent or correct hypoxemia and hypotension prior to advanced airway insertion attempts.Continuous physiological monitoring must be used during airway management to guide the timing of, limit the duration of, and inform decision making during advanced airway insertion attempts.Initial and ongoing confirmation of advanced airway placement must be performed using waveform capnography. Airway devices must be secured using a reliable method.Perfusion, oxygenation, and ventilation should be optimized before, during, and after advanced airway insertion.To mitigate aspiration after advanced airway insertion, EMS clinicians should consider placing a patient in a semi-upright position.When appropriate, patients undergoing advanced airway placement should receive suitable pharmacologic anxiolysis, amnesia, and analgesia. In select cases, the use of neuromuscular blocking agents may be appropriate.

Prevalence of significant traumatic brain injury among patients intubated in the field due to impaired level of consciousness

OBJECTIVE

Current guidelines advocate prehospital endotracheal intubation (ETI) in patients with suspected severe head injury and impaired level of consciousness. However, the ability to identify patients with traumatic brain injury (TBI) in the prehospital setting is limited and prehospital ETI carries a high complication rate. We investigated the prevalence of significant TBI among patients intubated in the field for that reason.

METHODS

Data were retrospectively collected from emergency medical services and hospital records of trauma patients for whom prehospital ETI was attempted and who were transferred to Rambam Health Care Campus, Israel. The indication for ETI was extracted. The primary outcome was significant TBI (clinical or radiographic) among patients intubated due to suspected severe head trauma.

RESULTS

In 57.3% (379/662) of the trauma patients, ETI was attempted due to impaired consciousness. 349 patients were included in the final analysis: 82.8% were male, the median age was 34 years (IQR 23.0-57.3), and 95.7% suffered blunt trauma. 253 patients (72.5%) had significant TBI. In a multivariable analysis, Glasgow Coma Scale>8 and alcohol intoxication were associated with a lower risk of TBI with OR of 0.26 (95% CI 0.13-0.51, p < 0.001) and 0.16 (95% CI 0.06-0.46, p < 0.001), respectively.

CONCLUSION

Altered mental status in the setting of trauma is a major reason for prehospital ETI. Although most of these patients had TBI, one in four of them did not suffer a significant TBI. Patients with a higher field GCS and those suffering from intoxication have a higher risk of misdiagnosis. Future studies should explore better tools for prehospital assessment of TBI and ways to better define and characterize patients who may benefit from early ETI.

Vital sign monitoring during out-of-hospital pediatric advanced airway management

OBJECTIVE

To evaluate physiologic monitoring in pediatric patients undergoing out-of-hospital advanced airway management.

METHODS

Retrospective case series of pediatric patients (<18 years) with advanced airways placed in the out-of-hospital setting. Patients given cardiopulmonary resuscitation (CPR) or defibrillation before the first advanced airway attempt were excluded. Reviewers abstracted physiologic data from the patient monitor files and patient care reports. The primary outcome was the proportion of time pulse oximetry was in place during airway management. Other outcomes included the proportion of time ECG monitoring and waveform end-tidal capnography were in place as well as the incidence of oxygen desaturation events.

RESULTS

We evaluated 23 pediatric patients with a mean age of 10.7 years (SD 6.5). Eleven of 18 (61%) children with medication-facilitated intubation had pulse oximetry in place when the first medication was documented as given. Eight of 18 (44%) had ECG monitoring, 12 of 18 (66%) had waveform capnography, and 5 of 18 (28%) had a blood pressure check within the 3 minutes before receiving the first medication. In the 3-minute preoxygenation phase, pulse oximetry was in place for an average of 1.4 minutes (47%, SD 0.37) and a visible photoplethysmogram (PPG) waveform obtained from the pulse oximeter was present for 0.6 minutes (20%, SD 0.34). During airway device placement, pulse oximetry was in place 73% (SD 0.39) of the time and 30% (SD 0.41) of the time there was a visible PPG waveform.

CONCLUSIONS

Pediatric patients had critical deficits in physiologic monitoring during advanced airway management.

Advanced airway management success rates in a national cohort of emergency medical services agencies

OBJECTIVE

Despite its important role in care of the critically ill, there have been few large-scale descriptions of the epidemiology of Emergency Medical Services (EMS) advanced airway management (AAM) and the variations in care with different patient subsets. We sought to characterize AAM performance in a national cohort of EMS agencies.

METHODS

We used data from ESO Solutions, Inc., a national EMS electronic health record system. We analyzed EMS emergency patient encounters during 2011-2015 with attempted AAM. We categorized AAM techniques as conventional endotracheal intubation (cETI), neuromuscular blockade assisted intubation (NMBA-ETI), supraglottic airway (SGA), and cricothyroidotomy (needle and open). Determination of successful AAM was based on EMS provider report. We analyzed the data using descriptive statistics, determining the incidence and clinical characteristics of AAM cases. We determined success rates for each AAM technique, stratifying by the subsets cardiac arrest, medical non-arrest, trauma, and pediatrics (age ≤12 years).

RESULTS

AAM occurred in 57,209 patients. Overall AAM success was 89.1% (95% CI: 88.8-89.3%) across all patients and techniques. Intubation success rates varied by technique; cETI (n = 38,004; 76.9%, 95% CI: 76.5-77.3%), NMBA-ETI (n = 6768; 89.7%, 88.9-90.4%). SGAs were used both for initial (n = 9461, 90.1% success, 95% CI: 89.5-90.7%) and rescue (n = 5994, 87.3% success, 95% CI: 86.4-88.1%) AAM. Cricothyroidotomy success rates were low: initial cricothyroidotomy (n = 202, 17.3% success, 95% CI: 12.4-23.3%), rescue cricothyroidotomy (n = 85, 52.9% success, 95% CI: 41.8-88%). AAM success rates varied by patient subset: cardiac arrest (n = 35,782; 91.7%, 95% CI: 91.4-92.0), medical non-arrest (n = 17,086; 84.7%, 84.2-85.2%); trauma (n = 4341; 84.3%, 83.1-85.3%); pediatric (n = 1223; 73.7%, 71.2-76.2%).

CONCLUSION

AAM success rates varied by airway technique and patient subset. In this national cohort, these results offer perspectives of EMS AAM practices.

The HEAVEN criteria predict laryngoscopic view and intubation success for both direct and video laryngoscopy: a cohort analysis

Background

Existing difficult airway prediction tools are not practical for emergency intubation and do not incorporate physiological data. The HEAVEN criteria (Hypoxaemia, Extremes of size, Anatomic challenges, Vomit/blood/fluid, Exsanguination, Neck mobility) may be more relevant for emergency rapid sequence intubation (RSI).

Methods

A retrospective analysis included air medical RSI patients. A checklist was used to assess HEAVEN criteria prior to RSI, and Cormack-Lehane (CL) laryngoscopic view was recorded for the first intubation attempt. The incidence of a difficult (CL III/IV) laryngoscopic view as well as failure to intubate on first attempt with and without oxygen desaturation were determined for each of the HEAVEN criteria and total number of HEAVEN criteria. In addition, the association between HEAVEN criteria and both laryngoscopic view and intubation performance were quantified using multivariate logistic regression for direct laryngoscopy (DL) and video laryngoscopy (VL) configured with a Macintosh #4 non-hyperangulated blade.

Results

A total of 5137 RSI patients over 24 months were included. Overall intubation success was 97%. A CL III/IV laryngoscopic view was reported in 25% of DL attempts and 15% of VL attempts. Each of the HEAVEN criteria and total number of HEAVEN criteria were associated with both CL III/IV laryngoscopic view and failure to intubate on the first attempt with and without oxygen desaturation for both DL and VL. These associations persisted after adjustment for multiple co-variables including the other HEAVEN criteria.

Conclusion

The HEAVEN criteria may be useful to predict laryngoscopic view and intubation performance for DL and VL during emergency RSI.

Electronic supplementary material

The online version of this article (10.1186/s13049-019-0614-6) contains supplementary material, which is available to authorized users.

Performance Standards of Comprehensive Airway Management for Emergency Medicine Residents

BACKGROUND

The Emergency Medicine (EM) Milestone Project provides guidance for assessment of resident trainee airway management proficiency (PC10). Although milestones provide a general structure for assessment, they do not define performance standards. The objective of this project was to establish comprehensive airway management performance standards for EM trainees at both novice and mastery levels of proficiency.

METHODS

Comprehensive airway management standards were derived using standard-setting procedures. A panel of residency education and airway management experts was convened to determine how trainees would be expected to perform on 51 individual tasks in a standardized airway management simulation encompassing preparation, endotracheal intubation, backup airway use, and ventilation. Experts participated in facilitated exercises in which they were asked to 1) define which items were critical for patient safety, 2) predict the performance of a "novice" learner, and 3) predict the performance of a "mastery" learner nearing independent practice. Experts were given a worksheet to complete and descriptive statistics were calculated using STATA 14.

RESULTS

Experts identified 39 of 51 (76%) airway management items as critical for patient safety. Experts also noted that novice trainees do not need to complete all the items deemed to be critical prior to starting practice since they will be supervised by a board-certified EM physician. In contrast, mastery-level trainees would be expected to successfully complete not only the critical tasks, but also nearly all the items in the assessment (49/51, 96%) since they are nearing independent practice.

CONCLUSION

In this study, we established EM resident performance standards for comprehensive airway management during a simulation scenario. Future work will focus on validating these performance standards in current resident trainees as they move from simulation to actual patient care.

A descriptive analysis of endotracheal intubation in a South African Helicopter Emergency Medical Service

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.

Prehospital Intubation and Outcome in Traumatic Brain Injury-Assessing Intervention Efficacy in a Modern Trauma Cohort

BACKGROUND

Prehospital intubation in traumatic brain injury (TBI) focuses on limiting the effects of secondary insults such as hypoxia, but no indisputable evidence has been presented that it is beneficial for outcome. The aim of this study was to explore the characteristics of patients who undergo prehospital intubation and, in turn, if these parameters affect outcome.

MATERIAL AND METHODS

Patients ≥15 years admitted to the Department of Neurosurgery, Stockholm, Sweden with TBI from 2008 through 2014 were included. Data were extracted from prehospital and hospital charts, including prospectively collected Glasgow Outcome Score (GOS) after 12 months. Univariate and multivariable logistic regression models were employed to examine parameters independently correlated to prehospital intubation and outcome.

RESULTS

A total of 458 patients were included (n = 178 unconscious, among them, n = 61 intubated). Multivariable analyses indicated that high energy trauma, prehospital hypotension, pupil unresponsiveness, mode of transportation, and distance to the hospital were independently correlated with intubation, and among them, only pupil responsiveness was independently associated with outcome. Prehospital intubation did not add independent information in a step-up model versus GOS (p = 0.154). Prehospital reports revealed that hypoxia was not the primary cause of prehospital intubation, and that the procedure did not improve oxygen saturation during transport, while an increasing distance from the hospital increased the intubation frequency.

CONCLUSION

In this modern trauma cohort, prehospital intubation was not independently associated with outcome; however, hypoxia was not a common reason for prehospital intubation. Prospective trials to assess efficacy of prehospital airway intubation will be difficult due to logistical and ethical considerations.

A tale of two cities: prehospital intubation with or without paralysing agents for traumatic brain injury

BACKGROUND

The role of prehospital endotracheal intubation (PETI) for traumatic brain injury is unclear. In Victoria, paramedics use rapid sequence induction (RSI) drugs to facilitate PETI, while in New South Wales (NSW) they do not have access to paralysing agents. We hypothesized that RSI would both increase PETI rates and improve mortality.

METHODS

Retrospective comparison of adult primary admissions (Glasgow Coma Scale <9 and abbreviated injury scale head and neck >2) to either Victorian or NSW trauma centre, which were compared with univariate and logistic regression analysis to estimate odds ratio for mortality and intensive care unit (ICU) length of stay.

RESULTS

One hundred and ninety-two Victorian and 91 NSW patients did not differ in: demographics (males: 77% versus 79%; P = 0.7 and age: 34 (18-88) versus 33 (18-85); P = 0.7), Glasgow Coma Scale (3 (3-8) versus 5 (3-8); P = 0.07), and injury severity score (38 (26-75) versus 35 (18-75); P = 0.09), prehospital hypotension (15.4% versus 11.7%; P = 0.5) and desaturation (14.6% versus 17.5%; P = 0.5). Victorians had higher abbreviated injury scale head and neck (5 (4-5) versus 5 (3-6); P = 0.04) and more often successful PETI (85% versus 22%; P < 0.05). On logistic regression analysis, mortality did not differ among groups (31.7% versus 26.3%; P = 0.34; OR = 0.84; 95% CI: 0.38-1.86; P = 0.67). Among survivors, Victorians had longer stay in ICU (364 (231-486) versus 144 (60-336) h), a difference that persisted on gamma regression (effect = 1.58; 95% CI: 1.30-1.92; P < 0.05).

CONCLUSION

Paramedics using RSI to obtain PETI in patients with traumatic brain injury had a higher success rate. This increase in successful PETI rate was not associated with an improvement in either mortality rate or ICU length of stay.

Implementation of a Clinical Bundle to Reduce Out-of-Hospital Peri-intubation Hypoxia

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.

Evaluation of Physiologic Alterations during Prehospital Paramedic-Performed Rapid Sequence Intubation

OBJECTIVE

Physiologic alterations during rapid sequence intubation (RSI) have been studied in several emergency airway management settings, but few data exist to describe physiologic alterations during prehospital RSI performed by ground-based paramedics. To address this evidence gap and provide guidance for future quality improvement initiatives in our EMS system, we collected electronic monitoring data to evaluate peri-intubation vital signs changes occurring during prehospital RSI.

METHODS

Electronic patient monitor data files from cases in which paramedic RSI was attempted were prospectively collected over a 15-month study period to supplement the standard EMS patient care documentation. Cases were analyzed to identify peri-intubation changes in oxygen saturation, heart rate, and blood pressure.

RESULTS

Data from 134 RSI cases were available for analysis. Paramedic-assigned prehospital diagnostic impression categories included neurologic (42%), respiratory (26%), toxicologic (22%), trauma (9%), and cardiac (1%). The overall intubation success rate (95%) and first-attempt success rate (82%) did not differ across diagnostic impression categories. Peri-intubation desaturation (SpO₂ decrease to below 90%) occurred in 43% of cases, and 70% of desaturation episodes occurred on first-attempt success. The incidence of desaturation varied among patient categories, with a respiratory diagnostic impression associated with more frequent, more severe, and more prolonged desaturations, as well as a higher incidence of accompanying cardiovascular instability. Bradycardia (HR decrease to below 60 bpm) occurred in 13% of cases, and 60% of bradycardia episodes occurred on first-attempt success. Hypotension (systolic blood pressure decrease to below 90 mmHg) occurred in 7% of cases, and 63% of hypotension episodes occurred on first-attempt success. Peri-intubation cardiac arrest occurred in 2 cases, one of which was on first-attempt success. Only 11% of desaturations and no instances of bradycardia were reflected in the standard EMS patient care documentation.

CONCLUSIONS

In this study, the majority of peri-intubation physiologic alterations occurred on first-attempt success, highlighting that first-attempt success is an incomplete and potentially deceptive measure of intubation quality. Supplementing the standard patient care documentation with electronic monitoring data can identify unrecognized physiologic instability during prehospital RSI and provide valuable guidance for quality improvement interventions.

[Different levels of experience with anesthetic agents of German emergency physicians : Results of an online survey]

BACKGROUND AND OBJECTIVE

In 2015 practice management guidelines on prehospital emergency anesthesia in adults were published in Germany. The aim of the present study was to evaluate whether emergency physicians follow these guidelines in daily practice and to assess their level of experience with the use of anesthetic agents.

MATERIAL AND METHODS

In an online survey the way of induction of preclinical anesthesia (including preoxygenation time and applied monitoring techniques) was assessed with the help of virtual scenarios based on the guidelines. Furthermore, the individual level of experience with specific anesthetic agents was estimated by the total number of anesthetic procedures performed with these drugs (0, 1-10, 11-25, 26-50, 51-100, and >100 procedures).

RESULT

A total of 155 emergency physicians answered the online survey. Except for cardiac patients and for the preoxygenation time, we found a high accordance between specific algorithms proposed in the guidelines and emergency physicians' clinical practice. Furthermore, the median level of experience with rocuronium and succinylcholine was significantly higher compared to vecuronium. With respect to induction agents the highest level of experience was found for propofol and thiopental, the lowest for the combination of ketamine/propofol and midazolam. Generally, compared to non-anesthetists, emergency physicians had significantly higher levels of experience with the use of these anesthetic agents (except for etomidate and vecuronium). Over 94% used a 4-lead electrocardiogram (ECG), pulse oxymetry, non-invasive blood pressure and quantitative capnography for monitoring. The availability of succinylcholine was 91%, rocuronium 55%, vecuronium 29% and sugammadex 9%.

CONCLUSION

The results of this survey demonstrate that clinical practice of emergency physicians is in high accordance with the recommendations named in the guidelines for prehospital emergency anesthesia in adults (except for cardiac patients and time of preoxygenation). With respect to the lower levels of experience of non-anesthetists in the use of anesthetic drugs, specific training concepts may help to further improve the quality of preclinical emergency care.

Unrecognized failed airway management using a supraglottic airway device

BACKGROUND

911 Emergency Medical Services (EMS) systems utilize supraglottic devices for either primary advanced airway management, or for airway rescue following failed attempts at direct laryngoscopy endotracheal intubation. There is, however, limited data on objective confirmation of supraglottic airway placement in the prehospital environment. Furthermore, the ability of EMS field providers to recognize a misplaced airway is unknown.

METHODS

Retrospective review of patients who underwent airway management using the King LTS-D supraglottic airway in a large urban EMS system, between 3/1/15-9/30/2015. Subjective success was defined as documentation of successful airway placement by the EMS provider. Objective success was confirmed by review of waveform capnography, with the presence of a 4-phase waveform greater than 5mmHg. Sensitivity and specificity of the field provider's assessment of success were then calculated.

RESULTS

A total of 344 supraglottic airway attempts were reviewed. No patients met obvious death criteria. 269 attempts (85.1%) met criteria for both subjective and objective success. 19 attempts (5.6%) were recognized failures by the EMS provider. 47 (13.8%) airways were misplaced but unrecognized by the EMS provider. 4 attempts (1.2%) were correctly placed but misidentified as failures, leading to the unnecessary removal and replacement of the airway. Sensitivity of the provider's assessment was 98.5%; specificity was 28.7%.

CONCLUSION

The use of supraglottic airway devices results in unrecognized failed placement. Appropriate utilization and review of waveform capnography may remedy a potential blind-spot in patient safety, and systemic monitoring/feedback processes may therefore be used to prevent unrecognized misplaced airways.

Magnitude and Predisposing Factors of Difficult Airway during Induction of General Anaesthesia

OBJECTIVE

To assess magnitude and predisposing factors of difficult airway during induction of general anaesthesia.

METHODS

Hospital based cross sectional study carried out to determine the incidence of difficult mask ventilation, difficult laryngoscopy (Cormack and Lehane III and IV), difficult intubation (IDS ≥ 5), and failed intubation. The association between each predisposing factor and airway parameters with components of difficult airway is investigated with binary logistic regression. Sensitivity, specificity, positive and negative predictive value of the test, and odds ratio with 95% confidence interval were calculated to determine the association between independent and dependent variable.

RESULT

The incidence of difficult laryngoscopy, difficult intubation, and failed intubation are 12.3%, 9%, and 0.005%, respectively. Mouth opening < 30 mm and Mallampati classes III and IV are the most sensitive tests and second high specific test next to combination of tests to predict difficult intubation and laryngoscopy (P value < 0.001). Unrestricted multiple attempt without alternative airway techniques resulted in exponential increase in desaturation episodes and further difficulty of airway management (P value < 0.001).

DISCUSSION AND CONCLUSION

Mallampati classes III and IV, mouth opening ≤ 30 mm, jaw slide grade C, attempt > 3, and ineffective alternative technique have increased predictability value of difficult airway.

Paramedic Intubation Experience Is Associated With Successful Tube Placement but Not Cardiac Arrest Survival

STUDY OBJECTIVE

Paramedic experience with intubation may be an important factor in skill performance and patient outcomes. Our objective is to examine the association between previous intubation experience and successful intubation. In a subcohort of out-of-hospital cardiac arrest cases, we also measure the association between patient survival and previous paramedic intubation experience.

METHODS

We analyzed data from Ambulance Victoria electronic patient care records and the Victorian Ambulance Cardiac Arrest Registry for January 1, 2008, to September 26, 2014. For each patient case, we defined intubation experience as the number of intubations attempted by each paramedic in the previous 3 years. Using logistic regression, we estimated the association between intubation experience and (1) successful intubation and (2) first-pass success. In the out-of-hospital cardiac arrest cohort, we determined the association between previous intubation experience and patient survival.

RESULTS

During the 6.7-year study period, 769 paramedics attempted intubation in 14,857 patients. Paramedics typically performed 3 intubations per year (interquartile range 1 to 6). Most intubations were successful (95%), including 80% on the first attempt. Previous intubation experience was associated with intubation success (odds ratio 1.04; 95% confidence interval 1.03 to 1.05) and intubation first-pass success (odds ratio 1.02; 95% confidence interval 1.01 to 1.03). In the out-of-hospital cardiac arrest subcohort (n=9,751), paramedic intubation experience was not associated with patient survival.

CONCLUSION

Paramedics in this Australian cohort performed few intubations. Previous experience was associated with successful intubation. Among out-of-hospital cardiac arrest patients for whom intubation was attempted, previous paramedic intubation experience was not associated with patient survival.

AAGBI: Safer pre-hospital anaesthesia 2017: Association of Anaesthetists of Great Britain and Ireland

Pre-hospital emergency anaesthesia with oral tracheal intubation is the technique of choice for trauma patients who cannot maintain their airway or achieve adequate ventilation. It should be carried out as soon as safely possible, and performed to the same standards as in-hospital emergency anaesthesia. It should only be conducted within organisations with comprehensive clinical governance arrangements. Techniques should be straightforward, reproducible, as simple as possible and supported by the use of checklists. Monitoring and equipment should meet in-hospital anaesthesia standards. Practitioners need to be competent in the provision of in-hospital emergency anaesthesia and have supervised pre-hospital experience before carrying out pre-hospital emergency anaesthesia. Training programmes allowing the safe delivery of pre-hospital emergency anaesthesia by non-physicians do not currently exist in the UK. Where pre-hospital emergency anaesthesia skills are not available, oxygenation and ventilation should be maintained with the use of second-generation supraglottic airways in patients without airway reflexes, or basic airway manoeuvres and basic airway adjuncts in patients with intact airway reflexes.

The Effect of Combined Out-of-Hospital Hypotension and Hypoxia on Mortality in Major Traumatic Brain Injury

STUDY OBJECTIVE

Survival is significantly reduced by either hypotension or hypoxia during the out-of-hospital management of major traumatic brain injury. However, only a handful of small studies have investigated the influence of the combination of both hypotension and hypoxia occurring together. In patients with major traumatic brain injury, we evaluate the associations between mortality and out-of-hospital hypotension and hypoxia separately and in combination.

METHODS

All moderate or severe traumatic brain injury cases in the preimplementation cohort of the Excellence in Prehospital Injury Care study (a statewide, before/after, controlled study of the effect of implementing the out-of-hospital traumatic brain injury treatment guidelines) from January 1, 2007, to March 31, 2014, were evaluated (exclusions: <10 years, out-of-hospital oxygen saturation ≤10%, and out-of-hospital systolic blood pressure <40 or >200 mm Hg). The relationship between mortality and hypotension (systolic blood pressure <90 mm Hg) or hypoxia (saturation <90%) was assessed with multivariable logistic regression, controlling for Injury Severity Score, head region severity, injury type (blunt versus penetrating), age, sex, race, ethnicity, payer, interhospital transfer, and trauma center.

RESULTS

Among the 13,151 patients who met inclusion criteria (median age 45 years; 68.6% men), 11,545 (87.8%) had neither hypotension nor hypoxia, 604 (4.6%) had hypotension only, 790 (6.0%) had hypoxia only, and 212 (1.6%) had both hypotension and hypoxia. Mortality for the 4 study cohorts was 5.6%, 20.7%, 28.1%, and 43.9%, respectively. The crude and adjusted odds ratios for death within the cohorts, using the patients with neither hypotension nor hypoxia as the reference, were 4.4 and 2.5, 6.6 and 3.0, and 13.2 and 6.1, respectively. Evaluation for an interaction between hypotension and hypoxia revealed that the effects were additive on the log odds of death.

CONCLUSION

In this statewide analysis of major traumatic brain injury, combined out-of-hospital hypotension and hypoxia were associated with significantly increased mortality. This effect on survival persisted even after controlling for multiple potential confounders. In fact, the adjusted odds of death for patients with both hypotension and hypoxia were more than 2 times greater than for those with either hypotension or hypoxia alone. These findings seem supportive of the emphasis on aggressive prevention and treatment of hypotension and hypoxia reflected in the current emergency medical services traumatic brain injury treatment guidelines but clearly reveal the need for further study to determine their influence on outcome.

Apneic oxygenation is associated with a reduction in the incidence of hypoxemia during the RSI of patients with intracranial hemorrhage in the emergency department

Critically ill patients undergoing emergent intubation are at risk of oxygen desaturation during the management of their airway. Patients with intracranial hemorrhage (ICH) are particularly susceptible to the detrimental effects of hypoxemia. Apneic oxygenation (AP OX) may be able to reduce the occurrence of oxygen desaturation during the emergent intubation of these patients. We sought to assess the effect AP OX on oxygen desaturation during the rapid sequence intubation (RSI) of patients with ICH in the emergency department (ED). We prospectively collected data on all patients intubated in an urban academic ED over the 2-year period from July 1, 2013 to June 30, 2015. Following each intubation, the operator completed a standardized continuous quality improvement (CQI) data form, which included information on patient, operator and intubation characteristics. Operators recorded data on the use of AP OX, the oxygen flow rate used for AP OX, and the starting and lowest saturations during intubation. Adult patients with ICH who underwent RSI by emergency medicine (EM) residents were included in the analyses. The primary outcome variable was any oxygen saturation <90 % during the intubation. We performed a backward stepwise multivariate logistic regression analysis to identify variables associated with oxygen desaturation. The primary independent variable of interest was the use of AP OX during the intubation. Inclusion criteria for the study was met by 127 patients. AP OX was used in 72 patients (AP OX group) and was not used in 55 patients (NO AP OX group). The incidence of desaturation was 5/72 (7 %) in the AP OX group and was 16/55 (29 %) in the NO AP OX group. In the multivariate logistic regression analysis the use of AP OX was associated with a reduced odds of desaturation (aOR 0.13; 95 % CI 0.03-0.53). Patients with ICH who received AP OX during RSI in the ED were seven times less likely to have an oxygen saturation of <90 % during the intubation compared to patients who did not receive AP OX. AP OX is a simple intervention that may minimize the risk of oxygen desaturation during the RSI of patients with ICH.

Apneic Oxygenation May Not Prevent Severe Hypoxemia During Rapid Sequence Intubation: A Retrospective Helicopter Emergency Medical Service Study

OBJECTIVE

This study sought to determine the effectiveness of apneic oxygenation in preventing hypoxemia during prehospital rapid sequence intubation (RSI).

METHODS

We performed a case-cohort study using a pre-existing database looking at intubation management by a single helicopter emergency medical service between July 2013 and June 2015. Apneic oxygenation using high-flow nasal cannula (15 L/min) was introduced to the standard RSI protocol in July 2014. Severe hypoxemia was defined as an incidence of oxygen saturation less than 90%. We compared patients who received apneic oxygenation during RSI with patients who did not using the Fisher exact test.

RESULTS

Ninety-three patients were identified from the database; 29 (31.2%) received apneic oxygenation. Nineteen patients had an incidence of severe hypoxemia during RSI (20.43%; 95% confidence interval, 12.77%-30.05%). There was no statistically significant difference between the rate of severe hypoxemia between patients in the apneic oxygenation group versus the control group (17.2% vs. 21.9%, P = .78).

CONCLUSION

In this study, patients who received apneic oxygenation did not show a statistically significant difference in severe hypoxemia during RSI.

Prehospital intubation for isolated severe blunt traumatic brain injury: worse outcomes and higher mortality

PURPOSE

Prehospital endotracheal intubation (ETI) for traumatic brain injury (TBI) is a controversial issue. The aim of this study was to investigate the effect of prehospital ETI in patients with TBI.

METHODS

Cohort-matched study using the US National Trauma Data Bank (NTDB) 2008-2012. Patients with isolated severe blunt TBI (AIS head ≥3, AIS chest/abdomen <3) and a field GCS ≤8 were extracted from NTDB. A 1:1 matching of patients with and without prehospital ETI was performed. Matching criteria were sex, age, exact field GCS, exact AIS head, field hypotension, field cardiac arrest, and the brain injury type (according PREDOT-code). The matched cohorts were compared with univariable and multivariable regression analysis.

RESULTS

A total of 27,714 patients were included. Matching resulted in 8139 cases with and 8139 cases without prehospital ETI. Prehospital ETI was associated with significantly longer scene (median 9 vs. 8 min, p < 0.001) and transport times (median 26 vs. 19 min, p < 0.001), lower Emergency Department (ED) GCS scores (in patients without sedation; mean 3.7 vs. 3.9, p = 0.026), more ventilator days (mean 7.3 vs. 6.9, p = 0.006), longer ICU (median 6.0 vs. 5.0 days, p < 0.001) and total hospital length of stay (median 10.0 vs. 9.0 days, p < 0.001), and higher in-hospital mortality (31.4 vs. 27.5 %, p < 0.001). In regression analysis prehospital ETI was independently associated with lower ED GCS scores (RC -4.213, CI -4.562/-3.864, p < 0.001) and higher in-hospital mortality (OR 1.399, CI 1.205/1.624, p < 0.001).

CONCLUSION

In this large cohort-matched analysis, prehospital ETI in patients with isolated severe blunt TBI was independently associated with lower ED GCS scores and higher mortality.

The role of prehospital advanced airway management on outcomes for out-of-hospital cardiac arrest patients: a meta-analysis

OBJECTIVE

The objective of this meta-analysis was to compare the benefits of prehospital advanced airway management (AAM) and basic airway management (BAM) for out-of-hospital cardiac arrest (OHCA) patients.

METHODS

Two investigators performed a systematic review of PubMed, EMBASE, and the Cochrane Database to identify all peer-reviewed articles relevant to this meta-analysis. We included all articles describing emergency medical system-treated nontraumatic OHCAs; specifically, all articles that described intervention of the prehospital AAM type were considered. The primary outcome was survival to discharge, whereas the secondary outcome was neurologic recovery after an OHCA event. For subgroup analysis, we compared the clinical outcome of endotracheal intubation (ETI), a specific type of AAM, vs BAM.

RESULTS

We reviewed 1452 studies, 10 of which satisfied all the inclusion criteria and involved 17 380 patients subjected to AAM and 67 525 subjected to BAM. Based on the full random effects model, patients who received AAM had lower odds of survival (odds ratio [OR], 0.51; 95% confidence interval [CI], 0.29-0.90) compared with BAM. Subgroup analysis for ETI vs BAM showed no significant association with respect to survival (OR, 0.44; 95% CI, 0.16-1.23). There were no significant differences in the odds of neurologic recovery between AAM and BAM (OR, 0.64; 95% CI, 0.03-1.37).

CONCLUSIONS

Our results reveal decreased survival odds for OHCA patients treated with AAM by emergency medical service personnel compared with BAM. However, the role of prehospital AAM, especially ETI, on achieving neurologic recovery remains unclear.

Isolated blunt severe traumatic brain injury in Bern, Switzerland, and the United States: A matched cohort study

BACKGROUND

The ideal prehospital management of patients with severe traumatic brain injury (TBI) including the impact of endotracheal intubation (ETI) and physicians on scene is unclear. Prehospital management differs substantially in Switzerland and the United States: in Switzerland, there is usually a physician on scene who may provide ETI and other advanced life support procedures, whereas in the United States, prehospital management (including ETI) is performed by paramedics.

METHODS

This is a retrospective cohort-matched study of patients with isolated blunt severe TBI (head Abbreviated Injury Scale [AIS] score, 4-5) and no major extracranial injuries, using Bern University Hospital data from the Swiss PEBITA [Patient-relevant Endpoints after Brain Injury from Traumatic Accidents] (TBI-specific) database and the US National Trauma Data Bank from 2009 to 2010. A 1:4 cohort matching of Bern and US patients was performed. Matching criteria were sex, age (±10 years), exact field Glasgow Coma Scale (GCS) score, exact head AIS score, and injury type (subdural hematoma, epidural hematoma, intraparenchymal hemorrhage, intraventricular hemorrhage, brain edema/swelling, brain stem injury). The matched cohorts were compared with univariable analysis (Fisher's exact test and Mann-Whitney U-test).

RESULTS

Matching of the Bern (n = 128) and US (n = 86,375) cohort resulted in 355 matched cases (71 Bern and 284 US patients). Bern patients had significantly longer scene times (median, 23.0 minutes vs. 9.0 minutes, p < 0.001) and more frequent prehospital ETI (31.0% vs. 18.7%, p = 0.034) and air transportation (39.4% vs. 19.4%, p < 0.001). No significant difference in procedures (craniotomy/craniectomy, intracranial pressure monitoring, tracheotomy), intensive care unit and total hospital lengths of stay, ventilator days, and in-hospital mortality (14.1% vs. 15.8%, p = 0.855) was found between the two cohorts.

CONCLUSION

When taking into account the limitation that patient- and injury-related factors, but not in-hospital treatment variables, were matched, the more frequent prehospital ETI and presence of a physician on scene in the Swiss cohort compared with the US cohort had no significant effect on outcomes, including intensive care unit and total hospital lengths of stay, ventilator days, and in-hospital mortality.

LEVEL OF EVIDENCE

Therapeutic study, level IV.

Field intubation in civilian patients with hemorrhagic shock is associated with higher mortality

BACKGROUND

Field intubation (FI) by emergency medical service personnel on severely injured trauma patients remains a contentious practice. Clinical studies suggest an association between FI and adverse outcomes in patients with traumatic brain injury. Military tactical emergency casualty care recommends deferring intubation and providing supplemental oxygenation until reaching a more equipped destination. In addition, animal models with penetrating hemorrhagic shock demonstrate increased acidosis with intubation before resuscitation. The purpose of this study was to evaluate the impact of FI on outcomes in trauma patients with hemorrhagic shock requiring massive transfusion.

METHODS

The Los Angeles County Trauma System Database was retrospectively queried for all trauma patients 16 years or older with hemorrhagic shock requiring massive transfusion (≥6 U packed red blood cells in the first 24 hours) between January 1, 2012, and June 30, 2014. Demographics, clinical and transfusion data, and outcomes were compared between patients who received FI and those who did not (NO-FI). Multivariate regression analysis was used to adjust for confounders.

RESULTS

Of 552 trauma patients meeting inclusion criteria, 63 (11%) received FI, and the remaining 489 (89%) were NO-FI. Age, sex, and incidence of blunt injury were similar between the FI and the NO-FI group. The FI cohort presented with a lower median Glasgow Coma Scale (GCS) score (3 vs. 14, p < 0.001), a lower median systolic blood pressure (86 mm Hg vs. 104 mm Hg, p < 0.001), and a higher median Injury Severity Score (ISS) (41 vs. 29, p < 0.001). Mortality was significantly higher in FI patients (83% vs. 43%, p < 0.001). Transfusion patterns and total field times were similar in both groups. After adjusting for confounders, FI patients had increased odds of mortality (adjusted odds ratio, 2.89; 95% confidence interval, 1.08-7.78; p = 0.035). In addition, FI was identified as an independent predictor of mortality (adjusted odds ratio, 3.41; 95% confidence interval, 1.35-8.59; p = 0.009).

CONCLUSION

FI may be associated with higher mortality in trauma patients with hemorrhagic shock requiring massive transfusion. Less invasive airway interventions and rapid transport might improve outcomes for these patients.

LEVEL OF EVIDENCE

Therapeutic study, level IV; epidemiologic study, level III.

Comparing the effectiveness of airway management devices in pre-hospital emergency care: A randomized clinical trial

Objective:

To assess the effectiveness of laryngeal mask airway, endotracheal tube and oropharyngeal airway for airway management in prehospital emergency care.

Methods:

The study sample of this randomized clinical trial was 54 patients needing pre-hospital airway management. All cases of intubation (ETI); after two failed attempts (37 patients), were randomly assigned to the oropharyngeal airway (OPA), and the laryngeal mask airway (LMA) groups. Patients’ hemodynamic, SaO2 and airway management parameters, were compared in three groups. The study data were analyzed by the Chi-square and one-way ANOVA, Bonferroni post-hoc, using SPSS, v. 18.0.

Results:

The results demonstrated that before and after the study, there was no significant difference among the study groups in terms of hemodynamic variables (P > 0.05) expect SaO₂ (P < 0.001). The results also revealed that in the ETI group (n=17), the number of attempts and the time spent on inserting the airway device was significantly more than other two groups (P < 0.05).

Conclusion:

Laryngeal mask airway is as effective as oropharyngial airway for pre-hospital airway management by paramedics.