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Davis DP, McKnight B, Meier E, Drennan IR, Newgard C, Wang HE, Bulger E, Schreiber M, Austin M, Vaillancourt C. Higher Oxygenation Is Associated with Improved Survival in Severe Traumatic Brain Injury but Not Traumatic Shock. Neurotrauma Rep 2023; 4:51-63. [PMID: 36726869 PMCID: PMC9886195 DOI: 10.1089/neur.2022.0065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Pre-hospital resuscitation of critically injured patients traditionally includes supplemental oxygen therapy to address potential hypoxemia. The objective of this study was to explore the association between pre-hospital hypoxemia, hyperoxemia, and mortality in patients with traumatic brain injury (TBI) and traumatic shock. We hypothesized that both hypoxemia and hyperoxemia would be associated with increased mortality. We used the Resuscitation Outcomes Consortium Prospective Observational Prehospital and Hospital Registry for Trauma (ROC PROPHET) database of critically injured patients to identify a severe TBI cohort (pre-hospital Glasgow Coma Scale [GCS] 3-8) and a traumatic shock cohort (systolic blood pressure ≤90 mm Hg and pre-hospital GCS >8). Arterial blood gas (ABG) obtained within 30 min of hospital arrival was required for inclusion. Patients with hypoxemia (PaO2 <80 mm Hg) and hyperoxemia (PaO2 >400 mm Hg) were compared to those with normoxemia (PaO2 80-400 mm Hg) with regard to the primary outcome measure of in-hospital mortality in both the TBI and traumatic shock cohorts. Multiple logistic regression was used to calculate odds ratios (ORs) after adjustment for multiple covariables. In addition, regression spline curves were generated to estimate the risk of death as a continuous function of PaO2 levels. A total of 1248 TBI patients were included, of whom 396 (32%) died before hospital discharge. Associations between hypoxemia and increased mortality (OR, 1.8; 95% confidence interval [CI], 1.2-2.8; p = 0.008) and between hyperoxemia and decreased mortality (OR, 0.6; 95% CI, 0.4-0.9; p = 0.018) were observed. A total of 582 traumatic shock patients were included, of whom 52 (9%) died before hospital discharge. No statistically significant associations were observed between in-hospital mortality and either hypoxemia (OR, 1.0; 95% CI, 0.4-2.4; p = 0.987) or hyperoxemia (OR, 1.9; 95% CI, 0.6-5.7; p = 0.269). Among patients with severe TBI but not traumatic shock, hypoxemia was associated with an increase of in-hospital mortality and hyperoxemia was associated with a decrease of in-hospital mortality.
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Affiliation(s)
- Daniel P. Davis
- Logan Health EMS, Kalispell, Montana, USA.,Department of Emergency Medicine, UC San Diego Medical Center, San Diego, California, USA.,*Address correspondence to: Daniel P. Davis, MD, Logan Health EMS, 310 Sunnyview Lane, Kalispell, MT 59901, USA;
| | - Barbara McKnight
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Eric Meier
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Ian R. Drennan
- Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.,Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Craig Newgard
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Henry E. Wang
- Department of Emergency Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Eileen Bulger
- Department of Surgery, University of Washington, Seattle, Washington, USA
| | - Martin Schreiber
- Department of Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Michael Austin
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
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Abstract
Airway management and ventilation are central to the resuscitation of the neurologically ill. These patients often have evolving processes that threaten the airway and adequate ventilation. Furthermore, intubation, ventilation, and sedative choices directly affect brain perfusion. Therefore, Airway, Ventilation, and Sedation was chosen as an Emergency Neurological Life Support protocol. Topics include airway management, when and how to intubate with special attention to hemodynamics and preservation of cerebral blood flow, mechanical ventilation settings and the use of sedative agents based on the patient's neurological status.
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Abstract
Traumatic brain injury is a highly prevalent and devastating cause of morbidity and mortality in children. A rapid, stepwise approach to the traumatized child should proceed, addressing life-threatening problems first. Management focuses on preventing secondary injury from physiologic extremes such as hypoxemia, hypotension, prolonged hyperventilation, temperature extremes, and rapid changes in cerebral blood flow. Initial Glasgow Coma Score, hyperglycemia, and imaging are often prognostic of outcome. Surgically amenable lesions should be evacuated promptly. Reduction of intracranial pressure through hyperosmolar therapy, decompressive craniotomy, and seizure prophylaxis may be considered after stabilization. Nonaccidental trauma should be considered when evaluating pediatric trauma patients.
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Affiliation(s)
- Aaron N Leetch
- Department of Emergency Medicine, The University of Arizona, PO Box 245057, Tucson, AZ 85724-5057, USA; Department of Pediatrics, The University of Arizona, PO Box 245057, Tucson, AZ 85724-5057, USA.
| | - Bryan Wilson
- Department of Emergency Medicine, The University of Arizona, PO Box 245057, Tucson, AZ 85724-5057, USA; Department of Pediatrics, The University of Arizona, PO Box 245057, Tucson, AZ 85724-5057, USA
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Sakles JC, Mosier JM, Patanwala AE, Dicken JM. Apneic oxygenation is associated with a reduction in the incidence of hypoxemia during the RSI of patients with intracranial hemorrhage in the emergency department. Intern Emerg Med 2016; 11:983-92. [PMID: 26846234 DOI: 10.1007/s11739-016-1396-8] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2015] [Accepted: 01/13/2016] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- John C Sakles
- Department of Emergency Medicine, University of Arizona College of Medicine, Tucson, AZ, USA.
| | - Jarrod M Mosier
- Department of Emergency Medicine, University of Arizona College of Medicine, Tucson, AZ, USA
| | - Asad E Patanwala
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, AZ, USA
| | - John M Dicken
- University of Arizona College of Medicine, Tucson, AZ, USA
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Abstract
Airway management and ventilation are central to the resuscitation of the neurologically ill. These patients often have evolving processes that threaten the airway and adequate ventilation. Furthermore, intubation, ventilation, and sedative choices directly affect brain perfusion. Therefore, airway, ventilation, and sedation was chosen as an emergency neurological life support protocol. Topics include airway management, when and how to intubate with special attention to hemodynamics and preservation of cerebral blood flow, mechanical ventilation settings, and the use of sedative agents based on the patient's neurological status.
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Little G, Kelly M, Glucksman E. Critical pitfalls in the immediate assessment of the trauma patient. TRAUMA-ENGLAND 2016. [DOI: 10.1177/146040860100300106] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
In the immediate assessment of trauma patients, critical pitfalls exist that may interfere with optimal clinical care. Failure to recognize the need for early anaesthesia and endotracheal intubation may put the patient at unnecessary risk and delay the assessment and treatment process. Pressure to clear the cervical spine may lead to inadequate imaging and premature removal of neck immobilization devices. The limitations of the initial chest X-ray in diagnosing pneumothoraces may not be appreciated and needle thoracentesis may be ineffective. ‘Springing’ the pelvis to assess for instability may cause life-threatening haemorrhage and should not be done prior to the initial pelvic X-ray. Log rolling may dislodge crucial clot formation and promote bleeding, and should only be used for diagnostic purposes. Applying clinical common sense to the assessment of trauma patients may avoid the pitfalls whilst allowing the clinician to operate within internationally agreed assessment and treatment frameworks.
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Affiliation(s)
- George Little
- Accident and Emergency Department, King’s College Hospital, London, UK,
| | - Michael Kelly
- Accident and Emergency Department, King’s College Hospital, London, UK
| | - E Glucksman
- Accident and Emergency Department, King’s College Hospital, London, UK
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Kuzak N, Harrison DW, Zed PJ. Use of lidocaine and fentanyl premedication for neuroprotective rapid sequence intubation in the emergency department. CAN J EMERG MED 2015; 8:80-4. [PMID: 17175867 DOI: 10.1017/s1481803500013518] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
ABSTRACT
Introduction:
Autoregulation is dysfunctional in the injured brain. Increases in intracranial and arterial pressure may therefore result in extension of the primary injury. Rapid sequence intubation (RSI) is a well-known cause of surges in both arterial pressure and intracranial pressure. Neuroprotective agents, namely lidocaine and fentanyl, have the potential to minimize the pressure surges implicated in secondary brain injury. The purpose of this study was to determine the frequency with which neuroprotective agents were used for neuroprotective RSI in the emergency department.
Methods:
We conducted a retrospective chart review of all 139 patients intubated in the emergency department of Vancouver General Hospital between March and October 2003. Patients were eligible if there was an indication for neuroprotective agents defined as presumed intracranial pathology and a mean arterial pressure (MAP) > 85 mm Hg. Contraindications to fentanyl included MAP < 85 mm Hg or allergy to fentanyl.
Results:
Seventy-seven patients were intubated for primary neurological indications. Indication for intubation included non-traumatic causes (n = 37) (including cerebrovascular accident or intracranial hemorrhage) and closed head injury (n = 40). The mean age (± standard deviation) was 52.3 ± 20.4 years, and 31.4% were female. Fifty-seven (74.0%) patients had indications for neuroprotective agents, without contraindications. When neuroprotective agents were indicated, lidocaine was used in 84.2% (95% confidence interval [CI] 72.6%–91.5%) of patients while fentanyl was used in 33.3% (95%CI 22.4%–46.3%) of patients. Eleven percent of the intubations were performed with a fentanyl dose of Δ 2 mcg/kg, which is the lower limit considered effective.
Conclusions:
Despite the potential benefit of using lidocaine and fentanyl in appropriate patients undergoing neuroprotective RSI in the emergency department, our study identified a significant underutilization of optimal premedication. The identification of barriers to use and the implementation of strategies to optimize use are necessary.
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Affiliation(s)
- Nick Kuzak
- R5 Emergency Medicine, University of British Columbia, Vancouver, BC
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Seder DB, Riker RR, Jagoda A, Smith WS, Weingart SD. Emergency neurological life support: airway, ventilation, and sedation. Neurocrit Care 2013; 17 Suppl 1:S4-20. [PMID: 22972019 DOI: 10.1007/s12028-012-9753-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Airway management is central to the resuscitation of the neurologically ill. These patients often have evolving processes that threaten the airway and adequate ventilation. Therefore, airway, ventilation, and sedation were chosen as an Emergency Neurological Life Support (ENLS) protocol. Reviewed topics include airway management; the decision to intubate; when and how to intubate with attention to cardiovascular status; mechanical ventilation settings; and the use of sedation, including how to select sedative agents based on the patient's neurological status.
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Affiliation(s)
- David B Seder
- Department of Critical Care Services, Maine Medical Center, Tufts University School of Medicine, Boston, MA, USA.
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Latency of Pulse Oximetry Signal with Use of Digital Probes Associated with Inappropriate Extubation during Prehospital Rapid Sequence Intubation in Head Injury Patients: Case Examples. J Emerg Med 2012; 42:424-8. [DOI: 10.1016/j.jemermed.2011.06.127] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2010] [Revised: 02/03/2011] [Accepted: 06/01/2011] [Indexed: 11/19/2022]
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[Sedation and analgesia in emergency structure. Which sedation and/or analgesia for tracheal intubation?]. ACTA ACUST UNITED AC 2012; 31:313-21. [PMID: 22440814 DOI: 10.1016/j.annfar.2012.01.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Davis DP, Aguilar S, Sonnleitner C, Cohen M, Jennings M. Latency and loss of pulse oximetry signal with the use of digital probes during prehospital rapid-sequence intubation. PREHOSP EMERG CARE 2010; 15:18-22. [PMID: 20858133 DOI: 10.3109/10903127.2010.514091] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Prehospital personnel rely on timely and accurate pulse oximetry data when performing critical skills, such as rapid-sequence intubation (RSI). However, loss of signal may be a frequent occurrence in patients with poor peripheral perfusion. In addition, a delay or latency period in the timeliness of pulse oximetry data may exist with probes placed on the fingers. OBJECTIVE To define the incidence of pulse oximetry signal loss or a latent period during prehospital RSI. METHODS Patients with severe traumatic brain injury (TBI) (Glasgow Coma Scale score [GCS] 3-8) undergoing prehospital RSI by air medical crews were enrolled. Data from hand-held oximetry-capnometry units were analyzed for either the loss of a pulse oximetry tracing (≥ 30 seconds) during the RSI procedure or the presence of a latent period, defined by the saturation of peripheral oxygen (SpO(2)) nadir occurring after intubation in patients undergoing desaturation (SpO(2) ≤ 93%) during the procedure. RESULTS A total of 98 of 124 patients (79%, 95% confidence interval [CI] 71-85%) had pulse oximetry failure during critical points in the RSI procedure. In the 49 patients with a desaturation during RSI, a latent period was observed in 27 patients (55%, 95% CI 41-68%). CONCLUSIONS A high incidence of pulse oximetry failure was observed with the use of a digital pulse oximetry probe during prehospital RSI. In addition, a latent period appears to exist in the majority of patients undergoing desaturation.
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Affiliation(s)
- Daniel P Davis
- Department of Emergency Medicine, UC San Diego, San Diego, California, USA.
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Davis DP, Meade W, Sise MJ, Kennedy F, Simon F, Tominaga G, Steele J, Coimbra R. Both Hypoxemia and Extreme Hyperoxemia May Be Detrimental in Patients with Severe Traumatic Brain Injury. J Neurotrauma 2009; 26:2217-23. [DOI: 10.1089/neu.2009.0940] [Citation(s) in RCA: 169] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Affiliation(s)
- Daniel P. Davis
- Univeristy of California–San Diego, Department of Emergency Medicine, San Diego, California
| | - William Meade
- Univeristy of California–San Diego, Department of Emergency Medicine, San Diego, California
| | | | | | - Fred Simon
- Scripps Memorial Hospital, San Diego, California
| | | | | | - Raul Coimbra
- Division of Trauma, University of California–San Diego, San Diego, California
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Lapinsky SE, Posadas-Calleja JG, McCullagh I. Clinical review: Ventilatory strategies for obstetric, brain-injured and obese patients. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2009; 13:206. [PMID: 19291279 PMCID: PMC2689449 DOI: 10.1186/cc7146] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
The ventilatory management of patients with acute respiratory failure is supported by good evidence, aiming to reduce lung injury by pressure limitation and reducing the duration of ventilatory support by regular assessment for discontinuation. Certain patient groups, however, due to their altered physiology or disease-specific complications, may require some variation in usual ventilatory management. The present manuscript reviews the ventilatory management in three special populations, namely the patient with brain injury, the pregnant patient and the morbidly obese patient.
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Affiliation(s)
- Stephen E Lapinsky
- Intensive Care Unit, Mount Sinai Hospital, 600 University Ave, Toronto, Ontario, M5G 1X5, Canada.
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Wang HE, Davis DP, Wayne MA, Delbridge T. PREHOSPITALRAPID-SEQUENCEINTUBATION-WHATDOES THEEVIDENCESHOW? PREHOSP EMERG CARE 2009. [DOI: 10.1080/312704000917] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Davis DP, Hwang JQ, Dunford JV. Rate of Decline in Oxygen Saturation at Various Pulse Oximetry Values with Prehospital Rapid Sequence Intubation. PREHOSP EMERG CARE 2009; 12:46-51. [DOI: 10.1080/10903120701710470] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Franschman G, Peerdeman SM, Greuters S, Vieveen J, Brinkman ACM, Christiaans HMT, Toor EJ, Jukema GN, Loer SA, Boer C. Prehospital endotracheal intubation in patients with severe traumatic brain injury: guidelines versus reality. Resuscitation 2009; 80:1147-51. [PMID: 19632024 DOI: 10.1016/j.resuscitation.2009.06.029] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2009] [Revised: 06/04/2009] [Accepted: 06/27/2009] [Indexed: 11/25/2022]
Abstract
The international Brain Trauma Foundation guidelines recommend prehospital endotracheal intubation in all patients with traumatic brain injury (TBI) and a Glasgow Coma Scale (GCS)< or =8. Close adherence to these guidelines is associated with improved outcome, but not all severely injured TBI patients receive adequate prehospital airway support. Here we hypothesized that guideline adherence varies when skills are involved that rely on training and expertise, such as endotracheal intubation. We retrospectively studied the medical records of CT-confirmed TBI patients with a GCS< or =8 who were referred to a level 1 trauma centre in Amsterdam (n=127). Records were analyzed for demographic parameters, prehospital treatment modalities, involvement of an emergency medical service (EMS) and respiratory and metabolic parameters upon arrival at the hospital. Patients were mostly male, aged 45+/-21 years with a median injury severity score (ISS) of 26. Of all patients for whom guidelines recommend endotracheal intubation, only 56% were intubated. In 21 out of 106 severe cases an EMS was not called for, suggesting low guideline adherence. Especially those TBI patients treated by paramedics tended to develop higher levels of stress markers like glucose and lactate. We observed a low degree of adherence to intubation guidelines in a Dutch urban area. Main reasons for low adherence were the unavailability of specialized care, scoop and run strategies and absence of a specialist physician in cases where intubation was recommended. The discrepancy between guidelines and reality warrants changing practice to improve guideline compliance and optimize outcome in TBI patients.
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Affiliation(s)
- G Franschman
- Department of Anesthesiology, VU University Medical Center, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.
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Davis DP, Fakhry SM, Wang HE, Bulger EM, Domeier RM, Trask AL, Bochicchio GV, Hauda WE, Robinson L. Paramedic Rapid Sequence Intubation for Severe Traumatic Brain Injury: Perspectives from an Expert Panel. PREHOSP EMERG CARE 2009; 11:1-8. [PMID: 17169868 DOI: 10.1080/10903120601021093] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Although early intubation has become standard practice in the prehospital management of severe traumatic brain injury (TBI), many patients cannot be intubated without neuromuscular blockade. Several emergency medical services (EMS) systems have implemented paramedic rapid sequence intubation (RSI) protocols, with published reports documenting apparently conflicting outcomes effects. In response, the Brain Trauma Foundation assembled a panel of experts to interpret the existing literature regarding paramedic RSI for severe TBI and offer guidance for EMS systems considering adding this skill to the paramedic scope of practice. The interpretation of this panel can be summarized as follows: (1) the existing literature regarding paramedic RSI is inconclusive, and apparent differences in outcome can be explained by use of different methodologies and variability in comparison groups; (2) the use of Glasgow Coma Scale score alone to identify TBI patients requiring RSI is limited, with additional research needed to refine our screening criteria; (3) suboptimal RSI technique as well as subsequent hyperventilation may account for some of the mortality increase reported with the procedure; (4) initial and ongoing training as well as experience with RSI appear to affect performance; and (5) the success of a paramedic RSI program is dependent on particular EMS and trauma system characteristics.
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Affiliation(s)
- Daniel P Davis
- Department of Emergency Medicine, University of California at San Diego, San Diego, California 92103-8676, and Trauma Services, Inova Regional Trauma Center, Inova Fairfax Hospital, Falls Church, VA, USA.
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Davis DP, Buono C, Ford J, Paulson L, Koenig W, Carrison D. The Effectiveness of a Novel, Algorithm-Based Difficult Airway Curriculum for Air Medical Crews Using Human Patient Simulators. PREHOSP EMERG CARE 2009; 11:72-9. [PMID: 17169882 DOI: 10.1080/10903120601023370] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Airway management is one of the most important skills possessed by flight crews. However, few data exist about the efficacy of various educational approaches. Traditional models for airway training, including cadaver labs, operating room exposure, and clinical apprenticeships, are scarce and offer variable educational quality. The objective of this analysis was to evaluate the effectiveness of a simulator-based difficult airway curriculum in a large, aeromedical company. METHODS Simulation training was integrated into existing airway training for all crew members; an original difficult airway algorithm was used to guide scenarios. To evaluate its effectiveness, rapid sequence intubation (RSI) success before and after curriculum implementation was determined. In addition, crew members rated their confidence with various aspects of airway management before and after exposure to the airway workshops. RESULTS First attempt and overall ETI success improved from 71.3% and 89.3% before (n=261) to 87.5% and 94.6% after (n=504) implementation of the algorithm and simulation training, whereas the incidence of hypoxic arrests during RSI decreased from 2.7% to 0.2% (p<0.01 for all comparisons). Crew members reported improvements in confidence with regard to all aspects of airway management following participation in the simulation workshops. CONCLUSIONS A novel, integrated airway management curriculum using treatment algorithms and simulation appeared to be effective for improving RSI success among air medical crews in this program.
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Affiliation(s)
- Daniel P Davis
- UC San Diego School of Medicine, Department of Emergency Medicine, Mercy Air Medical Services, CA 92103-8676, USA.
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Emergency care and managing toxicoses in the exotic animal patient. Vet Clin North Am Exot Anim Pract 2008; 11:211-28, v. [PMID: 18406385 DOI: 10.1016/j.cvex.2008.01.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The poisoned exotic veterinary patient remains a significant challenge to the clinician. A patient presenting with the history of exposure to a toxin or poison should be considered to have a potentially life-threatening problem. This article details the ABCs of emergency medicine including fluid therapy and discusses the principles of neurologic management. The last part of the article provides the clinician with guidelines for decontamination and critical care management of some of the more common toxicoses in exotic animals.
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Gouin P, Damm C, Villette-Baron K, Veber B, Dureuil B. Impact de la conférence d’experts intitulée « Modalités de la sédation et/ou de l’analgésie en situation extrahospitalière ». ACTA ACUST UNITED AC 2008; 27:390-6. [DOI: 10.1016/j.annfar.2008.03.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2007] [Accepted: 03/03/2008] [Indexed: 11/25/2022]
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Thomas JB, Abo BN, Wang HE. Paramedic perceptions of challenges in out-of-hospital endotracheal intubation. PREHOSP EMERG CARE 2007; 11:219-23. [PMID: 17454812 DOI: 10.1080/10903120701205802] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Paramedics often perform endotracheal intubation (ETI), insertion of a breathing tube, on critically ill out-of-hospital patients. Recent studies highlight important paramedic ETI shortcomings including adverse events, errors, and poor outcomes resulting from this procedure. Little is known about workforce perceptions of these events. We sought to identify paramedic and physician perceptions regarding the challenges and pitfalls of out-of-hospital ETI. METHODS We conducted a qualitative study involving paramedic focus groups sessions and individual interviews with Emergency Medical Services (EMS) physician medical directors. We recorded and transcribed all sessions. We used inductive theory construction to examine, organize, and classify thematic patterns. RESULTS Fourteen paramedics and 6 physicians participated. Although paramedics and physicians recognized problems with paramedic ETI, all participants strongly felt that paramedics should continue to perform the procedure. Physicians and paramedics disagreed about the ability of paramedics to perform neuromuscular blockade-assisted intubation. Both groups identified aspects of paramedic education, skills acquisition, and maintenance as core issues. Participants also identified broader factors about the structure of emergency services, the role of the medical director, and workforce culture and professionalism. CONCLUSION Paramedics and EMS physicians attribute paramedic ETI performance to a myriad of factors involving EMS education, organization, oversight, retention, and professionalism. Efforts to improve ETI must include strategies to address multiple aspects of EMS operations and culture.
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Affiliation(s)
- Jane Boyce Thomas
- Department of Anthropology, University of Pittsburgh, Pittsburgh, PA, USA
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Davis DP, Serrano JA, Vilke GM, Sise MJ, Kennedy F, Eastman AB, Velky T, Hoyt DB. The predictive value of field versus arrival Glasgow Coma Scale score and TRISS calculations in moderate-to-severe traumatic brain injury. ACTA ACUST UNITED AC 2006; 60:985-90. [PMID: 16688059 DOI: 10.1097/01.ta.0000205860.96209.1c] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Glasgow Coma Scale (GCS) scores are widely used to quantify level of consciousness in the prehospital environment. The predictive value of field versus arrival GCS is not well defined but has tremendous implications with regard to triage and therapeutic decisions as well as the use of various predictive scoring systems, such as Trauma Score and Injury Severity Score (TRISS). This study explores the predictive value of field GCS (fGCS) and arrival GCS (aGCS) as well as TRISS calculations using field (fTRISS) and arrival (aTRISS) data in patients with moderate-to-severe traumatic brain injury (TBI). METHODS Major trauma victims with head Abbreviated Injury Scores of 3 or greater were identified from our county trauma registry over a 16-year period. The predictive ability of fGCS with regard to aGCS was explored using univariate statistics and linear regression modeling. The difference between aGCS and fGCS was also modeled against mortality and the composite endpoint using logistic regression, adjusting for fGCS. The predictive value of preadmission GCS (pGCS), defined as either fGCS or aGCS in nonintubated patients without a documented fGCS, with regard to mortality and a composite endpoint representing the need for neurosurgical care (death, craniotomy, invasive intracranial pressure monitoring, or intensive care unit care >48 hours) was determined using receiver-operator curve (ROC) analysis. Finally, fTRISS and aTRISS predicted survival values were compared with each other and to observed survival. RESULTS A total of 12,882 patients were included. Mean values for fGCS and aGCS were similar (11.4 and 11.5, respectively, p = 0.336), and a strong correlation (r = 0.67, 95% CI 0.66-0.69, p < 0.0001) was observed between them. The difference between fGCS and aGCS was also predictive of outcome after adjusting for fGCS. Good predictive ability was observed for pGCS with regard to both mortality and neurosurgical intervention. Both fTRISS and aTRISS predicted survival values were nearly identical to observed survival. Observed and fTRISS predicted survival were nearly identical in patients undergoing prehospital intubation CONCLUSIONS Values for fGCS are highly predictive of aGCS, and both are associated with outcome from TBI. A change in GCS from the field to arrival is highly predictive of outcome. The use of field data for TRISS calculations appears to be a valid methodological approach, even in severely injured TBI patients undergoing prehospital intubation.
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Affiliation(s)
- Daniel P Davis
- Department of Emergency Medicine, University of California San Diego, San Diego, California 92103-8676, USA.
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Wang HE, Yealy DM. Out-of-hospital endotracheal intubation: where are we? Ann Emerg Med 2006; 47:532-41. [PMID: 16713780 DOI: 10.1016/j.annemergmed.2006.01.016] [Citation(s) in RCA: 108] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2005] [Revised: 01/09/2006] [Accepted: 01/11/2006] [Indexed: 11/21/2022]
Abstract
While remaining prominent in paramedic care and beneficial to some patients, out-of-hospital endotracheal intubation has not clearly improved survival or reduced morbidity from critical illness or injury when studied more broadly. Recent studies identify equivocal or unfavorable clinical effects, adverse events and errors, interaction with other important resuscitation interventions, and challenges in providing and maintaining procedural skill. We provide an overview of current data evaluating the overall effectiveness, safety, and feasibility of paramedic out-of-hospital endotracheal intubation. These studies highlight our limited understanding of out-of-hospital endotracheal intubation and the need for new strategies to improve airway support in the out-of-hospital setting.
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Affiliation(s)
- Henry E Wang
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA.
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Davis DP, Vadeboncoeur TF, Ochs M, Poste JC, Vilke GM, Hoyt DB. The association between field Glasgow Coma Scale score and outcome in patients undergoing paramedic rapid sequence intubation. J Emerg Med 2006; 29:391-7. [PMID: 16243194 DOI: 10.1016/j.jemermed.2005.04.012] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2004] [Revised: 02/18/2005] [Accepted: 04/29/2005] [Indexed: 10/25/2022]
Abstract
Early intubation is standard for treating severe traumatic brain injury (TBI). Aeromedical crews and select paramedic agencies use rapid sequence intubation (RSI) to facilitate intubation after TBI, with Glasgow Coma Scale (GCS) score commonly used as a screening tool. To explore the association between paramedic GCS and outcome in patients with TBI undergoing prehospital RSI, paramedics prospectively enrolled adult major trauma victims with GCS 3-8 and clinical suspicion for head trauma to undergo succinylcholine-assisted intubation as part of the San Diego Paramedic RSI Trial. The following data were abstracted from paramedic debriefing interviews and the county trauma registry: demographics, mechanism, vital signs including GCS score, clinical evidence of aspiration before RSI, arrival laboratory values, hospital course, and outcome. Paramedic GCS calculations were confirmed during debriefing interviews. Patients were stratified by GCS score, with chi-square and receiver-operator-curve (ROC) analysis used to explore the relationship between GCS and hypoxia, head injury severity, aspiration, intensive care unit (ICU) length of stay, and outcome. Cohort analysis was used to explore potential reasons for early extubation and discharge from the ICU in some patients. A total of 412 patients were included in this analysis. A total of 81 patients (20%) were extubated and discharged from the ICU in 48 h or less; these patients had higher pre-RSI oxygen saturation (SaO(2)) values and higher arrival serum ethanol levels. Paramedic and physician GCS calculations had high agreement (kappa=0.995). A statistically significant relationship was observed between GCS score and Head Abbreviated Injury Score (AIS), survival, and pre-RSI SaO(2) values. However, ROC analysis revealed a limited ability of GCS to predict the presence of severe TBI, injury severity, desaturation, aspiration, ICU length of stay, or ultimate survival. In conclusion, paramedics seem to accurately calculate GCS values before prehospital RSI. Although a relationship between paramedic GCS and outcome exists, the ability to predict the severity of injury, airway-related complications, ICU length of stay, and overall survival is limited using this single variable. Other factors should be considered to screen TBI patients for prehospital RSI.
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Affiliation(s)
- Daniel P Davis
- Department of Emergency Medicine, University of California San Diego (UCSD), San Diego, California 92103-8676, USA
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Vadeboncoeur TF, Davis DP, Ochs M, Poste JC, Hoyt DB, Vilke GM. The ability of paramedics to predict aspiration in patients undergoing prehospital rapid sequence intubation. J Emerg Med 2006; 30:131-6. [PMID: 16567245 DOI: 10.1016/j.jemermed.2005.04.019] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2004] [Revised: 02/19/2005] [Accepted: 04/29/2005] [Indexed: 10/24/2022]
Abstract
One of the purported benefits to invasive prehospital airway management is the prevention of aspiration; however, aspiration events may occur before the arrival of prehospital personnel. We explore the timing of aspiration in patients with severe traumatic brain injury (TBI) undergoing paramedic rapid sequence intubation (RSI). Severely head-injured (Glasgow Coma Scale [GCS] score 3-8) adults were prospectively enrolled into the San Diego Paramedic RSI Trial. As part of the prehospital data collection tool, paramedics prospectively assessed for clinical evidence of aspiration before RSI (pre-intubation), aspiration events occurring during RSI (peri-RSI), and regurgitation of vomitus or blood after intubation (post-intubation). Data were abstracted from work sheets used during the RSI procedure, a telephone debriefing by one of the principal investigators immediately after delivery of the patient, and San Diego County prehospital and trauma databases. The incidence of pre-intubation aspiration, peri-RSI aspiration, and post-intubation regurgitation of vomitus or blood were determined. Patients with and without pre-intubation aspiration were compared with regard to pre- and post-intubation hypoxia and the rate of aspiration pneumonia. Logistic regression was used to explore the association between pre-intubation aspiration and various demographic and clinical factors. The results showed that pre-intubation aspiration was noted by paramedics in 72/269 patients in whom complete data were available. Peri-RSI aspiration was reported in one patient; there were no reported cases of post-intubation regurgitation of vomitus or blood. Patients in the pre-intubation aspiration group required more intubation attempts, had a higher incidence of desaturations and lower pre- and post-intubation SaO(2) values, and were more frequently diagnosed with aspiration pneumonia. Pre-intubation aspiration was associated with severe TBI, GCS score of 3, younger age, and the absence of alcohol intoxication despite controlling for age, gender, GCS, Head AIS (Abbreviated Injury Score), and serum ethanol. It is concluded that paramedics seem to be able to accurately assess for aspiration in patients undergoing prehospital RSI. The vast majority of aspiration events seem to occur before the arrival of prehospital personnel. Alteration in consciousness from TBI may carry a higher risk of aspiration than with other causes, such as alcohol intoxication.
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Affiliation(s)
- Tyler F Vadeboncoeur
- Department of Emergency Medicine, University of California San Diego (UCSD) Medical Center, San Diego, California 92103-8676, USA
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Abstract
Airway management is unequivocally the most important responsibility of the emergency physician. No matter how prepared for the task, no matter what technologies are utilized, there will be cases that are difficult. The most important part of success in the management of a difficult airway is preparation. When the patient is encountered, it is too late to check whether appropriate equipment is available, whether a rescue plan has been in place, and what alternative strategies are available for an immediate response. The following article will review the principles of airway management with an emphasis upon preparation, strategies for preventing or avoiding difficulties, and recommended technical details that hopefully will encourage the reader to be more prepared and technically skillful in practice.
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Affiliation(s)
- Peter Rosen
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA.
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Davis DP, Stern J, Sise MJ, Hoyt DB. A Follow-Up Analysis of Factors Associated with Head-Injury Mortality After Paramedic Rapid Sequence Intubation. ACTA ACUST UNITED AC 2005; 59:486-90. [PMID: 16294099 DOI: 10.1097/00005373-200508000-00037] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The San Diego Paramedic Rapid Sequence Intubation (RSI) Trial documented an increase in mortality after paramedic RSI, with hyperventilation identified as a contributing factor in a small subgroup analysis. Here we explore factors affecting outcome in the entire cohort of patients undergoing paramedic RSI to confirm previous findings. This also represents a synthesis of findings from previous analyses METHODS Adult trauma patients with severe head injury (Glasgow Coma Scale score, 3-8) who could not be intubated without RSI were prospectively enrolled in the trial. This analysis excluded patients without traumatic brain injury (head/neck abbreviated injury score <2 or failure to meet Major Trauma Outcome Study criteria) or death in the field or within 30 minutes of arrival. Each remaining trial patient was matched to two nonintubated historical controls from the county trauma registry based on: age, sex, mechanism, abbreviated injury scores for each body system, and Injury Severity Score. Logistic regression, cohort analysis, mean least squares regression, and discordant group analysis were used to explore the impact of various factors on outcome. RESULTS Of the 426 trial patients, 352 met inclusion criteria for this analysis and were hand-matched to 704 controls. Trial patients and controls were identical with regard to all matching variables. Mortality was increased in RSI patients versus matched controls (31.8 versus 23.7%; odds ration, 1.5; 95% confidence interval, 1.1-2.0; p < 0.01). Hyperventilation was associated with an increase in mortality, whereas transport by aeromedical crews after paramedic RSI was associated with improved outcomes. The reported incidence of aspiration pneumonia was higher for the RSI patients. CONCLUSION Paramedic RSI was associated with an increase in mortality compared with matched historical controls. The association between hyperventilation and mortality was confirmed. In addition, patients transported by helicopter after paramedic RSI had improved outcomes. Paramedic RSI did not seem to prevent aspiration pneumonia.
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Affiliation(s)
- Daniel P Davis
- Department of Emergency Medicine, Division of Trauma, University of California-San Diego, CA92103-8946, USA.
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Davis DP, Peay J, Sise MJ, Vilke GM, Kennedy F, Eastman AB, Velky T, Hoyt DB. The Impact of Prehospital Endotracheal Intubation on Outcome in Moderate to Severe Traumatic Brain Injury. ACTA ACUST UNITED AC 2005; 58:933-9. [PMID: 15920406 DOI: 10.1097/01.ta.0000162731.53812.58] [Citation(s) in RCA: 156] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Although early intubation to prevent the mortality that accompanies hypoxia is considered the standard of care for severe traumatic brain injury (TBI), the efficacy of this approach remains unproven. METHODS Patients with moderate to severe TBI (Head/Neck Abbreviated Injury Scale [AIS] score 3+) were identified from our county trauma registry. Logistic regression was used to explore the impact of prehospital intubation on outcome, controlling for age, gender, mechanism, Glasgow Coma Scale score, Head/Neck AIS score, Injury Severity Score, and hypotension. Neural network analysis was performed to identify patients predicted to benefit from prehospital intubation. RESULTS A total of 13,625 patients from five trauma centers were included; overall mortality was 22.9%, and 19.3% underwent prehospital intubation. Logistic regression revealed an increase in mortality with prehospital intubation (odds ratio, 0.36; 95% confidence interval, 0.32-0.42; p < 0.001). This was true for all patients, for those with severe TBI (Head/Neck AIS score 4+ and/or Glasgow Coma Scale score of 3-8), and with exclusion of patients transported by aeromedical crews. Patients intubated in the field versus the emergency department had worse outcomes. Neural network analysis identified a subgroup of patients with more significant injuries as potentially benefiting from prehospital intubation. CONCLUSION Prehospital intubation is associated with a decrease in survival among patients with moderate-to-severe TBI. More critically injured patients may benefit from prehospital intubation but may be difficult to identify prospectively.
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Affiliation(s)
- Daniel P Davis
- Department of Emergency Medicine, School of Medicine, University of California, San Diego, 92103-8676, USA.
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30
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Bozeman WP, Idris AH. Intracranial pressure changes during rapid sequence intubation: a swine model. ACTA ACUST UNITED AC 2005; 58:278-83. [PMID: 15706188 DOI: 10.1097/01.ta.0000152536.71932.85] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Controversy and speculation exist regarding intracranial pressure (ICP) changes produced by various combinations of rapid sequence intubation (RSI) agents. In this pilot study, we sought to develop a swine model to investigate these changes in classic RSI. METHODS Eight adult swine were instrumented with arterial and intracranial pressure monitors. Four different versions of rapid sequence intubation were then performed sequentially in each animal in a crossover trial design: regimen 1, thiopental; regimen 2, thiopental and succinylcholine; regimen 3, lidocaine, thiopental, and succinylcholine; and regimen 4, pancuronium, lidocaine, thiopental, and succinylcholine. ICP and hemodynamic parameters were recorded and compared. Trials were excluded from analysis if baseline ICP measurements were unstable or if intubation was difficult. RESULTS Peak changes in ICP were noted at 2 to 3 minutes after administration of induction agents. Mean values for peak changes in ICP were as follows: regimen 1 (n = 5), 3.6 mm Hg (95% confidence interval [CI], 1.0-6.2 mm Hg); regimen 2 (n = 9), 13.6 mm Hg (95% CI, 9.6-17.6 mm Hg); regimen 3 (n = 2), 16.0 mm Hg (95% CI, -34.8-66.8 mm Hg); and regimen 4 (n = 3), 12.0 mm Hg (95% CI, -8.3-32.3 mm Hg). CONCLUSION The model is effective. It enables investigators to examine the aggregate ICP effects of combinations of RSI medications. RSI regimens with paralysis produced threefold increases in peak ICP change compared with the sedation-only regimen. Pretreatment agents did not affect ICP changes. Future investigations can examine other agents and add experimental manipulation of ICP to simulate head injury physiology. Additional parameters including cerebral metabolism and/or oxygenation may also be explored.
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Affiliation(s)
- William P Bozeman
- Department of Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, NC 27157, USA.
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Wang HE, Peitzman AB, Cassidy LD, Adelson PD, Yealy DM. Out-of-hospital endotracheal intubation and outcome after traumatic brain injury. Ann Emerg Med 2004; 44:439-50. [PMID: 15520702 DOI: 10.1016/j.annemergmed.2004.04.008] [Citation(s) in RCA: 196] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
STUDY OBJECTIVE Previous studies disagree about the effect of out-of-hospital endotracheal intubation on traumatic brain injury. This study compares the effects of out-of-hospital endotracheal intubation versus emergency department (ED) endotracheal intubation on mortality and neurologic and functional outcome after severe traumatic brain injury. METHODS From the 2000 to 2002 Pennsylvania Trauma Outcome Study (a registry of all patients treated at trauma centers in the Commonwealth of Pennsylvania), adult patients with head/neck Abbreviated Injury Scale score of 3 or greater and undergoing out-of-hospital endotracheal intubation or ED endotracheal intubation were included. Transferred patients were excluded. The primary outcome was death (on hospital discharge). The secondary outcomes were neurologic (good versus poor, inferred from discharge to home versus long-term care facility) and functional outcome (determined from a Functional Impairment Score). The key exposure was endotracheal intubation (out-of-hospital endotracheal intubation versus ED endotracheal intubation). Using multivariate logistic regression, odds estimates for out-of-hospital endotracheal intubation were adjusted using age, sex, head/neck Abbreviated Injury Scale score, Injury Severity Score, mechanism of injury (penetrating versus blunt), admission systolic blood pressure, mode of transport (ground only versus helicopter or helicopter + ground), and the use of out-of-hospital neuromuscular blocking agents. A propensity score adjustment accounted for the potential effects of preexisting conditions, inhospital complications, and social factors (drug and alcohol use, race, and insurance coverage). RESULTS There were 4,098 patients with head/neck Abbreviated Injury Scale score of 3 or greater who received either out-of-hospital endotracheal intubation (n=1,797, 43.9%) or ED endotracheal intubation (n=2,301, 56.1%). Adjusted odds of death were higher for out-of-hospital endotracheal intubation than ED endotracheal intubation (odds ratio [OR] 3.99; 95% confidence interval [CI] 3.21 to 4.93). Out-of-hospital endotracheal intubation was associated with an increased adjusted odds of poor neurologic outcome (OR 1.61; 95% CI 1.15 to 2.26), moderate or severe functional impairment (Functional Impairment Score 6 to 15; OR 1.92; 95% CI 1.40 to 2.64), and severe functional impairment (Functional Impairment Score 11 to 15; OR 1.80; 95% CI 1.29 to 2.52). CONCLUSION Out-of-hospital endotracheal intubation was associated with adverse outcomes after severe traumatic brain injury. The implications for current clinical care remain undefined.
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Affiliation(s)
- Henry E Wang
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA.
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Tentillier E, Dupont M, Thicoïpé M, Petitjean ME, Sztark F, Lassié P, Masson F, Dabadie P. Description d'un protocole de prise en charge préhospitalière du traumatisé crânien grave. ACTA ACUST UNITED AC 2004; 23:109-15. [PMID: 15030859 DOI: 10.1016/j.annfar.2003.11.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2003] [Revised: 11/16/2003] [Accepted: 11/16/2003] [Indexed: 10/26/2022]
Abstract
OBJECTIVES To analyze the frequency of systemic factors leading to secondary brain insults in victims of serious head trauma in a prehospital setting and to evaluate a protocol for the advanced prehospital emergency care by mobile intensive care unit (i.e., the French Samu-Smur system). STUDY DESIGN Prospective study, over a period of 24 months. PATIENTS AND METHODS This prospective study involved 60 victims of severe head injuries (with the exception of polytrauma patients). Tracheal intubation was performed on each patient under direct laryngoscopy and after induction of anaesthesia (fentanyl-etomidate-rocuronium). Controlled ventilation and vascular loading (objectives: SpO(2) >or= 97%, PETCO(2) between 30 and 35 mmHg, SAP >or= 90 mmHg) were administered. RESULTS Hypoxaemia was found to be the most frequent cause of secondary insults (57% of patients with SpO(2) < 97%). In the case involving an accident that occurred 17 km from the hospital (with extremes of 6-65 km), the speed of medical intervention was note-worthy: tracheal intubation was performed 50 min after the accident, and the patient was admitted into a trauma centre 101 min after impact (median). However, faster intervention could be obtained if the transmission of the alert was improved. The conditions under which the tracheal intubation was performed were found to be satisfactory (difficult intubation 1.6%) without deteriorating the haemodynamic status. This is probably related to the use of muscle relaxants and the choice of etomidate as the first line hypnotic in the prehospital emergency care.
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Affiliation(s)
- E Tentillier
- Département des urgences, Samu 33, Smur, hôpital Pellegrin, CHU de Bordeaux, 33076 Bordeaux cedex, France.
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Pearson S. Comparison of intubation attempts and completion times before and after the initiation of a rapid sequence intubation protocol in an air medical transport program. Air Med J 2003; 22:28-33. [PMID: 14762994 DOI: 10.1016/j.amj.2003.08.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2023]
Abstract
The purpose of this study was to test the hypothesis that the initiation of a rapid sequence intubation (RSI) protocol would decrease the number of intubation attempts and completion times. In the summer of 2001, an RSI protocol was implemented using succinylcholine and etomidate. Before the RSI protocol, patients were sedated with versed and fentanyl for intubation and then paralyzed with succinylcholine to complete intubation, if needed. Retrospectively reviewed patient transport charts yielded 70 patients in the pre-RSI group and 70 patients in the RSI group. The number of attempts in the RSI group significantly dropped in the pre-RSI group, and the time from medication administration to intubation statistically decreased. In this study, the implementation of an RSI protocol resulted in fewer intubation attempts and more rapid intubations.
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Ummenhofer W, Scheidegger D. Role of the physician in prehospital management of trauma: European perspective. Curr Opin Crit Care 2002; 8:559-65. [PMID: 12454542 DOI: 10.1097/00075198-200212000-00013] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Advanced prehospital trauma life support is challenged as a whole. Formerly well-accepted basic principles for stabilizing vital functions of the severely injured patient like volume resuscitation, airway protection, and immobilization have been questioned. In prehospital management of trauma, the role of not only the physician but also the paramedic must be redefined. In the absence of evidence about the effectiveness of advanced trauma life support training for paramedic crews, the needs of trauma victims and capacities of emergency medical systems must be re-evaluated. Assessment of patients' conditions, including mechanism of trauma (blunt vs penetrating), source of hypovolemic shock (controlled vs ongoing hemorrhage), concomitant disease (as in elderly patients), and identification of therapeutic goals (such as for cerebral perfusion pressure or secondary brain damage caused by hypoxia in severe head injury), is a subject of increasing importance. Invasive airway management techniques require skills, expertise, and daily routines available only to experienced in-hospital personnel. The controversial issue of paramedic vs physician-based systems should be abandoned. It is the skill, the technique, the awareness of pitfalls, and the capability to handle complications that makes the difference, not the person in possession of the skill.
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Affiliation(s)
- Wolfgang Ummenhofer
- Department of Anesthesia, Kantonsspital/University Clinics, Basel, Switzerland.
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Abstract
There is a significant variation in the management of ICH by neurologists, neurosurgeons, and emergency physicians. Most of the randomized clinical therapeutic trials have focused on subarachnoid hemorrhage (SAH) and acute ischemic stroke (AIS). Well-organized practice guidelines are now available for the management of ICH. Exciting research areas are being aggressively explored. Medical and surgical interventions for SAH, AIS, and ICH are always time-dependent, which places additional responsibility on the EP to correctly and promptly recognize these conditions to prevent further injury. The time-dependent care of these patients places the EP on the front lines of future stroke care. Special thanks to Dr. Daniel Woo and Dr. Stewart Wright for their assistance in reviewing the manuscript and Amy Hess for preparation of the manuscript.
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Affiliation(s)
- Peter D Panagos
- Department of Emergency Medicine, University of Cincinnati Medical Center, P.O. Box 67069, Cincinnati, OH 45267-0769, USA.
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Suzuki H, Saitoh K, Inoue S, Hirabayashi Y, Seo N. Rapid sequence induction for penetrating head injury from a chopstick in a paediatric patient. Paediatr Anaesth 2002; 12:88-9. [PMID: 11849589 DOI: 10.1046/j.1460-9592.2002.0787g.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Gabriel EJ, Ghajar J, Jagoda A, Pons PT, Scalea T, Walters BC. Guidelines for prehospital management of traumatic brain injury. J Neurotrauma 2002; 19:111-74. [PMID: 11852974 DOI: 10.1089/089771502753460286] [Citation(s) in RCA: 81] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Affiliation(s)
- Edward J Gabriel
- Bureau of Operations-EMS Command, Fire Department, The City of New York, USA
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Abstract
The ultimate neurologic outcome following severe head trauma depends on the extent of primary brain insult sustained at the time of the trauma itself, and the subsequent neurochemical and neurophysiologic pathologic changes occurring as a result of the injury. Although there are currently no specific therapies that have proven to be consistently effective in reversing the devastating consequences of primary brain insult, the reduction or prevention of secondary brain insult is possible. The emergent resuscitation and care of the severely head injured patient can therefore impact the patient's final neurologic outcome. As new data are accumulated, traditional and new therapies for severe head injury have come under scrutiny. While no absolute standards have been advanced, guidelines have been established that can help direct the acute stabilization of severely head injured patients.
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Affiliation(s)
- M H Biros
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota 55421, USA.
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Butler JM, Clancy M, Robinson N, Driscoll P. An observational survey of emergency department rapid sequence intubation. Emerg Med J 2001; 18:343-8. [PMID: 11559603 PMCID: PMC1725654 DOI: 10.1136/emj.18.5.343] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To study the current practice of rapid sequence intubations (RSIs) in four different emergency medicine training programmes in the UK. METHODS Observational study design involving four regional training programmes (Wessex, North West, Yorkshire, Avon). Data were collected in real time using a previously piloted survey tool. Data were collected by specialist registrars in emergency medicine over a continuous 28 day period. Data collected included: indications for RSI; key timings of RSI procedures; details of RSI practitioner; complications and outcome of procedure. RESULTS Data from 60 RSIs were recorded and collected. The majority of decisions to perform RSIs were made by emergency physicians (74% cases). Over 50% of the RSIs occurred after 4 pm. Emergency physicians performed 26% of RSIs although the majority were performed by anaesthetists. Most of the given indications for RSIs were based on an assessment of airway protection. Hypoxia was an uncommon reason for RSI in this study (5%). In two thirds of cases the time taken from the decision being made to perform an RSI, to the achievement of successful intubation, was greater than 20 minutes. No failed intubations were recorded, although six other complications (all minor problems) were recorded. There was no significant difference in the response times between anaesthetists and emergency physicians. CONCLUSIONS This study shows that emergency physicians are currently performing RSIs in emergency departments in the UK. It also suggests improvements could be made to patient care. In particular, standards of care should be agreed for the provision of RSI in the emergency department, including the personnel involved and the appropriate training of individuals. RSI activity in emergency departments in the UK should be audited nationally using an agreed audit tool.
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Affiliation(s)
- J M Butler
- Emergency Department, Manchester Royal Infirmary, UK.
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Clancy M, Halford S, Walls R, Murphy M. In patients with head injuries who undergo rapid sequence intubation using succinylcholine, does pretreatment with a competitive neuromuscular blocking agent improve outcome? A literature review. Emerg Med J 2001; 18:373-5. [PMID: 11559609 PMCID: PMC1725690 DOI: 10.1136/emj.18.5.373] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
A literature search was undertaken for evidence of the effect of succinylcholine (SCH) on the intracranial pressure (ICP) of patients with acute brain injury and whether pretreatment with a defasciculating dose of competitive neuromuscular blocker is beneficial in this patient group. The authors could find no definitive evidence that SCH caused a rise in ICP in patients with brain injury. However, these studies were often weak and small. For those patients suffering acute traumatic brain injury the authors could find no studies that investigated the issue of pretreatment with defasciculating doses of competitive neuromuscular blockers and their effect on ICP in patients given SCH. There is level 2 evidence that SCH caused an increase in ICP for patients undergoing neurosurgery for brain tumours with elective anaesthesia and that pretreatment with defasciculating doses of neuromuscular blockers reduced such increases. It is unknown if this affects neurological outcome for this patient group.
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Affiliation(s)
- M Clancy
- Emergency Department, Southampton General Hospital, Tremona Road, Southampton SO16 6YD, UK.
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Boker A, Ong BY. Anesthesia for Cesarean section and posterior fossa craniotomy in a patient with von Hippel-Lindau disease. Can J Anaesth 2001; 48:387-90. [PMID: 11339783 DOI: 10.1007/bf03014969] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
PURPOSE To describe the care of a pregnant woman with von Hippel-Lindau disease (VHLD) and intracranial mass lesions. CLINICAL FEATURES A 30-yr-old primigravida with VHLD at 35 weeks gestation was seen at the obstetric anesthesia clinic because she wished an epidural analgesia during labour. She had a history of headaches and dizziness. Further investigations showed an enlarged cerebellar hemangioblastoma with significant local mass effects. A combined Cesarean section delivery and posterior fossa craniotomy was performed at 37 weeks gestation. A general anesthetic with fentanyl, rocuronium, nitrous oxide, oxygen and isoflurane was given for Cesarean section delivery. After delivery, isoflurane was reduced and propofol infusion at 4-8 mg x kg(-1) x hr(-1) was initiated. The patient had an uneventful operative course and recovery. CONCLUSIONS Patients with VHLD may have worsening of preexisting lesions or develop other lesions during pregnancy. Some asymptomatic lesions can increase the risk for anesthesia complications. These patients need comprehensive assessment before administration of anesthesia.
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Affiliation(s)
- A Boker
- Department of Anesthesia, University of Manitoba, Winnipeg, Canada
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Mackay CA, Terris J, Coats TJ. Prehospital rapid sequence induction by emergency physicians: is it safe? Emerg Med J 2001; 18:20-4. [PMID: 11310456 PMCID: PMC1725520 DOI: 10.1136/emj.18.1.20] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVES To determine if there were differences in practice or intubation mishap rate between anaesthetists and accident and emergency physicians performing rapid sequence induction of anaesthesia (RSI) in the prehospital setting. METHODS All patients who underwent RSI by a Helicopter Emergency Medical Service (HEMS) doctor from 1 May 1997 to 30 April 1999 were studied by retrospective analysis of in-flight run sheets. Intubation mishaps were classified as repeat attempts at intubation, repeat drug administration and failed intubation. RESULTS RSI was performed on 359 patients by 10 anaesthetists (202 patients) and nine emergency physicians (157 patients). Emergency physicians recorded a larger number of patients as having Cormack and Lehane grade 3 or 4 laryngoscopy than anaesthetists (p<0.0001) but were less likely to use a gum elastic bougie to assist intubation (p=0.024). Patients treated by emergency physicians did not have a significantly different pulse, blood pressure, oxygen saturation or end tidal CO2 to patients treated by anaesthetists at any time after intubation. Emergency physicians were more likely to anaesthetise patients with a Glasgow Coma Score >12 than anaesthetists (p=0.003). There were two failed intubations (1%) in the anaesthetist group and four (2.5%) in the emergency physician group. Repeat attempts at intubation and repeat drug administration occurred in <2% of each group. CONCLUSIONS RSI performed by emergency physicians was not associated with a significantly higher failure rate or an increased number of intubation mishaps than RSI performed by anaesthetists. Emergency physicians were able to safely administer sedative and neuromuscular blocking drugs in the prehospital situation. It is suggested that emergency physicians can safely perform rapid sequence induction of anaesthesia and intubation.
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Affiliation(s)
- C A Mackay
- Helicopter Emergency Medical Service, Royal London Hospital, Whitechapel.
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Monaghan M. Intravenous lignocaine as pretreatment for intubation of patients with acute severe head injury. Emerg Med Australas 2000. [DOI: 10.1046/j.1442-2026.2000.00158.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Abstract
The practice of emergency medicine is a constant onslaught of decision making and challenges and the issues of airway management are no exception. Obtaining proper airway control requires thoughtful organization and planning, and necessitates a thorough working knowledge of the drugs or medications employed. Because there are so many agents available, expertise in airway pharmacology has become essential. The emergency physician who is well versed in the uses, and the physiologic effects, contraindications, and alternatives of drugs administered is both providing immediate intervention and positively affecting patient outcome, which is certainly a goal worth achieving.
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Affiliation(s)
- P S Wadbrook
- Department of Emergency Medicine, Maricopa Medical Center, Phoenix, Arizona, USA
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Meyer G, Orliaguet G, Blanot S, Jarreau MM, Charron B, Sauverzac R, Carli P. Complications of emergency tracheal intubation in severely head-injured children. Paediatr Anaesth 2000; 10:253-60. [PMID: 10792740 DOI: 10.1046/j.1460-9592.2000.00496.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
A high incidence of unsuccessful attempts and complications has been reported when emergency tracheal intubation (ETI) is performed outside the hospital in severely injured children. The aim of this prospective series was to analyse the incidence and related risk factors of complications of emergency tracheal intubation. The time to complete successful ETI and occurrence of incidents, e.g. cough reflex, hypoxia or spasm were related to the experience of the physician performing intubation and the use of drugs to facilitate ETI. The incidence of hypoxia, hypercarbia, postintubation complications such as extubation stridor and long-term sequelae were noted. Of the 188 children, 78% were successfully intubated at the site of the accident, 10% upon arrival at a local hospital from where they were secondarily transferred and 12% upon admission to our trauma centre. The most severely injured children were intubated in the field in 98% of cases without failure, nor life-threatening complications related to ETI. The experience of the operator influenced the number of attempts and the time to complete successful intubation. Immediate incidents were noted in 25% of children, e.g. cough in 18%. The regimen of drugs, but not level of consciousness, influenced the incidence of immediate incidents; without drugs, more than 67% experienced incidents. Early tracheal intubation and controlled ventilation resulted in adequate ventilation upon arrival (mean PaO2 of 35.8+/-24 kPa, mean PaCO2 of 4.35+/-1 kPa). Long-term complications, including transient stridor upon extubation in 33% of the cases, and laryngeal granuloma or tracheal stenosis, were comparable to those in other series. ETI in shocked patients and pulmonary infection in hospital, but not the technique of ETI, increased the risks of long-term complications. Emergency tracheal intubation can be performed safely in the field, and results in adequate ventilation during transportation of severely injured children, provided that it can be performed by trained physicians using adequate drugs to facilitate intubation.
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Affiliation(s)
- G Meyer
- Département d'Anesthésie-Réanimation et SAMU de Paris, Paris, France
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Abstract
INTRODUCTION Decision-making is an integral part of quality patient care. The aim of this study was to evaluate decision-making documentation. METHODS A retrospective descriptive design was used to examine the documentation for a convenience sample of 48 trauma patients transported by rotor-wing aircraft. RESULTS A total of 1012 decisions were documented in the 48 records. The decisions were grouped into major conceptual problems. An average of 10.2 +/- 4.56 conceptual problems were identified in each record. The top 10 conceptual problems were evaluated. Adequate documentation was found to support all decision-making related to the top 10 problems. CONCLUSION Although air medical personnel may not directly document statements of rationale for their decision-making, sufficient data were present in the records to support each documented decision.
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Affiliation(s)
- C Strong
- University of Utah College of Nursing, Salt Lake City, Utah, USA
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Rodricks MB, Deutschman CS. Emergent airway management. Indications and methods in the face of confounding conditions. Crit Care Clin 2000; 16:389-409. [PMID: 10941580 DOI: 10.1016/s0749-0704(05)70119-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Optimal airway management requires an experienced caregiver, attention to detail, and knowledge of the patient's physiology. A variety of pharmacologic agents have proved useful in obtaining a secure airway and minimizing risk to the patient. Depending on the skills of the caregiver, oral intubation has become the preferred means of airway control in most patients. Advances in technique, equipment, and pharmacology have greatly improved the art of airway management; however, there is no substitute for an experienced clinician.
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Affiliation(s)
- M B Rodricks
- Department of Anesthesia, University of Pennsylvania School of Medicine, Philadelphia, USA
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Olsen JC, Gurr DE, Hughes M. Video analysis of emergency medicine residents performing rapid-sequence intubations. J Emerg Med 2000; 18:469-72. [PMID: 10802428 DOI: 10.1016/s0736-4679(00)00168-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The purpose of this study was to evaluate Emergency Medicine resident physicians' compliance with our institution's rapid sequence intubation (RSI) protocol by the use of videotape analysis. We conducted a prospective, observational study of Emergency Medicine resident physicians (EM 1,2,3) as they were videotaped performing RSI on medical and trauma patients. The videotapes were reviewed by the study investigators to assess the rates of deviation from our standard RSI protocol. Forty-four RSIs performed by 33 residents were studied. The most common deviations from our standard RSI protocol concerned proper use of the Sellick maneuver (45%) and use of the end-tidal CO(2) detector (34%). Videotape analysis provides an objective measure of Emergency Medicine resident performance of RSI.
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Affiliation(s)
- J C Olsen
- Department of Emergency Medicine, Lutheran General Hospital, Park Ridge, Illinois 60068, USA
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Tentillier E, Ammirati C. [Prehospital management of patients with severe head injuries]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2000; 19:275-81. [PMID: 10836114 DOI: 10.1016/s0750-7658(99)00147-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Advanced prehospital emergency medical care of patients with a severe head injury must essentially focus on the impact of secondary cerebral insults of systemic origin on the outcome. The first objective of prehospital care is to prevent hypoxaemia and hypercapnia. Therefore, all patients with a Glasgow Coma Scale score equal to or lower than 8 must be treated with endotracheal intubation and controlled ventilation under continuous monitoring of SpO2 and PETCO2. Treatment is similar in head-injured patients with significant deterioration of consciousness level, seizures, respiratory distress, or severe facial and thoracoabdominal injuries. The endotracheal tube is inserted by the orotracheal route under direct laryngoscopy, after a rapid induction sequence of anaesthesia and immobilization of the cervical spine in neutral position. For the induction of anaesthesia in these high-risk patients (full stomach, unknown medical history, deteriorated haemodynamic status), etomidate and suxamethonium are the preferred agents. Sedation is maintained with an hypnoticopioid association (fentanyl). Simultaneously, the main goal is the maintenance of an optimal cerebral perfusion pressure, as arterial hypotension severely worsens cerebral ischaemia. Volume loading is accomplished with 0.9% saline and hydroxyethyl starch.
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Sams J, Kelly AM. Use of an emergency sedation protocol to assist intubation in helicopter patient retrieval in Victoria. Emerg Med Australas 1999. [DOI: 10.1046/j.1442-2026.1999.00019.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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