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Grissom TE, Samet RE. The Anesthesiologist's Role in Teaching Airway Management to Nonanesthesiologists: Who, Where, and How. Adv Anesth 2021; 38:131-156. [PMID: 34106831 PMCID: PMC7534755 DOI: 10.1016/j.aan.2020.08.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- Thomas E Grissom
- Department of Anesthesiology, University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, T1R77, 22 South Greene Street, Baltimore, MD 21201, USA.
| | - Ron E Samet
- Department of Anesthesiology, University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, T1R77, 22 South Greene Street, Baltimore, MD 21201, USA
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Gillett B, Saloum D, Aghera A, Marshall JP. Skill Proficiency is Predicted by Intubation Frequency of Emergency Medicine Attending Physicians. West J Emerg Med 2019; 20:601-609. [PMID: 31316699 PMCID: PMC6625678 DOI: 10.5811/westjem.2019.6.42946] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Accepted: 06/05/2019] [Indexed: 11/30/2022] Open
Abstract
Introduction Airway management is a fundamental skill of emergency medicine (EM) practice, and suboptimal management leads to poor outcomes. Endotracheal intubation (ETI) is a procedure that is specifically taught in residency, but little is known how best to maintain proficiency in this skill throughout the practitioner’s career. The goal of this study was to identify how the frequency of intubation correlated with measured performance. Methods We assessed 44 emergency physicians for proficiency at ETI by direct laryngoscopy on a simulator. The electronic health record was then queried to obtain their average number of annual ETIs and the time since their last ETI, supervised and individually performed, over a two-year period. We evaluated the strength of correlation between these factors and assessment scores, and then conducted a receiver operator characteristic (ROC) curve analysis to identify factors that predicted proficient performance. Results The mean score was 81% (95% confidence interval, 76% – 86%). Scores correlated well with the mean number of ETIs performed annually and with the mean number supervised annually (r = 0.6, p = 0.001 for both). ROC curve analysis identified that physicians would obtain a proficient score if they had performed an average of at least three ETIs annually (sensitivity = 90%, specificity = 64%, AUC = 0.87, p = 0.001) or supervised an average of at least five ETIs annually (sensitivity = 90%, specificity = 59%, AUC = 0.81, p = 0.006) over the previous two years. Conclusion Performing at least three or supervising at least five ETIs annually, averaged over a two-year period, predicted proficient performance on a simulation-based skills assessment. We advocate for proactive maintenance and enhancement of skills, particularly for those who infrequently perform this procedure.
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Affiliation(s)
- Brian Gillett
- Maimonides Medical Center, Department of Emergency Medicine, Brooklyn, New York
| | - David Saloum
- Maimonides Medical Center, Department of Emergency Medicine, Brooklyn, New York
| | - Amish Aghera
- Maimonides Medical Center, Department of Emergency Medicine, Brooklyn, New York
| | - John P Marshall
- Maimonides Medical Center, Department of Emergency Medicine, Brooklyn, New York
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3
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Chiaghana C, Giordano C, Cobb D, Vasilopoulos T, Tighe PJ, Sappenfield JW. Emergency Department Airway Management Responsibilities in the United States. Anesth Analg 2019; 128:296-301. [DOI: 10.1213/ane.0000000000003851] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Affiliation(s)
- Colin A Graham
- Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, Trauma and Emergency Centre, Prince of Wales Hospital, Shatin, New Territories, Hong Kong.
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5
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Abstract
The ability of the emergency physician to recognize and manage a patient with a compromised airway is probably the most important aspect of an individual’s care in the emergency department. Endotracheal intubation in a critically ill patient is a potentially hazardous procedure because of the technical difficulties that can be encountered during emergency airway management and the profound pathophy siological changes that the institution of mechanical ventilation can cause. This review article sets out to illustrate when invasive airway management should be considered and the potential consequences of attempts to perform endotracheal intubation and mechanical ventilation.
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Affiliation(s)
| | - Mav Manji
- University Hospital Birmingham NHS Trust, Birmingham, UK,
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Pugh HEJ, LeClerc S, Mclennan J. A review of pre-admission advanced airway management in combat casualties, Helmand Province 2013. J ROY ARMY MED CORPS 2014; 161:121-6. [PMID: 25138107 DOI: 10.1136/jramc-2014-000271] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2014] [Accepted: 07/19/2014] [Indexed: 11/03/2022]
Abstract
OBJECTIVES Airway compromise is the third leading cause of potentially preventable combat death. Pre-hospital airway management has lower success rates than in hospital. This study reviewed advanced airway management focusing on cricothyroidotomies and supraglottic airway devices in combat casualties prior to admission to a Role 3 Hospital in Afghanistan. METHODS This was a retrospective review of all casualties who required advanced airway management prior to arrival at the Role 3 Hospital, Bastion, Helmand Province over a 30-week period identified by the US Joint Theatre Trauma Registry. The notes and relevant X-rays were analysed. The opinions of US and UK clinical Subject Matter Experts (SME) were then sought. RESULTS Fifty-seven advanced airway interventions were identified. 45 casualties had attempted intubations, 37 (82%) were successful and of those who had failed intubations, one had a King LT Airway (supraglottic device) and seven had a rescue cricothyroidotomy. The other initial advanced airway interventions were five attempted King LT airways and seven attempted cricothyroidotomies. In total, 14 cricothyroidotomies were performed; in this group, there were nine complications/significant events. CONCLUSIONS The SMEs suggested that dedicated surgical airway kits should be used and students in training should be taught to secure the cricothyroidotomy tube as well as how to insert it. This review re-emphasises the need to 'ensure the right person, with the right equipment and the right training, is present at the right time if we are to improve the survival of patients with airway compromise on the battlefield'. The audit reference number is RCDM/Res/Audit/1036/12/0368.
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Affiliation(s)
- Harry E J Pugh
- 16 Medical Regiment, 144 Parachute Medical Squadron (V), Colchester, UK
| | - S LeClerc
- Academic Department of Military Medicine, Birmingham, UK
| | - J Mclennan
- Emergency Department, Manchester Royal Infirmary, Manchester, UK
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7
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Roth D, Schreiber W, Stratil P, Pichler K, Havel C, Haugk M. Airway management of adult patients without trauma in an ED led by internists. Am J Emerg Med 2013; 31:1338-42. [PMID: 23845473 DOI: 10.1016/j.ajem.2013.06.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Revised: 05/31/2013] [Accepted: 06/01/2013] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Airway management is a key competence in emergency medicine. Patients heavily differ from those in the operating room. They are acutely ill by definition and usually not fasting. Evaluation of risk factors is often impossible. Current literature primarily originates from countries where emergency medicine is an independent specialty. We evaluated intubations in a high-volume emergency department run by internists and comprising its own distinctive intensive care unit. METHODS In this prospective, noncontrolled, observational study, we continuously documented all intubations performed at the emergency department. We analyzed demographic, medical, and staff-related factors predicting difficulties during intubation using logistic regression models. RESULTS For 73 months, 660 cases were included, 69 (10.5%) of them were without any induction therapy. Two hundred fifty-two (38.2%) patients were female, and their mean age was 59 ± 17 years. Three hundred four (49.9%) had an initial Glasgow Coma Scale of 3. Leading indications were respiratory insufficiency (n = 246; 37.3%), resuscitation (n = 172; 26.1%), and intracranial hemorrhage (n = 75; 11.4%). First attempt was successful in 465 cases (75.1%); alternative airway devices were used in 22 cases (3.3%). Time from the first intubation attempt to a validated airway was 1 minute (interquartile range, 0-2 minutes). Physicians' experience and anatomical risk factors were associated with failure at the first attempt, prolonged intubation, and the need for alternative devices. CONCLUSIONS Airway management at the emergency department possesses a high potential of failure. Experience seems to be the key to success.
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Affiliation(s)
- Dominik Roth
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
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8
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HELM M, KREMERS G, LAMPL L, HOSSFELD B. Incidence of transient hypoxia during pre-hospital rapid sequence intubation by anaesthesiologists. Acta Anaesthesiol Scand 2013; 57:199-205. [PMID: 23210510 DOI: 10.1111/aas.12032] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/04/2012] [Indexed: 11/27/2022]
Abstract
BACKGROUND Pre-hospital tracheal intubation (TI) is an important but difficult procedure with the potential to produce hypoxaemia. The aim of this study was to determine the incidence of desaturation episodes during out-of-hospital rapid sequence induction (RSI) and TI by the medical team of a German Helicopter Emergency Medical Service (HEMS). METHODS We performed a prospective study at HEMS 'CHRISTOPH 22'. TI was performed as RSI according to a standard protocol. Desaturation was defined as a reduction in SpO(2) below 90% or a reduction of more than 10% from baseline SpO(2) when initial values were less than 90%. RESULTS The RSI/TI manoeuvre was attempted in 150 patients [107 male (71.3%); median age 40 years (IQR 21-61); overall success rate 100%]. The incidence of desaturation episodes was 13.3% with a median duration of 50 sec. (IQR 30-92) and a median SpO(2) decrease of 24 ± 10%. Upon hospital admission, all patients had SpO(2) values ≥ 96%. In the desaturation group the duration of successful TI was significantly longer [median 85 sec. (IQR 60-119) vs. median 63 sec. (IQR 48-70); P < 0.01], and the number of patients with a baseline SpO(2) ≥ 90% was significantly lower (65.0% vs. 88.5%; P < 0.01). Among patients with difficult to manage airway, those with desaturation were significantly younger, and technical problems were significantly more frequent. CONCLUSION The incidence of episodes of desaturation during pre-hospital RSI/TI at HEMS Ulm is relatively low, and the duration of such episodes is short.
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Affiliation(s)
- M. HELM
- Department of Anaesthesiology and Intensive Care Medicine; Section Emergency Medicine; Federal Armed Forces Medical Centre; Ulm; Germany
| | - G. KREMERS
- Department of Anaesthesiology and Intensive Care Medicine; Section Emergency Medicine; Federal Armed Forces Medical Centre; Ulm; Germany
| | - L. LAMPL
- Department of Anaesthesiology and Intensive Care Medicine; Section Emergency Medicine; Federal Armed Forces Medical Centre; Ulm; Germany
| | - B. HOSSFELD
- Department of Anaesthesiology and Intensive Care Medicine; Section Emergency Medicine; Federal Armed Forces Medical Centre; Ulm; Germany
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9
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BERNHARD M, MOHR S, WEIGAND MA, MARTIN E, WALTHER A. Developing the skill of endotracheal intubation: implication for emergency medicine. Acta Anaesthesiol Scand 2012; 56:164-71. [PMID: 22060976 DOI: 10.1111/j.1399-6576.2011.02547.x] [Citation(s) in RCA: 121] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/24/2011] [Indexed: 12/01/2022]
Abstract
BACKGROUND Securing the airway by means of endotracheal intubation (ETI) represents a fundamental skill for anaesthesiologists in emergency situations. This study aimed to evaluate the time needed by first-year anaesthesiology residents to perform 200 ETIs and assessed the associated success rates and number of attempts until successful ETI. METHODS This prospective single centre study evaluated the number of working days, the success rate, the attempts needed until successful ETI in consecutive blocks of 25 ETI procedures and the related difficulties and complications. RESULTS From 2007 to 2010, 21 residents were evaluated consecutively. These residents needed a mean (mean ± standard deviation) of 15.6 ± 3.0 days for 25 ETIs. Out of all residents 52% reached the target value of 200 ETIs after 50.2 ± 14.8 weeks of total working time. The ETI success rate after the first 25 ETIs increased steadily to the results after 200 ETIs (ETI success rate within one ETI attempt: 67% vs. 83%, P = 0.0001; ETI success rate within all ETI attempts: 82% vs. 92%, P = 0.0001). The number of attempts required until successful ETI decreased from 1.6 ± 0.8 after the first 25 ETIs to 1.3 ± 0.6 after 200 ETIs (P = 0.0001). CONCLUSION The increasing rate of relative ETI success and the decreasing rate of necessary attempts for successful airway management suggest a steadily increasing gain in ETI experience. The complications that developed during the first 200 ETI procedures justify supervision by a specialist in the field or a senior physician. Moreover, these results may influence the minimum requirement for qualification in anaesthesiology and emergency medicine.
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Affiliation(s)
| | - S. MOHR
- Department of Anaesthesiology; University Hospital of Heidelberg; Heidelberg; Germany
| | | | - E. MARTIN
- Department of Anaesthesiology; University Hospital of Heidelberg; Heidelberg; Germany
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Gangadharan L, Sreekanth C, Vasnaik MC. Prediction of difficult intubations using conventional indicators: Does rapid sequence intubation ease difficult intubations? A prospective randomised study in a tertiary care teaching hospital. J Emerg Trauma Shock 2011; 4:42-7. [PMID: 21633566 PMCID: PMC3097578 DOI: 10.4103/0974-2700.76836] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2010] [Accepted: 09/17/2010] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Endotracheal intubations performed in the Emergency Department. AIMS To assess whether conventional indicators of difficult airway can predict a difficult intubation in the Emergency Setting and to investigate the effect of rapid sequence intubation (RSI) on ease of intubation. SETTINGS AND DESIGN A prospective randomized study was designed involving 60 patients requiring intubation, over a period of 4 months. MATERIALS AND METHODS Demographic profile, details of methods used, airway assessment, ease of intubation, and Cormack and Lehane score were recorded. Airway assessment score and ease of intubation criteria were devised and assessed. STATISTICAL ANALYSIS Descriptive statistical analysis was carried out. Chi-square/2 × 2, 2 × 3, 3 × 3, Fisher Exact test have been used to find the significance of study parameters on categorical scale between two or more groups. RESULTS Patients with a Mallampatti score of three or four were found to have worse laryngoscopic views (Cormack-Lehane score, 3 or 4). Of all airway indicators assessed, an increased Mallampatti score was found to have significant correlation with increased difficulty in intubation. The use of RSI was associated with better laryngoscopic views, and easier intubations. CONCLUSIONS An airway assessment using the Mallampatti score is invaluable as a tool to predict a difficult airway and should be performed routinely if possible. RSI aids intubation ease. If not otherwise contraindicated, it should be performed routinely for all intubations in the ED.
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Affiliation(s)
- Lakshmi Gangadharan
- Department of Emergency Medicine, St. Johns' Medical College and Hospital, Bangalore, India
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11
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Cavus E, Neumann T, Doerges V, Moeller T, Scharf E, Wagner K, Bein B, Serocki G. First clinical evaluation of the C-MAC D-Blade videolaryngoscope during routine and difficult intubation. Anesth Analg 2010; 112:382-5. [PMID: 21156978 DOI: 10.1213/ane.0b013e31820553fb] [Citation(s) in RCA: 85] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
In the present preliminary study we evaluated the C-MAC® D-Blade (Karl Storz, Tuttlingen, Germany), a new videolaryngoscopic C-MAC blade for difficult intubation, during both routine and difficult intubations. First, both the conventional direct laryngoscopy and the D-Blade were used in 15 consecutive patients with normal airways during routine induction of anesthesia. Second, the D-Blade was used as a rescue device in 20 of 300 (6.7%) consecutive patients, when conventional direct laryngoscopy failed. In the 15 patients during routine induction of anesthesia, with direct laryngoscopy, a Cormack-Lehane (C/L) grade 1 and grade 2a view was seen in 7 and 8 patients, respectively. It was possible to insert the D-Blade and to get a video view of the glottis on the first attempt in all patients; with the D-Blade, all 15 patients had a C/L 1 view. The time to successful intubation with the D-Blade was 15 (8-26) seconds (median (range)). In the 20 patients, in whom unexpected difficulty with direct laryngoscopy was observed, C/L grades 3 and 4 were present in 15 and 5 patients, respectively. With the use of the D-Blade, indirect C/L video view improved to C/L class 1 in 15 patients, and to 2a in 5 patients, respectively. The time from touching the laryngoscope to optimal laryngoscopic view was 11 (5-45) seconds and for successful intubation 17 (3-80) seconds. In all 35 patients, with the D-Blade no direct view of the glottis was possible and subsequently a semiflexible tube guide was required.
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Affiliation(s)
- Erol Cavus
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Campus Kiel, Schwanenweg 21, D-24105 Kiel, Germany.
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12
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Aghdashi MM, Abassivash R, Hassani E. Intralingual tracheal intubation! ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2007; 26:889-90. [PMID: 17693050 DOI: 10.1016/j.annfar.2007.07.072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
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Corfield AR, Thomas L, Inglis A, Hearns S. A rural emergency medical retrieval service: the first year. Emerg Med J 2007; 23:679-83. [PMID: 16921078 PMCID: PMC2564207 DOI: 10.1136/emj.2006.034355] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION We describe the first year of operation of a rural emergency medical retrieval service (EMRS), staffed by emergency medicine and anaesthetic consultants and providing air based retrieval of critically ill and injured patients from general practitioner led community hospitals in rural west Scotland. METHODS Data were collected on all patients referred to the service, both those subsequently transported and those where transport by the service was not indicated, for a period of 1 year from 1 October 2004 to 30 September 2005. Data collected included information on demographics, physiology, and medical interventions. Detailed data were collected regarding advanced airway care and any complications relating to transfer. RESULTS Forty patients were attended and advice was given on a further 21 patients. Twenty one of the 40 patients (53%) required rapid sequence intubation prior to transfer. The median Injury Severity Score (ISS) for trauma patients was 26 (range 2-59). The median Acute Physiology and Chronic Health Evaluation (APACHE) II score for all patients was 11 (range 2-37). CONCLUSION Our data show a high level of acuity among this patient group and a need for advanced medical intervention to ensure safe transfer.
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Affiliation(s)
- A R Corfield
- Emergency Medicine, Royal Alexandra Hospital, Paisley, PA2 9PN, UK.
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Stevenson AGM, Graham CA, Hall R, Korsah P, McGuffie AC. Tracheal intubation in the emergency department: the Scottish district hospital perspective. Emerg Med J 2007; 24:394-7. [PMID: 17513533 PMCID: PMC2658270 DOI: 10.1136/emj.2006.041988] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Tracheal intubation is the accepted gold standard for emergency department (ED) airway management. It may be performed by both anaesthetists and emergency physicians (EPs), with or without drugs. OBJECTIVE To characterise intubation practice in a busy district general hospital ED in Scotland over 40 months between 2003 and 2006. SETTING Crosshouse Hospital, a 450-bed district general hospital serving a mixed urban and rural population; annual ED census 58,000 patients. METHODS Prospective observational study using data collection sheets prepared by the Scottish Trauma Audit Group. Proformas were completed at the time of intubation and checked by investigators. Rapid-sequence induction (RSI) was defined as the co-administration of an induction agent and suxamethonium. RESULTS 234 intubations over 40 months, with a mean of 6 per month. EPs attempted 108 intubations (46%). Six patients in cardiac arrest on arrival were intubated without drugs. 29 patients were intubated after a gas induction or non-RSI drug administration. RSI was performed on 199 patients. Patients with trauma constituted 75 (38%) of the RSI group. 29 RSIs (15%) were immediate (required on arrival at the ED) and 154 (77%) were urgent (required within 30 min of arrival at the ED). EPs attempted RSI in 88 (44%) patients and successfully intubated 85 (97%). Anaesthetists attempted RSI in 111 (56%) patients and successfully intubated 108 (97%). Anaesthetists had a higher proportion of good views at first laryngoscopy and there was a trend to a higher rate of successful intubation at the first attempt for anaesthetists. Complication rates were comparable for the two specialties. CONCLUSIONS Tracheal intubations using RSI in the ED are performed by EPs almost as often as by anaesthetists in this district hospital. Overall success and complication rates are comparable for the two specialties. Laryngoscopy training and the need to achieve intubation at the first (optimum) attempt needs to be emphasised in EP airway training.
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Affiliation(s)
- A G M Stevenson
- Department of Emergency Medicine, Crosshouse Hospital, Kilmarnock KA2 0BE, UK
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15
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Abstract
Prehospital anaesthesia is carried out regularly by a small number of prehospital care practitioners in the UK. Although mostly predictable, prehospital disorders can be more difficult than those in hospital, and, in addition, peer and skilled anaesthetic assistance is usually not available. Hence, patient safety should be given paramount importance, and systems need to be in place to ensure that the highest standards are achieved.
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Affiliation(s)
- Colin A Graham
- Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, Trauma and Emergency Centre, Prince of Wales Hospital, Shatin, New Territories, Hong Kong.
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Graham CA. Advanced airway management in the emergency department: what are the training and skills maintenance needs for UK emergency physicians? Emerg Med J 2005; 21:14-9. [PMID: 14734367 PMCID: PMC1756338 DOI: 10.1136/emj.2003.003368] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
This article reviews the evidence for the training of emergency physicians in advanced airway management.
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Affiliation(s)
- C A Graham
- Accident and Emergency Department, Southern General Hospital, Glasgow G51 4TF, UK.
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18
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Keul W, Bernhard M, Völkl A, Gust R, Gries A. Methoden des Atemwegsmanagements in der pr�klinischen Notfallmedizin. Anaesthesist 2004; 53:978-92. [PMID: 15502884 DOI: 10.1007/s00101-004-0734-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
In the majority of emergency situations definite airway control can be achieved by endotracheal intubation with or without preceding bag valve mask ventilation. However, both techniques can fail because of many different reasons. Therefore, alternative techniques for routine anaesthesia and emergency situations are required. In the present article difficulties that may arise using bag valve mask ventilation and endotracheal intubation are discussed and an overview of available alternatives is given.
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Affiliation(s)
- W Keul
- Klinik für Anaesthesiologie, Bereich Notfallmedizin, Ruprecht-Karls-Universität, Heidelberg.
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Kovacs G, Law JA, Ross J, Tallon J, MacQuarrie K, Petrie D, Campbell S, Soder C. Acute airway management in the emergency department by non-anesthesiologists. Can J Anaesth 2004; 51:174-80. [PMID: 14766697 DOI: 10.1007/bf03018780] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
PURPOSE The responsibility of acute airway management often falls into the hands of non-anesthesiologists. Emergency physicians now routinely use neuromuscular blockade to facilitate intubation. The literature in support of this practice has almost exclusively been published in emergency medicine (EM) journals. This body of literature is presented and issues of educational support are discussed. SOURCE A narrative review of the literature on the practice of airway management by non-anesthesiologists. PRINCIPAL FINDINGS A significant proportion of acute airway management occurring outside the operating room is being performed by non-anesthesiologists. Rapid sequence intubation (RSI) is recognized as a core procedure within the domain of EM. RSI is being performed routinely by emergency physicians practicing in larger centres. Anesthesiologist support for the practice of RSI by non-anesthesiologists has been weak. Formal educational support outside of postgraduate training in the form of dedicated programs for advanced airway management are now being offered. The majority of the literature on the use of RSI by non-anesthesiologists represents retrospective case series, observational studies and registry data published in EM journals. The reported success rates for RSI performed by non-anesthesiologists is high. Complication rates are significant, however reporting consistency has been poor. CONCLUSIONS The role of non-anesthesiologists in acute airway management is significant. Despite shortcomings in methodology, current evidence and practice supports the use of RSI by trained emergency physicians. Constructive collaborative efforts between anesthesiology and EM need to occur to ensure that educational needs are met and that competent airway management is provided.
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Affiliation(s)
- George Kovacs
- Department of Emergency Medicine, Dalhousie University, Halifax, Nova Scotia, Canada.
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20
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Graham CA, Beard D, Henry JM, McKeown DW. Rapid sequence intubation of trauma patients in Scotland. ACTA ACUST UNITED AC 2004; 56:1123-6. [PMID: 15179256 DOI: 10.1097/01.ta.0000109066.62811.8a] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Endotracheal intubation remains the gold standard for trauma airway management. Rapid sequence intubation (RSI) has traditionally been performed by anesthesiologists but increasingly, emergency physicians are also undertaking RSI. We aimed to compare success and complication rates for trauma intubations for the two specialties. METHODS Two year, prospective multi-center descriptive study of trauma RSI in seven Scottish urban emergency departments. RESULTS 439 trauma patients were identified, including 233 RSIs. Patients intubated by emergency physicians had a higher median ISS (p < 0.001) and lower median RTS (p < 0.001) compared with anesthesiologists. For RSI, anesthesiologists had more grade I & II views at laryngoscopy (p = 0.051) and more successful first attempt intubations (p = 0.034) but there was no difference in the number of patients suffering complications (emergency physicians 10.0%, anesthesiologists 10.6%). CONCLUSION There is no significant difference in complication rates for trauma RSI between emergency physicians and anesthesiologists in Scottish urban centers. A collaborative approach to the critical trauma airway is vital. Emergency physicians should consult with senior anesthesiologists before RSI when intubation is predicted to be difficult.
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Affiliation(s)
- Colin A Graham
- Emergency Medicine, Southern General Hospital, Glasgow, Scotland.
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21
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Yarrow S, Hare J, Robinson KN. Recent trends in tracheal intubation: a retrospective analysis of 97904 cases. Anaesthesia 2003; 58:1019-22. [PMID: 12969046 DOI: 10.1046/j.1365-2044.2003.03361.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
We conducted a review of routine anaesthetic audit data collected between April 1995 and December 2001 at Northampton General Hospital. A total of 97 904 anaesthetics were given. The average monthly rate of tracheal intubation fell during the study period from approximately 450 per month to approximately 280 per month. This was largely at the expense of tracheal tubes used during normal working hours, which fell by 40% (from approximately 390 per month to approximately 230 per month). Use outside normal working hours did not change. Of those cases managed in normal working hours with a tracheal tube, the decline in use over time was most obvious in patients of ASA physical status 1-2, and whose surgery was classified as elective or scheduled. The proportion of cases classified as ASA 3-5 or whose surgery was urgent or emergency increased (from 15.5% to 22.3%, and from 7.5% to 15.5%, respectively.) There was considerable variation across surgical specialities, with the greatest decline in tracheal intubation in head and neck surgery. These changes in practice have implications for the teaching of airway management skills.
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Affiliation(s)
- S Yarrow
- Department of Anaesthesia & Intensive Care, Northampton General Hospital, Billing Road, Cliftonville, Northampton, UK.
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