1
|
Ljungqvist H, Tommila M, Setälä P, Raatiniemi L, Pulkkinen I, Toivonen P, Nurmi J. Front of neck airway in Finnish helicopter emergency medical services. Injury 2024; 55:111689. [PMID: 38924838 DOI: 10.1016/j.injury.2024.111689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Revised: 06/03/2024] [Accepted: 06/17/2024] [Indexed: 06/28/2024]
Abstract
INTRODUCTION An emergent front of neck airway (FONA) is needed when a 'can't intubate, can't oxygenate' crisis occurs. A FONA may also in specific cases be the primary choice of airway management. Two techniques exist for FONA, with literature favouring the surgical technique over the percutaneous. The reported need for a prehospital FONA is fortunately rare as the mortality has been shown to be high. Due to the low incidence, literature on FONA is limited with regards to different settings, techniques and operators. As a foundation for future research and improvement of patient care, we aim to describe the frequency, indications, technique, success, and outcomes of FONA in the Finnish helicopter emergency medical services (HEMS). MATERIALS AND METHODS This retrospective descriptive study reviews FONA performed at the Finnish HEMS during 1.1.2012 to 8.9.2019. The Finnish HEMS consists of six units, staffed mainly by anaesthesiologists. Clinical data was gathered from a national HEMS database and trough chart reviews. Data on mortality was obtained from a population registry. Only descriptive statistics were performed. RESULTS A total of 22 FONA were performed during the study period, 7 were primary and 14 performed after failure to intubate (missing data regarding indication for one attempt). This equals a 0.13 % (14/10,813) need for a rescue FONA and a rate of 0.20 % (22/10,813) FONA out of all advanced airway management. All but one FONA was performed using a surgical approach (20/21, 95 %, missing data = 1) and all were successful (22/22, 100 %). Indications were mainly cardiac arrest (10/22, 45 %) and trauma (6/22, 27 %), and the most common reason for a need for a secondary FONA was obstruction of airway by food or fluids (7/14, 50 %). On-scene mortality was 36 % (8/22) and 30-day mortality 90 % (19/21, missing data = 1). CONCLUSION The need for FONA is scarce in a HEMS system with experienced airway providers. Even though the procedure is successfully performed, the mortality is markedly high.
Collapse
Affiliation(s)
- Harry Ljungqvist
- Emergency Medicine and Services, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Miretta Tommila
- Department of Perioperative Services, Intensive Care Medicine and Pain Management, Turku University Hospital and University of Turku, Turku, Finland
| | - Piritta Setälä
- Centre for Prehospital Emergency Care, Tampere University Hospital, Tampere, Finland
| | - Lasse Raatiniemi
- Research Group of Surgery, Anaesthesiology and Intensive Care, Medical Research Centre, University of Oulu, Oulu, Finland and Department of air ambulance, University Hospital of North Norway, Tromsoe, Norway
| | - Ilkka Pulkkinen
- Prehospital Emergency Care, Lapland Hospital District, Rovaniemi, Finland
| | - Pamela Toivonen
- Centre for Prehospital Emergency Care, Kuopio University Hospital, Kuopio, Finland
| | - Jouni Nurmi
- Emergency Medicine and Services, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
| |
Collapse
|
2
|
Liu J, Ma L, Hu C, Kang J, Zhang B, Li R, Liao H. A robot-assisted tracheal intubation system based on a soft actuator? Int J Comput Assist Radiol Surg 2024; 19:1495-1504. [PMID: 38862746 DOI: 10.1007/s11548-024-03209-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 05/30/2024] [Indexed: 06/13/2024]
Abstract
PURPOSE Tracheal intubation is the gold standard of airway protection and constitutes a pivotal life-saving technique frequently employed in emergency medical interventions. Hence, in this paper, a system is designed to execute tracheal intubation tasks automatically, offering a safer and more efficient solution, thereby alleviating the burden on physicians. METHODS The system comprises a tracheal tube with a bendable front end, a drive system, and a tip endoscope. The soft actuator provides two degrees of freedom for precise orientation. It is fabricated with varying-hardness silicone and reinforced with fibers and spiral steel wire for flexibility and safety. The hydraulic actuation system and tube feeding mechanism enable controlled bending and delivery. Object detection of key anatomical features guides the robotic arm and soft actuator. The control strategy involves visual servo control for coordinated robotic arm and soft actuator movements, ensuring accurate and safe tracheal intubation. RESULTS The kinematics of the soft actuator were established using a constant curvature model, allowing simulation of its workspace. Through experiments, the actuator is capable of 90° bending as well as 20° deflection on the left and right sides. The maximum insertion force of the tube is 2 N. Autonomous tracheal intubation experiments on a training manikin were successful in all 10 trials, with an average insertion time of 45.6 s. CONCLUSION Experimental validation on the manikin demonstrated that the robot tracheal intubation system based on a soft actuator was able to perform safe, stable, and automated tracheal intubation. In summary, this paper proposed a safe and automated robot-assisted tracheal intubation system based on a soft actuator, showing considerable potential for clinical applications.
Collapse
Affiliation(s)
- Jiayuan Liu
- School of Biomedical Engineering, Tsinghua University, Beijing, 100084, China
| | - Longfei Ma
- School of Biomedical Engineering, Tsinghua University, Beijing, 100084, China
| | - Chengquan Hu
- School of Biomedical Engineering, Tsinghua University, Beijing, 100084, China
| | - Jingyi Kang
- School of Biomedical Engineering, Tsinghua University, Beijing, 100084, China
| | - Boyu Zhang
- School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
- Institute of Medical Robotics, Shanghai Jiao Tong University, Shanghai, China
| | - Ruiyang Li
- School of Biomedical Engineering, Tsinghua University, Beijing, 100084, China
| | - Hongen Liao
- School of Biomedical Engineering, Tsinghua University, Beijing, 100084, China.
- School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China.
- Institute of Medical Robotics, Shanghai Jiao Tong University, Shanghai, China.
| |
Collapse
|
3
|
Borgström AM, Bäckström D. Swedish consensus regarding difficult pre-hospital airway management: a Delphi study. BMC Emerg Med 2024; 24:88. [PMID: 38802737 PMCID: PMC11129497 DOI: 10.1186/s12873-024-01013-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Accepted: 05/23/2024] [Indexed: 05/29/2024] Open
Abstract
BACKGROUND The aim of this study was to establish a consensus among experts in prehospital work regarding the management of difficult airways in prehospital care in Sweden. The results were subsequently used to develop an algorithm for handling difficult airway in prehospital care, as there was none available in Sweden prior to this study. METHODS This two-round Delphi study was conducted by forming an expert panel comprising anesthesiologists and anesthesia nurses working in prehospital setting in Sweden. The expert panel responded digital forms with questions and statements related to airway management. The study continued until consensus was reached, defined as more than 70% agreement. The study took place from December 4, 2021, to May 15, 2022. RESULTS In the first round, 74 participants took part, while the second round involved 37 participants. Consensus was reached in 16 out of 17 statements. 92% of the participants agreed that an airway algorithm adapted for prehospital use is necessary. CONCLUSIONS The capacity to adapt the approach to airway management based on specific pre-hospital circumstances is crucial. It holds significance to establish a uniform framework that is applicable across various airway management scenarios. Consequently, the airway management algorithm that has been devised should be regarded as a recommendation, allowing for flexibility rather than being interpreted as a rigid course of action. This represents the inaugural nationwide algorithm for airway management designed exclusively for pre-hospital operations in Sweden. The algorithm is the result of a consensus reached by experts in pre-hospital care.
Collapse
Affiliation(s)
- Anton Modée Borgström
- Department of Anaesthesiology and Intensive Care, Capio St. Göran's Hospital, Stockholm, 112 19, Sweden
| | - Denise Bäckström
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, 581 83, Sweden.
- Capio Akutläkarbilar, Stockholm, Sweden.
| |
Collapse
|
4
|
Hayes-Bradley C, McCreery M, Delorenzo A, Bendall J, Lewis A, Bowles KA. Predictive and protective factors for failing first pass intubation in prehospital rapid sequence intubation: an aetiology and risk systematic review with meta-analysis. Br J Anaesth 2024; 132:918-935. [PMID: 38508943 DOI: 10.1016/j.bja.2024.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 01/15/2024] [Accepted: 02/01/2024] [Indexed: 03/22/2024] Open
Abstract
BACKGROUND Prehospital rapid sequence intubation first pass success rates vary between 59% and 98%. Patient morbidity is associated with repeat intubation attempts. Understanding what influences first pass success can guide improvements in practice. We performed an aetiology and risk systematic review to answer the research question 'what factors are associated with success or failure at first attempt laryngoscopy in prehospital rapid sequence intubation?'. METHODS MEDLINE, EMBASE, CINAHL, and Cochrane Library were searched on March 3, 2023 for studies examining first pass success rates for rapid sequence intubation of prehospital live patients. Screening was performed via Covidence, and data synthesised by meta-analysis. The review was registered with PROSPERO and performed and reported as per Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. RESULTS Reasonable evidence was discovered for predictive and protective factors for failure of first pass intubation. Predictive factors included age younger than 1 yr, the presence of blood or fluid in the airway, restricted jaw or neck movement, trauma patients, nighttime procedures, chronic or acute distortions of normal face/upper airway anatomy, and equipment issues. Protective factors included an experienced intubator, adequate training, use of certain videolaryngoscopes, elevating the patient on a stretcher in an inclined position, use of a bougie, and laryngeal manoeuvres. CONCLUSIONS Managing bloody airways, positioning well, using videolaryngoscopes with bougies, and appropriate training should be further explored as opportunities for prehospital services to increase first pass success. Heterogeneity of studies limits stronger conclusions. SYSTEMATIC REVIEW PROTOCOL PROSPERO (CRD42022353609).
Collapse
Affiliation(s)
- Clare Hayes-Bradley
- Department of Paramedicine, Monash University, Frankston, VIC, Australia; NSW Ambulance Aeromedical Operations, Sydney, NSW, Australia.
| | | | - Ashleigh Delorenzo
- Department of Paramedicine, Monash University, Frankston, VIC, Australia
| | | | | | - Kelly-Ann Bowles
- Department of Paramedicine, Monash University, Frankston, VIC, Australia
| |
Collapse
|
5
|
Azurdia AR, Walters J, Mellon CR, Lettieri SC, Kopelman TR, Pieri P, Feiz-Erfan I. Airway risk associated with patients in halo fixation. Surg Neurol Int 2024; 15:104. [PMID: 38628525 PMCID: PMC11021081 DOI: 10.25259/sni_386_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 12/30/2023] [Indexed: 04/19/2024] Open
Abstract
Background The halo fixation device introduces a significant obstacle for clinicians attempting to secure a definitive airway in trauma patients with cervical spine injuries. The authors sought to determine the airway-related mortality rate of adult trauma patients in halo fixation requiring endotracheal intubation. Methods This study was a retrospective chart review of patients identified between 2007 and 2012. Only adult trauma patients who were intubated while in halo fixation were included in the study. Results A total of 46 patients underwent 60 intubations while in halo. On five occasions, (8.3%) patients were unable to be intubated and required an emergent surgical airway. Two (4.4%) of the patients out of our study population died specifically due to airway complications. Elective intubations had a failure rate of 5.8% but had no related permanent morbidity or mortality. In contrast to that, 25% of non-elective intubations failed and resulted in the deaths of two patients. The association between mortality and non-elective intubations was statistically highly significant (P = 0.0003). Conclusion The failed intubation and airway-related mortality rates of patients in halo fixation were substantial in this study. This finding suggests that the halo device itself may present a major obstacle in airway management. Therefore, heightened vigilance is appropriate for intubations of patients in halo fixation.
Collapse
Affiliation(s)
- Adrienne R. Azurdia
- Department of Emergency Medicine, HonorHealth Osborn, Scottsdale, United States
| | - Jarvis Walters
- Department of Surgery, Division of Trauma, Valleywise Health Medical Center, Phoenix, United States
| | - Chris R. Mellon
- Department of Trauma Surgery and Surgical Critical Care, HonorHealth Osborn, Phoenix, United States
| | - Salvatore C. Lettieri
- Department of Surgery, Division of Plastic Surgery, Valleywise Health Medical Center, Phoenix, United States
| | - Tammy R. Kopelman
- Department of Surgery, Division of Trauma, Valleywise Health Medical Center, Phoenix, United States
| | - Paola Pieri
- Department of Surgery, Division of Trauma, Valleywise Health Medical Center, Phoenix, United States
| | - Iman Feiz-Erfan
- Department of Surgery, Division of Neurosurgery, Valleywise Health Medical Center, Phoenix, United States
| |
Collapse
|
6
|
Gómez-Ríos MÁ, Sastre JA, Onrubia-Fuertes X, López T, Abad-Gurumeta A, Casans-Francés R, Gómez-Ríos D, Garzón JC, Martínez-Pons V, Casalderrey-Rivas M, Fernández-Vaquero MÁ, Martínez-Hurtado E, Martín-Larrauri R, Reviriego-Agudo L, Gutierrez-Couto U, García-Fernández J, Serrano-Moraza A, Rodríguez Martín LJ, Camacho Leis C, Espinosa Ramírez S, Fandiño Orgeira JM, Vázquez Lima MJ, Mayo-Yáñez M, Parente-Arias P, Sistiaga-Suárez JA, Bernal-Sprekelsen M, Charco-Mora P. Spanish Society of Anesthesiology, Reanimation and Pain Therapy (SEDAR), Spanish Society of Emergency and Emergency Medicine (SEMES) and Spanish Society of Otolaryngology, Head and Neck Surgery (SEORL-CCC) Guideline for difficult airway management. Part II. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2024; 71:207-247. [PMID: 38340790 DOI: 10.1016/j.redare.2024.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 08/28/2023] [Indexed: 02/12/2024]
Abstract
The Airway Management section of the Spanish Society of Anesthesiology, Resuscitation, and Pain Therapy (SEDAR), the Spanish Society of Emergency Medicine (SEMES), and the Spanish Society of Otorhinolaryngology and Head and Neck Surgery (SEORL-CCC) present the Guide for the comprehensive management of difficult airway in adult patients. Its principles are focused on the human factors, cognitive processes for decision-making in critical situations, and optimization in the progression of strategies application to preserve adequate alveolar oxygenation in order to enhance safety and the quality of care. The document provides evidence-based recommendations, theoretical-educational tools, and implementation tools, mainly cognitive aids, applicable to airway management in the fields of anesthesiology, critical care, emergencies, and prehospital medicine. For this purpose, an extensive literature search was conducted following PRISMA-R guidelines and was analyzed using the GRADE methodology. Recommendations were formulated according to the GRADE methodology. Recommendations for sections with low-quality evidence were based on expert opinion through consensus reached via a Delphi questionnaire.
Collapse
Affiliation(s)
- M Á Gómez-Ríos
- Anesthesiology and Perioperative Medicine, Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain.
| | - J A Sastre
- Anesthesiology and Perioperative Medicine, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | - X Onrubia-Fuertes
- Department of Anesthesiology, Hospital Universitary Dr Peset, Valencia, Spain
| | - T López
- Anesthesiology and Perioperative Medicine, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | - A Abad-Gurumeta
- Department of Anesthesiology, Hospital Universitario Infanta Leonor, Madrid, Spain
| | - R Casans-Francés
- Department of Anesthesiology, Hospital Universitario Infanta Elena, Valdemoro, Madrid, Spain
| | | | - J C Garzón
- Anesthesiology and Perioperative Medicine, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | - V Martínez-Pons
- Department of Anesthesiology, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - M Casalderrey-Rivas
- Department of Anesthesiology. Complejo Hospitalario Universitario de Ourense, Ourense, Spain
| | - M Á Fernández-Vaquero
- Department of Anesthesiology, Hospital Clínica Universitaria de Navarra, Madrid, Spain
| | - E Martínez-Hurtado
- Department of Anesthesiology, Hospital Universitario Infanta Leonor, Madrid, Spain
| | | | - L Reviriego-Agudo
- Department of Anesthesiology, Hospital Clínico Universitario, Valencia, Spain
| | - U Gutierrez-Couto
- Biblioteca, Complejo Hospitalario Universitario de Ferrol (CHUF), Ferrol, A Coruña, Spain
| | - J García-Fernández
- Department of Anesthesiology, Hospital Universitario Puerta de Hierro-Majadahonda, Majadahonda, Madrid, Spain; President of the Spanish Society of Anesthesiology, Resuscitation and Pain Therapy (SEDAR), Spain
| | | | | | | | | | - J M Fandiño Orgeira
- Emergency Department, Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain
| | - M J Vázquez Lima
- Emergency Department, Hospital do Salnes, Vilagarcía de Arousa, Pontevedra, Spain; President of the Spanish Emergency Medicine Society (SEMES), Spain
| | - M Mayo-Yáñez
- Department of Otorhinolaryngology/Head Neck Surgery, Complexo Hospitalario Universitario A Coruña, A Coruña, Spain
| | - P Parente-Arias
- Department of Otorhinolaryngology/Head Neck Surgery, Complexo Hospitalario Universitario A Coruña, A Coruña, Spain
| | - J A Sistiaga-Suárez
- Department of Otorhinolaryngology, Hospital Universitario Donostia, Donostia, Gipuzkoa, Spain
| | - M Bernal-Sprekelsen
- Department of Otorhinolaryngology, Hospital Clínic Barcelona, University of Barcelona, Barcelona, Spain; President of the Spanish Society for Otorhinolaryngology Head & Neck Surgery (SEORL-CCC), Spain
| | - P Charco-Mora
- Department of Anesthesiology, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| |
Collapse
|
7
|
Waldron O, Sena R, Boehmer S, Flamm A. Using a Bougie With C-MAC Video Laryngoscopy Did Not Improve First-Attempt Intubation Success Rates in Critical Care Air Transport. Air Med J 2023; 42:445-449. [PMID: 37996180 DOI: 10.1016/j.amj.2023.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 07/03/2023] [Accepted: 07/12/2023] [Indexed: 11/25/2023]
Abstract
OBJECTIVE Studies have shown a bougie improves first-attempt success rates when used in combination with direct laryngoscopy during the initial attempt. The purpose of this study was to determine whether the use of a bougie in combination with C-MAC (Karl Storz, Tuttlingen, Germany) improves first-attempt success rates of endotracheal intubation (ETI) compared with C-MAC with a traditional stylet. METHODS This study is a retrospective chart review using data collected on 371 intubations completed by a single air medical service using the C-MAC laryngoscope and either a bougie or a stylet. RESULTS The overall success rate using C-MAC for ETI with either a bougie or a stylet was 83%. There was no statistically significant difference between first-attempt successful intubations using C-MAC and a bougie (82%) or a stylet (86%) (χ1 = 0.871, P = .351). There was no statistically significant difference between laryngoscopy grade and the number of attempts that resulted in a successful intubation (χ1 = 0.743, P = .7). CONCLUSION There was no difference between first-attempt success rates using video laryngoscopy with a bougie, overall intubation success rates, or difficult intubation success rates compared with video laryngoscopy with a stylet, indicating that the purpose of a bougie as a rescue device did not hold true in the prehospital setting of our critical care air medical service.
Collapse
Affiliation(s)
| | - Rodney Sena
- Department of Emergency Medicine, The Pennsylvania State University College of Medicine, Hershey, PA
| | - Susan Boehmer
- Department of Public Health Sciences, The Pennsylvania State College of Medicine, Hershey, PA
| | - Avram Flamm
- The Pennsylvania State College of Medicine, Hershey, PA; Department of Emergency Medicine, WellSpan Health, York, PA.
| |
Collapse
|
8
|
Stampfl M, Tillman D, Borelli N, Bandara T, Cathers A. Rapid Sequence Intubation Using the SEADUC Manual Suction Unit in a Contaminated Airway. Air Med J 2023; 42:296-299. [PMID: 37356893 DOI: 10.1016/j.amj.2023.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 03/11/2023] [Accepted: 03/15/2023] [Indexed: 06/27/2023]
Abstract
The case presented here highlights the utility/feasibility of the SEADUC (EM Innovations, Galloway, OH) manual suction unit in clearing a contaminated airway during rapid sequence intubation. The case also highlights the importance of intubation in a patient with declining mental status in the prehospital environment. A 75-year-old woman suffered a head injury, and a helicopter emergency medical service team staffed with a physician and nurse was tasked with retrieval and transfer back to the tertiary care center. As the flight team rendezvoused with ground emergency medical services and the patient, a decision to intubate was made because of the patient's declining mental status and inability to protect her own airway. While in preparation for intubation, it was noted that the ambulance's electrical suction system was not working, and the flight crew had to resort to a SEADUC manual suction unit to clear the patient's airway of contaminants. The patient's airway was cleared, and she was successfully intubated and transported to a tertiary care center where the patient underwent an emergent neurosurgery procedure/decompression and was discharged home a few weeks later.
Collapse
Affiliation(s)
- Matthew Stampfl
- UW Health Med Flight, Madison, WI; BerbeeWalsh Department of Emergency Medicine, Madison, WI.
| | - David Tillman
- UW Health Med Flight, Madison, WI; BerbeeWalsh Department of Emergency Medicine, Madison, WI
| | | | | | - Andrew Cathers
- UW Health Med Flight, Madison, WI; BerbeeWalsh Department of Emergency Medicine, Madison, WI
| |
Collapse
|
9
|
Morton S, Avery P, Kua J, O'Meara M. Success rate of prehospital emergency front-of-neck access (FONA): a systematic review and meta-analysis. Br J Anaesth 2023; 130:636-644. [PMID: 36858888 PMCID: PMC10170392 DOI: 10.1016/j.bja.2023.01.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 01/11/2023] [Accepted: 01/18/2023] [Indexed: 03/02/2023] Open
Abstract
BACKGROUND Front-of-neck access (FONA) is an emergency procedure used as a last resort to achieve a patent airway in the prehospital environment. In this systematic review with meta-analysis, we aimed to evaluate the number and success rate of FONA procedures in the prehospital setting, including changes since 2017, when a surgical technique was outlined as the first-line prehospital method. METHODS A systematic literature search (PROSPERO CRD42022348975) was performed from inception of databases to July 2022 to identify studies in patients of any age undergoing prehospital FONA, followed by data extraction. Meta-analysis was used to derive pooled success rates. Methodological quality of included studies was interpreted using the Cochrane risk of bias tool, and rated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. RESULTS From 909 studies, 69 studies were included (33 low quality; 36 very low quality) with 3292 prehospital FONA attempts described (1229 available for analysis). The crude median success rate increased from 99.2% before 2017 to 100.0% after 2017. Meta-analysis revealed a pooled overall FONA success rate of 88.0% (95% confidence interval [CI], 85.0-91.0%). Surgical techniques had the highest success rate at a median of 100.0% (pooled rate=92.0%; 95% CI, 88.0-95.0%) vs 50.0% for needle techniques (pooled rate=52.0%; 95% CI, 28.0-76.0%). CONCLUSIONS Despite being a relatively rare procedure in the prehospital setting, the success rate for FONA is high. A surgical technique for FONA appears more successful than needle techniques, and supports existing UK prehospital guidelines. SYSTEMATIC REVIEW PROTOCOL PROSPERO CRD42022348975.
Collapse
Affiliation(s)
- Sarah Morton
- Essex and Herts Air Ambulance, Colchester, UK; Imperial College London, London, UK.
| | - Pascale Avery
- Emergency Retrieval and Transfer Service (EMRTS) Wales Air Ambulance, Dafen, UK
| | | | - Matt O'Meara
- Essex and Herts Air Ambulance, Colchester, UK; Emergency Retrieval and Transfer Service (EMRTS) Wales Air Ambulance, Dafen, UK; University Hospitals North Midlands, Stoke-on-Trent, UK
| |
Collapse
|
10
|
von Vopelius-Feldt J, Peddle M, Lockwood J, Mal S, Sawadsky B, Diamond W, Williams T, Baumber B, Van Houwelingen R, Nolan B. The effect of a multi-faceted quality improvement program on paramedic intubation success in the critical care transport environment: a before-and-after study. Scand J Trauma Resusc Emerg Med 2023; 31:9. [PMID: 36814266 PMCID: PMC9945597 DOI: 10.1186/s13049-023-01074-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 02/13/2023] [Indexed: 02/24/2023] Open
Abstract
INTRODUCTION Endotracheal intubation (ETI) is an infrequent but key component of prehospital and retrieval medicine. Common measures of quality of ETI are the first pass success rates (FPS) and ETI on the first attempt without occurrence of hypoxia or hypotension (DASH-1A). We present the results of a multi-faceted quality improvement program (QIP) on paramedic FPS and DASH-1A rates in a large regional critical care transport organization. METHODS We conducted a retrospective database analysis, comparing FPS and DASH-1A rates before and after implementation of the QIP. We included all patients undergoing advanced airway management with a first strategy of ETI during the time period from January 2016 to December 2021. RESULTS 484 patients met the inclusion criteria during the study period. Overall, the first pass intubation success (FPS) rate was 72% (350/484). There was an increase in FPS from the pre-intervention period (60%, 86/144) to the post-intervention period (86%, 148/173), p < 0.001. DASH-1A success rates improved from 45% (55/122) during the pre-intervention period to 55% (84/153) but this difference did not meet pre-defined statistical significance (p = 0.1). On univariate analysis, factors associated with improved FPS rates were the use of video-laryngoscope (VL), neuromuscular blockage, and intubation inside a healthcare facility. CONCLUSIONS A multi-faceted advanced airway management QIP resulted in increased FPS intubation rates and a non-significant improvement in DASH-1A rates. A combination of modern equipment, targeted training, standardization and ongoing clinical governance is required to achieve and maintain safe intubation by paramedics in the prehospital and retrieval environment.
Collapse
Affiliation(s)
- Johannes von Vopelius-Feldt
- Ornge, 5310 Explorer Drive, Mississauga, ON, L4W 5H8, Canada. .,Department of Emergency Medicine, St. Michael's Hospital Toronto, 36 Queen St East, Toronto, ON, M5B 1W8, Canada.
| | - Michael Peddle
- Ornge, 5310 Explorer Drive, Mississauga, ON L4W 5H8 Canada ,grid.412745.10000 0000 9132 1600Department of Emergency Medicine, London Health Sciences Centre, 800 Commissioners Drive, London, ON N6A 5W9 Canada
| | - Joel Lockwood
- Ornge, 5310 Explorer Drive, Mississauga, ON L4W 5H8 Canada ,grid.415502.7Department of Emergency Medicine, St. Michael’s Hospital Toronto, 36 Queen St East, Toronto, ON M5B 1W8 Canada
| | - Sameer Mal
- Ornge, 5310 Explorer Drive, Mississauga, ON L4W 5H8 Canada ,grid.412745.10000 0000 9132 1600Department of Emergency Medicine, London Health Sciences Centre, 800 Commissioners Drive, London, ON N6A 5W9 Canada
| | - Bruce Sawadsky
- Ornge, 5310 Explorer Drive, Mississauga, ON L4W 5H8 Canada ,grid.413104.30000 0000 9743 1587Department of Emergency Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Ave, Toronto, ON M4N 3M5 Canada
| | - Wayde Diamond
- Ornge, 5310 Explorer Drive, Mississauga, ON L4W 5H8 Canada
| | - Tara Williams
- Ornge, 5310 Explorer Drive, Mississauga, ON L4W 5H8 Canada
| | - Brad Baumber
- Ornge, 5310 Explorer Drive, Mississauga, ON L4W 5H8 Canada
| | | | - Brodie Nolan
- Ornge, 5310 Explorer Drive, Mississauga, ON L4W 5H8 Canada ,grid.415502.7Department of Emergency Medicine, St. Michael’s Hospital Toronto, 36 Queen St East, Toronto, ON M5B 1W8 Canada
| |
Collapse
|
11
|
Intubation success in prehospital emergency anaesthesia: a retrospective observational analysis of the Inter-Changeable Operator Model (ICOM). Scand J Trauma Resusc Emerg Med 2022; 30:44. [PMID: 35804435 PMCID: PMC9264686 DOI: 10.1186/s13049-022-01032-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 06/22/2022] [Indexed: 01/30/2023] Open
Abstract
Background Pre hospital emergency anaesthesia (PHEA) is a complex procedure with significant risks. First-pass intubation success (FPS) is recommended as a quality indicator in pre hospital advanced airway management. Previous data demonstrating significantly lower FPS by non-physicians does not distinguish between non-physicians operating in isolation or within physician teams. In several UK HEMS, the role of the intubating provider is interchangeable between the physician and critical care paramedic—termed the Inter-Changeable Operator Model (ICOM). The objectives of this study were to compare first-pass intubation success rate between physicians and critical care paramedics (CCP) in a large regional, multi-organisational dataset of trauma PHEA patients, and to report the application of the ICOM. Methods A retrospective observational study of consecutive trauma patients ≥ 16 years old who underwent PHEA at two different ICOM Helicopter Emergency Medical Services in the East of England, 2015–2020. Data are presented as number (percentage) and median [inter-quartile range]. Fisher’s exact test was used to compare proportions, reported as odds ratio (OR (95% confidence interval, 95% CI)), p value. The study design complied with the STROBE (Strengthening The Reporting of Observational studies in Epidemiology) reporting guidelines. Results In the study period, 13,654 patients were attended. 674 (4.9%) trauma patients ≥ 16 years old who underwent PHEA were included in the final analysis: the median age was 44 [28–63] years old, and 502 (74.5%) were male. There was no significant difference in the FPS rate between physicians and CCPs—90.2% and 87.4% respectively, OR 1.3 (95% CI 0.7–2.5), p = 0.38. The cumulative first, second, third, and fourth-pass intubation success rates were 89.6%, 98.7%, 99.7%, and 100%. Patients who had a physician-operated initial intubation attempt weighed more and had a higher heart rate, compared to those who had a CCP-operated initial attempt. Conclusion In an ICOM setting, we demonstrated 100% intubation success in adult trauma patients undergoing PHEA. There was no significant difference in first-pass intubation success between physicians and CCPs.
Collapse
|
12
|
Bedolla CN, Rauschendorfer C, Havard DB, Guenther BA, Rizzo JA, Blackburn AN, Ryan KL, Blackburn MB. Spectral Reflectance as a Unique Tissue Identifier in Healthy Humans and Inhalation Injury Subjects. SENSORS (BASEL, SWITZERLAND) 2022; 22:3377. [PMID: 35591067 PMCID: PMC9103967 DOI: 10.3390/s22093377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 04/22/2022] [Accepted: 04/26/2022] [Indexed: 06/15/2023]
Abstract
Tracheal intubation is the preferred method of airway management, a common emergency trauma medicine problem. Currently, methods for confirming tracheal tube placement are lacking, and we propose a novel technology, spectral reflectance, which may be incorporated into the tracheal tube for verification of placement. Previous work demonstrated a unique spectral profile in the trachea, which allowed differentiation from esophageal tissue in ex vivo swine, in vivo swine, and human cadavers. The goal of this study is to determine if spectral reflectance can differentiate between trachea and other airway tissues in living humans and whether the unique tracheal spectral profile persists in the presence of an inhalation injury. Reflectance spectra were captured using a custom fiber-optic probe from the buccal mucosa, posterior oropharynx, and trachea of healthy humans intubated for third molar extraction and from the trachea of patients admitted to a burn intensive care unit with and without inhalation injury. Using ratio comparisons, we found that the tracheal spectral profile was significantly different from buccal mucosa or posterior oropharynx, but the area under the curve values are not high enough to be used clinically. In addition, inhalation injury did not significantly alter the spectral reflectance of the trachea. Further studies are needed to determine the utility of this technology in a clinical setting and to develop an algorithm for tissue differentiation.
Collapse
Affiliation(s)
- Carlos N. Bedolla
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, San Antonio, TX 78234, USA; (C.N.B.); (C.R.); (J.A.R.); (M.B.B.)
| | - Catherine Rauschendorfer
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, San Antonio, TX 78234, USA; (C.N.B.); (C.R.); (J.A.R.); (M.B.B.)
| | - Drew B. Havard
- Naval Medical Research Unit San Antonio, JBSA Fort Sam Houston, San Antonio, TX 78234, USA;
| | - Blaine A. Guenther
- 59th Medical Wing, Brooke Army Medical Center, JBSA Fort Sam Houston, San Antonio, TX 78234, USA;
| | - Julie A. Rizzo
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, San Antonio, TX 78234, USA; (C.N.B.); (C.R.); (J.A.R.); (M.B.B.)
| | | | - Kathy L. Ryan
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, San Antonio, TX 78234, USA; (C.N.B.); (C.R.); (J.A.R.); (M.B.B.)
| | - Megan B. Blackburn
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, San Antonio, TX 78234, USA; (C.N.B.); (C.R.); (J.A.R.); (M.B.B.)
| |
Collapse
|
13
|
Andresen ÅEL, Kramer-Johansen J, Kristiansen T. Emergency cricothyroidotomy in difficult airway simulation – a national observational study of Air Ambulance crew performance. BMC Emerg Med 2022; 22:64. [PMID: 35397493 PMCID: PMC8994306 DOI: 10.1186/s12873-022-00624-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 04/05/2022] [Indexed: 11/27/2022] Open
Abstract
Background Advanced prehospital airway management includes complex procedures carried out in challenging environments, necessitating a high level of technical and non-technical skills. We aimed to describe Norwegian Air Ambulance-crews’ performance in a difficult airway scenario simulation, ending with a “cannot intubate, cannot oxygenate”-situation. Methods The study describes Air Ambulance crews’ management of a simulated difficult airway scenario. We used video-observation to assess time expenditure according to pre-defined time intervals and technical and non-technical performance was evaluated according to a structured evaluation-form. Results Thirty-six crews successfully completed the emergency cricothyroidotomy with mean procedural time 118 (SD: ±70) seconds. There was variation among the crews in terms of completed procedural steps, including preparation of equipment, patient- monitoring and management. The participants demonstrated uniform and appropriate situational awareness, and effective communication and resource utilization within the crews was evident. Conclusions We found that Norwegian Air Ambulance crews managed a prehospital “cannot intubate, cannot oxygenate”-situation with an emergency cricothyroidotomy under stressful conditions with effective communication and resource utilization, and within a reasonable timeframe. Some discrepancies between standard operating procedures and performance are observed. Further studies to assess the impact of check lists on procedural aspects of airway management in the prehospital environment are warranted.
Collapse
|
14
|
Impact of Operator Medical Specialty on Endotracheal Intubation Rates in Prehospital Emergency Medicine—A Retrospective Cohort Study. J Clin Med 2022; 11:jcm11071992. [PMID: 35407600 PMCID: PMC8999662 DOI: 10.3390/jcm11071992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 03/10/2022] [Accepted: 03/28/2022] [Indexed: 02/01/2023] Open
Abstract
Prehospital endotracheal intubation (ETI) can be challenging, and the risk of complications is higher than in the operating room. The goal of this study was to compare prehospital ETI rates between anaesthesiologists and non-anaesthesiologists. This retrospective cohort study compared prehospital interventions performed by either physicians from the anaesthesiology department (ADP) or physicians from another department (NADP, for non-anaesthesiology department physicians). The primary outcome was the prehospital ETI rate. Overall, 42,190 interventions were included in the analysis, of whom 68.5% were performed by NADP. Intubation was attempted on 2797 (6.6%) patients, without any difference between NADPs and ADPs (6.5 versus 6.7%, p = 0.555). However, ADPs were more likely to proceed to an intubation when patients were not in cardiac arrest (3.4 versus 3.0%, p = 0.026), whereas no difference was found regarding cardiac arrest patients (65.2 versus 67.7%, p = 0.243) (p for homogeneity = 0.005). In a prehospital physician-staffed emergency medical service, overall ETI rates did not depend on the frontline operator’s medical specialty background. ADPs were, however, more likely to proceed with ETI than NADPs when patients were not in cardiac arrest. Further studies should help to understand the reasons for this difference.
Collapse
|
15
|
Fayed M, Nowak K, Angappan S, Patel N, Abdulkarim F, Penning DH, Chhina AK. Emergent Surgical Airway Skills: Time to Re-evaluate the Competencies. Cureus 2022; 14:e23260. [PMID: 35342673 PMCID: PMC8929234 DOI: 10.7759/cureus.23260] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/17/2022] [Indexed: 11/05/2022] Open
Abstract
Introduction One of the most challenging scenarios an anesthesia provider can face is treating a can't intubate can't ventilate (CICV) patient. The incidence of CICV is estimated to be around one in 10,000 cases. According to the American Society of Anesthesiology Closed Claims Study, adverse respiratory events are the most common type of injury, with difficult intubation and ventilation contributing to the majority of these cases. The objective of this non-interventional quality improvement project was to evaluate the prior training, exposure, and self-reported confidence in handling the CICV scenario among anesthesia providers at Henry Ford Hospital in Detroit, MI. Methods An online questionnaire was distributed via email to all residents, certified registered nurse anesthetists (CRNAs), and attending anesthesiologists in March 2021. The email contained a link to an online questionnaire via Microsoft Forms (Microsoft Corporation, Redmond, WA). Univariate group comparisons were carried out between the respondents’ role (attending, CRNA, or resident), as well as between the number of years that the respondents were in practice (< 5 years, 5-10 years, > 10 years). Results Out of the total 170 anesthesia providers, 119 participated in the study where 54 (45%) were attendings, 44 (37%) were residents, and 21 (18%) were CRNAs. The majority (75%) did not know the surgical airway kit location, and 87% had not performed the surgical airway procedure before. The vast majority (96.7%) recommended simulation training compared to online training or lecture series, and just over 50% recommended annual training frequency. When looking at the differences in responses based on years of experience as an anesthesia provider, the majority of those with > 10 years in practice knew how to perform the surgical airway technique while respondents with < 5 years did not know how to perform the technique, and 50% of those with five to 10 years experience knew how to perform the surgical airway procedure for a CICV scenario. Conclusion Although there were many significant differences observed between the various provider roles and years in practice, surprisingly, the responses revealed both a lack of experience and confidence in performing the surgical airway procedure in all provider roles. These findings highlight a need for better emergency airway teaching and training. These findings will be used to guide the design and implementation of improved surgical airway training for residents, CRNAs, and attending anesthesiologists with the goal of better preparedness for handling a CICV scenario.
Collapse
Affiliation(s)
- Mohamed Fayed
- Anesthesiology, Pain Management and Perioperative Medicine, Henry Ford Health System, Detroit, USA
| | | | - Santhalakshmi Angappan
- Anesthesiology, Pain Management and Perioperative Medicine, Henry Ford Health System, Detroit, USA
| | - Nimesh Patel
- Anesthesiology, Pain Management and Perioperative Medicine, Henry Ford Health System, Detroit, USA
| | - Fawaz Abdulkarim
- Anesthesiology, Pain Management and Perioperative Medicine, Henry Ford Health System, Detroit, USA
| | - Donald H Penning
- Anesthesiology, Pain Management and Perioperative Medicine, Henry Ford Health System, Detroit, USA
| | - Anoop K Chhina
- Anesthesiology, Pain Management and Perioperative Medicine, Henry Ford Health System, Detroit, USA
| |
Collapse
|
16
|
Reinert L, Herdtle S, Hohenstein C, Behringer W, Arrich J. Predictors for Prehospital First-Pass Intubation Success in Germany. J Clin Med 2022; 11:jcm11030887. [PMID: 35160336 PMCID: PMC8836538 DOI: 10.3390/jcm11030887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Revised: 02/01/2022] [Accepted: 02/05/2022] [Indexed: 12/04/2022] Open
Abstract
(1) Background: Endotracheal intubation in the prehospital setting is an important skill for emergency physicians, paramedics, and other members of the EMS providing airway management. Its success determines complications and patient mortality. The aim of this study was to find predictors for first-pass intubation success in the prehospital emergency setting. (2) The study was based on a retrospective analysis of a population-based registry of prehospital advanced airway management in Germany. Cases of endotracheal intubation by the emergency medical services in the cities of Tübingen and Jena between 2016 and 2019 were included. The outcome of interest was first-pass intubation success. Univariate and multivariable regression analysis were used to analyse the influence of predefined predictors, including the characteristics of patients, the intubating staff, and the clinical situation. (3) Results: A total of 308 patients were analysed. After adjustment for multiple confounders, the direct vocal cord view, a less favourable Cormack–Lehane classification, the general practitioner as medical specialty, and location and type of EMS were independent predictors for first-pass intubation success. (4) Conclusions: In physician-led emergency medical services, the laryngoscopic view, medical specialty, type of EMS, and career level are associated with FPS. The latter points towards the importance of experience and regular training in endotracheal intubation.
Collapse
Affiliation(s)
- Lukas Reinert
- Department of Emergency Medicine, Faculty of Medicine, Friedrich Schiller University Jena, 07747 Jena, Germany;
| | - Steffen Herdtle
- Department of Emergency Medicine, Hospital of Agatharied, 83734 Hausham, Germany;
| | - Christian Hohenstein
- Department of Emergency Medicine, Zentralklinik Bad Berka, 99438 Bad Berka, Germany;
| | - Wilhelm Behringer
- Department of Emergency Medicine, Medical University of Vienna, 1090 Wien, Austria;
| | - Jasmin Arrich
- Department of Emergency Medicine, Medical University of Vienna, 1090 Wien, Austria;
- Correspondence:
| |
Collapse
|
17
|
Yamanaka S, Goto T, Morikawa K, Watase H, Okamoto H, Hagiwara Y, Hasegawa K. Machine Learning Approaches for Predicting Difficult Airway and First-Pass Success in the Emergency Department: Multicenter Prospective Observational Study. Interact J Med Res 2022; 11:e28366. [PMID: 35076398 PMCID: PMC8826144 DOI: 10.2196/28366] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 06/07/2021] [Accepted: 12/06/2021] [Indexed: 12/13/2022] Open
Abstract
Background There is still room for improvement in the modified LEMON (look, evaluate, Mallampati, obstruction, neck mobility) criteria for difficult airway prediction and no prediction tool for first-pass success in the emergency department (ED). Objective We applied modern machine learning approaches to predict difficult airways and first-pass success. Methods In a multicenter prospective study that enrolled consecutive patients who underwent tracheal intubation in 13 EDs, we developed 7 machine learning models (eg, random forest model) using routinely collected data (eg, demographics, initial airway assessment). The outcomes were difficult airway and first-pass success. Model performance was evaluated using c-statistics, calibration slopes, and association measures (eg, sensitivity) in the test set (randomly selected 20% of the data). Their performance was compared with the modified LEMON criteria for difficult airway success and a logistic regression model for first-pass success. Results Of 10,741 patients who underwent intubation, 543 patients (5.1%) had a difficult airway, and 7690 patients (71.6%) had first-pass success. In predicting a difficult airway, machine learning models—except for k-point nearest neighbor and multilayer perceptron—had higher discrimination ability than the modified LEMON criteria (all, P≤.001). For example, the ensemble method had the highest c-statistic (0.74 vs 0.62 with the modified LEMON criteria; P<.001). Machine learning models—except k-point nearest neighbor and random forest models—had higher discrimination ability for first-pass success. In particular, the ensemble model had the highest c-statistic (0.81 vs 0.76 with the reference regression; P<.001). Conclusions Machine learning models demonstrated greater ability for predicting difficult airway and first-pass success in the ED.
Collapse
Affiliation(s)
- Syunsuke Yamanaka
- Department of Emergency Medicine & General Internal Medicine, The University of Fukui, Fukui, Japan
| | - Tadahiro Goto
- Department of Clinical Epidemiology & Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | | | - Hiroko Watase
- Department of Surgery, University of Washington, Seattle, WA, United States
| | - Hiroshi Okamoto
- Department of Intensive Care, St. Luke's International Hospital, Tokyo, Japan
| | - Yusuke Hagiwara
- Department of Pediatric Emergency and Critical Care Medicine, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Kohei Hasegawa
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, United States
| |
Collapse
|
18
|
Lyng JW, Baldino KT, Braude D, Fritz C, March JA, Peterson TD, Yee A. Prehospital Supraglottic Airways: An NAEMSP Position Statement and Resource Document. PREHOSP EMERG CARE 2022; 26:32-41. [PMID: 35001830 DOI: 10.1080/10903127.2021.1983680] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Supraglottic airway (SGA) devices provide effective conduits for oxygenation and ventilation and may offer protection from gastric aspiration. SGA devices are widely used by EMS clinicians as both rescue and primary airway management devices. While in common use for more than four decades, major developments in SGA education, science, and technology have influenced clinical strategies of SGA insertion and use in prehospital airway management for patients of all ages. NAEMSP recommends:SGAs have utility as a primary or secondary EMS airway intervention. EMS agencies should select SGA strategies that best suit available resources and local clinician skillset, as well as the nature of their clinical practice setting.EMS agencies that perform endotracheal intubation must also equip their clinicians with SGA devices and ensure adequate training and competence.In select situations, drug-assisted airway management may be used by properly credentialed EMS clinicians to facilitate SGA insertion.Confirmation of initial and continuous SGA placement using waveform capnography is strongly encouraged as a best practice.When it is functioning properly, EMS clinicians should refrain from converting an SGA to an endotracheal tube. The decision to convert an SGA to an endotracheal tube must consider the patient's condition, the effectiveness of SGA ventilations, and the clinical context and course of initial SGA insertionSGA training, competency, and clinical use must be continuously evaluated by EMS agencies using focused quality management programs.
Collapse
|
19
|
Okada A, Okada Y, Kandori K, Ishii W, Narumiya H, Iizuka R. Adverse events of emergency surgical front of neck airway access: an observational descriptive study. Acute Med Surg 2022; 9:e750. [PMID: 35441035 PMCID: PMC9012838 DOI: 10.1002/ams2.750] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 03/29/2022] [Indexed: 11/25/2022] Open
Abstract
Aim Emergency front of neck access (eFONA), such as scalpel cricothyroidotomy, is a rescue technique used to open the airway during “cannot intubate, cannot oxygenate” situations. However, little is known about the adverse events associated with the procedure. This study aimed to describe the adverse events that occur in patients who undergo eFONA and their management. Methods This retrospective observational cohort study included emergency patients who underwent eFONA between April 2012 and August 2020. We described the patients’ characteristics and the adverse events during or immediately after the procedure. Results Among 75,529 emergency patients during the study period, 31 (0.04%) underwent an eFONA. The median (interquartile range) age was 53 (39–67) years, and 23 patients (74.2%) were men. Of all cases, 13 (41.9%) experienced adverse events. Of these, three cases (23.2%) were cephalad misplacement of the intubation tube, one case (7.7%) was cuff injury, one case (7.7%) was tube obstruction due to vomiting, and one case (7.7%) was tube kink. In cases with these adverse events, the initial attempt of eFONA failed, and alternative immediate action was necessary to secure the airway. Conclusion This single‐center retrospective observational study described several adverse events of eFONA. In particular, it is important to understand the possible life‐threatening adverse events that lead to failure of securing airways such as cephalad displacement, tube obstruction, and tube kink and respond promptly to ensure a secure definitive airway for patients’ safety.
Collapse
Affiliation(s)
- Asami Okada
- Department of Emergency Medicine and Critical Care Japanese Red Cross Society Kyoto Daini Hospital Kyoto Japan
| | - Yohei Okada
- Preventive Services, School of Public Health Kyoto University Japan
- Department of Primary Care and Emergency Medicine, Graduate School of Medicine Kyoto University Kyoto Japan
| | - Kenji Kandori
- Department of Emergency Medicine and Critical Care Japanese Red Cross Society Kyoto Daini Hospital Kyoto Japan
| | - Wataru Ishii
- Department of Emergency Medicine and Critical Care Japanese Red Cross Society Kyoto Daini Hospital Kyoto Japan
| | - Hiromichi Narumiya
- Department of Emergency Medicine and Critical Care Japanese Red Cross Society Kyoto Daini Hospital Kyoto Japan
| | - Ryoji Iizuka
- Department of Emergency Medicine and Critical Care Japanese Red Cross Society Kyoto Daini Hospital Kyoto Japan
| |
Collapse
|
20
|
High Success Rate of Prehospital and En Route Cricothyroidotomy Performed in the Israel Defense Forces: 20 Years of Experience. Prehosp Disaster Med 2021; 36:713-718. [PMID: 34743777 DOI: 10.1017/s1049023x21001199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
INTRODUCTION Securing the airway is a crucial stage of trauma care. Cricothyroidotomy (CRIC) is often addressed as a salvage procedure in complicated cases or following a failed endotracheal intubation (ETI). Nevertheless, it is a very important skill in prehospital settings, such as on the battlefield. HYPOTHESIS/PROBLEM This study aimed to review the Israel Defense Forces (IDF) experience with CRIC over the past two decades. METHODS The IDF Trauma Registry (IDF-TR) holds data on all trauma casualties (civilian and military) cared for by military medical teams since 1997. Data of all casualties treated by IDF from 1998 through 2018 were extracted and analyzed to identify all patients who underwent CRIC procedures.Variables describing the incident scenario, patient's characteristics, injury pattern, treatment, and outcome were extracted. The success rate of the procedure was described, and selected variables were further analyzed and compared using the Fisher's-exact test to identify their effect on the success and failure rates. Odds Ratio (OR) was further calculated for the effect of different body part involvement on success and for the mortality after failed ETI. RESULTS One hundred fifty-three casualties on which a CRIC attempt was made were identified from the IDF-TR records. The overall success rate of CRIC was reported at 88%. In patients who underwent one or two attempts, the success rate was 86%. No difference was found across providers (physician versus paramedic). The CRIC success rates for casualties with and without head trauma were 80% and 92%, respectively (P = .06). Overall mortality was 33%. CONCLUSIONS This study shows that CRIC is of merit in airway management as it has shown to have consistently high success rates throughout different levels of training, injuries, and previous attempts with ETI. Care providers should be encouraged to retain and develop this skill as part of their tool box.
Collapse
|
21
|
Strauss R, Menchetti I, Perrier L, Blondal E, Peng H, Sullivan-Kwantes W, Tien H, Nathens A, Beckett A, Callum J, da Luz LT. Evaluating the Tactical Combat Casualty Care principles in civilian and military settings: systematic review, knowledge gap analysis and recommendations for future research. Trauma Surg Acute Care Open 2021; 6:e000773. [PMID: 34746434 PMCID: PMC8527149 DOI: 10.1136/tsaco-2021-000773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 07/27/2021] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVES The Tactical Combat Casualty Care (TCCC) guidelines detail resuscitation practices in prehospital and austere environments. We sought to review the content and quality of the current TCCC and civilian prehospital literature and characterize knowledge gaps to offer recommendations for future research. METHODS MEDLINE, EMBASE, CINAHL, and Cochrane Central Register of Controlled Trials were searched for studies assessing intervention techniques and devices used in civilian and military prehospital settings that could be applied to TCCC guidelines. Screening and data extraction were performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Quality appraisal was conducted using appropriate tools. RESULTS Ninety-two percent (n=57) of studies were observational. Most randomized trials had low risk of bias, whereas observational studies had higher risk of bias. Interventions of massive hemorrhage control (n=17) were wound dressings and tourniquets, suggesting effective hemodynamic control. Airway management interventions (n=7) had high success rates with improved outcomes. Interventions of respiratory management (n=12) reported low success with needle decompression. Studies assessing circulation (n=18) had higher quality of evidence and suggested improved outcomes with component hemostatic therapy. Hypothermia prevention interventions (n=2) were generally effective. Other studies identified assessed the use of extended focused assessment with sonography in trauma (n=3) and mixed interventions (n=2). CONCLUSIONS The evidence was largely non-randomized with heterogeneous populations, interventions, and outcomes, precluding robust conclusions in most subjects addressed in the review. Knowledge gaps identified included the use of blood products and concentrate of clotting factors in the prehospital setting. LEVEL OF EVIDENCE Systematic review, level III.
Collapse
Affiliation(s)
- Rachel Strauss
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Isabella Menchetti
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Laure Perrier
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Erik Blondal
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Henry Peng
- Defence Research and Development Canada, Toronto Research Centre, Toronto, Ontario, Canada
| | - Wendy Sullivan-Kwantes
- Defence Research and Development Canada, Toronto Research Centre, Toronto, Ontario, Canada
| | - Homer Tien
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Avery Nathens
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Andrew Beckett
- Department of Surgery, St Michael's Hospital, Toronto, Ontario, Canada
| | - Jeannie Callum
- Laboratory Medicine and Molecular Diagnostics, Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | - Luis Teodoro da Luz
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| |
Collapse
|
22
|
Árnason B, Hertzberg D, Kornhall D, Günther M, Gellerfors M. Pre-hospital emergency anaesthesia in trauma patients treated by anaesthesiologist and nurse anaesthetist staffed critical care teams. Acta Anaesthesiol Scand 2021; 65:1329-1336. [PMID: 34152597 PMCID: PMC9291089 DOI: 10.1111/aas.13946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 05/06/2021] [Accepted: 05/08/2021] [Indexed: 12/05/2022]
Abstract
Background Pre‐hospital tracheal intubation in trauma patients has recently been questioned. However, not only the trauma and patient characteristics but also airway provider competence differ between systems making simplified statements difficult. Method The study is a subgroup analysis of trauma patients included in the PHAST study. PHAST was a prospective, observational, multicentre study on pre‐hospital advanced airway management by anaesthesiologist and nurse anaesthetist manned pre‐hospital critical care teams in the Nordic countries May 2015‐November 2016. Endpoints include intubation success rate, complication rate (airway‐related complication according to Utstein Airway Template by Sollid et al), scene time (time from arrival of the critical care team to departure of the patient) and pre‐hospital mortality. Result The critical care teams intubated 385 trauma patients, of which 65 were in shock (SBP <90 mm Hg), during the study. Of the trauma patients, 93% suffered from blunt trauma, the mean GCS was 6 and 75% were intubated by an experienced provider who had performed >2500 tracheal intubations. The pre‐hospital tracheal intubation overall success rate was 98.6% and the complication rate was 13.6%, with no difference between patients with or without shock. The mean scene time was significantly shorter in trauma patients with shock (21.4 min) compared to without shock (21.4 vs 25.1 min). Following pre‐hospital tracheal intubation, 97% of trauma patients without shock and 91% of the patients in shock with measurable blood pressure were alive upon arrival to the ED. Conclusion Pre‐hospital tracheal intubation success and complication rates in trauma patients were comparable with in‐hospital rates in a system with very experienced airway providers. Whether the short scene times contributed to a low pre‐hospital mortality needs further investigation in future studies.
Collapse
Affiliation(s)
- Bjarni Árnason
- Department of Perioperative Medicine and Intensive Care Karolinska University Hospital Stockholm Sweden
- Rapid Response CarCapio Stockholm Sweden
| | - Daniel Hertzberg
- Department of Perioperative Medicine and Intensive Care Karolinska University Hospital Stockholm Sweden
- Department of Physiology and PharmacologyKarolinska Institutet Stockholm Sweden
| | - Daniel Kornhall
- Swedish Air Ambulance (SLA) Mora Sweden
- East Anglian Air Ambulance Cambridge UK
| | - Mattias Günther
- Department of Clinical Research and Education Karolinska Institutet Stockholm Sweden
| | - Mikael Gellerfors
- Department of Perioperative Medicine and Intensive Care Karolinska University Hospital Stockholm Sweden
- Rapid Response CarCapio Stockholm Sweden
- Department of Physiology and PharmacologyKarolinska Institutet Stockholm Sweden
- Swedish Air Ambulance (SLA) Mora Sweden
| |
Collapse
|
23
|
Claret PG, Villoing B, Rousseau G, Peschanski N, Catoire P, Gil-Jardine C. Actualités en médecine d’urgence. ANNALES FRANCAISES DE MEDECINE D URGENCE 2021. [DOI: 10.3166/afmu-2021-0340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|
24
|
Hock SM, Martin JJ, Stanfield SC, Alcorn TR, Binstadt ES. Novel cricothyrotomy assessment tool for attending physicians: A multicenter study of an error avoidance checklist. AEM EDUCATION AND TRAINING 2021; 5:e10687. [PMID: 34589660 PMCID: PMC8457693 DOI: 10.1002/aet2.10687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 07/24/2021] [Accepted: 08/03/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND This study used existing literature and expert feedback to develop and pilot a novel error-avoidance checklist tool for cricothyrotomy in attending physicians. Prior literature has not focused on expert cricothyrotomy performance. While published checklists teach a specific procedural method, ideal for novice learners, this may hinder expert learners. OBJECTIVES We endeavored to create a succinct error-avoidance checklist for cricothyrotomy. We hypothesized that such a checklist would prove feasible and acceptable to attending physicians. METHODS This is a multicenter prospective checklist creation, evaluation, and feasibility study. Multiple experts pursued an iterative process to reach consensus on a 7-item error-avoidance checklist. The checklist was trialed for feasibility in pilot sessions at two sites by 45 attending emergency physicians who used the checklist for peer performance assessment and provided feedback. RESULTS During the pilot implementation, 94% of respondents completed the procedure within the allotted 120 s. Greater than 85% of respondents agreed that four of the five procedural errors on the checklist were very or somewhat critical to avoid, including cutting >2 cm from midline, creating a false passage, failing to continuously maintain an object in the trachea, and injuring oneself during the procedure. Only 66% of participants felt severing the cricoid cartilage was critical. Successful breath administration and time under 120 s were critical for 100% and 95% of participants, respectively. The checklist was rated "easy" or "very easy" to use by 93% of participants, and 95% found this checklist reasonable for evaluating attending physicians. CONCLUSIONS We present the multicenter development and implementation of a novel error-avoidance checklist tool for use in expert cricothyrotomy performance. Attending emergency medicine (EM) physicians rated our tool easy to use and agreed that most of the proposed errors were critical. Participants overwhelmingly agreed this tool would be reasonable for evaluation of cricothyrotomy performance among attending EM physicians.
Collapse
Affiliation(s)
- Sara M. Hock
- Emergency DepartmentRush University Medical CenterChicagoIllinoisUSA
| | - Jerome J. Martin
- Emergency DepartmentRush University Medical CenterChicagoIllinoisUSA
| | | | - Thomas R. Alcorn
- Emergency DepartmentRush University Medical CenterChicagoIllinoisUSA
| | - Emily S. Binstadt
- Emergency DepartmentRegions HospitalHealth PartnersSt PaulMinnesotaUSA
| |
Collapse
|
25
|
Wong DJN, El-Boghdadly K, Owen R, Johnstone C, Neuman MD, Andruszkiewicz P, Baker PA, Biccard BM, Bryson GL, Chan MTV, Cheng MH, Chin KJ, Coburn M, Jonsson Fagerlund M, Lobo CA, Martinez-Hurtado E, Myatra SN, Myles PS, Navarro G, O'Sullivan E, Pasin L, Quintero K, Shallik N, Shamim F, van Klei WA, Ahmad I. Emergency Airway Management in Patients with COVID-19: A Prospective International Multicenter Cohort Study. Anesthesiology 2021; 135:292-303. [PMID: 33848324 PMCID: PMC8274456 DOI: 10.1097/aln.0000000000003791] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background: Tracheal intubation for patients with COVID-19 is required for invasive mechanical ventilation. The authors sought to describe practice for emergency intubation, estimate success rates and complications, and determine variation in practice and outcomes between high-income and low- and middle-income countries. The authors hypothesized that successful emergency airway management in patients with COVID-19 is associated with geographical and procedural factors. Methods: The authors performed a prospective observational cohort study between March 23, 2020, and October 24, 2020, which included 4,476 episodes of emergency tracheal intubation performed by 1,722 clinicians from 607 institutions across 32 countries in patients with suspected or confirmed COVID-19 requiring mechanical ventilation. The authors investigated associations between intubation and operator characteristics, and the primary outcome of first-attempt success. Results: Successful first-attempt tracheal intubation was achieved in 4,017/4,476 (89.7%) episodes, while 23 of 4,476 (0.5%) episodes required four or more attempts. Ten emergency surgical airways were reported—an approximate incidence of 1 in 450 (10 of 4,476). Failed intubation (defined as emergency surgical airway, four or more attempts, or a supraglottic airway as the final device) occurred in approximately 1 of 120 episodes (36 of 4,476). Successful first attempt was more likely during rapid sequence induction versus non–rapid sequence induction (adjusted odds ratio, 1.89 [95% CI, 1.49 to 2.39]; P < 0.001), when operators used powered air-purifying respirators versus nonpowered respirators (adjusted odds ratio, 1.60 [95% CI, 1.16 to 2.20]; P=0.006), and when performed by operators with more COVID-19 intubations recorded (adjusted odds ratio, 1.03 for each additional previous intubation [95% CI, 1.01 to 1.06]; P=0.015). Intubations performed in low- or middle-income countries were less likely to be successful at first attempt than in high-income countries (adjusted odds ratio, 0.57 [95% CI, 0.41 to 0.79]; P=0.001). Conclusions: The authors report rates of failed tracheal intubation and emergency surgical airway in patients with COVID-19 requiring emergency airway management, and identified factors associated with increased success. Risks of tracheal intubation failure and success should be considered when managing COVID-19. The authors report a secondary analysis of associations of intubation and operator characteristics related to the primary outcome of first-attempt intubation success in 4,476 intubations among 1,722 clinicians at 607 institutions across 32 countries, also considering differential rates of success between high-income and low- and middle-income countries. Although successful first-attempt intubation was noted in 89.7% of intubations, 0.5% required four or more attempts, an emergency surgical airway was required in 0.2%, and a composite variable of failed intubation occurred in 0.8%. Multivariable analysis demonstrated that successful first attempts were more likely with rapid sequence intubations, when operators used powered air-purifying respirators, and with increasing operator experience. Intubations performed in low- and middle-income countries were nearly half as likely to be successful on first attempt than in high-income countries. These results provide potentially useful information for global and local policy-making related to this and future pandemics. However, the observational nature, along with lack of patient level characteristics, leave room for substantial residual confounding of these associations. Supplemental Digital Content is available in the text.
Collapse
|
26
|
Mazzoli CA, Tartaglione M, Chiarini V, Lupi C, Coniglio C, Gordini G, Gamberini L. Letter in reply to Curry et al. Air Med J 2021; 40:145. [PMID: 33933213 DOI: 10.1016/j.amj.2020.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Accepted: 11/10/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Carlo Alberto Mazzoli
- Department of Anesthesia, Intensive Care and Emergency Medical Services, Ospedale Maggiore Carlo Alberto Pizzardi, Bologna, Italy
| | - Marco Tartaglione
- Department of Anesthesia, Intensive Care and Emergency Medical Services, Ospedale Maggiore Carlo Alberto Pizzardi, Bologna, Italy
| | - Valentina Chiarini
- Department of Anesthesia, Intensive Care and Emergency Medical Services, Ospedale Maggiore Carlo Alberto Pizzardi, Bologna, Italy
| | - Cristian Lupi
- Department of Anesthesia, Intensive Care and Emergency Medical Services, Ospedale Maggiore Carlo Alberto Pizzardi, Bologna, Italy
| | - Carlo Coniglio
- Department of Anesthesia, Intensive Care and Emergency Medical Services, Ospedale Maggiore Carlo Alberto Pizzardi, Bologna, Italy
| | - Giovanni Gordini
- Department of Anesthesia, Intensive Care and Emergency Medical Services, Ospedale Maggiore Carlo Alberto Pizzardi, Bologna, Italy
| | - Lorenzo Gamberini
- Department of Anesthesia, Intensive Care and Emergency Medical Services, Ospedale Maggiore Carlo Alberto Pizzardi, Bologna, Italy
| |
Collapse
|
27
|
McNarry AF, Asai T. New evidence to inform decisions and guidelines in difficult airway management. Br J Anaesth 2021; 126:1094-1097. [PMID: 33836852 DOI: 10.1016/j.bja.2021.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 02/14/2021] [Accepted: 03/03/2021] [Indexed: 12/13/2022] Open
Affiliation(s)
| | - Takashi Asai
- Department of Anesthesiology, Dokkyo Medical University Saitama Medical Centre, Koshigaya, Japan
| |
Collapse
|
28
|
Asselin M, Lafleur A, Labrecque P, Pellerin H, Tremblay MH, Chiniara G. Simulation of Adult Surgical Cricothyrotomy for Anesthesiology and Emergency Medicine Residents: Adapted for COVID-19. MEDEDPORTAL : THE JOURNAL OF TEACHING AND LEARNING RESOURCES 2021; 17:11134. [PMID: 33816795 PMCID: PMC8015712 DOI: 10.15766/mep_2374-8265.11134] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 02/01/2021] [Indexed: 06/12/2023]
Abstract
INTRODUCTION In a CICO (cannot intubate, cannot oxygenate) situation, anesthesiologists and acute care physicians must be able to perform an emergency surgical cricothyrotomy (front-of-neck airway procedure). CICOs are high-acuity situations with rare opportunities for safe practice. In COVID-19 airway management guidelines, bougie-assisted surgical cricothyrotomy is the recommended emergency strategy for CICO situations. METHODS We designed a 4-hour procedural simulation workshop on surgical cricothyrotomy to train 16 medical residents. We provided prerequisite readings, a lecture, and a videotaped demonstration. Two clinical scenarios introduced deliberate practice on partial-task neck simulators and fresh human cadavers. We segmented an evidence-based procedure and asked participants to verbalize the five steps of the procedure on multiple occasions. RESULTS Thirty-two residents who participated in the workshops were surveyed, with a 97% response rate (16 of 16 from anesthesiology, 15 of 16 from emergency medicine). Participants commented positively on the workshop's authenticity, its structure, the quality of the feedback provided, and its perceived impact on improving skills in surgical cricothyrotomy. We analyzed narrative comments related to three domains: preparation for the procedure, performing the procedure, and maintaining the skills. Participants highlighted the importance of performing the procedure many times and mentioned the representativeness of fresh cadavers. DISCUSSION We developed a surgical cricothyrotomy simulation workshop for anesthesiology and emergency medicine residents. Residents in the two specialities uniformly appreciated its format and content. We identified common pitfalls when executing the procedure and provided practical tips and material to facilitate implementation, in particular to face the COVID-19 pandemic.
Collapse
Affiliation(s)
- Mathieu Asselin
- Assistant Clinical Professor, Département d'anesthésiologie et de soins intensifs, Faculté de médecine, Université Laval
| | - Alexandre Lafleur
- Associate Clinical Professor, Département de médecine, Faculté de médecine, Université Laval; Co-Chairholder of the CMA-MD Educational Leadership Chair in Health Professions Education, Faculté de médecine, Université Laval
| | - Pascal Labrecque
- Associate Clinical Professor, Département d'anesthésiologie et de soins intensifs, Faculté de médecine, Université Laval
| | - Hélène Pellerin
- Associate Professor, Département d'anesthésiologie et de soins intensifs, Faculté de médecine, Université Laval
| | - Marie-Hélène Tremblay
- Assistant Clinical Professor, Département d'anesthésiologie et de soins intensifs, Faculté de médecine, Université Laval
| | - Gilles Chiniara
- Professor and Department Chair, Département d'anesthésiologie et de soins intensifs, Faculté de médecine, Université Laval; Chairholder of the Educational Leadership Chair in Health Sciences Simulation, Université Laval and Université Côte d'Azur
| |
Collapse
|
29
|
Knapp J, Eberle B, Bernhard M, Theiler L, Pietsch U, Albrecht R. Analysis of tracheal intubation in out-of-hospital helicopter emergency medicine recorded by video laryngoscopy. Scand J Trauma Resusc Emerg Med 2021; 29:49. [PMID: 33731197 PMCID: PMC7968290 DOI: 10.1186/s13049-021-00863-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 03/04/2021] [Indexed: 11/13/2022] Open
Abstract
Background Tracheal intubation remains the gold standard of airway management in emergency medicine and maximizing safety, intubation success, and especially first-pass intubation success (FPS) in these situations is imperative. Methods We conducted a prospective observational study on all 12 helicopter emergency medical service (HEMS) bases of the Swiss Air Rescue, between February 15, 2018, and February 14, 2019. All 428 patients on whom out-of-hospital advanced airway management was performed by the HEMS crew were included. The C-MAC video laryngoscope was used as the primary device for tracheal intubation. Intubation procedures were recorded by the video laryngoscope and precise time points were recorded to verify the time necessary for each attempt and the overall procedure time until successful intubation. The videos were further analysed for problems and complications during airway management by an independent reviewer. Additionally, a questionnaire about the intubation procedure, basic characteristics of the patient, circumstances, environmental factors, and the provider’s level of experience in airway management was filled out. Main outcome measures were FPS of tracheal intubation, overall success rate, overall intubation time, problems and complications of video laryngoscopy. Results FPS rate was 87.6% and overall success rate 98.6%. Success rates, overall time to intubation, and subjective difficulty were not associated to the providers’ expertise in airway management. In patients undergoing CPR FPS was 84.8%, in trauma patients 86.4% and in non-trauma patients 93.3%. FPS in patients with difficult airway characteristics, facial trauma/burns or obesity ranges between 87 and 89%. Performing airway management indoors or inside an ambulance resulted in a significantly higher FPS of 91.1% compared to outdoor locations (p < 0.001). Direct solar irradiation on the screen, fogging of the lens, and blood on the camera significantly impaired FPS. Several issues for further improvements in the use of video laryngoscopy in the out-of-hospital setting and for quality control in airway management were identified. Conclusion Airway management using the C-MAC video laryngoscope with Macintosh blade in a group of operators with mixed experience showed high FPS and overall rates of intubation success. Video recording emergency intubations may improve education and quality control.
Collapse
Affiliation(s)
- Jürgen Knapp
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, 3010, Bern, Switzerland.
| | - Bettina Eberle
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, 3010, Bern, Switzerland.,Department of Anaesthesiology, Cantonal Hospital of Graubünden, Chur, Switzerland
| | - Michael Bernhard
- Emergency Department, Heinrich-Heine-University, University Hospital of Düsseldorf, Düsseldorf, Germany
| | - Lorenz Theiler
- Department of Anaesthesiology, Cantonal Hospital of Aargau, Aarau, Switzerland.,Swiss Air Rescue, Rega, Zurich, Switzerland
| | - Urs Pietsch
- Swiss Air Rescue, Rega, Zurich, Switzerland.,Department of Anaesthesiology and Intensive Care Medicine, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Roland Albrecht
- Swiss Air Rescue, Rega, Zurich, Switzerland.,Department of Anaesthesiology and Intensive Care Medicine, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| |
Collapse
|
30
|
Ghaffar S, Blankenstein TN, Patel D, Theodosiou C, Griffith D. Quantification of the effect of body mass index on cricothyroid membrane depth: a cross-sectional analysis of clinical CT images. Emerg Med J 2021; 38:355-358. [PMID: 33627374 DOI: 10.1136/emermed-2019-209046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 01/19/2021] [Accepted: 02/07/2021] [Indexed: 01/25/2023]
Abstract
OBJECTIVES The recommended front of neck access procedure in can't intubate, can't oxygenate scenarios relies on palpation of the cricothyroid membrane (CTM), or dissection of the neck down to the larynx if CTM is impalpable. CTM palpation is particularly challenging in obese patients, most likely due to an increased distance between the skin and the CTM (CTM depth). The aims of this study were to measure the CTM depth in a representative clinical sample, and to quantify the relationship between body mass index (BMI) and CTM depth. METHODS This is a retrospective analysis of 355 clinical CT scans performed at a teaching hospital over an 8-month period. CTM depth was measured by two radiologists, and mean CTM depth calculated. Age, gender, height and weight were recorded, and BMI calculated. Linear relationships between patient characteristics and CTM depth were assessed in order to derive a predictive equation for calculating CTM depth. The variables included for this model were those with a strong association with CTM depth, that is, a p value of 0.10 or less. RESULTS Mean CTM depth was 8.12 mm (IQR 6.36-11.70). There was no association between CTM depth and sex (β -0.33, 95% CI -1.33 to 0.68, p=0.53), height (cm) (β 0.01, 95% CI -0.05 to 0.06, p=0.79) or age (years) (β -0.01, 95% CI 0.10 to 0.15, p=0.62). Increasing weight (kg) (β 0.12, 95% CI 0.10 to 0.15, p<0.001) and BMI (kg/m3) (β 0.52, 95% CI 0.44 to 0.60, p<0.001) were strongly associated with CTM depth. Predicted CTM depth increased from 6.4 mm (95% CI 4.9 to 8.1) at a BMI of 20 kg/m2 to 16.8 (95% CI 13.7 to 20.1) at BMI 40 kg/m2. CONCLUSION CTM depth was strongly associated with BMI in a retrospective analysis of patients having clinical CT scans.
Collapse
Affiliation(s)
- Sadia Ghaffar
- Department of Anaesthesia, Edinburgh Royal Infirmary, Edinburgh, UK
| | - Tom Nicholas Blankenstein
- HQ Army Medical Directorate, Army Medical Services, Camberley, Surrey, UK.,Clinical Radiology, South- East Scotland Deanery, Edinburgh, UK
| | - Dilip Patel
- Department of Radiology, Royal Infirmary of Edinburgh, Edinburgh, UK
| | | | - David Griffith
- Division of Medical and Radiological Sciences, University of Edinburgh, Edinburgh, UK
| |
Collapse
|
31
|
Aziz S, Foster E, Lockey DJ, Christian MD. Emergency scalpel cricothyroidotomy use in a prehospital trauma service: a 20-year review. Emerg Med J 2021; 38:349-354. [DOI: 10.1136/emermed-2020-210305] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 01/08/2021] [Accepted: 01/17/2021] [Indexed: 12/13/2022]
Abstract
BackgroundThis study aimed to determine the rate of scalpel cricothyroidotomy conducted by a physician–paramedic prehospital trauma service over 20 years and to identify indications for, and factors associated with the intervention.MethodsA retrospective observational study was conducted from 1 January 2000 to 31 December 2019 using clinical database records. This study was conducted in a physician–paramedic prehospital trauma service, serving a predominantly urban population of approximately 10 million in an area of approximately 2500 km2.ResultsOver 20 years, 37 725 patients were attended by the service, and 72 patients received a scalpel cricothyroidotomy. An immediate ‘primary’ cricothyroidotomy was performed in 17 patients (23.6%), and ‘rescue’ cricothyroidotomies were performed in 55 patients (76.4%). Forty-one patients (56.9%) were already in traumatic cardiac arrest during cricothyroidotomy. Thirty-two patients (44.4%) died on scene, and 32 (44.4%) subsequently died in hospital. Five patients (6.9%) survived to hospital discharge, and three patients (4.2%) were lost to follow-up. The most common indication for primary cricothyroidotomy was mechanical entrapment of patients (n=5, 29.4%). Difficult laryngoscopy, predominantly due to airway soiling with blood (n=15, 27.3%) was the most common indication for rescue cricothyroidotomy. The procedure was successful in 97% of cases. During the study period, 6570 prehospital emergency anaesthetics were conducted, of which 30 underwent rescue cricothyroidotomy after failed tracheal intubation (0.46%, 95% CI 0.31% to 0.65%).ConclusionsThis study identifies a number of indications leading to scalpel cricothyroidotomy both as a primary procedure or after failed intubation. The main indication for scalpel cricothyroidotomy in our service was as a rescue airway for failed laryngoscopy due to a large volume of blood in the airway. Despite high levels of procedural success, 56.9% of patients were already in traumatic cardiac arrest during cricothyroidotomy, and overall mortality in patients with trauma receiving this procedure was 88.9% in our service.
Collapse
|
32
|
Tsur N, Benov A, Nadler R, Tsur AM, Glick Y, Radomislensky I, Abuhasira S, Mizrachi A, Chen J. Neck injuries - israel defense forces 20 years' experience. Injury 2021; 52:274-280. [PMID: 32972724 DOI: 10.1016/j.injury.2020.09.042] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 09/01/2020] [Accepted: 09/18/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Neck injuries are an important cause of combat mortality and morbidity. This study's objective was to examine the characteristics and causes of neck injuries among Israel Defense Forces (IDF) and emphasize the best treatment protocols for the advanced life support providers in the prehospital combat environment. METHODS The IDF Trauma Registry (IDF-TR) includes prehospital data regarding casualties treated by the IDF's medical forces. This study was a retrospective, observational study that included all casualties who were injured between January 2006 and December 2018. RESULTS Between January 2016 and December 2018, 3294 casualties were recorded. During the study period, 1% (41/3,394) of all injury casualties in the registry were isolated neck injuries compared to 94% (3185/3,394) without neck injury. 42% (14/41) percent of the neck casualties were classified as urgent compared to 26% (830/3185, P = 0.09) in the no neck group. The most frequent type of injury mechanism in the neck casualties was penetrating injury (54% 22/41), mostly due to shrapnel (68% 15/22). 60% of neck injured personnel were injured during the 2nd Lebanon War and Operation Protective Edge in high-intensity conflicts. As for life-saving interventions, advanced airway interventions were performed in 12% of neck injured group (5/41) compared to 3% (104/3185, P = 0.02) in the no neck group. We revealed that cricothyroidotomy was performed in almost 10% (4/41) of neck injured casualties compared to only 1% (19/3185, P<0.0001) in no neck casualties. As for damage control resuscitation, neck injury casualties received higher amounts of Fresh Dried Plasma 7% (3/41) Vs. 1% (32/3185, P = 0.02) and Tranexamic acid 15% (6/41) Vs. 4% (124/3185, P = 0.01) compared to non-neck casualties. CONCLUSIONS Military neck injuries are a significant cause of substantial disability and result in incompatibility with combat duties in previously healthy soldiers. Prompt medical care, especially urgent hemodynamic and airway management, is paramount in these injuries. Routine use of designated neck protection might lower the number of neck injuries, mitigate their severity, and even decrease mortality. LEVEL OF EVIDENCE Level III (Retrospective study with up to two negative criteria).
Collapse
Affiliation(s)
- Nir Tsur
- Israel Defense Forces, Medical Corps, Tel Hashomer, Ramat Gan, Israel; Department of Otolaryngology-Head and Neck Surgery, Rabin Medical Center, Petah Tikva, Israel.
| | - Avi Benov
- Israel Defense Forces, Medical Corps, Tel Hashomer, Ramat Gan, Israel; Bar-Ilan University, Ramat Gan, Israel
| | - Roy Nadler
- Israel Defense Forces, Medical Corps, Tel Hashomer, Ramat Gan, Israel; Department of General Surgery and Transplantation, Chaim Sheba Medical Center, Tel Hashomer, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Avishai M Tsur
- Israel Defense Forces, Medical Corps, Tel Hashomer, Ramat Gan, Israel
| | - Yuval Glick
- Israel Defense Forces, Medical Corps, Tel Hashomer, Ramat Gan, Israel
| | | | | | - Aviram Mizrachi
- Department of Otolaryngology-Head and Neck Surgery, Rabin Medical Center, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jacob Chen
- Israel Defense Forces, Medical Corps, Tel Hashomer, Ramat Gan, Israel
| |
Collapse
|
33
|
Hardjo S, Croton C, Woldeyohannes S, Purcell SL, Haworth MD. Cricothyrotomy Is Faster Than Tracheostomy for Emergency Front-of-Neck Airway Access in Dogs. Front Vet Sci 2021; 7:593687. [PMID: 33505998 PMCID: PMC7829300 DOI: 10.3389/fvets.2020.593687] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 12/03/2020] [Indexed: 12/04/2022] Open
Abstract
Objectives: In novice final year veterinary students, we sought to: (1) compare the procedure time between a novel cricothyrotomy (CTT) technique and an abbreviated tracheostomy (TT) technique in canine cadavers, (2) assess the success rate of each procedure, (3) assess the complication rate of each procedure via a damage score, (4) evaluate the technical difficulty of each procedure and (5) determine the preferred procedure of study participants for emergency front-of-neck access. Materials and Methods: A prospective, cross-over, block randomised trial was performed, where veterinary students completed CTT and TT procedures on cadaver dogs. Eight students were recruited and performed 32 procedures on 16 dogs. A generalised estimating equation approach to modelling the procedure times was used. Results: The procedure time was significantly faster for the CTT than the TT technique, on average (p < 0.001). The mean time taken to complete the CTT technique was 49.6 s (95% CI: 29.5–69.6) faster on average, with a mean CTT time of less than half that of the TT. When taking into account the attempt number, the procedure time for a CTT was 66.4 s (95% CI: 38.9–93.9) faster than TT for the first attempt, and for the second attempt, this was 32.7 s (95% CI: 15.2–50.2) faster, on average. The success rate for both procedures was 100% and there was no difference detected in the damage or difficulty scores (P = 0.13 and 0.08, respectively). Seven of eight participants preferred the CTT. Clinical Significance: CTT warrants consideration as the primary option for emergency front-of-neck airway access for dogs.
Collapse
Affiliation(s)
- Sureiyan Hardjo
- School of Veterinary Science, The University of Queensland, Gatton, QLD, Australia
| | - Catriona Croton
- School of Veterinary Science, The University of Queensland, Gatton, QLD, Australia.,Faculty of Health, Engineering and Sciences, School of Sciences, University of Southern Queensland, Toowoomba, QLD, Australia
| | | | - Sarah Leonie Purcell
- School of Veterinary Science, The University of Queensland, Gatton, QLD, Australia
| | - Mark David Haworth
- School of Veterinary Science, The University of Queensland, Gatton, QLD, Australia
| |
Collapse
|
34
|
Crewdson K, Heywoth A, Rehn M, Sadek S, Lockey D. Apnoeic oxygenation for emergency anaesthesia of pre-hospital trauma patients. Scand J Trauma Resusc Emerg Med 2021; 29:10. [PMID: 33413576 PMCID: PMC7789511 DOI: 10.1186/s13049-020-00817-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Accepted: 11/24/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Efficient and timely airway management is universally recognised as a priority for major trauma patients, a proportion of whom require emergency intubation in the pre-hospital setting. Adverse events occur more commonly in emergency airway management, and hypoxia is relatively frequent. The aim of this study was to establish whether passive apnoeic oxygenation was effective in reducing the incidence of desaturation during pre-hospital emergency anaesthesia. METHODS A prospective before-after study was performed to compare patients receiving standard care and those receiving additional oxygen via nasal prongs. The primary endpoint was median oxygen saturation in the peri-rapid sequence induction period, (2 minutes pre-intubation to 2 minutes post-intubation) for all patients. Secondary endpoints included the incidence of hypoxia in predetermined subgroups. RESULTS Of 725 patients included; 188 patients received standard treatment and 537 received the intervention. The overall incidence of hypoxia (first recorded SpO2 < 90%) was 16.7%; 10.9% had SpO2 < 85%. 98/725 patients (13.5%) were hypoxic post-intubation (final SpO2 < 90% 10 minutes post-intubation). Median SpO2 was 100% vs. 99% for the standard vs. intervention group. There was a statistically significant benefit from apnoeic oxygenation in reducing the frequency of peri-intubation hypoxia (SpO2 < =90%) for patients with initial SpO2 > 95%, p = 0.0001. The other significant benefit was observed in the recovery phase for patients with severe hypoxia prior to intubation. CONCLUSION Apnoeic oxygenation did not influence peri-intubation oxygen saturations, but it did reduce the frequency and duration of hypoxia in the post-intubation period. Given that apnoeic oxygenation is a simple low-cost intervention with a low complication rate, and that hypoxia can be detrimental to outcome, application of nasal cannulas during the drug-induced phase of emergency intubation may benefit a subset of patients undergoing emergency anaesthesia.
Collapse
Affiliation(s)
- Kate Crewdson
- London's Air Ambulance, London, UK. .,Intensive Care Unit, Gate 37, Level 2, Brunel Building, Southmead Hospital, Southmead Road, Bristol, BS10 5NB, UK.
| | | | - Marius Rehn
- London's Air Ambulance, London, UK.,Department of Research, Norwegian Air Ambulance Foundation, Oslo, Norway.,Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
| | - Samy Sadek
- Essex & Herts Air Ambulance Trust, Essex, UK
| | - David Lockey
- London's Air Ambulance, London, UK.,Blizard Institute, Queen Mary University of London, London, UK
| |
Collapse
|
35
|
Law JA, Duggan LV, Asselin M, Baker P, Crosby E, Downey A, Hung OR, Jones PM, Lemay F, Noppens R, Parotto M, Preston R, Sowers N, Sparrow K, Turkstra TP, Wong DT, Kovacs G. Canadian Airway Focus Group updated consensus-based recommendations for management of the difficult airway: part 1. Difficult airway management encountered in an unconscious patient. Can J Anaesth 2021; 68:1373-1404. [PMID: 34143394 PMCID: PMC8212585 DOI: 10.1007/s12630-021-02007-0] [Citation(s) in RCA: 70] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 03/11/2021] [Accepted: 03/14/2021] [Indexed: 02/08/2023] Open
Abstract
PURPOSE Since the last Canadian Airway Focus Group (CAFG) guidelines were published in 2013, the literature on airway management has expanded substantially. The CAFG therefore re-convened to examine this literature and update practice recommendations. This first of two articles addresses difficulty encountered with airway management in an unconscious patient. SOURCE Canadian Airway Focus Group members, including anesthesia, emergency medicine, and critical care physicians, were assigned topics to search. Searches were run in the Medline, EMBASE, Cochrane Central Register of Controlled Trials, and CINAHL databases. Results were presented to the group and discussed during video conferences every two weeks from April 2018 to July 2020. These CAFG recommendations are based on the best available published evidence. Where high-quality evidence was lacking, statements are based on group consensus. FINDINGS AND KEY RECOMMENDATIONS Most studies comparing video laryngoscopy (VL) with direct laryngoscopy indicate a higher first attempt and overall success rate with VL, and lower complication rates. Thus, resources allowing, the CAFG now recommends use of VL with appropriately selected blade type to facilitate all tracheal intubations. If a first attempt at tracheal intubation or supraglottic airway (SGA) placement is unsuccessful, further attempts can be made as long as patient ventilation and oxygenation is maintained. Nevertheless, total attempts should be limited (to three or fewer) before declaring failure and pausing to consider "exit strategy" options. For failed intubation, exit strategy options in the still-oxygenated patient include awakening (if feasible), temporizing with an SGA, a single further attempt at tracheal intubation using a different technique, or front-of-neck airway access (FONA). Failure of tracheal intubation, face-mask ventilation, and SGA ventilation together with current or imminent hypoxemia defines a "cannot ventilate, cannot oxygenate" emergency. Neuromuscular blockade should be confirmed or established, and a single final attempt at face-mask ventilation, SGA placement, or tracheal intubation with hyper-angulated blade VL can be made, if it had not already been attempted. If ventilation remains impossible, emergency FONA should occur without delay using a scalpel-bougie-tube technique (in the adult patient). The CAFG recommends all institutions designate an individual as "airway lead" to help institute difficult airway protocols, ensure adequate training and equipment, and help with airway-related quality reviews.
Collapse
Affiliation(s)
- J. Adam Law
- grid.55602.340000 0004 1936 8200Department of Anesthesia, Pain Management and Perioperative Medicine, QEII Health Sciences Centre, Dalhousie University, Halifax Infirmary Site, 1796 Summer Street, Room 5452, Halifax, NS B3H 3A7 Canada
| | - Laura V. Duggan
- grid.28046.380000 0001 2182 2255Department of Anesthesiology and Pain Medicine, The Ottawa Hospital Civic Campus, University of Ottawa, Room B307, 1053 Carling Avenue, Mail Stop 249, Ottawa, ON K1Y 4E9 Canada
| | - Mathieu Asselin
- grid.23856.3a0000 0004 1936 8390Département d’anesthésiologie et de soins intensifs, Université Laval, 2325 rue de l’Université, Québec, QC G1V 0A6 Canada ,grid.411081.d0000 0000 9471 1794Département d’anesthésie du CHU de Québec, Hôpital Enfant-Jésus, 1401 18e rue, Québec, QC G1J 1Z4 Canada
| | - Paul Baker
- grid.9654.e0000 0004 0372 3343Department of Anaesthesiology, Faculty of Medical and Health Science, University of Auckland, Private Bag 92019, Auckland, 1142 New Zealand
| | - Edward Crosby
- grid.28046.380000 0001 2182 2255Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, University of Ottawa, Suite CCW1401, 501 Smyth Road, Ottawa, ON K1H 8L6 Canada
| | - Andrew Downey
- grid.1055.10000000403978434Department of Anaesthesia, Perioperative and Pain Medicine, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Orlando R. Hung
- grid.55602.340000 0004 1936 8200Department of Anesthesia, Pain Management and Perioperative Medicine, QEII Health Sciences Centre, Dalhousie University, 1796 Summer Street, Halifax, NS B3H 3A7 Canada
| | - Philip M. Jones
- grid.39381.300000 0004 1936 8884Department of Anesthesia & Perioperative Medicine, Department of Epidemiology & Biostatistics, Schulich School of Medicine & Dentistry, University of Western Ontario, LHSC- University Hospital, 339 Windermere Rd., London, ON N6A 5A5 Canada
| | - François Lemay
- grid.417661.30000 0001 2190 0479Département d’anesthésiologie, CHU de Québec – Université Laval, Hôtel-Dieu de Québec, 11, Côte du Palais, Québec, QC G1R 2J6 Canada
| | - Rudiger Noppens
- grid.39381.300000 0004 1936 8884Department of Anesthesia & Perioperative Medicine, Schulich School of Medicine & Dentistry, University of Western Ontario, LHSC- University Hospital, 339 Windermere Road, London, ON N6A 5A5 Canada
| | - Matteo Parotto
- grid.17063.330000 0001 2157 2938Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto General Hospital, Toronto, ON Canada ,grid.17063.330000 0001 2157 2938Interdepartmental Division of Critical Care Medicine, University of Toronto, EN 442 200 Elizabeth St, Toronto, ON M5G 2C4 Canada
| | - Roanne Preston
- grid.413264.60000 0000 9878 6515Department of Anesthesia, BC Women’s Hospital, 4500 Oak Street, Vancouver, BC V6H 3N1 Canada
| | - Nick Sowers
- grid.55602.340000 0004 1936 8200Department of Emergency Medicine, QEII Health Sciences Centre, Dalhousie University, 1796 Summer Street, Halifax, NS B3H 3A7 Canada
| | - Kathryn Sparrow
- grid.25055.370000 0000 9130 6822Discipline of Anesthesia, St. Clare’s Mercy Hospital, Memorial University of Newfoundland, 300 Prince Phillip Drive, St. John’s, NL A1B V6 Canada
| | - Timothy P. Turkstra
- grid.39381.300000 0004 1936 8884Department of Anesthesia & Perioperative Medicine, Schulich School of Medicine & Dentistry, University of Western Ontario, LHSC- University Hospital, 339 Windermere Road, London, ON N6A 5A5 Canada
| | - David T. Wong
- grid.17063.330000 0001 2157 2938Department of Anesthesia, Toronto Western Hospital, University Health Network, University of Toronto, 399, Bathurst St, Toronto, ON M5T2S8 Canada
| | - George Kovacs
- grid.55602.340000 0004 1936 8200Department of Emergency Medicine, QEII Health Sciences Centre, Dalhousie University, 1796 Summer Street, Halifax, NS B3H 3A7 Canada
| | | |
Collapse
|
36
|
Latimer AJ, Harrington B, Counts CR, Ruark K, Maynard C, Watase T, Sayre MR. Routine Use of a Bougie Improves First-Attempt Intubation Success in the Out-of-Hospital Setting. Ann Emerg Med 2020; 77:296-304. [PMID: 33342596 DOI: 10.1016/j.annemergmed.2020.10.016] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 09/28/2020] [Accepted: 10/05/2020] [Indexed: 11/25/2022]
Abstract
STUDY OBJECTIVE The bougie is typically treated as a rescue device for difficult airways. We evaluate whether first-attempt success rate during paramedic intubation in the out-of-hospital setting changed with routine use of a bougie. METHODS A prospective, observational, pre-post study design was used to compare first-attempt success rate during out-of-hospital intubation with direct laryngoscopy for patients intubated 18 months before and 18 months after a protocol change that directed the use of the bougie on the first intubation attempt. We included all patients with a paramedic-performed intubation attempt. Logistic regression was used to examine the association between routine bougie use and first-attempt success rate. RESULTS Paramedics attempted intubation in 823 patients during the control period and 771 during the bougie period. The first-attempt success rate increased from 70% to 77% (difference 7.0% [95% confidence interval 3% to 11%]). Higher first-attempt success rate was observed during the bougie period across Cormack-Lehane grades, with rates of 91%, 60%, 27%, and 6% for Cormack-Lehane grade 1, 2, 3, and 4 views, respectively, during the control period and 96%, 85%, 50%, and 14%, respectively, during the bougie period. Intubation during the bougie period was independently associated with higher first-attempt success rate (adjusted odds ratio 2.82 [95% confidence interval 1.96 to 4.01]). CONCLUSION Routine out-of-hospital use of the bougie during direct laryngoscopy was associated with increased first-attempt intubation success rate.
Collapse
Affiliation(s)
- Andrew J Latimer
- Department of Emergency Medicine, University of Washington, Seattle, WA; Seattle Fire Department, Seattle, WA.
| | - Brenna Harrington
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Catherine R Counts
- Department of Emergency Medicine, University of Washington, Seattle, WA; Seattle Fire Department, Seattle, WA
| | - Katelyn Ruark
- University of North Dakota College of Medicine, Grand Forks, ND
| | - Charles Maynard
- Department of Health Services, University of Washington, Seattle, WA
| | - Taketo Watase
- Department of Emergency Medicine, University of Washington, Seattle, WA
| | - Michael R Sayre
- Department of Emergency Medicine, University of Washington, Seattle, WA; Seattle Fire Department, Seattle, WA
| |
Collapse
|
37
|
Cavaliere GA, Jasani GN, Gordon D, Lawner BJ. Difficulty Ventilating: A Case Report on Ventilation Considerations of an Intubated Asthmatic Undergoing Air Medical Critical Care Transport. Air Med J 2020; 40:135-138. [PMID: 33637279 DOI: 10.1016/j.amj.2020.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 11/17/2020] [Accepted: 11/23/2020] [Indexed: 11/25/2022]
Abstract
The air medical transport of intubated patients is a high-risk mission that requires preplanning before helicopter launch. This case describes a scenario in which the helicopter emergency medical services (HEMS) team was unable to ventilate a patient because of the mechanical limitations of the transport ventilator. The HEMS mission was ultimately aborted, and the patient had to be transported by a ground crew equipped with a hospital-based ventilator. In addition to the optimal medical management of the patient in status asthmaticus, critical care transport crews must be familiar with the treatment of patients exhibiting extremely high peak airway pressures. Specifically, ventilator manipulations as well as the technical specifications of the transport ventilator may preclude the patient from being transported by the HEMS team. It is imperative that the patient's current ventilator setting be evaluated before the launch of the aircraft to prevent any possible delays in patient care.
Collapse
Affiliation(s)
- Garrett A Cavaliere
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 S Paca St 6th floor, Ste 200, Baltimore, MD 21201.
| | - Gregory N Jasani
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 S Paca St 6th floor, Ste 200, Baltimore, MD 21201
| | - David Gordon
- Department of Internal Medicine, University of Maryland Medical Center, Baltimore, MD 21201
| | - Benjamin J Lawner
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 S Paca St 6th floor, Ste 200, Baltimore, MD 21201; Maryland ExpressCare Critical Care Transport Program, Baltimore, MD
| |
Collapse
|
38
|
Abstract
Management of the unanticipated difficult airway is one of the most relevant and challenging crisis management scenarios encountered in clinical anesthesia practice. Several guidelines and approaches have been developed to assist clinicians in navigating this high-acuity scenario. In the most serious cases, the clinician may encounter a failed airway that results from failure to ventilate an anesthetized patient via facemask or supraglottic airway or intubate the patient with an endotracheal tube. This dreaded cannot intubate, cannot oxygenate situation necessitates emergency invasive access. This article reviews the incidence, management, and complications of the failed airway and training issues related to its management.
Collapse
Affiliation(s)
- Paul Potnuru
- Department of Anesthesiology, McGovern Medical School, University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.020, Houston, TX 77030, USA
| | - Carlos A Artime
- Department of Anesthesiology, McGovern Medical School, University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.020, Houston, TX 77030, USA
| | - Carin A Hagberg
- Anesthesiology, Critical Care & Pain Medicine, Department of Anesthesiology and Perioperative Medicine, University of Texas MD Anderson Cancer Center, 1400 Holcombe Boulevard, Unit 409, Houston, TX 77030, USA.
| |
Collapse
|
39
|
van Schuppen H, Boomars R, Kooij FO, den Tex P, Koster RW, Hollmann MW. Optimizing airway management and ventilation during prehospital advanced life support in out-of-hospital cardiac arrest: A narrative review. Best Pract Res Clin Anaesthesiol 2020; 35:67-82. [PMID: 33742579 DOI: 10.1016/j.bpa.2020.11.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 11/03/2020] [Accepted: 11/06/2020] [Indexed: 12/20/2022]
Abstract
Airway management and ventilation are essential components of cardiopulmonary resuscitation to achieve oxygen delivery in order to prevent hypoxic injury and increase the chance of survival. Weighing the relative benefits and downsides, the best approach is a staged strategy; start with a focus on high-quality chest compressions and defibrillation, then optimize mask ventilation while preparing for advanced airway management with a supraglottic airway device. Endotracheal intubation can still be indicated, but has the largest downsides of all advanced airway techniques. Whichever stage of airway management, ventilation and chest compression quality should be closely monitored. Capnography has many advantages and should be used routinely. Optimizing ventilation strategies, harmonizing ventilation with mechanical chest compression devices, and implementation in complex and stressful environments are challenges we need to face through collaborative innovation, research, and implementation.
Collapse
Affiliation(s)
- Hans van Schuppen
- Amsterdam UMC, University of Amsterdam, Department of Anesthesiology, Meibergdreef 9, Amsterdam, the Netherlands.
| | - René Boomars
- Regional Ambulance Service Utrecht (RAVU), Jan van Eijcklaan 6, Bilthoven, the Netherlands
| | - Fabian O Kooij
- Amsterdam UMC, University of Amsterdam, Department of Anesthesiology, Meibergdreef 9, Amsterdam, the Netherlands; Amsterdam UMC, Vrije Universiteit Amsterdam, Helicopter Mobile Medical Team (MMT), De Boelelaan 1117, Amsterdam, the Netherlands
| | - Paul den Tex
- University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
| | - Rudolph W Koster
- Amsterdam UMC, University of Amsterdam, Amsterdam Resuscitation Studies (ARREST), Meibergdreef 9, Amsterdam, the Netherlands
| | - Markus W Hollmann
- Amsterdam UMC, University of Amsterdam, Department of Anesthesiology, Meibergdreef 9, Amsterdam, the Netherlands
| |
Collapse
|
40
|
Oxygenation strategies prior to and during prehospital emergency anaesthesia in UK HEMS practice (PREOXY survey). Scand J Trauma Resusc Emerg Med 2020; 28:99. [PMID: 33046111 PMCID: PMC7552361 DOI: 10.1186/s13049-020-00794-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 10/07/2020] [Indexed: 11/19/2022] Open
Abstract
Background Maintaining effective oxygenation throughout the process of Pre-Hospital Emergency Anaesthesia (PHEA) is critical. There are multiple strategies available to clinicians to oxygenate patients both prior to and during PHEA. The optimal pre-oxygenation technique remains unclear, and it is unknown what techniques are being used by United Kingdom Helicopter Emergency Medical Services (HEMS). This study aimed to determine the current pre- and peri-PHEA oxygenation strategies used by UK HEMS services. Methods An electronic questionnaire survey was delivered to all UK HEMS services between 05 July and 26 December 2019. Questions investigated service standard operating procedures (SOPs) and individual clinician practice regarding oxygenation strategies prior to airway instrumentation (pre-oxygenation) and oxygenation strategies during airway instrumentation (apnoeic oxygenation). Service SOPs were obtained to corroborate questionnaire replies. Results Replies were received from all UK HEMS services (n = 21) and 40 individual clinicians. All services specified oxygenation strategies within their PHEA/RSI SOP and most referred to pre-oxygenation as mandatory (81%), whilst apnoeic oxygenation was mandatory in eight (38%) SOPs. The most commonly identified pre-oxygenation strategies were bag-valve-mask without PEEP (95%), non-rebreathable face mask (81%), and nasal cannula at high flow (81%). Seven (33%) services used Mapleson C circuits, whilst there were eight services (38%) that did not carry bag-valve-masks with PEEP valve nor Mapleson C circuits. All clinicians frequently used pre-oxygenation, however there was variability in clinician use of apnoeic oxygenation by nasal cannula. Nearly all clinicians (95%) reported manually ventilating patients during the apnoeic phase, with over half (58%) stating this was their routine practice. Differences in clinician pre-hospital and in-hospital practice related to availability of humidified high flow nasal oxygenation and Mapleson C circuits. Conclusions Pre-oxygenation is universal amongst UK HEMS services and is most frequently delivered by bag-valve-mask without PEEP or non-rebreathable face masks, whereas apnoeic oxygenation by nasal cannula is highly variable. Multiple services carry Mapleson C circuits, however many services are unable to deliver PEEP due to the equipment they carry. Clinicians are regularly manually ventilating patients during the apnoeic phase of PHEA. The identified variability in clinical practice may indicate uncertainty and further research is warranted to assess the impact of different strategies on clinical outcomes.
Collapse
|
41
|
Overgaard MF, Heino A, Andersen SA, Thomas O, Holmén J, Mikkelsen S. Physician staffed emergency medical service for children: a retrospective population-based registry cohort study in Odense region, Southern Denmark. BMJ Open 2020; 10:e037567. [PMID: 32792443 PMCID: PMC7430407 DOI: 10.1136/bmjopen-2020-037567] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES The aim of this study is to determine diagnostic patterns in the prehospital paediatric population, age distribution, the level of monitoring and the treatment initiated in the prehospital paediatric case. Hypothesis was that advanced prehospital interventions are rare in the paediatric patient population. SETTING We performed a retrospective population-based registry cohort study of children attended by a physician-staffed emergency medical service (EMS) unit (P-EMS), in the Odense area of Denmark during a 10-year study period. PARTICIPANTS We screened 44 882 EMS contacts and included 5043 children. Patient characteristics, monitoring and interventions performed by the P-EMS crews were determined. RESULTS We found that paediatric patients were a minority among patients attended by P-EMS units: 11.2% (10.9 to 11.5) (95% CI) of patients were children. The majority of the children were <5 years old; one-third being <2 years old. Respiratory problems, traffic accidents and febrile seizures were the three most common dispatch codes. Oxygen supplementation, intravenous access and application of a cervical collar were the three most common interventions. Oxygen saturation and heart rate were documented in more than half of the cases, but more than one-third of the children had no vital parameters documented. Only 22% of the children had respiratory rate, saturation, heart rate and blood pressure documented. Prehospital invasive procedures such as tracheal intubation (n=74), intraosseous access (n=22) and chest drainage (n=2) were infrequently performed. CONCLUSION Prehospital paediatric contacts are uncommon, more frequently involving smaller children. Monitoring or at least documentation of basic vital parameters is infrequent and may be an area for improvement. Advanced and potentially life-saving prehospital interventions provide a dilemma since these likely occur too infrequently to allow service providers to maintain their technical skills working solely in the prehospital environment.
Collapse
Affiliation(s)
- Morten Føhrby Overgaard
- Department of Anaesthesiology and Intensive Care Medicine, Odense University Hospital, Odense, Denmark
- Department of Anaesthesia and Intensive Care Medicine, The Hospital of South West Jutland, Esbjerg, Denmark
| | - Anssi Heino
- Department of Perioperative Services, Intensive Care Medicine and Pain management, Turku University Hospital, Turku Finnish University Association, Turku, Finland
| | - Sofie Allerød Andersen
- Department of Anaesthesiology and Intensive Care Medicine, Odense University Hospital, Odense, Denmark
| | - Owain Thomas
- Paediatric Anesthesia and Intensive Care, Skåne University Hospital Lund, Lund, Skåne, Sweden
- Institution of Clinical Sciences, Lund University, Lund, Sweden
| | - Johan Holmén
- Pediatric Anesthesia and Intensive Care, Department of Prehospital and Emergency Care, Queen Silvia's Children's Hospital, Sahlgrenska University Hospital, Goteborg, Sweden
| | - Søren Mikkelsen
- Department of Anaesthesiology and Intensive Care Medicine, Odense University Hospital, Odense, Denmark
- Mobile Emergency Care Unit, Odense University Hospital, Odense, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| |
Collapse
|
42
|
Sharma A, Sharma S, Sharma A, Muddassir K. Broken Scalpel Blade During Emergent Cricothyroidotomy: An Unexpected Complication in a Critical Situation. Cureus 2020; 12:e8868. [PMID: 32754405 PMCID: PMC7386060 DOI: 10.7759/cureus.8868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Scalpel-bougie cricothyroidotomy is the most common surgical procedure to obtain emergency airway access when routine methods fail. We present a case of a broken scalpel blade during emergency cricothyroidotomy further complicating respiratory access.
Collapse
Affiliation(s)
- Arindam Sharma
- Internal Medicine, University of Tennessee Health Science Center, Memphis, USA
| | - Shreyak Sharma
- Renal Medicine, Brigham and Women's Hospital, Boston, USA
| | - Arunima Sharma
- Internal Medicine, Sikkim Manipal Institute of Medical Sciences, Gangtok, IND
| | - Khawaja Muddassir
- Pulmonary and Critical Care, University of Tennessee Health Science Center, Memphis, USA
| |
Collapse
|
43
|
Schweizer MA, Wampler D, Lu K, Oh AS, Rahm SJ, Studer NM, Cunningham CW. Prehospital Battlefield Casualty Intervention Decision Cognitive Study. Mil Med 2020; 185:274-278. [PMID: 32074373 DOI: 10.1093/milmed/usz226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Airway compromise is the third most common cause of preventable battlefield death. Surgical cricothyroidotomy (SC) is recommended by Tactical Combat Casualty Care (TCCC) guidelines when basic airway maneuvers fail. This is a descriptive analysis of the decision-making process of prehospital emergency providers to perform certain airway interventions. METHODS We conducted a scenario-based survey using two sequential video clips of an explosive injury event. The answers were used to conduct descriptive analyses and multivariable logistic regression models to estimate the association between the choice of intervention and training factors. RESULTS There were 254 respondents in the survey, 176 (69%) of them were civilians and 78 (31%) were military personnel. Military providers were more likely to complete TCCC certification (odds ratio [OR]: 13.1; confidence interval [CI]: 6.4-26.6; P-value < 0.001). The SC was the most frequently chosen intervention after each clip (29.92% and 22.10%, respectively). TCCC-certified providers were more likely to choose SC after viewing the two clips (OR: 1.9; CI: 1.2-3.2; P-value: 0.009), even after controlling for relevant factors (OR: 2.3; CI: 1.1-4.8; P-value: 0.033). CONCLUSIONS Military providers had a greater propensity to be certified in TCCC, which was found to increase their likelihood to choose the SC in early prehospital emergency airway management.
Collapse
Affiliation(s)
- Marc A Schweizer
- Department of Defense Joint Trauma System, 3698 Chambers Pass Bldg. 3611, Joint Base San Antonio Fort Sam Houston, TX 78234-6315
| | - David Wampler
- Department of Emergency Health Sciences, University of Texas Health San Antonio, 4201 Medical Dr. Suite 120, San Antonio, TX 78229
| | - Kevin Lu
- Emergency Department, Medical College of Georgia at Augusta University, 1465 Laney Walker Blvd., Augusta, GA 30912
| | - Andrew S Oh
- 1st Battalion, 1st Special Forces Group (Airborne), Okinawa, Japan
| | - Stephen J Rahm
- Centre for Emergency Health Sciences, 353 Rodeo Dr., Spring Branch, TX 78070
| | - Nicholas M Studer
- Department of Emergency Medicine, Brooke Army Medical Center, MCHE-ZSE-R, Joint Base San Antonio Fort Sam Houston, 3551 Roger Brooke Dr., San Antonio, TX 78234-4551
| | - Cord W Cunningham
- Department of Defense Joint Trauma System, 3698 Chambers Pass Bldg. 3611, Joint Base San Antonio Fort Sam Houston, TX 78234-6315
| |
Collapse
|
44
|
Intubation of emergency traumatic head injury patient outside the operation theatre: Cross-sectional study. INTERNATIONAL JOURNAL OF SURGERY OPEN 2020. [DOI: 10.1016/j.ijso.2020.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
|
45
|
Sollid SJM, Kämäräinen A. The checklist, your friend or foe? Acta Anaesthesiol Scand 2020; 64:4-5. [PMID: 31545514 DOI: 10.1111/aas.13479] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 09/14/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Stephen J. M. Sollid
- Norwegian Air Ambulance Foundation Oslo Norway
- Faculty of Healthcare Sciences University of Stavanger Stavanger Norway
| | - Antti Kämäräinen
- Greater Sydney Area HEMS Sydney NSW Australia
- Emergency Medical Services Tampere University Hospital Tampere Finland
| |
Collapse
|
46
|
Lockey DJ, Wilson M. Early airway management of patients with severe head injury: opportunities missed? Anaesthesia 2020; 75:7-10. [PMID: 31531980 DOI: 10.1111/anae.14854] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/20/2019] [Indexed: 11/27/2022]
Affiliation(s)
- D J Lockey
- School of Clinical Sciences, University of Bristol, UK.,Emergency Medical Retrieval and Transfer Service (EMRTS), UK
| | - M Wilson
- Imperial College London, UK.,Faculty of Pre-hospital Care, Royal College of Surgeons Edinburgh, UK
| |
Collapse
|
47
|
Okada Y, Hashimoto K, Ishii W, Iiduka R, Koike K. Development and validation of a model to predict the need for emergency front-of-neck airway procedures in trauma patients. Anaesthesia 2019; 75:591-598. [PMID: 31788784 DOI: 10.1111/anae.14895] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/24/2019] [Indexed: 12/17/2022]
Abstract
The present study aimed to develop and validate a model for predicting the need for emergency front-of neck airway (eFONA) procedures among trauma patients. This was a multicentre retrospective cohort study using data from the Japan Trauma Data Bank between January 2004 and December 2017. Only adult trauma patients were included. The cohort was divided into development and validation cohorts. A simple scoring system was developed to predict the necessity for emergency front-of neck airway procedures in the development cohort using a logistic regression model. The external validity and diagnostic ability of the scoring system was assessed in the validation cohort. In total, 198,182 out of 294,274 patients were included; emergency front-of-neck airway occurred in 467 patients (0.24%) they were divided into development (n = 100,120 with 0.22% undergoing emergency front-of neck airway) and validation (n = 98,062 with 0.25% undergoing emergency front-of neck airway) cohorts. The 'eFONA' prediction scoring system was developed in the development cohort, with a score of +1 for each of the following: Eye opening (no eye opening in response to any stimuli); Fall from height or motor bike; Oral-maxillofacial injury; Neck tracheal injury; and Airway management by paramedics. In the validation cohort, the C-statistic of the scoring system was 0.820. Setting the cut-off value at one for rule-out, the sensitivity and negative likelihood ratios were 0.86 and 0.22, respectively. Setting the cut-off value at two for rule-in, the specificity and positive likelihood ratios were 0.91 and 6.6, respectively. The present scoring system may assist in predicting the need for emergency front-of neck airway procedures among the general trauma population.
Collapse
Affiliation(s)
- Y Okada
- Department of Primary Care and Emergency Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan.,Department of Preventive Services, Kyoto University, Kyoto, Japan
| | - K Hashimoto
- Department of Healthcare Epidemiology, School of Public Health, Kyoto University, Kyoto, Japan
| | - W Ishii
- Department of Emergency Medicine and Critical Care, Japanese Red Cross Society Kyoto Daini Hospital, Kyoto, Japan
| | - R Iiduka
- Department of Emergency Medicine and Critical Care, Japanese Red Cross Society Kyoto Daini Hospital, Kyoto, Japan
| | - K Koike
- Department of Primary Care and Emergency Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| |
Collapse
|
48
|
Andresen ÅEL, Kramer‐Johansen J, Kristiansen T. Percutaneous vs surgical emergency cricothyroidotomy: An experimental randomized crossover study on an animal-larynx model. Acta Anaesthesiol Scand 2019; 63:1306-1312. [PMID: 31287154 DOI: 10.1111/aas.13447] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 06/17/2019] [Accepted: 06/18/2019] [Indexed: 12/24/2022]
Abstract
BACKGROUND Airway management is a paramount clinical skill for the anaesthesiologist. The Emergency Cricothyroidotomy (EC) constitutes the final step in difficult airway algorithms securing a patent airway via a front-of-neck access. The main distinction among available techniques is whether the procedure is surgical and scalpel-based or percutaneous and needle-based. METHODS In an experimental randomized crossover trial, using an animal larynx model, we compared two EC techniques; the Rapid Four Step Technique and the Melker Emergency Cricothyrotomy Kit®. We assessed time expenditure and success rates among 20 anaesthesiologists and related this to previous training, seniority and clinical experience with EC. RESULTS All participants achieved successful airway access with both methods. Average time to successful airway access for scalpel-based EC was 54 (±31) seconds and for percutaneous EC 89 (±38) seconds, with 35 (95% CI: 14-57) seconds time difference, P = .003. Doctors with recent (<12 months) EC training performed better compared to the non-training group (37 vs 61 seconds, P = .03 for scalpel-based EC, and 65 vs 99 seconds, P = .02 for percutaneous EC). We found no differences according to clinical seniority or previous real-life EC experience. CONCLUSIONS Our study demonstrated that anaesthesiologists achieved successful airway access on an animal experimental model with both EC methods within a reasonable time frame, but the scalpel-based EC is performed more promptly. Recent EC training affected the time expenditure positively, while seniority and clinical EC experience did not. EC procedures should be regularly trained for.
Collapse
Affiliation(s)
- Åke Erling L. Andresen
- Department of Research Norwegian Air Ambulance Foundation Oslo Norway
- Department of Anaesthesiology and Intensive Care Vestre Viken Hospital Trust Drammen Norway
| | - Jo Kramer‐Johansen
- Division of Prehospital Services, Institute of Clinical Medicine University of Oslo Oslo Norway
- Norwegian National Advisory Unit on Prehospital Emergency Medicine Oslo University Hospital Oslo Norway
| | - Thomas Kristiansen
- Department of Anaesthesiology, Division of Emergencies and Critical Care Oslo University Hospital, Rikshospitalet Oslo Norway
- Division of Emergencies and Critical Care Institute of Clinical Medicine, University of Oslo Oslo Norway
- Norwegian National Advisory Unit on Trauma, Division of Emergencies and Critical Care Oslo University Hospital Oslo Norway
| |
Collapse
|
49
|
Kwon YS, Lee CA, Park S, Ha SO, Sim YS, Baek MS. Incidence and outcomes of cricothyrotomy in the "cannot intubate, cannot oxygenate" situation. Medicine (Baltimore) 2019; 98:e17713. [PMID: 31626153 PMCID: PMC6824795 DOI: 10.1097/md.0000000000017713] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Few data are available regarding factors that impact cricothyrotomy use and outcome in general hospital setting. The aim of the present study was to determine the incidence and outcomes of the patients underwent cricothyrotomy in a "cannot intubate, cannot oxygenate" (CICO) situation at university hospitals in Korea.This was a retrospective review of the electronic medical records of consecutive patients who underwent cricothyrotomy during a CICO situation between March, 2007, and October, 2018, at 2 university hospitals in Korea. Data regarding patient characteristics and outcomes were analyzed using descriptive statistics.During the study period, a total of 10,187 tracheal intubations were attempted and 23 patients received cricothyrotomy. Hospitalwide incidence of cricothyrotomy was 2.3 per 1000 tracheal intubations (0.23%). The majority of cricothyrotomy procedures (22 cases, 95.7%) were performed in the emergency department (ED); 1 cricothyrotomy was attempted in the endoscopy room. In the ED, 5663 intubations were attempted and the incidence of cricothyrotomy was 3.9 per 1000 tracheal intubations (0.39%). Survival rate at hospital discharge was 47.8% (11 of 23 cases). Except for cardiac arrest at admission, survival rate was 62.5% (10 of 16 cases). Successful cricothyrotomy was performed in 17 patients (73.9%) and 9 patients (52.9%) were survived. Among 6 patients of failed cricothyrotomy (26.1%), 2 patients (33.3%) were survived. After failure of cricothyrotomy, various methods of securing airway were established: 3 tracheal intubations, 1 nasotracheal intubation, and 1 tracheostomy.The success rate of cricothyrotomy and survival rate in the CICO situation were not high. After failure of cricothyrotomy, various methods of securing airway were performed.
Collapse
Affiliation(s)
- Young Suk Kwon
- Department of Anaesthesiology and Pain Medicine, College of Medicine, Hallym University, Chuncheon Sacred Heart Hospital, Chuncheon
| | - Choung Ah Lee
- Department of Emergency Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong-si
| | - Sunghoon Park
- Division of Pulmonary, Allergy, and Critical Care Medicine
| | - Sang Ook Ha
- Department of Emergency Medicine, Hallym University Sacred Heart Hospital, Anyang-si, Gyeonggi-do
| | - Yun Su Sim
- Division of Pulmonary, Allergy, and Critical Care Medicine, Hallym University Kangnam Sacred Heart Hospital, Seoul
| | - Moon Seong Baek
- Division of Pulmonary, Allergy, and Critical Care Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong-si, Republic of Korea
| |
Collapse
|
50
|
Clough RAJ, Khan M. Initial CABC: Advances that have led to increased survival in military casualties. TRAUMA-ENGLAND 2019. [DOI: 10.1177/1460408619838438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Reece AJ Clough
- Barts and The London School of Medicine and Dentistry, London, UK
| | - Mansoor Khan
- Department of Surgery and Cancer, St Mary’s Hospital, London, UK
| |
Collapse
|