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Wang HE, Yu MI, Crowe RP, Nassal MMJ, Gage C, Hyer JM, Powell J, Ulintz A, Sharkey-Toppen T, Wei L, Moeller K, Panchal AR. Longitudinal Changes in Emergency Medical Services Advanced Airway Management. JAMA Netw Open 2024; 7:e2427763. [PMID: 39172452 DOI: 10.1001/jamanetworkopen.2024.27763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/23/2024] Open
Abstract
Importance Identifying longitudinal changes in advanced airway management by emergency medical services (EMS) is crucial for understanding practice patterns and optimizing care. Objective To examine the longitudinal trends in endotracheal intubation (ETI) and supraglottic airway (SGA) utilization in a national EMS cohort. Design, Setting, and Participants This retrospective cross-sectional study analyzed 2011 to 2022 data from the ESO Data Collaborative, a national database of US prehospital electronic health records. The study included all 911 EMS events in which advanced airway management was attempted. Data were analyzed from November 2022 to January 2024. Exposures Advanced airway management attempts, including ETI, SGA, and surgical airways. Main Outcomes and Measures The annual percentage of ETI and SGA attempts, stratified by underlying condition (cardiac arrest, nonarrest medical, nonarrest trauma, pediatrics). Results Among 47.5 million EMS activations, 444 041 (mean [SD] age, 60.6 [19.8] years; 273 296 [61.5%] men) involved advanced airway management, including 305 584 (68.8%) that used ETI and 200 437 (45.1%) that used SGA. The overall incidence was 9.3 per 1000 EMS events. In the cardiac arrest cohort from 2011 to 2022, EMS events with ETI attempts decreased from 2470 of 2831 (87.3%) to 40 083 of 72 793 (55.1%) and those with SGA attempts increased from 711 of 2831 (25.1%) to 44 386 of 72 793 (61.0%). In the pediatric subset, there were similarly large decreases in ETI attempts, from 117 of 182 EMS events (97.3%) to 1573 of 2307 EMS events (68.2%), and increases in SGA attempts, from 11 of 182 EMS events (6.6%) to 1058 of 2307 EMS events (45.9%). In the nonarrest medical and nonarrest trauma cohorts, ETI attempts decreased and SGA attempts increased but to a much lower extent. Conclusions and Relevance In this national cross-sectional study of EMS care episodes, there were marked shifts in advanced airway management practices, with the increased use of SGA and decreased use of ETI. These observations highlight current trends in EMS airway management practices.
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Affiliation(s)
- Henry E Wang
- Department of Emergency Medicine, The Ohio State University, Columbus
| | - Mengda Ivy Yu
- Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University, Columbus
| | | | | | - Christopher Gage
- Department of Emergency Medicine, The Ohio State University, Columbus
| | - J Madison Hyer
- Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University, Columbus
| | - Jonathan Powell
- Department of Emergency Medicine, The Ohio State University, Columbus
| | - Alexander Ulintz
- Department of Emergency Medicine, The Ohio State University, Columbus
| | | | - Lai Wei
- Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University, Columbus
| | - Kim Moeller
- Department of Emergency Medicine, The Ohio State University, Columbus
| | - Ashish R Panchal
- Department of Emergency Medicine, The Ohio State University, Columbus
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Carlson JN, De Lorenzo R. Does Practice Make Perfect, or Is There More to Consider? Ann Emerg Med 2024; 84:9-10. [PMID: 38795080 DOI: 10.1016/j.annemergmed.2024.04.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Accepted: 04/12/2024] [Indexed: 05/27/2024]
Affiliation(s)
- Jestin N Carlson
- Department of Emergency Medicine, Allegheny Health Network, Erie, PA.
| | - Robert De Lorenzo
- Department of Emergency Medicine, University of Texas Health San Antonio, San Antonio, TX
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Thomas J, Crowe R, Schulz K, Wang HE, De Oliveira Otto MC, Karfunkle B, Boerwinkle E, Huebinger R. Association Between Emergency Medical Service Agency Intubation Rate and Intubation Success. Ann Emerg Med 2024; 84:1-8. [PMID: 38180402 DOI: 10.1016/j.annemergmed.2023.11.005] [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: 04/24/2023] [Revised: 10/10/2023] [Accepted: 11/03/2023] [Indexed: 01/06/2024]
Abstract
STUDY OBJECTIVE Airway management is a crucial part of out-of-hospital care. It is not known if the rate of overall agency intubation attempts is associated with intubation success. We sought to evaluate the association between agency intubation attempt rate and intubation success using a national out-of-hospital database. METHODS We conducted a retrospective secondary analysis of the ESO Data Collaborative from 2018 to 2019, and included all adult cases with an endotracheal intubation attempt. We calculated the number of intubations attempted per 100 responses, advanced life support responses, and transports for each agency. We excluded cases originating at health care facilities and outliers. We used multivariable logistic regression to evaluate the association between agency intubation attempt rate and 1) intubation success and 2) first-pass success. We adjusted for confounders. RESULTS We included 1,005 agencies attempting 58,509 intubations. Overall, the intubation success rate was 78.8%, and the first-pass success rate was 68.5%. Per agency, the median rate of intubation attempts per 100 emergency medical service responses was 0.8 (interquartile range 0.6 to 1.1). Rates of intubation attempts per 100 responses (adjusted odds ratio [aOR] 1.7; 95% confidence interval [CI] 1.6 to 1.8), advanced life support responses (aOR 1.18; 95% CI 1.16 to 1.20), and transports (aOR 1.21; 95% CI 1.18 to 1.22) were all associated with intubation success. These relationships were similar for first-pass success but with smaller effect sizes. CONCLUSION Higher agency rates of intubation attempts were associated with increased rates of intubation success and first-pass success.
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Affiliation(s)
- Jordan Thomas
- Department of Emergency Medicine, McGovern Medical School, University of Texas Health Science Center, Houston, TX
| | | | - Kevin Schulz
- Department of Emergency Medicine, McGovern Medical School, University of Texas Health Science Center, Houston, TX; Texas Emergency Medicine Research Center, McGovern Medical School, University of Texas Health Science Center, Houston, TX; Houston Fire Department, Houston, TX
| | - Henry E Wang
- Department of Emergency Medicine, the Ohio State University, Columbus, OH
| | | | - Bejamin Karfunkle
- Texas Emergency Medicine Research Center, McGovern Medical School, University of Texas Health Science Center, Houston, TX
| | | | - Ryan Huebinger
- Department of Emergency Medicine, McGovern Medical School, University of Texas Health Science Center, Houston, TX; Texas Emergency Medicine Research Center, McGovern Medical School, University of Texas Health Science Center, Houston, TX; Department of Emergency Medicine (Huebinger), University of New Mexico, Albuquerque, NM.
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Forestell B, Ramsden S, Sharif S, Centofanti J, Al Lawati K, Fernando SM, Welsford M, Nichol G, Nolan JP, Rochwerg B. Supraglottic Airway Versus Tracheal Intubation for Airway Management in Out-of-Hospital Cardiac Arrest: A Systematic Review, Meta-Analysis, and Trial Sequential Analysis of Randomized Controlled Trials. Crit Care Med 2024; 52:e89-e99. [PMID: 37962112 DOI: 10.1097/ccm.0000000000006112] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
OBJECTIVES Given the uncertainty regarding the optimal approach for airway management for adult patients with out-of-hospital cardiac arrest (OHCA), we conducted a systematic review and meta-analysis to compare the use of supraglottic airways (SGAs) with tracheal intubation for initial airway management in OHCA. DATA SOURCES We searched MEDLINE, PubMed, Embase, Cochrane Library, as well as unpublished sources, from inception to February 7, 2023. STUDY SELECTION We included randomized controlled trials (RCTs) of adult OHCA patients randomized to SGA compared with tracheal intubation for initial prehospital airway management. DATA EXTRACTION Reviewers screened abstracts, full texts, and extracted data independently and in duplicate. We pooled data using a random-effects model. We used the modified Cochrane risk of bias 2 tool and assessed certainty of evidence using the Grading Recommendations Assessment, Development, and Evaluation approach. We preregistered the protocol on PROSPERO (CRD42022342935). DATA SYNTHESIS We included four RCTs ( n = 13,412 patients). Compared with tracheal intubation , SGA use probably increases return of spontaneous circulation (ROSC) (relative risk [RR] 1.09; 95% CI, 1.02-1.15; moderate certainty) and leads to a faster time to airway placement (mean difference 2.5 min less; 95% CI, 1.6-3.4 min less; high certainty). SGA use may have no effect on survival at longest follow-up (RR 1.06; 95% CI, 0.84-1.34; low certainty), has an uncertain effect on survival with good functional outcome (RR 1.11; 95% CI, 0.82-1.50; very low certainty), and may have no effect on risk of aspiration (RR 1.04; 95% CI, 0.94 to 1.16; low certainty). CONCLUSIONS In adult patients with OHCA, compared with tracheal intubation, the use of SGA for initial airway management probably leads to more ROSC, and faster time to airway placement, but may have no effect on longer-term survival outcomes or aspiration events.
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Affiliation(s)
- Ben Forestell
- Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Sophie Ramsden
- Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Sameer Sharif
- Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada
- Division of Critical Care Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
- Department of Critical Care, Lakeridge Health Corporation, Oshawa, ON, Canada
- Departments of Emergency Medicine and Medicine, Harborview Center for Prehospital Emergency Care, University of Washington, Seattle, WA
- Warwick Clinical Trials Unit, University of Warwick, Coventry, United Kingdom
- Department of Anesthesia and Intensive Care Medicine, Royal United Hospital, Bath, United Kingdom
| | - John Centofanti
- Division of Critical Care Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - Kumait Al Lawati
- Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada
- Division of Critical Care Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Shannon M Fernando
- Department of Critical Care, Lakeridge Health Corporation, Oshawa, ON, Canada
| | - Michelle Welsford
- Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Graham Nichol
- Departments of Emergency Medicine and Medicine, Harborview Center for Prehospital Emergency Care, University of Washington, Seattle, WA
| | - Jerry P Nolan
- Warwick Clinical Trials Unit, University of Warwick, Coventry, United Kingdom
- Department of Anesthesia and Intensive Care Medicine, Royal United Hospital, Bath, United Kingdom
| | - Bram Rochwerg
- Division of Critical Care Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
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Kim JG, Ahn C, Kim W, Lim TH, Jang BH, Cho Y, Shin H, Lee H, Lee J, Choi KS, Na MK, Kwon SM. Comparison of video laryngoscopy with direct laryngoscopy for intubation success in critically ill patients: a systematic review and Bayesian network meta-analysis. Front Med (Lausanne) 2023; 10:1193514. [PMID: 37358992 PMCID: PMC10289197 DOI: 10.3389/fmed.2023.1193514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 05/22/2023] [Indexed: 06/28/2023] Open
Abstract
Introduction This review compares the efficacy of video laryngoscopy (VL) with direct laryngoscopy (DL) for successful tracheal intubation in critically ill or emergency-care patients. Methods We searched the MEDLINE, Embase, and Cochrane Library databases for randomized controlled trials (RCTs) that compared one or more video laryngoscopes to DL. Sensitivity analysis, subgroup analysis, and network meta-analysis were used to investigate factors potentially influencing the efficacy of VL. The primary outcome was the success rate of first-attempt intubation. Results This meta-analysis included 4244 patients from 22 RCTs. After sensitivity analysis, the pooled analysis revealed no significant difference in the success rate between VL and DL (VL vs. DL, 77.3% vs. 75.3%, respectively; OR, 1.36; 95% CI, 0.84-2.20; I2 = 80%; low-quality evidence). However, based on a moderate certainty of evidence, VL outperformed DL in the subgroup analyses of intubation associated with difficult airways, inexperienced practitioners, or in-hospital settings. In the network meta-analysis comparing VL blade types, nonchanneled angular VL provided the best outcomes. The nonchanneled Macintosh video laryngoscope ranked second, and DL ranked third. Channeled VL was associated with the worst treatment outcomes. Discussion This pooled analysis found, with a low certainty of evidence, that VL does not improve intubation success relative to DL. Channeled VL had low efficacy in terms of intubation success compared with nonchanneled VL and DL. Systematic review registration https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=285702, identifier: CRD42021285702.
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Affiliation(s)
- Jae Guk Kim
- Department of Emergency Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Chiwon Ahn
- Department of Emergency Medicine, College of Medicine, Chung-Ang University, Seoul, Republic of Korea
| | - Wonhee Kim
- Department of Emergency Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Tae-Ho Lim
- Department of Emergency Medicine, Hanyang University College of Medicine, Seoul, Republic of Korea
| | - Bo-Hyong Jang
- Department of Preventive Medicine, College of Korean Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Youngsuk Cho
- Department of Emergency Medicine, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Hyungoo Shin
- Department of Emergency Medicine, Hanyang University College of Medicine, Seoul, Republic of Korea
| | - Heekyung Lee
- Department of Emergency Medicine, Hanyang University College of Medicine, Seoul, Republic of Korea
| | - Juncheol Lee
- Department of Emergency Medicine, Hanyang University College of Medicine, Seoul, Republic of Korea
| | - Kyu-Sun Choi
- Department of Neurosurgery, Hanyang University College of Medicine, Seoul, Republic of Korea
| | - Min Kyun Na
- Department of Neurosurgery, Hanyang University College of Medicine, Seoul, Republic of Korea
| | - Sae Min Kwon
- Department of Neurosurgery, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Republic of Korea
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Gil-Jardiné C, Jabre P, Adnet F, Nicol T, Ecollan P, Guihard B, Ferdynus C, Bocquet V, Combes X. Incidence and factors associated with out-of-hospital peri-intubation cardiac arrest: a secondary analysis of the CURASMUR trial. Intern Emerg Med 2022; 17:611-617. [PMID: 35037125 DOI: 10.1007/s11739-021-02903-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 11/27/2021] [Indexed: 11/25/2022]
Abstract
The Incidence of peri-intubation cardiac arrest (PICA) has been rarely assessed in the out-of-hospital setting. The objectives of this study were to assess the incidence and factors associated with PICA (cardiac arrest occurring within 15 min of intubation) in an out-of-hospital emergency setting, wherein emergency physicians perform standardized airway management using a rapid sequence intubation technique in adult patients. This was a secondary analysis of the "Succinylcholine versus Rocuronium for out-of-hospital emergency intubation" (CURASMUR) trial, which compared the first attempt intubation success rate between succinylcholine and rocuronium in adult patients requiring emergency tracheal intubation for any vital distress except cardiac arrest. Enrollment occurred from January 2014 to August 2016 in 17 French out-of-hospital emergency medical units. All operators were emergency physicians. The PICA incidence was recorded and multivariable logistic regression analysis was used to identify the factors associated with its occurrence. A total of 1226 patients were included with a mean age of 55.9 ± 19 years. PICA was recorded in 35 (2.8%) patients. Multivariable analysis indicated that the occurrence of PICA was independently associated with a body mass index (BMI) > 30 kg m2 [adjusted odds ratio (aOR) 4.85; 95% confidence interval (CI) 1.82-12.90, p = 0.02], oxygen saturation (SpO2) before intubation < 90% (aOR 3.4; 95% CI 1.50-7.60, p = 0.003), difficult intubation (defined by an Intubation Difficulty Score [IDS] > 5, [aOR 3.59; 95% CI 1.82-8.08, p = 0.02], the use of rocuronium instead of succinylcholine (aOR 2.47; 95% CI 1.08-5.64, p = 0.03), post intubation hypoxaemia (aOR 2.70; 95% CI 1.05-6.95, p = 0.04), post-intubation hypotension (aOR 4.07; 95% CI 1.62-10.22, p = 0.003), and pulmonary aspiration(aOR 4.78; 95% CI 1.48-15.36, p = 0.009). Early PICA occurred in approximately 3% of cases in the out-of-hospital setting. We identified several independent risk factors for PICA, including obesity, hypoxaemia before intubation and difficult intubation.
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Affiliation(s)
- Cédric Gil-Jardiné
- Department of Emergency, CHU de Bordeaux, Place Amélie Raba Léon, 33076, Bordeaux cedex, France
| | - Patricia Jabre
- AP-HP, Service d'Aide Médicale d'Urgence (SAMU) de Paris and Paris Sudden Death Expertise Center, Université Paris Descartes, Paris, France
- Department of Anesthesia and Critical Care-SAMU, Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants Malades, Université Paris Descartes, 149 rue de Sèvres, 75015, Paris, France
| | - Frederic Adnet
- Urgences-SAMU 93, Unite Recherche-Enseignement-Qualite, Hopital Avicenne, Bobigny, France
| | - Thomas Nicol
- Department of Anesthesia and Critical Care-SAMU, Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants Malades, Université Paris Descartes, 149 rue de Sèvres, 75015, Paris, France
| | - Patrick Ecollan
- Department of Anesthesia and Critical Care-SAMU, Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants Malades, Université Paris Descartes, 149 rue de Sèvres, 75015, Paris, France
| | - Bertrand Guihard
- Department of Emergency, CHU de la Réunion, Université de La Réunion, Réunion, France
| | - Cyril Ferdynus
- INSERM CIC 1410 Clinical and Epidemiology/CHU Réunion/Université de la Réunion, Saint-Pierre, Reunion, France
| | - Valery Bocquet
- Departement d'Informatique Clinique, Centre Hospitalier Universitaire de La Réunion Site Félix Guyon, Saint-Denis, France
| | - Xavier Combes
- Department of Emergency, CHU de Bordeaux, Place Amélie Raba Léon, 33076, Bordeaux cedex, France.
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Vithalani V, Sondheim S, Cornelius A, Gonzales J, Mercer MP, Burton B, Redlener M. Quality Management of Prehospital Airway Programs: An NAEMSP Position Statement and Resource Document. PREHOSP EMERG CARE 2022; 26:14-22. [PMID: 35001828 DOI: 10.1080/10903127.2021.1989530] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Prehospital airway management encompasses a multitude of complex decision-making processes, techniques, and interventions. Quality management (encompassing quality assurance and quality improvement activities) in EMS is dynamic, evidence-based, and most of all, patient-centric. Long a mainstay of the EMS clinician skillset, airway management deserves specific focus and attention and dedicated quality management processes to ensure the delivery of high-quality clinical care.It is the position of NAEMSP that:All EMS agencies should dedicate sufficient resources to patient-centric, comprehensive prehospital airway quality management program. These quality management programs should consist of prospective, concurrent, and retrospective activities. Quality management programs should be developed and operated with the close involvement of the medical director.Quality improvement and quality assurance efforts should operate in an educational, non-disciplinary, non-punitive, evidence-based medicine culture focused on patient safety. The highest quality of care is only achieved when the quality management program rewards those who identify and seek to prevent errors before they occur.Information evaluated in prehospital airway quality management programs should include both subjective and objective data elements with uniform reporting and operational definitions.EMS systems should regularly measure and report process, outcome, and balancing airway management measures.Quality management activities require large-scale bidirectional information sharing between EMS agencies and receiving facilities. Hospital outcome information should be shared with agencies and the involved EMS clinicians.Findings from quality management programs should be used to guide and develop initial education and continued training.Quality improvement programs must continually undergo evaluation and assessment to identify strengths and shortcomings with a focus on continuous improvement.
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Braithwaite S, Stephens C, Remick K, Barrett W, Guyette FX, Levy M, Colwell C. Prehospital Trauma Airway Management: An NAEMSP Position Statement and Resource Document. PREHOSP EMERG CARE 2022; 26:64-71. [PMID: 35001817 DOI: 10.1080/10903127.2021.1994069] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Definitive management of trauma is not possible in the out-of-hospital environment. Rapid treatment and transport of trauma casualties to a trauma center are vital to improve survival and outcomes. Prioritization and management of airway, oxygenation, ventilation, protection from gross aspiration, and physiologic optimization must be balanced against timely patient delivery to definitive care. The optimal prehospital airway management strategy for trauma has not been clearly defined; the best choice should be patient-specific. NAEMSP recommends:The approach to airway management and the choice of airway interventions in a trauma patient requires an iterative, individualized assessment that considers patient, clinician, and environmental factors.Optimal trauma airway management should focus on meeting the goals of adequate oxygenation and ventilation rather than on specific interventions. Emergency medical services (EMS) clinicians should perform frequent reassessments to determine if there is a need to escalate from basic to advanced airway interventions.Management of immediately life-threatening injuries should take priority over advanced airway insertion.Drug-assisted airway management should be considered within a comprehensive algorithm incorporating failed airway options and balanced management of pain, agitation, and delirium.EMS medical directors must be highly engaged in assuring clinician competence in trauma airway assessment, management, and interventions.
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Länkimäki S, Spalding M, Saari A, Alahuhta S. Procedural Sedation Intubation in a Paramedic-Staffed Helicopter Emergency Medical System in Northern Finland. Air Med J 2021; 40:385-389. [PMID: 34794775 DOI: 10.1016/j.amj.2021.08.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 07/14/2021] [Accepted: 08/26/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Airway management to ensure sufficient gas exchange is of major importance in emergency care. Prehospital endotracheal intubation (ETI) by paramedics is a widely debated method to ensure a patent airway. ETI is performed with procedural sedation in comatose patients because of the regulation. The use of medications increases the rate of successful airway management compared with nonmedication ETI and may also improve outcomes in patients with traumatic brain injury. In the absence of an operative emergency physician and with long distances, paramedic-induced airway management may increase the survival of patients in selected scenarios. A paramedic-staffed helicopter emergency medical system in Northern Finland operates in a rural area without an emergency physician and paralytic medications and treats critically ill patients using basic or advanced life support ground units. The aim of this study was to evaluate the success rates of ETI performed by a small, appropriately trained, and experienced group of 8 nurse paramedics in an out-of-hospital setting. METHODS The inclusion criterion for the study was an attempted intubation in patients with medical or traumatic indication for airway management by nurse paramedic. RESULTS Fifty-one patients were treated with ETI. The first-pass success rate was 72.5%, the second-pass success rate was 94.1%, and the overall success rate was 100% within 4 attempts. The median on-scene time was 54 minutes, and there were no signs of aspiration during laryngoscopy or after successful ETI. The primary mortality rate was 11.7%. CONCLUSION The use of a rigid standard operating procedure for paramedic rapid sequence induction, paralytics, a video laryngoscope, and a gum elastic bougie might positively affect the ETI first-pass success rate. A follow-up study after these future modifications is needed. This small study suggests that intubation might be 1 option for airway management by an experienced nonanesthesiologist in Lapland.
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Affiliation(s)
- Sami Länkimäki
- Emergency Medical Service, Department of Emergency Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; Department of Anaesthesiology, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland.
| | - Michael Spalding
- Department of Anaesthesiology, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Antti Saari
- Centre for Prehospital Emergency Care, Lapland Hospital District, Rovaniemi, Finland
| | - Seppo Alahuhta
- Department of Anaesthesiology, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
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Deaver KS, Cone DC, Rhone AM, Kupas DF. The Clinical Role and Activity of Advanced Clinicians in the Out-of-Hospital Environment. PREHOSP EMERG CARE 2021; 26:682-688. [PMID: 34477480 DOI: 10.1080/10903127.2021.1976330] [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: 10/20/2022]
Abstract
Objective: Recent evolution of the EMS system has resulted in an increased role for specially trained advanced clinicians (physicians, physician assistants, and registered nurses) in out-of-hospital field response. Despite this expansion into the out-of-hospital environment there is a lack of data regarding the actual clinical roles and activity of these clinicians in the United States. We seek to describe the clinical roles of advanced clinicians in the field through description of skills used during both 9-1-1 field responses and interfacility transports in the state of Pennsylvania. Methods: Our data were taken from existing Pennsylvania Department of Health EMS records for all 9-1-1 and interfacility requests for service from January 2018 through June 2020. Descriptive statistics were applied to skills used, medications administered, clinician activity data, and patient demographics for each clinician type in four response categories: 9-1-1 air, 9-1-1 ground, interfacility air, and interfacility ground. Results: There were few statistically significant differences in skill or medication usage between clinician types. There were no statistically significant differences in level of skills (basic life support, ALS, or specialty skills) performed between clinician levels. Patient demographics for each clinician type were similar. Conclusions: Our findings indicate advanced clinicians provide care at the ALS and specialty care levels in similar patient populations with little difference in the roles between clinician types in the out-of-hospital environment. Our data demonstrate successful integration of advanced clinicians into the out-of-hospital environment in Pennsylvania and provide a framework for future planning and expansion of these roles and responsibilities.
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Affiliation(s)
- Kyle S Deaver
- Received June 1, 2021 from Yale School of Medicine, Yale University, New Haven, Connecticut (KSD, DCC); Pennsylvania Department of Health, Bureau of EMS, Harrisburg, Pennsylvania (AMR); Division of EMS, Geisinger Health System, Danville, Virginia (DFK). Revision received August 13, 2021; accepted for publication August 30, 2021
| | - David C Cone
- Received June 1, 2021 from Yale School of Medicine, Yale University, New Haven, Connecticut (KSD, DCC); Pennsylvania Department of Health, Bureau of EMS, Harrisburg, Pennsylvania (AMR); Division of EMS, Geisinger Health System, Danville, Virginia (DFK). Revision received August 13, 2021; accepted for publication August 30, 2021
| | - Aaron M Rhone
- Received June 1, 2021 from Yale School of Medicine, Yale University, New Haven, Connecticut (KSD, DCC); Pennsylvania Department of Health, Bureau of EMS, Harrisburg, Pennsylvania (AMR); Division of EMS, Geisinger Health System, Danville, Virginia (DFK). Revision received August 13, 2021; accepted for publication August 30, 2021
| | - Douglas F Kupas
- Received June 1, 2021 from Yale School of Medicine, Yale University, New Haven, Connecticut (KSD, DCC); Pennsylvania Department of Health, Bureau of EMS, Harrisburg, Pennsylvania (AMR); Division of EMS, Geisinger Health System, Danville, Virginia (DFK). Revision received August 13, 2021; accepted for publication August 30, 2021
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Lesnick JA, Moore JX, Zhang Y, Jarvis J, Nichol G, Daya MR, Idris AH, Klug C, Dennis D, Carlson JN, Doshi P, Sopko G, Schmicker RH, Wang HE. Airway insertion first pass success and patient outcomes in adult out-of-hospital cardiac arrest: The Pragmatic Airway Resuscitation Trial. Resuscitation 2021; 158:151-156. [PMID: 33278521 PMCID: PMC7855546 DOI: 10.1016/j.resuscitation.2020.11.030] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 11/03/2020] [Accepted: 11/17/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE While emphasized in clinical practice, the association between advanced airway insertion first-pass success (FPS) and patient outcomes is incompletely understood. We sought to determine the association of airway insertion FPS with adult out-of-hospital cardiac arrest (OHCA) outcomes in the Pragmatic Airway Resuscitation Trial (PART). METHODS We performed a secondary analysis of PART, a multicenter clinical trial comparing LT and ETI upon adult OHCA outcomes. We defined FPS as successful LT insertion or ETI on the first attempt as reported by EMS personnel. We examined the outcomes return of spontaneous circulation (ROSC), 72-h survival, hospital survival, and hospital survival with favorable neurologic status (Modified Rankin Scale ≤3). Using multivariable GEE (generalized estimating equations), we determined the association between FPS and OHCA outcomes, adjusting for age, sex, witnessed arrest, bystander CPR, initial rhythm, and initial airway type. RESULTS Of 3004 patients enrolled in the trial, 1423 received LT, 1227 received ETI, 354 received bag-valve-mask ventilation only. FPS was: LT 86.2% and ETI 46.7%. FPS was associated with increased ROSC (aOR 1.23; 95%CI: 1.07-1.41)), but not 72-h survival (1.22; 0.94-1.58), hospital survival (0.90; 0.68-1.19) or hospital survival with favorable neurologic status (0.66; 0.37-1.19). CONCLUSION In adult OHCA, airway insertion FPS was associated with increased ROSC but not other OHCA outcomes. The influence of airway insertion FPS upon OHCA outcomes is unclear.
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Affiliation(s)
- Jason A Lesnick
- Department of Emergency Medicine, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Justin X Moore
- Division of Epidemiology, Department of Population Health Sciences, Augusta University, Augusta, GA, USA
| | - Yefei Zhang
- Department of Biostatistics and Data Science, School of Public Health, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Jeffrey Jarvis
- Williamson County Emergency Medical Services, Georgetown, TX, USA; Texas A&M Health Science Center, Temple, TX, USA
| | - Graham Nichol
- University of Washington[HYPHEN]Harborview Center for Prehospital Emergency Care, Departments of Medicine and Emergency Medicine, University of Washington, Seattle, WA, USA
| | - Mohamud R Daya
- Department of Emergency Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Ahamed H Idris
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Cameron Klug
- Legacy Meridian Park Medical Center. Tualatin, OR, USA
| | | | - Jestin N Carlson
- University of Pittsburgh, Pittsburgh, PA, USA; Department of Emergency Medicine, Saint Vincent Hospital, Allegheny Health Network, Erie, PA, USA
| | - Pratik Doshi
- Department of Emergency Medicine, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - George Sopko
- National Institutes of Health, Bethesda, MD, USA
| | - Robert H Schmicker
- Department of Biostatistics, School of Public Health, University of Washington, Seattle, WA, USA
| | - Henry E Wang
- Department of Emergency Medicine, The University of Texas Health Science Center at Houston, Houston, TX, USA.
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Benoit JL, Wang HE. Intubation for Out-of-Hospital Cardiac Arrest: The Elephant Is in the Room. Ann Emerg Med 2020; 75:637-639. [PMID: 32160966 DOI: 10.1016/j.annemergmed.2020.01.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Indexed: 02/04/2023]
Affiliation(s)
- Justin L Benoit
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH.
| | - Henry E Wang
- Department of Emergency Medicine, The University of Texas Health Science Center at Houston, Houston, TX
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13
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Wang HE, Benger JR. Endotracheal intubation during out-of-hospital cardiac arrest: New insights from recent clinical trials. J Am Coll Emerg Physicians Open 2020; 1:24-29. [PMID: 33000010 PMCID: PMC7493580 DOI: 10.1002/emp2.12003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Revised: 10/22/2019] [Accepted: 10/24/2019] [Indexed: 11/10/2022] Open
Abstract
Airway management is an important intervention during resuscitation of out-of-hospital cardiac arrest (OHCA). Endotracheal intubation is commonly used by emergency medical services paramedics in the advanced airway management of OHCA, but numerous studies question its safety and effectiveness. Furthermore, there is now increasing use of supraglottic airway devices. In this review, we provide an overview of 3 recent randomized clinical trials of advanced airway management (Pragmatic Airway Resuscitation Trial [PART], AIRWAYS-2, and Cardiac Arrest Airway Management [CAAM]) and highlight new information that is available to guide OHCA airway management practices.
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Affiliation(s)
- Henry E. Wang
- Department of Emergency MedicineThe University of Texas Health Science Center at HoustonHoustonTexas
| | - Jonathan R. Benger
- Faculty of Health and Applied SciencesUniversity of the West of EnglandBristolUK
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Nwanne T, Jarvis J, Barton D, Donnelly JP, Wang HE. Advanced airway management success rates in a national cohort of emergency medical services agencies. Resuscitation 2019; 146:43-49. [PMID: 31756361 DOI: 10.1016/j.resuscitation.2019.11.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 11/06/2019] [Accepted: 11/11/2019] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Despite its important role in care of the critically ill, there have been few large-scale descriptions of the epidemiology of Emergency Medical Services (EMS) advanced airway management (AAM) and the variations in care with different patient subsets. We sought to characterize AAM performance in a national cohort of EMS agencies. METHODS We used data from ESO Solutions, Inc., a national EMS electronic health record system. We analyzed EMS emergency patient encounters during 2011-2015 with attempted AAM. We categorized AAM techniques as conventional endotracheal intubation (cETI), neuromuscular blockade assisted intubation (NMBA-ETI), supraglottic airway (SGA), and cricothyroidotomy (needle and open). Determination of successful AAM was based on EMS provider report. We analyzed the data using descriptive statistics, determining the incidence and clinical characteristics of AAM cases. We determined success rates for each AAM technique, stratifying by the subsets cardiac arrest, medical non-arrest, trauma, and pediatrics (age ≤12 years). RESULTS AAM occurred in 57,209 patients. Overall AAM success was 89.1% (95% CI: 88.8-89.3%) across all patients and techniques. Intubation success rates varied by technique; cETI (n = 38,004; 76.9%, 95% CI: 76.5-77.3%), NMBA-ETI (n = 6768; 89.7%, 88.9-90.4%). SGAs were used both for initial (n = 9461, 90.1% success, 95% CI: 89.5-90.7%) and rescue (n = 5994, 87.3% success, 95% CI: 86.4-88.1%) AAM. Cricothyroidotomy success rates were low: initial cricothyroidotomy (n = 202, 17.3% success, 95% CI: 12.4-23.3%), rescue cricothyroidotomy (n = 85, 52.9% success, 95% CI: 41.8-88%). AAM success rates varied by patient subset: cardiac arrest (n = 35,782; 91.7%, 95% CI: 91.4-92.0), medical non-arrest (n = 17,086; 84.7%, 84.2-85.2%); trauma (n = 4341; 84.3%, 83.1-85.3%); pediatric (n = 1223; 73.7%, 71.2-76.2%). CONCLUSION AAM success rates varied by airway technique and patient subset. In this national cohort, these results offer perspectives of EMS AAM practices.
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Affiliation(s)
- Tracy Nwanne
- McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Jeffrey Jarvis
- Williamson County Emergency Medical Services, Georgetown, TX, United States; Texas A&M Health Science Center, Temple, TX, United States
| | | | - John P Donnelly
- Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI, United States; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, United States
| | - Henry E Wang
- Department of Emergency Medicine, The University of Texas Health Science Center at Houston, Houston, TX, United States.
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Ostermayer DG, Camp EA, Langabeer JR, Brown CA, Mondragon J, Persse DE, Shah MI. Impact of an Extraglottic Device on Pediatric Airway Management in an Urban Prehospital System. West J Emerg Med 2019; 20:962-969. [PMID: 31738725 PMCID: PMC6860396 DOI: 10.5811/westjem.2019.8.44464] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Accepted: 08/25/2019] [Indexed: 11/30/2022] Open
Abstract
Introduction Prehospital pediatric endotracheal intubation has lower first-pass success rates compared to adult intubations and in general may not offer a survival benefit. Increasingly, emergency medical services (EMS) systems are deploying prehospital extraglottic airways (EGA) for primary pediatric airway management, yet little is known about their efficacy. We evaluated the impact of a pediatric prehospital airway management protocol change, inclusive of EGAs, on airway management and patient outcomes in children in cardiac arrest or respiratory failure. Methods Using data from a large, metropolitan, fire-based EMS service, we performed an observational study of pediatric patients with respiratory failure or cardiac arrest who were transported by EMS before and after implementation of an evidence-based airway management protocol inclusive of the addition of the EGA. The primary outcome was change in frequency of intubation attempts when paired with an initial EGA. Secondary outcomes included EGA and intubation success rates and patient survival to hospitalization and discharge. Results We included 265 patients age <16 years old, with 142 pre- and 123 post-protocol change. Patient demographics and event characteristics were similar between groups. Intubation attempts declined from 79.6% pre- to 44.7% (p<0.01) post-protocol change. In patients with an intubation attempt, overall intubation success declined from 81.4% to 63.6% (p<0.01). Post-protocol change, an EGA was attempted in 52.8% of patients with 95.4% success. Conclusion Implementation of an evidenced-based airway management algorithm for pediatric patients, inclusive of an EGA device for all age groups, was associated with fewer prehospital intubations. Intubation success may be negatively impacted due to decreases in procedural frequency.
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Affiliation(s)
- Daniel G Ostermayer
- McGovern Medical School, University of Texas Health Sciences Center, Department of Emergency Medicine, Houston, Texas.,Houston Fire Department, Houston, Texas
| | - Elizabeth A Camp
- Baylor College of Medicine, Texas Children's Hospital, Department of Pediatrics, Section of Emergency Medicine, Houston, Texas
| | - James R Langabeer
- McGovern Medical School, University of Texas Health Sciences Center, Department of Emergency Medicine, Houston, Texas
| | - Charles A Brown
- University of Michigan Medical School, Department of Emergency Medicine, Ann Arbor, Michigan
| | - Juan Mondragon
- Baylor College of Medicine, Texas Children's Hospital, Department of Pediatrics, Section of Emergency Medicine, Houston, Texas
| | | | - Manish I Shah
- Baylor College of Medicine, Texas Children's Hospital, Department of Pediatrics, Section of Emergency Medicine, Houston, Texas
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Kreutziger J, Hornung S, Harrer C, Urschl W, Doppler R, Voelckel WG, Trimmel H. Comparing the McGrath Mac Video Laryngoscope and Direct Laryngoscopy for Prehospital Emergency Intubation in Air Rescue Patients: A Multicenter, Randomized, Controlled Trial. Crit Care Med 2019; 47:1362-1370. [PMID: 31389835 PMCID: PMC6791500 DOI: 10.1097/ccm.0000000000003918] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Tracheal intubation in prehospital emergency care is challenging. The McGrath Mac Video Laryngoscope (Medtronic, Minneapolis, MN) has been proven to be a reliable alternative for in-hospital airway management. This trial compared the McGrath Mac Video Laryngoscope and direct laryngoscopy for the prehospital setting. DESIGN Multicenter, prospective, randomized, controlled equivalence trial. SETTING Oesterreichischer Automobil- und Touring Club (OEAMTC) Helicopter Emergency Medical Service in Austria, 18-month study period. PATIENTS Five-hundred fourteen adult emergency patients (≥ 18 yr old). INTERVENTIONS Helicopter Emergency Medical Service physicians followed the institutional algorithm, comprising a maximum of two tracheal intubation attempts with each device, followed by supraglottic, then surgical airway access in case of tracheal intubation failure. No restrictions were given for tracheal intubation indication. MEASUREMENTS MAIN RESULTS The Primary outcome was the rate of successful tracheal intubation; equivalence range was ± 6.5% of success rates. Secondary outcomes were the number of attempts to successful tracheal intubation, time to glottis passage and first end-tidal CO2 measurement, degree of glottis visualization, and number of problems. The success rate for the two devices was equivalent: direct laryngoscopy 98.5% (254/258), McGrath Mac Video Laryngoscope 98.1% (251/256) (difference, 0.4%; 99% CI, -2.58 to 3.39). There was no statistically significant difference with regard to tracheal intubation times, number of attempts or difficulty. The view to the glottis was significantly better, but the number of technical problems was increased with the McGrath Mac Video Laryngoscope. After a failed first tracheal intubation attempt, immediate switching of the device was significantly more successful than after the second attempt (90.5% vs 57.1%; p = 0.0003), regardless of the method. CONCLUSIONS Both devices are equivalently well suited for use in prehospital emergency tracheal intubation of adult patients. Switching the device following a failed first tracheal intubation attempt was more successful than a second attempt with the same device.
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Affiliation(s)
- Janett Kreutziger
- Department of General and Surgical Critical Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Sonja Hornung
- Department of Anesthesiology, Emergency and Critical Care Medicine, Wiener Neustadt General Hospital, Wiener Neustadt, Austria
- Karl Landsteiner Institute of Emergency Medicine, Wiener Neustadt General Hospital, Wiener Neustadt, Austria
- OEAMTC Air Rescue, Vienna, Austria
| | | | | | | | - Wolfgang G Voelckel
- OEAMTC Air Rescue, Vienna, Austria
- Department of Anesthesiology and Critical Care Medicine, AUVA Trauma Center, Dr.-Franz-Rehrl-Platz 5, Salzburg, Austria
- Paracelsus Medical University Salzburg, Salzburg, Austria
- Network for Medical Science, University of Stavanger, Stavanger, Norway
| | - Helmut Trimmel
- Department of Anesthesiology, Emergency and Critical Care Medicine, Wiener Neustadt General Hospital, Wiener Neustadt, Austria
- Karl Landsteiner Institute of Emergency Medicine, Wiener Neustadt General Hospital, Wiener Neustadt, Austria
- OEAMTC Air Rescue, Vienna, Austria
- Medical University of Vienna, Vienna, Austria
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Burjek NE, Burns KM, Jagannathan N. Aligning airway management strategy with resuscitation priorities for out-of-hospital cardiac arrest. J Thorac Dis 2019; 11:364-368. [PMID: 30962975 DOI: 10.21037/jtd.2018.12.38] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Nicholas E Burjek
- Department of Pediatric Anesthesiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Katharine M Burns
- Department of Emergency Medicine, Advocate Christ Medical Center, Oak Lawn, IL, USA
| | - Narasimhan Jagannathan
- Department of Pediatric Anesthesiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
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19
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Wang HE, Schmicker RH, Daya MR, Stephens SW, Idris AH, Carlson JN, Colella MR, Herren H, Hansen M, Richmond NJ, Puyana JCJ, Aufderheide TP, Gray RE, Gray PC, Verkest M, Owens PC, Brienza AM, Sternig KJ, May SJ, Sopko GR, Weisfeldt ML, Nichol G. Effect of a Strategy of Initial Laryngeal Tube Insertion vs Endotracheal Intubation on 72-Hour Survival in Adults With Out-of-Hospital Cardiac Arrest: A Randomized Clinical Trial. JAMA 2018; 320:769-778. [PMID: 30167699 PMCID: PMC6583103 DOI: 10.1001/jama.2018.7044] [Citation(s) in RCA: 239] [Impact Index Per Article: 39.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
IMPORTANCE Emergency medical services (EMS) commonly perform endotracheal intubation (ETI) or insertion of supraglottic airways, such as the laryngeal tube (LT), on patients with out-of-hospital cardiac arrest (OHCA). The optimal method for OHCA advanced airway management is unknown. OBJECTIVE To compare the effectiveness of a strategy of initial LT insertion vs initial ETI in adults with OHCA. DESIGN, SETTING, AND PARTICIPANTS Multicenter pragmatic cluster-crossover clinical trial involving EMS agencies from the Resuscitation Outcomes Consortium. The trial included 3004 adults with OHCA and anticipated need for advanced airway management who were enrolled from December 1, 2015, to November 4, 2017. The final date of follow-up was November 10, 2017. INTERVENTIONS Twenty-seven EMS agencies were randomized in 13 clusters to initial airway management strategy with LT (n = 1505 patients) or ETI (n = 1499 patients), with crossover to the alternate strategy at 3- to 5-month intervals. MAIN OUTCOMES AND MEASURES The primary outcome was 72-hour survival. Secondary outcomes included return of spontaneous circulation, survival to hospital discharge, favorable neurological status at hospital discharge (Modified Rankin Scale score ≤3), and key adverse events. RESULTS Among 3004 enrolled patients (median [interquartile range] age, 64 [53-76] years, 1829 [60.9%] men), 3000 were included in the primary analysis. Rates of initial airway success were 90.3% with LT and 51.6% with ETI. Seventy-two hour survival was 18.3% in the LT group vs 15.4% in the ETI group (adjusted difference, 2.9% [95% CI, 0.2%-5.6%]; P = .04). Secondary outcomes in the LT group vs ETI group were return of spontaneous circulation (27.9% vs 24.3%; adjusted difference, 3.6% [95% CI, 0.3%-6.8%]; P = .03); hospital survival (10.8% vs 8.1%; adjusted difference, 2.7% [95% CI, 0.6%-4.8%]; P = .01); and favorable neurological status at discharge (7.1% vs 5.0%; adjusted difference, 2.1% [95% CI, 0.3%-3.8%]; P = .02). There were no significant differences in oropharyngeal or hypopharyngeal injury (0.2% vs 0.3%), airway swelling (1.1% vs 1.0%), or pneumonia or pneumonitis (26.1% vs 22.3%). CONCLUSIONS AND RELEVANCE Among adults with OHCA, a strategy of initial LT insertion was associated with significantly greater 72-hour survival compared with a strategy of initial ETI. These findings suggest that LT insertion may be considered as an initial airway management strategy in patients with OHCA, but limitations of the pragmatic design, practice setting, and ETI performance characteristics suggest that further research is warranted. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02419573.
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Affiliation(s)
- Henry E. Wang
- Department of Emergency Medicine, University of Texas Health Science Center at Houston
- Department of Emergency Medicine, University of Alabama at Birmingham
| | - Robert H. Schmicker
- Clinical Trials Center, Department of Biostatistics, University of Washington, Seattle
| | - Mohamud R. Daya
- Department of Emergency Medicine, Oregon Health and Science University, Portland
| | | | - Ahamed H. Idris
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas
| | - Jestin N. Carlson
- Department of Emergency Medicine, Saint Vincent Hospital, Allegheny Health Network, Erie, Pennsylvania
- University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Heather Herren
- Clinical Trials Center, Department of Biostatistics, University of Washington, Seattle
| | - Matthew Hansen
- Department of Emergency Medicine, Oregon Health and Science University, Portland
| | - Neal J. Richmond
- MedStar Mobile Healthcare, Fort Worth, Texas
- currently with Department of Emergency Medicine, John Peter Smith Health Network, Fort Worth, Texas
| | | | - Tom P. Aufderheide
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee
| | - Randal E. Gray
- Department of Emergency Medicine, University of Alabama at Birmingham
| | - Pamela C. Gray
- Department of Emergency Medicine, University of Alabama at Birmingham
| | | | - Pamela C. Owens
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas
| | | | | | - Susanne J. May
- Clinical Trials Center, Department of Biostatistics, University of Washington, Seattle
| | - George R. Sopko
- National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - Myron L. Weisfeldt
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Graham Nichol
- Departments of Emergency Medicine and Medicine, Harborview Center for Prehospital Emergency Care, University of Washington, Seattle
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Ono Y, Tanigawa K, Kakamu T, Shinohara K, Iseki K. Out-of-hospital endotracheal intubation experience, confidence and confidence-associated factors among Northern Japanese emergency life-saving technicians: a population-based cross-sectional study. BMJ Open 2018; 8:e021858. [PMID: 30007929 PMCID: PMC6082470 DOI: 10.1136/bmjopen-2018-021858] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Revised: 05/02/2018] [Accepted: 06/06/2018] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVE Clinical procedural experience and confidence are both important when performing complex medical procedures. Since out-of-hospital endotracheal intubation (ETI) is a complex intervention, we sought to clarify clinical ETI experience among prehospital rescuers as well as their confidence in performing ETI and confidence-associated factors. DESIGN Population-based cross-sectional study conducted from January to September 2017. SETTING Northern Japan, including eight prefectures. PARTICIPANTS Emergency life-saving technicians (ELSTs) authorised to perform ETI. OUTCOME MEASURES Annual ETI exposure and confidence in performing ETI, according to a five-point Likert scale. To determine factors associated with ETI confidence, differences between confident ELSTs (those scoring 4 or 5 on the Likert scale) and non-confident ELSTs were evaluated. RESULTS Questionnaires were sent to 149 fire departments (FDs); 140 agreed to participate. Among the 2821 ELSTs working at responding FDs, 2620 returned the questionnaire (response rate, 92.9%); complete data sets were available for 2567 ELSTs (complete response rate, 91.0%). Of those 2567 respondents, 95.7% performed two or fewer ETI annually; 46.6% reported lack of confidence in performing ETI. Multivariable logistic regression analysis showed that years of clinical experience (adjusted OR (AOR) 1.09; 95% CI 1.05 to 1.13), annual ETI exposure (AOR 1.79; 95% CI 1.59 to 2.03) and the availability of ETI skill retention programmes including regular simulation training (AOR 1.31; 95% CI 1.02 to 1.68) and operating room training (AOR 1.44; 95% CI 1.14 to 1.83) were independently associated with confidence in performing ETI. CONCLUSIONS ETI is an uncommon event for most ELSTs, and nearly half of respondents did not have confidence in performing this procedure. Since confidence in ETI was independently associated with availability of regular simulation and operating room training, standardisation of ETI re-education that incorporates such methods may be useful for prehospital rescuers.
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Affiliation(s)
- Yuko Ono
- Emergency and Critical Care Medical Center, Fukushima Medical University, Fukushima, Japan
- Department of Pharmacology, School of Medicine, Fukushima Medical University, Fukushima, Japan
- Department of Anesthesiology, Ohta General Hospital Foundation, Ohta Nishinouchi Hospital, Koriyama, Japan
| | - Koichi Tanigawa
- Fukushima Global Medical Science Center, Fukushima Medical University, Fukushima, Japan
| | - Takeyasu Kakamu
- Department of Hygiene and Preventive Medicine, School of Medicine, Fukushima Medical University, Fukushima, Japan
- Section of Environment and Radiation, International Agency for Research on Cancer, Lyon, France
| | - Kazuaki Shinohara
- Department of Anesthesiology, Ohta General Hospital Foundation, Ohta Nishinouchi Hospital, Koriyama, Japan
| | - Ken Iseki
- Emergency and Critical Care Medical Center, Fukushima Medical University, Fukushima, Japan
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Wang HE, Donnelly JP, Barton D, Jarvis JL. Assessing Advanced Airway Management Performance in a National Cohort of Emergency Medical Services Agencies. Ann Emerg Med 2018; 71:597-607.e3. [DOI: 10.1016/j.annemergmed.2017.12.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Revised: 11/22/2017] [Accepted: 12/05/2017] [Indexed: 10/18/2022]
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22
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Mann V, Limberg F, Mann STW, Little S, Müller M, Sander M, Röhrig R. Routineerhalt beim Umgang mit extraglottischen Atemwegen im Rettungsdienst: Effektivität und Nachhaltigkeit einer simulatorbasierten Ausbildung. Med Klin Intensivmed Notfmed 2018; 114:541-551. [DOI: 10.1007/s00063-018-0429-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2018] [Revised: 02/25/2018] [Accepted: 03/07/2018] [Indexed: 11/28/2022]
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23
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Wang HE. The (Continued) Challenges of Out-of-Hospital Rapid Sequence Intubation. Ann Emerg Med 2017; 70:460-462. [DOI: 10.1016/j.annemergmed.2017.04.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2017] [Indexed: 11/28/2022]
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Vithalani VD, Vlk S, Davis SQ, Richmond NJ. Unrecognized failed airway management using a supraglottic airway device. Resuscitation 2017; 119:1-4. [PMID: 28750882 DOI: 10.1016/j.resuscitation.2017.07.019] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Revised: 06/29/2017] [Accepted: 07/21/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND 911 Emergency Medical Services (EMS) systems utilize supraglottic devices for either primary advanced airway management, or for airway rescue following failed attempts at direct laryngoscopy endotracheal intubation. There is, however, limited data on objective confirmation of supraglottic airway placement in the prehospital environment. Furthermore, the ability of EMS field providers to recognize a misplaced airway is unknown. METHODS Retrospective review of patients who underwent airway management using the King LTS-D supraglottic airway in a large urban EMS system, between 3/1/15-9/30/2015. Subjective success was defined as documentation of successful airway placement by the EMS provider. Objective success was confirmed by review of waveform capnography, with the presence of a 4-phase waveform greater than 5mmHg. Sensitivity and specificity of the field provider's assessment of success were then calculated. RESULTS A total of 344 supraglottic airway attempts were reviewed. No patients met obvious death criteria. 269 attempts (85.1%) met criteria for both subjective and objective success. 19 attempts (5.6%) were recognized failures by the EMS provider. 47 (13.8%) airways were misplaced but unrecognized by the EMS provider. 4 attempts (1.2%) were correctly placed but misidentified as failures, leading to the unnecessary removal and replacement of the airway. Sensitivity of the provider's assessment was 98.5%; specificity was 28.7%. CONCLUSION The use of supraglottic airway devices results in unrecognized failed placement. Appropriate utilization and review of waveform capnography may remedy a potential blind-spot in patient safety, and systemic monitoring/feedback processes may therefore be used to prevent unrecognized misplaced airways.
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Affiliation(s)
- Veer D Vithalani
- Office of the Medical Director, Emergency Physicians Advisory Board, MedStar Mobile Healthcare, Area Metropolitan EMS Authority, 2900 Alta Mere Drive, Fort Worth, TX 76116, United States.
| | - Sabrina Vlk
- Office of the Medical Director, Emergency Physicians Advisory Board, MedStar Mobile Healthcare, Area Metropolitan EMS Authority, 2900 Alta Mere Drive, Fort Worth, TX 76116, United States.
| | - Steven Q Davis
- Office of the Medical Director, Emergency Physicians Advisory Board, MedStar Mobile Healthcare, Area Metropolitan EMS Authority, 2900 Alta Mere Drive, Fort Worth, TX 76116, United States.
| | - Neal J Richmond
- Office of the Medical Director, Emergency Physicians Advisory Board, MedStar Mobile Healthcare, Area Metropolitan EMS Authority, 2900 Alta Mere Drive, Fort Worth, TX 76116, United States.
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Dyson K, Bray JE, Smith K, Bernard S, Straney L, Nair R, Finn J. Paramedic Intubation Experience Is Associated With Successful Tube Placement but Not Cardiac Arrest Survival. Ann Emerg Med 2017; 70:382-390.e1. [PMID: 28347556 DOI: 10.1016/j.annemergmed.2017.02.002] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 01/02/2017] [Accepted: 01/31/2017] [Indexed: 10/19/2022]
Abstract
STUDY OBJECTIVE Paramedic experience with intubation may be an important factor in skill performance and patient outcomes. Our objective is to examine the association between previous intubation experience and successful intubation. In a subcohort of out-of-hospital cardiac arrest cases, we also measure the association between patient survival and previous paramedic intubation experience. METHODS We analyzed data from Ambulance Victoria electronic patient care records and the Victorian Ambulance Cardiac Arrest Registry for January 1, 2008, to September 26, 2014. For each patient case, we defined intubation experience as the number of intubations attempted by each paramedic in the previous 3 years. Using logistic regression, we estimated the association between intubation experience and (1) successful intubation and (2) first-pass success. In the out-of-hospital cardiac arrest cohort, we determined the association between previous intubation experience and patient survival. RESULTS During the 6.7-year study period, 769 paramedics attempted intubation in 14,857 patients. Paramedics typically performed 3 intubations per year (interquartile range 1 to 6). Most intubations were successful (95%), including 80% on the first attempt. Previous intubation experience was associated with intubation success (odds ratio 1.04; 95% confidence interval 1.03 to 1.05) and intubation first-pass success (odds ratio 1.02; 95% confidence interval 1.01 to 1.03). In the out-of-hospital cardiac arrest subcohort (n=9,751), paramedic intubation experience was not associated with patient survival. CONCLUSION Paramedics in this Australian cohort performed few intubations. Previous experience was associated with successful intubation. Among out-of-hospital cardiac arrest patients for whom intubation was attempted, previous paramedic intubation experience was not associated with patient survival.
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Affiliation(s)
- Kylie Dyson
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Ambulance Victoria, Victoria, Australia.
| | - Janet E Bray
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Alfred Hospital, Melbourne, Victoria, Australia; School of Nursing, Midwifery and Paramedicine, Curtin University, Perth, Western Australia, Australia
| | - Karen Smith
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Ambulance Victoria, Victoria, Australia; Discipline of Emergency Medicine, University of Western Australia, Perth, Australia
| | - Stephen Bernard
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Ambulance Victoria, Victoria, Australia; Alfred Hospital, Melbourne, Victoria, Australia
| | - Lahn Straney
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | | | - Judith Finn
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Discipline of Emergency Medicine, University of Western Australia, Perth, Australia; School of Nursing, Midwifery and Paramedicine, Curtin University, Perth, Western Australia, Australia
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Prehospital intubation for isolated severe blunt traumatic brain injury: worse outcomes and higher mortality. Eur J Trauma Emerg Surg 2016; 43:731-739. [PMID: 27567923 DOI: 10.1007/s00068-016-0718-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Accepted: 08/15/2016] [Indexed: 10/21/2022]
Abstract
PURPOSE Prehospital endotracheal intubation (ETI) for traumatic brain injury (TBI) is a controversial issue. The aim of this study was to investigate the effect of prehospital ETI in patients with TBI. METHODS Cohort-matched study using the US National Trauma Data Bank (NTDB) 2008-2012. Patients with isolated severe blunt TBI (AIS head ≥3, AIS chest/abdomen <3) and a field GCS ≤8 were extracted from NTDB. A 1:1 matching of patients with and without prehospital ETI was performed. Matching criteria were sex, age, exact field GCS, exact AIS head, field hypotension, field cardiac arrest, and the brain injury type (according PREDOT-code). The matched cohorts were compared with univariable and multivariable regression analysis. RESULTS A total of 27,714 patients were included. Matching resulted in 8139 cases with and 8139 cases without prehospital ETI. Prehospital ETI was associated with significantly longer scene (median 9 vs. 8 min, p < 0.001) and transport times (median 26 vs. 19 min, p < 0.001), lower Emergency Department (ED) GCS scores (in patients without sedation; mean 3.7 vs. 3.9, p = 0.026), more ventilator days (mean 7.3 vs. 6.9, p = 0.006), longer ICU (median 6.0 vs. 5.0 days, p < 0.001) and total hospital length of stay (median 10.0 vs. 9.0 days, p < 0.001), and higher in-hospital mortality (31.4 vs. 27.5 %, p < 0.001). In regression analysis prehospital ETI was independently associated with lower ED GCS scores (RC -4.213, CI -4.562/-3.864, p < 0.001) and higher in-hospital mortality (OR 1.399, CI 1.205/1.624, p < 0.001). CONCLUSION In this large cohort-matched analysis, prehospital ETI in patients with isolated severe blunt TBI was independently associated with lower ED GCS scores and higher mortality.
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27
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Field intubation in civilian patients with hemorrhagic shock is associated with higher mortality. J Trauma Acute Care Surg 2016; 80:278-82. [PMID: 26491803 DOI: 10.1097/ta.0000000000000901] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Field intubation (FI) by emergency medical service personnel on severely injured trauma patients remains a contentious practice. Clinical studies suggest an association between FI and adverse outcomes in patients with traumatic brain injury. Military tactical emergency casualty care recommends deferring intubation and providing supplemental oxygenation until reaching a more equipped destination. In addition, animal models with penetrating hemorrhagic shock demonstrate increased acidosis with intubation before resuscitation. The purpose of this study was to evaluate the impact of FI on outcomes in trauma patients with hemorrhagic shock requiring massive transfusion. METHODS The Los Angeles County Trauma System Database was retrospectively queried for all trauma patients 16 years or older with hemorrhagic shock requiring massive transfusion (≥6 U packed red blood cells in the first 24 hours) between January 1, 2012, and June 30, 2014. Demographics, clinical and transfusion data, and outcomes were compared between patients who received FI and those who did not (NO-FI). Multivariate regression analysis was used to adjust for confounders. RESULTS Of 552 trauma patients meeting inclusion criteria, 63 (11%) received FI, and the remaining 489 (89%) were NO-FI. Age, sex, and incidence of blunt injury were similar between the FI and the NO-FI group. The FI cohort presented with a lower median Glasgow Coma Scale (GCS) score (3 vs. 14, p < 0.001), a lower median systolic blood pressure (86 mm Hg vs. 104 mm Hg, p < 0.001), and a higher median Injury Severity Score (ISS) (41 vs. 29, p < 0.001). Mortality was significantly higher in FI patients (83% vs. 43%, p < 0.001). Transfusion patterns and total field times were similar in both groups. After adjusting for confounders, FI patients had increased odds of mortality (adjusted odds ratio, 2.89; 95% confidence interval, 1.08-7.78; p = 0.035). In addition, FI was identified as an independent predictor of mortality (adjusted odds ratio, 3.41; 95% confidence interval, 1.35-8.59; p = 0.009). CONCLUSION FI may be associated with higher mortality in trauma patients with hemorrhagic shock requiring massive transfusion. Less invasive airway interventions and rapid transport might improve outcomes for these patients. LEVEL OF EVIDENCE Therapeutic study, level IV; epidemiologic study, level III.
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Wang HE, Prince DK, Stephens SW, Herren H, Daya M, Richmond N, Carlson J, Warden C, Colella MR, Brienza A, Aufderheide TP, Idris AH, Schmicker R, May S, Nichol G. Design and implementation of the Resuscitation Outcomes Consortium Pragmatic Airway Resuscitation Trial (PART). Resuscitation 2016; 101:57-64. [PMID: 26851059 PMCID: PMC4792760 DOI: 10.1016/j.resuscitation.2016.01.012] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Revised: 01/07/2016] [Accepted: 01/19/2016] [Indexed: 10/22/2022]
Abstract
Airway management is an important component of resuscitation from out-of-hospital cardiac arrest (OHCA). The optimal approach to advanced airway management is unknown. The Pragmatic Airway Resuscitation Trial (PART) will compare the effectiveness of endotracheal intubation (ETI) and Laryngeal Tube (LT) insertion upon 72-h survival in adult OHCA. Encompassing United States Emergency Medical Services agencies affiliated with the Resuscitation Outcomes Consortium (ROC), PART will use a cluster-crossover randomized design. Participating subjects will include adult, non-traumatic OHCA requiring bag-valve-mask ventilation. Trial interventions will include (1) initial airway management with ETI and (2) initial airway management with LT. The primary and secondary trial outcomes are 72-h survival and return of spontaneous circulation. Additional clinical outcomes will include airway management process and adverse events. The trial will enroll a total of 3000 subjects. Results of PART may guide the selection of advanced airway management strategies in OHCA.
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Affiliation(s)
- Henry E Wang
- Department of Emergency Medicine, University of Alabama School of Medicine, Birmingham, AL, United States.
| | - David K Prince
- Clinical Trials Center, Department of Biostatistics, University of Washington, Seattle, WA, United States.
| | - Shannon W Stephens
- Department of Emergency Medicine, University of Alabama School of Medicine, Birmingham, AL, United States.
| | - Heather Herren
- Clinical Trials Center, Department of Biostatistics, University of Washington, Seattle, WA, United States.
| | - Mohamud Daya
- Department of Emergency Medicine, Oregon Health and Science University, Portland, OR, United States.
| | | | - Jestin Carlson
- St Vincent's Medical Center, Erie, PA, United States; Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, United States.
| | - Craig Warden
- Department of Emergency Medicine, Oregon Health and Science University, Portland, OR, United States.
| | - M Riccardo Colella
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI, United States.
| | - Ashley Brienza
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, United States.
| | - Tom P Aufderheide
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI, United States.
| | - Ahamed H Idris
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, TX, United States.
| | - Robert Schmicker
- Clinical Trials Center, Department of Biostatistics, University of Washington, Seattle, WA, United States.
| | - Susanne May
- Clinical Trials Center, Department of Biostatistics, University of Washington, Seattle, WA, United States.
| | - Graham Nichol
- Clinical Trials Center, Department of Biostatistics, University of Washington, Seattle, WA, United States.
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Sanghavi P, Jena AB, Newhouse JP, Zaslavsky AM. Outcomes of Basic Versus Advanced Life Support for Out-of-Hospital Medical Emergencies. Ann Intern Med 2015; 163:681-90. [PMID: 26457627 PMCID: PMC4945100 DOI: 10.7326/m15-0557] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Most Medicare patients seeking emergency medical transport are treated by ambulance providers trained in advanced life support (ALS). Evidence supporting the superiority of ALS over basic life support (BLS) is limited, but some studies suggest ALS may harm patients. OBJECTIVE To compare outcomes after ALS and BLS in out-of-hospital medical emergencies. DESIGN Observational study with adjustment for propensity score weights and instrumental variable analyses based on county-level variations in ALS use. SETTING Traditional Medicare. PATIENTS 20% random sample of Medicare beneficiaries from nonrural counties between 2006 and 2011 with major trauma, stroke, acute myocardial infarction (AMI), or respiratory failure. MEASUREMENTS Neurologic functioning and survival to 30 days, 90 days, 1 year, and 2 years. RESULTS Except in cases of AMI, patients showed superior unadjusted outcomes with BLS despite being older and having more comorbidities. In propensity score analyses, survival to 90 days among patients with trauma, stroke, and respiratory failure was higher with BLS than ALS (6.1 percentage points [95% CI, 5.4 to 6.8 percentage points] for trauma; 7.0 percentage points [CI, 6.2 to 7.7 percentage points] for stroke; and 3.7 percentage points [CI, 2.5 to 4.8 percentage points] for respiratory failure). Patients with AMI did not exhibit differences in survival at 30 days but had better survival at 90 days with ALS (1.0 percentage point [CI, 0.1 to 1.9 percentage points]). Neurologic functioning favored BLS for all diagnoses. Results from instrumental variable analyses were broadly consistent with propensity score analyses for trauma and stroke, showed no survival differences between BLS and ALS for respiratory failure, and showed better survival at all time points with BLS than ALS for patients with AMI. LIMITATION Only Medicare beneficiaries from nonrural counties were studied. CONCLUSION Advanced life support is associated with substantially higher mortality for several acute medical emergencies than BLS. PRIMARY FUNDING SOURCE National Science Foundation, Agency for Healthcare Research and Quality, and National Institutes of Health.
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Affiliation(s)
- Prachi Sanghavi
- From University of Chicago, Chicago, Illinois, and Harvard Medical School, Boston, Massachusetts
| | - Anupam B. Jena
- From University of Chicago, Chicago, Illinois, and Harvard Medical School, Boston, Massachusetts
| | - Joseph P. Newhouse
- From University of Chicago, Chicago, Illinois, and Harvard Medical School, Boston, Massachusetts
| | - Alan M. Zaslavsky
- From University of Chicago, Chicago, Illinois, and Harvard Medical School, Boston, Massachusetts
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Brown CA, Cox K, Hurwitz S, Walls RM. 4,871 Emergency airway encounters by air medical providers: a report of the air transport emergency airway management (NEAR VI: "A-TEAM") project. West J Emerg Med 2015; 15:188-93. [PMID: 24672610 PMCID: PMC3966436 DOI: 10.5811/westjem.2013.11.18549] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2013] [Revised: 10/03/2013] [Accepted: 11/11/2013] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Pre-hospital airway management is a key component of resuscitation although the benefit of pre-hospital intubation has been widely debated. We report a large series of pre-hospital emergency airway encounters performed by air-transport providers in a large, multi-state system. METHODS We retrospectively reviewed electronic intubation flight records from an 89 rotorcraft air medical system from January 01, 2007, through December 31, 2009. We report patient characteristics, intubation methods, success rates, and rescue techniques with descriptive statistics. We report proportions with 95% confidence intervals and binary comparisons using chi square test with p-values <0.05 considered significant. RESULTS 4,871 patients had active airway management, including 2,186 (44.9%) medical and 2,685 (55.1%) trauma cases. There were 4,390 (90.1%) adult and 256 (5.3%) pediatric (age ≤ 14) intubations; 225 (4.6%) did not have an age recorded. 4,703 (96.6%) had at least one intubation attempt. Intubation was successful on first attempt in 3,710 (78.9%) and was ultimately successful in 4,313 (91.7%). Intubation success was higher for medical than trauma patients (93.4% versus 90.3%, p=0.0001 JT test). 168 encounters were managed primarily with an extraglottic device (EGD). Cricothyrotomy was performed 35 times (0.7%) and was successful in 33. Patients were successfully oxygenated and ventilated with an endotracheal tube, EGD, or surgical airway in 4809 (98.7%) encounters. There were no reported deaths from a failed airway. CONCLUSION Airway management, predominantly using rapid sequence intubation protocols, is successful within this high-volume, multi-state air-transport system.
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Affiliation(s)
- Calvin A Brown
- Brigham and Women's Hospital, Harvard Medical School, Department of Emergency Medicine, Boston, Massachusetts
| | - Kelly Cox
- University of Illinois-Peoria, Department of Emergency Medicine, Peoria, Illinois
| | - Shelley Hurwitz
- Brigham and Women's Hospital, Harvard Medical School, Department of Medicine, Boston, Massachusetts
| | - Ron M Walls
- Brigham and Women's Hospital, Harvard Medical School, Department of Emergency Medicine, Boston, Massachusetts
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Should laryngeal tubes or masks be used for out-of-hospital cardiac arrest patients? Am J Emerg Med 2015; 33:1360-3. [PMID: 26306437 DOI: 10.1016/j.ajem.2015.07.043] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2015] [Revised: 07/23/2015] [Accepted: 07/24/2015] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE Few studies have compared airway management via laryngeal masks (LM) or laryngeal tubes (LT) in patients with out-of-hospital cardiac arrest (OHCA). This study evaluated whether LT insertion by emergency medical service (EMS) personnel affected ventilation and outcomes in OHCA patients (vs. the standard LM treatment). METHODS This prospective, cluster-randomized, and open-label study evaluated data that were collected by the Sapporo Fire Department between June 2012 and January 2013. We selected the 14 EMS teams that treated the greatest number of OHCA patients in Sapporo, Japan during 2011, and randomized the teams into Groups A and B. In the first study period (June 2012 to September 2012), Group A treated OHCA patients via LT and Group B treated OHCA patients via LM. In the second period (October 2012 to January 2013), Group A treated OHCA patients via LM and Group B treated OHCA patients via LT. If necessary, both groups were allowed to use an esophageal obturator airway (EOA) kit. The primary endpoints were time from cardiopulmonary resuscitation to device insertion and the rate of successful pre-hospital ventilation. The secondary endpoints were return of spontaneous circulation and survival and favorable neurological outcomes at 1 month after cardiac arrest. RESULTS LT was used in 148 OHCA patients and LM was used in 165 OHCA patients. Our intention-to-treat analyses revealed no significant differences in the primary and secondary outcomes of the LT- and LM-treated groups. CONCLUSION Prehospital advanced airway management via LT provides similar outcomes to those of LM in OHCA patients.
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Improvement in glottic visualisation by using the C-MAC PM video laryngoscope as a first-line device for out-of-hospital emergency tracheal intubation. Eur J Anaesthesiol 2015; 32:425-31. [DOI: 10.1097/eja.0000000000000249] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Jung JY. Airway management of patients with traumatic brain injury/C-spine injury. Korean J Anesthesiol 2015; 68:213-9. [PMID: 26045922 PMCID: PMC4452663 DOI: 10.4097/kjae.2015.68.3.213] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Revised: 12/08/2014] [Accepted: 12/09/2014] [Indexed: 11/26/2022] Open
Abstract
Traumatic brain injury (TBI) is usually combined with cervical spine (C-spine) injury. The possibility of C-spine injury is always considered when performing endotracheal intubation in these patients. Rapid sequence intubation is recommended with adequate sedative or analgesics and a muscle relaxant to prevent an increase in intracranial pressure during intubation in TBI patients. Normocapnia and mild hyperoxemia should be maintained to prevent secondary brain injury. The manual-in-line-stabilization (MILS) technique effectively lessens C-spine movement during intubation. However, the MILS technique can reduce mouth opening and lead to a poor laryngoscopic view. The newly introduced video laryngoscope can manage these problems. The AirWay Scope® (AWS) and AirTraq laryngoscope decreased the extension movement of C-spines at the occiput-C1 and C2-C4 levels, improving intubation conditions and shortening the time to complete tracheal intubation compared with a direct laryngoscope. The Glidescope® also decreased cervical movement in the C2-C5 levels during intubation and improved vocal cord visualization, but a longer duration was required to complete intubation compared with other devices. A lightwand also reduced cervical motion across all segments. A fiberoptic bronchoscope-guided nasal intubation is the best method to reduce cervical movement, but a skilled operator is required. In conclusion, a video laryngoscope assists airway management in TBI patients with C-spine injury.
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Affiliation(s)
- Jin Yong Jung
- Department of Anesthesiology and Pain Medicine, Catholic University of Daegu School of Medicine, Daegu, Korea
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Kempema J, Trust MD, Ali S, Cabanas JG, Hinchey PR, Brown LH, Brown CVR. Prehospital endotracheal intubation vs extraglottic airway device in blunt trauma. Am J Emerg Med 2015; 33:1080-3. [PMID: 25963681 DOI: 10.1016/j.ajem.2015.04.046] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Revised: 04/13/2015] [Accepted: 04/23/2015] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE The objective of the study is to compare outcomes in blunt trauma patients managed with prehospital insertion of an extraglottic airway device (EGD) vs endotracheal intubation (ETI). The null hypothesis was that there would be no difference in mortality for the 2 groups. METHODS This is a retrospective study of blunt trauma patients with Glasgow Coma Scale score less than or equal to 8 transported by ground emergency medical services directly from the scene of injury to a single urban level 1 trauma center. Patients managed with only noninvasive airway techniques were excluded, leaving patients undergoing either EGD placement or ETI. Outcomes included in-emergency department (ED) traumatic arrest and hospital mortality. Multivariable logistic regression was used to control for the potential confounding effects of demographic and clinical variables. For all analyses, P < .05 was used to establish statistical significance. RESULTS In bivariate analysis, patients managed with EGD were more likely than those managed with ETI to have an in-ED traumatic arrest (36.5% vs 17.1%; P = .005), but eventual hospital mortality did not significantly differ between the 2 groups (75.7% vs 67.1%; P = .228). After controlling for demographic and clinical characteristics, patients managed with EGD were no more likely than patients managed with ETI to experience traumatic arrest in the ED (adjusted odds ratio, 1.67; 95% confidence interval, 0.72-3.89), and there was also no difference in overall hospital mortality (adjusted odds ratio, 0.912; 95% confidence interval, 0.36-2.30). CONCLUSION In this preliminary, retrospective analysis, we found no difference in overall survival among trauma patients managed with prehospital EGD and those managed with prehospital ETI.
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Affiliation(s)
- James Kempema
- Emergency Medicine Residency Program, University of Texas-Austin and University Medical Center Brackenridge, Austin, TX 78701
| | - Marc D Trust
- Department of Surgery, University of Texas-Austin and University Medical Center Brackenridge, Austin, TX 78701
| | - Sadia Ali
- Department of Surgery, University of Texas-Austin and University Medical Center Brackenridge, Austin, TX 78701
| | - Jose G Cabanas
- Austin-Travis County Office of the Medical Director, Austin, TX 78741
| | - Paul R Hinchey
- Austin-Travis County Office of the Medical Director, Austin, TX 78741
| | - Lawrence H Brown
- Emergency Medicine Residency Program, University of Texas-Austin and University Medical Center Brackenridge, Austin, TX 78701; Mount Isa Centre for Rural & Remote Health, James Cook University, Townsville, QLD, Australia, 4811.
| | - Carlos V R Brown
- Department of Surgery, University of Texas-Austin and University Medical Center Brackenridge, Austin, TX 78701
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Länkimäki S, Alahuhta S, Silfvast T, Kurola J. Feasibility of LMA Supreme for airway management in unconscious patients by ALS paramedics. Scand J Trauma Resusc Emerg Med 2015; 23:24. [PMID: 25888519 PMCID: PMC4345009 DOI: 10.1186/s13049-015-0105-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Accepted: 02/16/2015] [Indexed: 11/29/2022] Open
Abstract
Background Airway management to ensure sufficient gas exchange is of major importance in emergency care. The accepted basic technique is to maintain an open airway and perform artificial ventilation in emergency situations is bag-valve mask (BVM) ventilation with manual airway management without airway adjuncts or with an oropharyngeal tube (OPA) only. Endotracheal intubation (ETI) is often referred to as the golden standard of airway management, but is associated with low success rates and significant insertion-related complications when performed by non-anaesthetists. Supraglottic devices (SADs) are one alternative to ETI in these situations, but there is limited evidence regarding the use of SAD in non-cardiac arrest situations. LMA Supreme (LMA-S) is a new SAD which theoretically has an advantage concerning the risk of aspiration due to an oesophageal inlet gastric tube port. Methods Forty paramedics were recruited to participate in the study. Adult (>18 years) patients, unconscious due to medical or traumatic cause with a GCS score corresponding to 3–5 and needed airway management were included in the study. Our aim was to study the feasibility of LMA-S as a primary airway method in unconscious patients by advanced life support (ALS) trained paramedics in prehospital care. Results Three regional Emergency Medical Service (EMS) services participated and 21 patients were treated during the survey. The LMA-S was placed correctly on the first attempt in all instances 21/21 (100%), with a median time to first ventilation of 9.8 s. Paramedics evaluated the insertion to be easy in every case 21/21 (100%). Because of air leak later in the patient care, the LMA-S was exchanged to an LT-D in two cases and to ETI in three cases (23.81%) by the paramedics. Regurgitation occurred after insertion two times out of 21 (9.52%) and in one of these cases (4.76%), paramedics reported regurgitation inside the LMA-S. Conclusion We conclude that the LMA-S seems to be relatively easy and quick to insert in unconscious patients by paramedics. However, we found out that there were ventilation related problems with the LMA-S. Further studies are warranted.
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Affiliation(s)
- Sami Länkimäki
- Helsinki Area Helicopter Emergency Medical Service, Helsinki University Central Hospital, FI-00029 HUS, Helsinki, Finland. .,Centre for Prehospital Emergency Care, Länsi-Pohja Healthcare District, Kauppakatu 25, FI-94100, Kemi, Finland.
| | - Seppo Alahuhta
- Department of Anaesthesiology, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland.
| | - Tom Silfvast
- Helsinki Area Helicopter Emergency Medical Service, Helsinki University Central Hospital, FI-00029 HUS, Helsinki, Finland.
| | - Jouni Kurola
- Centre for Prehospital Emergency Care, Kuopio University Hospital, PO Box 1777, FI-70210, Kuopio, Finland.
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Martin-Gill C, Prunty HA, Ritter SC, Carlson JN, Guyette FX. Risk factors for unsuccessful prehospital laryngeal tube placement. Resuscitation 2015; 86:25-30. [DOI: 10.1016/j.resuscitation.2014.10.015] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2014] [Revised: 10/20/2014] [Accepted: 10/20/2014] [Indexed: 11/28/2022]
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Murphy LD, Kovacs GJ, Reardon PM, Law JA. Comparison of the King Vision Video Laryngoscope with the Macintosh Laryngoscope. J Emerg Med 2014; 47:239-46. [DOI: 10.1016/j.jemermed.2014.02.008] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2013] [Revised: 12/30/2013] [Accepted: 02/09/2014] [Indexed: 02/07/2023]
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The process of prehospital airway management: challenges and solutions during paramedic endotracheal intubation. Crit Care Med 2014; 42:1372-8. [PMID: 24589641 DOI: 10.1097/ccm.0000000000000213] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Endotracheal intubation success rates in the prehospital setting are variable. Our objective was to describe the challenges encountered and corrective actions taken during the process of endotracheal intubation by paramedics. DESIGN Analysis of prehospital airway management using a prospective registry that was linked to an emergency medical services administrative database. SETTING Emergency medical services system serving King County, Washington, 2006-2011. Paramedics in this system have the capability to administer neuromuscular blocking agents to facilitate intubation (i.e., rapid sequence intubation). PATIENTS A total of 7,523 patients more than 12 years old in whom paramedics attempted prehospital endotracheal intubation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS An intubation attempt was defined as the introduction of the laryngoscope into the patient's mouth, and the attempt concluded when the laryngoscope was removed from the mouth. Endotracheal intubation was successful on the first attempt in 77% and ultimately successful in 99% of patients (7,433 of 7,523). Paramedics used a rapid sequence intubation strategy on 54% of first attempts. Among the subset with a failed first attempt (n = 1,715), bodily fluids obstructing the laryngeal view (50%), obesity (28%), patient positioning (17%), and facial or spinal trauma (6%) were identified as challenges to intubation. A variety of adjustments were made to achieve intubation success, including upper airway suctioning (used in 43% of attempts resulting in success), patient repositioning (38%), rescue bougie use (19%), operator change (16%), and rescue rapid sequence intubation (6%). Surgical cricothyrotomy (0.4%, n = 27) and bag-valve-mask ventilation (0.8%, n = 60) were rarely performed by paramedics as final rescue airway strategies. CONCLUSIONS Airway management in the prehospital setting has substantial challenges. Success can require a collection of adjustments that involve equipment, personnel, and medication often in a simultaneous fashion.
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Characterizing Demographics, Injury Severity, and Intubation Status for Patients Transported by Air or Ground Ambulance to a Rural Burn Center. J Burn Care Res 2014; 35:e151-8. [DOI: 10.1097/bcr.0b013e31829b3365] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Mal S, McLeod S, Iansavichene A, Dukelow A, Lewell M. Effect of out-of-hospital noninvasive positive-pressure support ventilation in adult patients with severe respiratory distress: a systematic review and meta-analysis. Ann Emerg Med 2013; 63:600-607.e1. [PMID: 24342819 DOI: 10.1016/j.annemergmed.2013.11.013] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Revised: 11/05/2013] [Accepted: 11/15/2013] [Indexed: 11/30/2022]
Abstract
STUDY OBJECTIVE Noninvasive positive-pressure ventilation (NIPPV) is increasingly being used by emergency medical services (EMS) for treatment of patients in respiratory distress. The primary objective of this systematic review is to determine whether out-of-hospital NIPPV for treatment of adults with severe respiratory distress reduces inhospital mortality compared with "standard" therapy. Secondary objectives are to examine the need for invasive ventilation, hospital and ICU length of stay, and complications. METHODS Electronic searches of MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and Cumulative Index to Nursing and Allied Health Literature were conducted and reference lists of relevant articles hand searched. Randomized controlled trials comparing out-of-hospital NIPPV with standard therapy in adults (aged ≥16 years) with severe respiratory distress published in English were included. Two reviewers independently screened abstracts, assessed quality of the studies, and extracted data. Data were pooled with random-effects models and reported as risk ratios (RRs) with 95% confidence intervals (CIs) and number needed to treat (NNT). RESULTS Seven randomized controlled trials were included, with a combined total of 632 patients; 313 in the standard therapy group and 319 in the NIPPV group. In patients treated with NIPPV, the pooled estimate showed a reduction in both inhospital mortality (RR 0.58; 95% CI 0.35 to 0.95; NNT=18) and need for invasive ventilation (RR 0.37; 95% CI 0.24 to 0.58; NNT=8). There was no difference in ICU or hospital length of stay. CONCLUSION Out-of-hospital administration of NIPPV appears to be an effective therapy for adult patients with severe respiratory distress.
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Affiliation(s)
- Sameer Mal
- Division of Emergency Medicine, Department of Medicine, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada; London Health Sciences Centre, London, Ontario, Canada.
| | - Shelley McLeod
- Division of Emergency Medicine, Department of Medicine, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada; London Health Sciences Centre, London, Ontario, Canada
| | | | - Adam Dukelow
- Division of Emergency Medicine, Department of Medicine, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada; London Health Sciences Centre, London, Ontario, Canada
| | - Michael Lewell
- Division of Emergency Medicine, Department of Medicine, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada; London Health Sciences Centre, London, Ontario, Canada
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Use of rapid sequence intubation predicts improved survival among patients intubated after out-of-hospital cardiac arrest. Resuscitation 2013; 84:1353-8. [DOI: 10.1016/j.resuscitation.2013.04.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2012] [Revised: 04/09/2013] [Accepted: 04/15/2013] [Indexed: 11/21/2022]
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Two hundred sixty pediatric emergency airway encounters by air transport personnel: a report of the air transport emergency airway management (NEAR VI: "A-TEAM") project. Pediatr Emerg Care 2013; 29:963-8. [PMID: 23974713 DOI: 10.1097/pec.0b013e3182a219ea] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Effective airway management is the cornerstone of resuscitative efforts for any critically ill or injured patient. The role and safety of pediatric prehospital intubation is controversial, particularly after prior research has shown varying degrees of intubation success. We report a series of consecutive prehospital pediatric intubations performed by air-transport providers. METHODS We retrospectively reviewed intubation flight records from an 89-rotorcraft, multistate emergency flight service during the time period from January 1, 2007, to December 31, 2009. All patients younger than 15 years were included in our analysis. We characterized patient, flight, and operator demographics; intubation methods; success rates; rescue techniques; and adverse events with descriptive statistics. We report proportions with 95% confidence intervals and differences between groups with Fisher exact and χ tests; P < 0.05 was considered significant. RESULTS Two hundred sixty pediatric intubations were performed consisting of 88 medical (33.8%) and 172 trauma (66.2%) cases; 98.8% (n = 257) underwent an orotracheal intubation attempt as the first method. First-pass intubation success was 78.6% (n = 202), and intubation was ultimately successful in 95.7% (n = 246) of cases. Medical and trauma intubations had similar success rates (98% vs 95%, Fisher exact test P = 0.3412). There was no difference in intubation success between age groups (χ = 0.26, P = 0.88). Three patients were managed primarily with an extraglottic device. Rescue techniques were used in 11 encounters (4.2%), all of which were successful. Cricothyrotomy was performed twice, both successful. CONCLUSIONS Prehospital pediatric intubation performed by air-transport providers, using rapid sequence intubation protocols, is highly successful. This effect on patient outcome requires further study.
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RAATINIEMI L, LÄNKIMÄKI S, MARTIKAINEN M. Pre-hospital airway management by non-physicians in Northern Finland -- a cross-sectional survey. Acta Anaesthesiol Scand 2013; 57:654-9. [PMID: 23496058 DOI: 10.1111/aas.12101] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/10/2013] [Indexed: 12/15/2022]
Abstract
BACKGROUND Airway management is an important skill in pre-hospital emergency medicine. The most optimal method depends on the resources and experience of the emergency medical service (EMS) providers. We wanted to study the frequency of occurrence, equipment used, problems experienced and maintenance of skills in pre-hospital airway management by non-physicians. METHODS A structured questionnaire consisting of 30 questions was distributed to 383 EMS providers in three hospital districts (population 597,521 and area 147,467 km(2) ) in Northern Finland. RESULTS The questionnaire was answered by 226 EMS providers and 58.5% (224/383) were included in the final analyses. In all, 82.6% (185/224) of the EMS providers were allowed to perform endotracheal intubation (ETI) and 44.2% (99/224) could perform ETI using sedative agents. The annual mean frequency of using a supraglottic airway device (SAD) was 1.0 (range 0-20, n = 224), for ETI it was 2.0 (range 0-16, n = 185) and for bag-valve-mask ventilation it was 4.3 (range 0-30, n = 223). The mean frequency of drug-assisted ETI was 1.1 (range 0-13, n = 99). Unsuccessful ETI had been experienced by 65.7% (119/181) of the EMS providers. Airway management had been practised in an operating room by 25.9% (56/216) and with a manikin by 81.3% (182/224) of the EMS providers during the past 12 months. CONCLUSION Advanced airway management procedures are uncommon for most EMS providers in Northern Finland. Procedures, training in and maintenance of airway management skills should be re-evaluated.
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Affiliation(s)
- L. RAATINIEMI
- Department of Anaesthesia; Central Hospital of Lapland; Rovaniemi; Finland
| | - S. LÄNKIMÄKI
- Department of Anaesthesia and Intensive Care; Oulu University Hospital; Oulu; Finland
| | - M. MARTIKAINEN
- Centre for Pre-hospital Emergency Care; Oulu University Hospital; Oulu; Finland
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Länkimäki S, Alahuhta S, Kurola J. Feasibility of a laryngeal tube for airway management during cardiac arrest by first responders. Resuscitation 2013; 84:446-9. [DOI: 10.1016/j.resuscitation.2012.08.326] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2012] [Revised: 07/26/2012] [Accepted: 08/20/2012] [Indexed: 10/27/2022]
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[Supraglottic airway devices in emergency medicine : impact of gastric drainage]. Anaesthesist 2013; 62:285-92. [PMID: 23494024 DOI: 10.1007/s00101-013-2154-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2012] [Revised: 02/16/2013] [Accepted: 02/17/2013] [Indexed: 10/27/2022]
Abstract
This case report describes a life-saving use of a supraglottic airway device (LT-D™-Larynxtubus, VBM Medizintechnik, Sulz, Germany) in an out-of-hospital emergency patient suffering from severe traumatic brain injury. Mechanical ventilation with the laryngeal tube was complicated by repeated airway obstructions and pronounced gastric distension with air as a consequence of oropharyngeal leakage. In this situation pulmonary ventilation of the patient was compromised so that emergency endotracheal intubation became necessary in the resuscitation area with vital indications. In this context the status of supraglottic airway devices in emergency medicine is discussed as well as the reasons for the gastric distension. Besides the immediate drastic consequences of gastric distension with respect to pulmonary ventilation, potential deleterious non-pulmonary consequences of this complication are highlighted. The clinical relevance of the described complications as well as the associated possibility of an optimized position control necessitate the recommendation only to use second generation supraglottic airway devices with integrated gastric access in (out-of-hospital) emergency medicine.
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Westgard BC, Peterson BK, Salzman JG, Anderson R, Buldra M, Burnett AM. Longitudinal and regional trends in paramedic student exposure to advanced airway placement: 2001-2011. PREHOSP EMERG CARE 2013; 17:379-85. [PMID: 23410104 DOI: 10.3109/10903127.2013.764949] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES The primary aims of this study were to determine whether the frequency of placement, type of advanced airway, and settings of advanced airway placement (clinical vs. field) have changed for paramedic students over the last 11 years, and to describe regional differences regarding the same set of variables. METHODS This study was a retrospective review of prospectively reported airway procedures documented by paramedic students in Fisdap ( http://www.fisdap.net ). Students were included if they graduated from a paramedic program, had procedure entries verified by a preceptor, and provided consent for research. Exclusion criteria included students who had a total number of airway placements ≥2 standard deviations from the mean or had 0 airway placements recorded, and programs with <10 graduating students total over the study period. Airway device types and educational settings were descriptively compared over the 11-year study period by year and region. RESULTS A total of 8,934 paramedic student records were reviewed, with 2,811 excluded based on a priori criteria, leaving 6,123 records for analysis. In each year, the median number of airway devices placed per student was greater in the clinical setting. Endotracheal intubation (ETI) was more common than alternative airway placement in both the field and clinical settings. The median number of clinical ETIs per student has remained relatively constant at 7. The median number of field ETIs per student ranged from 0 to 1 over the study period, with a median alternative airway placement rate of 0 for both clinical and field settings. For all regions, the majority of procedures were performed in a clinical environment. The median number of clinical alternative airway device placements was 0 for all regions. The number of clinical ETIs ranged from 5 to 11 per student, with the highest number of ETIs per student in the West North Central and New England regions and the lowest in the West South Central and East South Central regions. CONCLUSION Paramedic students gain the majority of their advanced airway experience in the clinical setting. ETI remains more common than alternative airway placement, although there is significant geographic variation in the number of ETIs per student. High rates of clinical intubations do not correlate with high rates of field intubations.
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Affiliation(s)
- Bjorn C Westgard
- Regions Hospital, Emergency Medical Services, 640 Jackson Street, Mail Stop 13801B, Saint Paul, MN 55101, USA
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HELM M, KREMERS G, LAMPL L, HOSSFELD B. Incidence of transient hypoxia during pre-hospital rapid sequence intubation by anaesthesiologists. Acta Anaesthesiol Scand 2013; 57:199-205. [PMID: 23210510 DOI: 10.1111/aas.12032] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/04/2012] [Indexed: 11/27/2022]
Abstract
BACKGROUND Pre-hospital tracheal intubation (TI) is an important but difficult procedure with the potential to produce hypoxaemia. The aim of this study was to determine the incidence of desaturation episodes during out-of-hospital rapid sequence induction (RSI) and TI by the medical team of a German Helicopter Emergency Medical Service (HEMS). METHODS We performed a prospective study at HEMS 'CHRISTOPH 22'. TI was performed as RSI according to a standard protocol. Desaturation was defined as a reduction in SpO(2) below 90% or a reduction of more than 10% from baseline SpO(2) when initial values were less than 90%. RESULTS The RSI/TI manoeuvre was attempted in 150 patients [107 male (71.3%); median age 40 years (IQR 21-61); overall success rate 100%]. The incidence of desaturation episodes was 13.3% with a median duration of 50 sec. (IQR 30-92) and a median SpO(2) decrease of 24 ± 10%. Upon hospital admission, all patients had SpO(2) values ≥ 96%. In the desaturation group the duration of successful TI was significantly longer [median 85 sec. (IQR 60-119) vs. median 63 sec. (IQR 48-70); P < 0.01], and the number of patients with a baseline SpO(2) ≥ 90% was significantly lower (65.0% vs. 88.5%; P < 0.01). Among patients with difficult to manage airway, those with desaturation were significantly younger, and technical problems were significantly more frequent. CONCLUSION The incidence of episodes of desaturation during pre-hospital RSI/TI at HEMS Ulm is relatively low, and the duration of such episodes is short.
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Affiliation(s)
- M. HELM
- Department of Anaesthesiology and Intensive Care Medicine; Section Emergency Medicine; Federal Armed Forces Medical Centre; Ulm; Germany
| | - G. KREMERS
- Department of Anaesthesiology and Intensive Care Medicine; Section Emergency Medicine; Federal Armed Forces Medical Centre; Ulm; Germany
| | - L. LAMPL
- Department of Anaesthesiology and Intensive Care Medicine; Section Emergency Medicine; Federal Armed Forces Medical Centre; Ulm; Germany
| | - B. HOSSFELD
- Department of Anaesthesiology and Intensive Care Medicine; Section Emergency Medicine; Federal Armed Forces Medical Centre; Ulm; Germany
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