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Jang J, Kim KH, Park JH, Jeong J, Ro YS, Song KJ, Shin SD. Association Between Ambulance Station Case Volume and Clinical Outcomes in Moderate to Severe Trauma. PREHOSP EMERG CARE 2024:1-7. [PMID: 38830202 DOI: 10.1080/10903127.2024.2364062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Accepted: 05/28/2024] [Indexed: 06/05/2024]
Abstract
OBJECTIVES The effect of the case volume of emergency medical services (EMS) on the clinical outcomes of trauma is uncertain. The purpose of this study was to evaluate the association between the case volume of an ambulance station and clinical outcomes in moderate to severe trauma patients. METHODS Adult trauma patients with injury severity scores greater than 8 who were transported by the EMS between 2018 and 2019 were analyzed. The main exposure was the annual case volume of moderate to severe trauma at the ambulance station where the patient-transporting ambulance was based: low-volume (less than 60 cases), intermediate-volume (between 60 and 89 cases), and high-volume (equal or greater than 90 cases). The primary outcome was in-hospital mortality. Multilevel multivariable logistic regression analysis was conducted to calculate adjusted odds ratios (AORs) and 95% confidence intervals (CIs), with the high-volume group used as the reference. RESULTS In total, 21,498 trauma patients were analyzed. The high-volume group exhibited lower in-hospital mortality, 447 (9.0%), compared to 867 (14.1%) in the intermediate-volume group and 1,458 (14.1%) in the low-volume group. There were a significantly higher odds of in-hospital mortality: the low-volume group (AOR 95% CI: 1.20 (0.95-1.51)) and intermediate-volume group (AOR 95% CI: 1.29 (1.02-1.64)) when compared to the high-volume group. CONCLUSIONS The case volume at an ambulance station is associated with in-hospital mortality in patients with moderate to severe trauma. These results should be considered when constructing an EMS system and education program for prehospital trauma care.
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Affiliation(s)
- Jaehyeon Jang
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Ki Hong Kim
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, South Korea
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, South Korea
| | - Jeong Ho Park
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, South Korea
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, South Korea
| | - Joo Jeong
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, South Korea
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Sungnam, South Korea
| | - Young Sun Ro
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, South Korea
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, South Korea
| | - Kyoung Jun Song
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, South Korea
- Department of Emergency Medicine, Seoul Metropolitan Boramae Medical Center, Seoul, South Korea
| | - Sang Do Shin
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, South Korea
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, South Korea
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Sungnam, South Korea
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Lulla A, Lumba-Brown A, Totten AM, Maher PJ, Badjatia N, Bell R, Donayri CTJ, Fallat ME, Hawryluk GWJ, Goldberg SA, Hennes HMA, Ignell SP, Ghajar J, Krzyzaniak BP, Lerner EB, Nishijima D, Schleien C, Shackelford S, Swartz E, Wright DW, Zhang R, Jagoda A, Bobrow BJ. Prehospital Guidelines for the Management of Traumatic Brain Injury - 3rd Edition. PREHOSP EMERG CARE 2023:1-32. [PMID: 37079803 DOI: 10.1080/10903127.2023.2187905] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/22/2023]
Affiliation(s)
- Al Lulla
- Department of Emergency Medicine, UT Southwestern Medical Center, Dallas, Texas
| | - Angela Lumba-Brown
- Department of Emergency Medicine, Stanford University, Stanford, California
| | - Annette M Totten
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon
| | - Patrick J Maher
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Neeraj Badjatia
- Department of Neurocritical Care, Neurology, Anesthesiology, Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Randy Bell
- Uniformed Services University, Bethesda, Maryland
| | | | - Mary E Fallat
- Hiram C. Polk Jr Department of Pediatric Surgery, University of Louisville, Norton Children's Hospital, Louisville, Kentucky
| | - Gregory W J Hawryluk
- Department of Neurosurgery, Cleveland Clinic and Akron General Hospital, Fairlawn, Ohio
| | - Scott A Goldberg
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Halim M A Hennes
- Department of Pediatric Emergency Medicine, UT Southwestern Medical Center, Dallas Children's Medical Center, Dallas, Texas
| | - Steven P Ignell
- Department of Emergency Medicine, Stanford University, Stanford, California
| | - Jamshid Ghajar
- Department of Neurosurgery, Stanford University, Stanford, California
| | | | - E Brooke Lerner
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Daniel Nishijima
- Department of Emergency Medicine, UC Davis, Sacramento, California
| | - Charles Schleien
- Pediatric Critical Care, Cohen Children's Medical Center, Hofstra Northwell School of Medicine, Uniondale, New York
| | - Stacy Shackelford
- Trauma and Critical Care, USAF Center for Sustainment of Trauma Readiness Skills, Seattle, Washington
| | - Erik Swartz
- Department of Physical Therapy and Kinesiology, University of Massachusetts, Lowell, Massachusetts
| | - David W Wright
- Department of Emergency Medicine, Emory University, Atlanta, Georgia
| | - Rachel Zhang
- University of Arizona College of Medicine-Phoenix, Phoenix, Arizona
| | - Andy Jagoda
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Bentley J Bobrow
- Department of Emergency Medicine, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, Texas
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Jarvis JL, Lyng JW, Miller BL, Perlmutter MC, Abraham H, Sahni R. Prehospital Drug Assisted Airway Management: An NAEMSP Position Statement and Resource Document. PREHOSP EMERG CARE 2022; 26:42-53. [PMID: 35001829 DOI: 10.1080/10903127.2021.1990447] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Airway management is a critical intervention for patients with airway compromise, respiratory failure, and cardiac arrest. Many EMS agencies use drug-assisted airway management (DAAM) - the administration of sedatives alone or in combination with neuromuscular blockers - to facilitate advanced airway placement in patients with airway compromise or impending respiratory failure who also have altered mental status, agitation, or intact protective airway reflexes. While DAAM provides several benefits including improving laryngoscopy and making insertion of endotracheal tubes and supraglottic airways easier, DAAM also carries important risks. NAEMSP recommends:DAAM is an appropriate tool for EMS clinicians in systems with clear guidelines, sufficient training, and close EMS physician oversight. DAAM should not be used in settings without adequate resources.EMS physicians should develop clinical guidelines informed by evidence and oversee the training and credentialing for safe and effective DAAM.DAAM programs should include best practices of airway management including patient selection, assessmenct and positioning, preoxygenation strategies including apneic oxygenation, monitoring and management of physiologic abnormalities, selection of medications, post-intubation analgesia and sedation, equipment selection, airway confirmation and monitoring, and rescue airway techniques.Post-DAAM airway placement must be confirmed and continually monitored with waveform capnography.EMS clinicians must have the necessary equipment and training to manage patients with failed DAAM, including bag mask ventilation, supraglottic airway devices and surgical airway approaches.Continuous quality improvement for DAAM must include assessment of individual and aggregate performance metrics. Where available for review, continuous physiologic recordings (vital signs, pulse oximetry, and capnography), audio and video recordings, and assessment of patient outcomes should be part of DAAM continuous quality improvement.
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Davis DP, Bosson N, Guyette FX, Wolfe A, Bobrow BJ, Olvera D, Walker RG, Levy M. Optimizing Physiology During Prehospital Airway Management: An NAEMSP Position Statement and Resource Document. PREHOSP EMERG CARE 2022; 26:72-79. [PMID: 35001819 DOI: 10.1080/10903127.2021.1992056] [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: 12/14/2022]
Abstract
Airway management is a critical component of resuscitation but also carries the potential to disrupt perfusion, oxygenation, and ventilation as a consequence of airway insertion efforts, the use of medications, and the conversion to positive-pressure ventilation. NAEMSP recommends:Airway management should be approached as an organized system of care, incorporating principles of teamwork and operational awareness.EMS clinicians should prevent or correct hypoxemia and hypotension prior to advanced airway insertion attempts.Continuous physiological monitoring must be used during airway management to guide the timing of, limit the duration of, and inform decision making during advanced airway insertion attempts.Initial and ongoing confirmation of advanced airway placement must be performed using waveform capnography. Airway devices must be secured using a reliable method.Perfusion, oxygenation, and ventilation should be optimized before, during, and after advanced airway insertion.To mitigate aspiration after advanced airway insertion, EMS clinicians should consider placing a patient in a semi-upright position.When appropriate, patients undergoing advanced airway placement should receive suitable pharmacologic anxiolysis, amnesia, and analgesia. In select cases, the use of neuromuscular blocking agents may be appropriate.
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Gaither JB, Spaite DW, Bobrow BJ, Keim SM, Barnhart BJ, Chikani V, Sherrill D, Denninghoff KR, Mullins T, Adelson PD, Rice AD, Viscusi C, Hu C. Effect of Implementing the Out-of-Hospital Traumatic Brain Injury Treatment Guidelines: The Excellence in Prehospital Injury Care for Children Study (EPIC4Kids). Ann Emerg Med 2021; 77:139-153. [PMID: 33187749 PMCID: PMC7855946 DOI: 10.1016/j.annemergmed.2020.09.435] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 08/28/2020] [Accepted: 09/14/2020] [Indexed: 11/30/2022]
Abstract
STUDY OBJECTIVE We evaluate the effect of implementing the out-of-hospital pediatric traumatic brain injury guidelines on outcomes in children with major traumatic brain injury. METHODS The Excellence in Prehospital Injury Care for Children study is the preplanned secondary analysis of the Excellence in Prehospital Injury Care study, a multisystem, intention-to-treat study using a before-after controlled design. This subanalysis included children younger than 18 years who were transported to Level I trauma centers by participating out-of-hospital agencies between January 1, 2007, and June 30, 2015, throughout Arizona. The primary and secondary outcomes were survival to hospital discharge or admission for children with major traumatic brain injury and in 3 subgroups, defined a priori as those with moderate, severe, and critical traumatic brain injury. Outcomes in the preimplementation and postimplementation cohorts were compared with logistic regression, adjusting for risk factors and confounders. RESULTS There were 2,801 subjects, 2,041 in preimplementation and 760 in postimplementation. The primary analysis (postimplementation versus preimplementation) yielded an adjusted odds ratio of 1.16 (95% confidence interval 0.70 to 1.92) for survival to hospital discharge and 2.41 (95% confidence interval 1.17 to 5.21) for survival to hospital admission. In the severe traumatic brain injury cohort (Regional Severity Score-Head 3 or 4), but not the moderate or critical subgroups, survival to discharge significantly improved after guideline implementation (adjusted odds ratio = 8.42; 95% confidence interval 1.01 to 100+). The improvement in survival to discharge among patients with severe traumatic brain injury who received positive-pressure ventilation did not reach significance (adjusted odds ratio = 9.13; 95% confidence interval 0.79 to 100+). CONCLUSION Implementation of the pediatric out-of-hospital traumatic brain injury guidelines was not associated with improved survival when the entire spectrum of severity was analyzed as a whole (moderate, severe, and critical). However, both adjusted survival to hospital admission and discharge improved in children with severe traumatic brain injury, indicating a potential severity-based interventional opportunity for guideline effectiveness. These findings support the widespread implementation of the out-of-hospital pediatric traumatic brain injury guidelines.
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Affiliation(s)
- Joshua B Gaither
- Arizona Emergency Medicine Research Center, College of Medicine-Phoenix, The University of Arizona, Phoenix, AZ; Department of Emergency Medicine, College of Medicine-Tucson, The University of Arizona, Tucson, AZ.
| | - Daniel W Spaite
- Arizona Emergency Medicine Research Center, College of Medicine-Phoenix, The University of Arizona, Phoenix, AZ; Department of Emergency Medicine, College of Medicine-Tucson, The University of Arizona, Tucson, AZ
| | - Bentley J Bobrow
- Department of Emergency Medicine, McGovern Medical School at UT Health, Houston, TX
| | - Samuel M Keim
- Arizona Emergency Medicine Research Center, College of Medicine-Phoenix, The University of Arizona, Phoenix, AZ; Department of Emergency Medicine, College of Medicine-Tucson, The University of Arizona, Tucson, AZ; Mel and Enid Zuckerman College of Public Health, The University of Arizona, Tucson, AZ
| | - Bruce J Barnhart
- Arizona Emergency Medicine Research Center, College of Medicine-Phoenix, The University of Arizona, Phoenix, AZ
| | - Vatsal Chikani
- Arizona Department of Health Services, Bureau of EMS, Phoenix, AZ
| | - Duane Sherrill
- Mel and Enid Zuckerman College of Public Health, The University of Arizona, Tucson, AZ
| | - Kurt R Denninghoff
- Arizona Emergency Medicine Research Center, College of Medicine-Phoenix, The University of Arizona, Phoenix, AZ; Department of Emergency Medicine, College of Medicine-Tucson, The University of Arizona, Tucson, AZ
| | - Terry Mullins
- Arizona Department of Health Services, Bureau of EMS, Phoenix, AZ
| | - P David Adelson
- Barrow Neurological Institute at Phoenix Children's Hospital and Department of Child Health/Neurosurgery, College of Medicine, The University of Arizona, Phoenix, AZ
| | - Amber D Rice
- Arizona Emergency Medicine Research Center, College of Medicine-Phoenix, The University of Arizona, Phoenix, AZ; Department of Emergency Medicine, College of Medicine-Tucson, The University of Arizona, Tucson, AZ
| | - Chad Viscusi
- Arizona Emergency Medicine Research Center, College of Medicine-Phoenix, The University of Arizona, Phoenix, AZ; Department of Emergency Medicine, College of Medicine-Tucson, The University of Arizona, Tucson, AZ
| | - Chengcheng Hu
- Arizona Emergency Medicine Research Center, College of Medicine-Phoenix, The University of Arizona, Phoenix, AZ; Mel and Enid Zuckerman College of Public Health, The University of Arizona, Tucson, AZ
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6
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Prehospital end-tidal carbon dioxide predicts massive transfusion and death following trauma. J Trauma Acute Care Surg 2020; 89:703-707. [PMID: 32590557 DOI: 10.1097/ta.0000000000002846] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The lack of an accurate marker of prehospital hemorrhagic shock limits our ability to triage patients to the correct level of care, delays treatment in the emergency department, and inhibits our ability to perform prehospital interventional research in trauma. End-tidal carbon dioxide (ETCO2) is the measurement of alveolar carbon dioxide concentration at end expiration and is measured noninvasively in the ventilator circuit for intubated patients in continuous manner. Several hospital-based studies have been able to demonstrate that either low or decreasing levels of ETCO2 as well as disparities between ETCO2 and plasma carbon dioxide correlate with increasing mortality in trauma. We hypothesized that prehospital ETCO2 values will be predictive of mortality and need for massive transfusion following injury. METHODS This is a single-center retrospective study from an urban level 1 trauma center. We reviewed all intubated adult patients transported for injury who had prehospital ETCO2 values available. Unadjusted comparisons of continuous variables were done with the Wilcoxon two-sample test. The predictive performance of prehospital ETCO2, the prehospital shock index, and prehospital systolic blood pressure were assessed and compared using areas under the receiver operating characteristic curves. Optimal cutoffs were estimated by maximizing the Youden index. Massive transfusion was defined as >10 U of blood or death in 24 hours. RESULTS A total of 173 patients were identified with prehospital ETCO2 values during the 2-year study period. Population was 78.5% male with a median age of 37.5 years (interquartile range, 23.5-53.5 years). Injury mechanism was penetrating in 22.8%. This cohort had a median Injury Severity Score of 26 (interquartile range, 17-36), massive transfusion rate of 34.7%, and mortality of 42.1%. In the evaluation of prediction of postinjury mortality and massive transfusion, ETCO2 outperformed systolic blood pressure and shock index, but these differences did not reach statistical significance. CONCLUSION End-tidal carbon dioxide is a novel prehospital predictor of mortality and massive transfusion after injury. LEVEL OF EVIDENCE Prognostic/Epidemiologic, level III.
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7
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Curry BW, Ward S, Lindsell CJ, Hart KW, McMullan JT. Mechanical Ventilation of Severe Traumatic Brain Injury Patients in the Prehospital Setting. Air Med J 2020; 39:410-413. [PMID: 33012481 DOI: 10.1016/j.amj.2020.04.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 04/20/2020] [Accepted: 04/29/2020] [Indexed: 01/22/2023]
Abstract
OBJECTIVE Suboptimal ventilation may impact outcomes in patients with traumatic brain injury (TBI). This study compares the incidence of eucapnia between manually and mechanically ventilated patients with severe TBI during helicopter transport. METHODS This retrospective chart review included consecutive intubated adults with severe TBI (Glasgow Coma Scale score < 9) transported by helicopter from the scene of injury to a level 1 trauma center between 2009 and 2015. The primary outcome was the first venous partial pressure of carbon dioxide obtained in the emergency department. Hypocapnia, eucapnia, and hypercapnia were defined based on the normal range for the testing instrument. The Fisher exact test was used to compare groups. RESULTS Of 1,070 trauma patients intubated and transported, 93 met the inclusion criteria with full data. The mean age was 43 years, 81 of 93 were white, and 70 of 93 were men. The mean Injury Severity Score was 29, and 26 of 93 were mechanically ventilated. Hypocapnia occurred in 4 of 93 and hypercapnia in 56 of 93. There was no difference in the rate of eucapnia in manually ventilated compared with mechanically ventilated patients (36% vs. 35%, P = 1.00). CONCLUSION Eucapnia at emergency department arrival occurred in 36% of patients and was unaffected by whether ventilation was manually or mechanically controlled. Few patients were hypocapnic, indicating a low incidence of hyperventilation during helicopter transport.
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Affiliation(s)
- Bentley Woods Curry
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH.
| | - Steven Ward
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Christopher J Lindsell
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Kimberly W Hart
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Jason T McMullan
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
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Rakhit S, Nordness MF, Lombardo SR, Cook M, Smith L, Patel MB. Management and Challenges of Severe Traumatic Brain Injury. Semin Respir Crit Care Med 2020; 42:127-144. [PMID: 32916746 DOI: 10.1055/s-0040-1716493] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Traumatic brain injury (TBI) is the leading cause of death and disability in trauma patients, and can be classified into mild, moderate, and severe by the Glasgow coma scale (GCS). Prehospital, initial emergency department, and subsequent intensive care unit (ICU) management of severe TBI should focus on avoiding secondary brain injury from hypotension and hypoxia, with appropriate reversal of anticoagulation and surgical evacuation of mass lesions as indicated. Utilizing principles based on the Monro-Kellie doctrine and cerebral perfusion pressure (CPP), a surrogate for cerebral blood flow (CBF) should be maintained by optimizing mean arterial pressure (MAP), through fluids and vasopressors, and/or decreasing intracranial pressure (ICP), through bedside maneuvers, sedation, hyperosmolar therapy, cerebrospinal fluid (CSF) drainage, and, in refractory cases, barbiturate coma or decompressive craniectomy (DC). While controversial, direct ICP monitoring, in conjunction with clinical examination and imaging as indicated, should help guide severe TBI therapy, although new modalities, such as brain tissue oxygen (PbtO2) monitoring, show great promise in providing strategies to optimize CBF. Optimization of the acute care of severe TBI should include recognition and treatment of paroxysmal sympathetic hyperactivity (PSH), early seizure prophylaxis, venous thromboembolism (VTE) prophylaxis, and nutrition optimization. Despite this, severe TBI remains a devastating injury and palliative care principles should be applied early. To better affect the challenging long-term outcomes of severe TBI, more and continued high quality research is required.
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Affiliation(s)
- Shayan Rakhit
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee.,Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mina F Nordness
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee.,Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sarah R Lombardo
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Madison Cook
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee.,Meharry Medical College, Nashville, Tennessee
| | - Laney Smith
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee.,Washington and Lee University, Lexington, Virginia
| | - Mayur B Patel
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee.,Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Neurosurgery and Hearing and Speech Sciences, Vanderbilt Brain Institute, Vanderbilt University Medical Center, Nashville, Tennessee.,Surgical Service, Nashville VA Medical Center, Tennessee Valley Healthcare System, US Department of Veterans Affairs, Nashville, Tennessee.,Geriatric Research, Education, and Clinical Center Service, Nashville VA Medical Center, Tennessee Valley Healthcare System, US Department of Veterans Affairs, Nashville, Tennessee
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Lentz S, Grossman A, Koyfman A, Long B. High-Risk Airway Management in the Emergency Department: Diseases and Approaches, Part II. J Emerg Med 2020; 59:573-585. [PMID: 32591298 DOI: 10.1016/j.jemermed.2020.05.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 04/30/2020] [Accepted: 05/04/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Successful airway management is critical to the practice of emergency medicine. Thus, emergency physicians must be ready to optimize and prepare for airway management in critically ill patients with a wide range of physiologic challenges. Challenges in airway management commonly encountered in the emergency department are discussed using a pearl and pitfall discussion in this second part of a 2-part series. OBJECTIVE This narrative review presents an evidence-based approach to airway and patient management during endotracheal intubation in challenging cases commonly encountered in the emergency department. DISCUSSION Adverse events during emergent airway management are common with postintubation cardiac arrest, reported in as many as 1 in 25 intubations. Many of these adverse events can be avoided by proper identification and understanding the underlying physiology, preparation, and postintubation management. Those with high-risk features including trauma, elevated intracranial pressure, upper gastrointestinal bleed, cardiac tamponade, aortic stenosis, morbid obesity, and pregnancy must be managed with airway expertise. CONCLUSIONS This narrative review discusses the pearls and pitfalls of commonly encountered physiologic high-risk intubations with a focus on the emergency clinician.
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Affiliation(s)
- Skyler Lentz
- Division of Emergency Medicine, Department of Surgery, Larner College of Medicine, University of Vermont, Burlington, Vermont
| | - Alexandra Grossman
- Department of Emergency Medicine, Harbor-University of California, Los Angeles Medical Center, Torrance, California
| | - Alex Koyfman
- Department of Emergency Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas
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10
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Spaite DW, Bobrow BJ, Keim SM, Barnhart B, Chikani V, Gaither JB, Sherrill D, Denninghoff KR, Mullins T, Adelson PD, Rice AD, Viscusi C, Hu C. Association of Statewide Implementation of the Prehospital Traumatic Brain Injury Treatment Guidelines With Patient Survival Following Traumatic Brain Injury: The Excellence in Prehospital Injury Care (EPIC) Study. JAMA Surg 2019; 154:e191152. [PMID: 31066879 PMCID: PMC6506902 DOI: 10.1001/jamasurg.2019.1152] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 03/03/2019] [Indexed: 12/27/2022]
Abstract
Importance Traumatic brain injury (TBI) is a massive public health problem. While evidence-based guidelines directing the prehospital treatment of TBI have been promulgated, to our knowledge, no studies have assessed their association with survival. Objective To evaluate the association of implementing the nationally vetted, evidence-based, prehospital treatment guidelines with outcomes in moderate, severe, and critical TBI. Design, Setting, and Participants The Excellence in Prehospital Injury Care (EPIC) Study included more than 130 emergency medical services systems/agencies throughout Arizona. This was a statewide, multisystem, intention-to-treat study using a before/after controlled design with patients with moderate to critically severe TBI (US Centers for Disease Control and Prevention Barell Matrix-Type 1 and/or Abbreviated Injury Scale Head region severity ≥3) transported to trauma centers between January 1, 2007, and June 30, 2015. Data were analyzed between October 25, 2017, and February 22, 2019. Interventions Implementation of the prehospital TBI guidelines emphasizing avoidance/treatment of hypoxia, prevention/correction of hyperventilation, and avoidance/treatment of hypotension. Main Outcomes and Measures Primary: survival to hospital discharge; secondary: survival to hospital admission. Results Of the included patients, the median age was 45 years, 14 666 (67.1%) were men, 7181 (32.9%) were women; 16 408 (75.1% ) were white, 1400 (6.4%) were Native American, 743 (3.4% ) were Black, 237 (1.1%) were Asian, and 2791 (12.8%) were other race/ethnicity. Of the included patients, 21 852 met inclusion criteria for analysis (preimplementation phase [P1]: 15 228; postimplementation [P3]: 6624). The primary analysis (P3 vs P1) revealed an adjusted odds ratio (aOR) of 1.06 (95% CI, 0.93-1.21; P = .40) for survival to hospital discharge. The aOR was 1.70 (95% CI, 1.38-2.09; P < .001) for survival to hospital admission. Among the severe injury cohorts (but not moderate or critical), guideline implementation was significantly associated with survival to discharge (Regional Severity Score-Head 3-4: aOR, 2.03; 95% CI, 1.52-2.72; P < .001; Injury Severity Score 16-24: aOR, 1.61; 95% CI, 1.07-2.48; P = .02). This was also true for survival to discharge among the severe, intubated subgroups (Regional Severity Score-Head 3-4: aOR, 3.14; 95% CI, 1.65-5.98; P < .001; Injury Severity Score 16-24: aOR, 3.28; 95% CI, 1.19-11.34; P = .02). Conclusions and Relevance Statewide implementation of the prehospital TBI guidelines was not associated with significant improvement in overall survival to hospital discharge (across the entire, combined moderate to critical injury spectrum). However, adjusted survival doubled among patients with severe TBI and tripled in the severe, intubated cohort. Furthermore, guideline implementation was significantly associated with survival to hospital admission. These findings support the widespread implementation of the prehospital TBI treatment guidelines. Trial Registration ClinicalTrials.gov identifier: NCT01339702.
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Affiliation(s)
- Daniel W. Spaite
- Arizona Emergency Medicine Research Center, College of Medicine, The University of Arizona, Phoenix
- Department of Emergency Medicine, College of Medicine, The University of Arizona, Tucson
| | - Bentley J. Bobrow
- Arizona Emergency Medicine Research Center, College of Medicine, The University of Arizona, Phoenix
- Department of Emergency Medicine, College of Medicine, The University of Arizona, Tucson
- Arizona Department of Health Services, Bureau of EMS, Phoenix, Arizona
| | - Samuel M. Keim
- Arizona Emergency Medicine Research Center, College of Medicine, The University of Arizona, Phoenix
- Department of Emergency Medicine, College of Medicine, The University of Arizona, Tucson
- Mel and Enid Zuckerman College of Public Health, The University of Arizona, Tucson
| | - Bruce Barnhart
- Arizona Emergency Medicine Research Center, College of Medicine, The University of Arizona, Phoenix
| | - Vatsal Chikani
- Arizona Department of Health Services, Bureau of EMS, Phoenix, Arizona
| | - Joshua B. Gaither
- Arizona Emergency Medicine Research Center, College of Medicine, The University of Arizona, Phoenix
- Department of Emergency Medicine, College of Medicine, The University of Arizona, Tucson
| | - Duane Sherrill
- Mel and Enid Zuckerman College of Public Health, The University of Arizona, Tucson
| | - Kurt R. Denninghoff
- Arizona Emergency Medicine Research Center, College of Medicine, The University of Arizona, Phoenix
- Department of Emergency Medicine, College of Medicine, The University of Arizona, Tucson
| | - Terry Mullins
- Arizona Department of Health Services, Bureau of EMS, Phoenix, Arizona
| | - P. David Adelson
- Barrow Neurological Institute at Phoenix Children’s Hospital, Department of Child Health/Neurosurgery, College of Medicine, The University of Arizona, Phoenix
| | - Amber D. Rice
- Arizona Emergency Medicine Research Center, College of Medicine, The University of Arizona, Phoenix
- Department of Emergency Medicine, College of Medicine, The University of Arizona, Tucson
| | - Chad Viscusi
- Arizona Emergency Medicine Research Center, College of Medicine, The University of Arizona, Phoenix
- Department of Emergency Medicine, College of Medicine, The University of Arizona, Tucson
| | - Chengcheng Hu
- Arizona Emergency Medicine Research Center, College of Medicine, The University of Arizona, Phoenix
- Mel and Enid Zuckerman College of Public Health, The University of Arizona, Tucson
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McLachlan B, Bilbrey C, Mausner K, Lenz TJ. Effectiveness of Manual Ventilation in Intubated Helicopter Emergency Services-Transported Trauma Patients. Air Med J 2019; 38:273-275. [PMID: 31248536 DOI: 10.1016/j.amj.2019.03.013] [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: 11/24/2018] [Revised: 03/01/2019] [Accepted: 03/27/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND Helicopter Emergency Medical Services agencies frequently transport intubated patients to definitive care. No evidence exists to determine the type of ventilation in this population. Practice varies amongst programs from bag-valve-mask to mechanical ventilation. STUDY OBJECTIVE Evaluate the effectiveness of bag-valve ventilation in intubated trauma patients. We hypothesized manual ventilation provides adequate support to maintain physiologic ETCO2. METHODS From June to December 2015, twenty patients were enrolled in this prospective, observational study. Included were endotracheally intubated trauma patients transported by this HEMS program. Excluded were interfacility transports, non-scene calls, and patients with supraglottic devices. ETCO2 was recorded every 30 seconds during the flight. As a descriptive pilot study, power was not considered. RESULTS 20 patients provided over 500 cumulative minutes of manual ventilation data. The percentage of cumulative time spent with adequate oxygen saturations was 83.6%. The percentage of cumulative time spent with adequate ETCO2 was 48.7%, with 34.6% of time spent under and 16.7% above this range. CONCLUSION Manual ventilation maintained a physiologic ETCO2 only 16.7% of the time. Significant variability existed, resulting in intermittent hypoxia and hyperventilation. Prior research linked such events to increased morbidity and mortality. Further studies are warranted to compare manual against mechanically ventilated patients.
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Affiliation(s)
- Brett McLachlan
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Craig Bilbrey
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Keith Mausner
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Timothy J Lenz
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI.
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Abstract
Airway management and ventilation are central to the resuscitation of the neurologically ill. These patients often have evolving processes that threaten the airway and adequate ventilation. Furthermore, intubation, ventilation, and sedative choices directly affect brain perfusion. Therefore, Airway, Ventilation, and Sedation was chosen as an Emergency Neurological Life Support protocol. Topics include airway management, when and how to intubate with special attention to hemodynamics and preservation of cerebral blood flow, mechanical ventilation settings and the use of sedative agents based on the patient's neurological status.
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Fouche PF, Stein C, Simpson P, Carlson JN, Zverinova KM, Doi SA. Flight Versus Ground Out-of-hospital Rapid Sequence Intubation Success: a Systematic Review and Meta-analysis. PREHOSP EMERG CARE 2018; 22:578-587. [PMID: 29377753 DOI: 10.1080/10903127.2017.1423139] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Endotracheal intubation (ETI) is a critical procedure performed by both air medical and ground based emergency medical services (EMS). Previous work has suggested that ETI success rates are greater for air medical providers. However, air medical providers may have greater airway experience, enhanced airway education, and access to alternative ETI options such as rapid sequence intubation (RSI). We sought to analyze the impact of the type of EMS on RSI success. METHODS A systematic literature search of Medline, Embase, and the Cochrane Library was conducted and eligibility, data extraction, and assessment of risk of bias were assessed independently by two reviewers. A bias-adjusted meta-analysis using a quality-effects model was conducted for the primary outcomes of overall intubation success and first-pass intubation success. RESULTS Forty-nine studies were included in the meta-analysis. There was no difference in the overall success between flight and ground based EMS; 97% (95% CI 96-98) vs. 98% (95% CI 91-100), and no difference in first-pass success for flight compared to ground based RSI; 82% (95% CI 73-89) vs. 82% (95% CI 70-93). Compared to flight non-physicians, flight physicians have higher overall success 99% (95% CI 98-100) vs. 96% (95% CI 94-97) and first-pass success 89% (95% CI 77-98) vs. 71% (95% CI 57-84). Ground-based physicians and non-physicians have a similar overall success 98% (95% CI 88-100) vs. 98% (95% CI 95-100), but no analysis for physician ground first pass was possible. CONCLUSIONS Both overall and first-pass success of RSI did not differ between flight and road based EMS. Flight physicians have a higher overall and first-pass success compared to flight non-physicians and all ground based EMS, but no such differences are seen for ground EMS. Our results suggest that ground EMS can use RSI with similar outcomes compared to their flight counterparts.
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Capnography Use During Intubation and Cardiopulmonary Resuscitation in the Pediatric Emergency Department. Pediatr Emerg Care 2017; 33:457-461. [PMID: 27455341 PMCID: PMC5259553 DOI: 10.1097/pec.0000000000000813] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Capnography is indicated as a guide to assess and monitor both endotracheal intubation and cardiopulmonary resuscitation (CPR). Our primary objective was to determine the effect of the 2010 American Heart Association (AHA) guidelines on the frequency of capnography use during critical events in children in the emergency department (ED). Our secondary objective was to examine associations between patient characteristics and capnography use among these patients. METHODS A retrospective chart review was performed on children aged 0 to 21 years who were intubated or received CPR in 2 academic children's hospital EDs between January 2009 and December 2012. Age, sex, time of arrival, medical or traumatic cause, length of CPR, return of spontaneous circulation (ROSC), documented use of capnography and colorimetry, capnography values, and adverse events were recorded. RESULTS Two hundred ninety-two patients were identified and analyzed. Intubation occurred in 95% of cases and CPR in 30% of cases. Capnography was documented in only 38% of intubated patients and 13% of patients requiring CPR. There was an overall decrease in capnography use after publication of the 2010 AHA recommendations (P = 0.05). Capnography use was associated with a longer duration of CPR and return of spontaneous circulation. CONCLUSIONS Despite the 2010 AHA recommendations, a minority of critically ill children are being monitored with capnography and an unexpected decrease in documented use occurred among our sample. Further education and implementation of capnography should take place to improve the use of this monitoring device for critically ill pediatric patients in the ED.
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Gaither JB, Chikani V, Stolz U, Viscusi C, Denninghoff K, Barnhart B, Mullins T, Rice AD, Mhayamaguru M, Smith JJ, Keim SM, Bobrow BJ, Spaite DW. Body Temperature after EMS Transport: Association with Traumatic Brain Injury Outcomes. PREHOSP EMERG CARE 2017; 21:575-582. [PMID: 28481163 DOI: 10.1080/10903127.2017.1308609] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Low body temperatures following prehospital transport are associated with poor outcomes in patients with traumatic brain injury (TBI). However, a minimal amount is known about potential associations across a range of temperatures obtained immediately after prehospital transport. Furthermore, a minimal amount is known about the influence of body temperature on non-mortality outcomes. The purpose of this study was to assess the correlation between temperatures obtained immediately following prehospital transport and TBI outcomes across the entire range of temperatures. METHODS This retrospective observational study included all moderate/severe TBI cases (CDC Barell Matrix Type 1) in the pre-implementation cohort of the Excellence in Prehospital Injury Care (EPIC) TBI Study (NIH/NINDS: 1R01NS071049). Cases were compared across four cohorts of initial trauma center temperature (ITCT): <35.0°C [Very Low Temperature (VLT)]; 35.0-35.9°C [Low Temperature (LT)]; 36.0-37.9°C [Normal Temperature (NT)]; and ≥38.0°C [Elevated Temperature (ET)]. Multivariable analysis was performed adjusting for injury severity score, age, sex, race, ethnicity, blunt/penetrating trauma, and payment source. Adjusted odds ratios (aORs) with 95% confidence intervals (CI) for mortality were calculated. To evaluate non-mortality outcomes, deaths were excluded and the adjusted median increase in hospital length of stay (LOS), ICU LOS and total hospital charges were calculated for each ITCT group and compared to the NT group. RESULTS 22,925 cases were identified and cases with interfacility transfer (7361, 32%), no EMS transport (1213, 5%), missing ITCT (2083, 9%), or missing demographic data (391, 2%) were excluded. Within this study cohort the aORs for death (compared to the NT group) were 2.41 (CI: 1.83-3.17) for VLT, 1.62 (CI: 1.37-1.93) for LT, and 1.86 (CI: 1.52-3.00) for ET. Similarly, trauma center (TC) LOS, ICU LOS, and total TC charges increased in all temperature groups when compared to NT. CONCLUSION In this large, statewide study of major TBI, both ETs and LTs immediately following prehospital transport were independently associated with higher mortality and with increased TC LOS, ICU LOS, and total TC charges. Further study is needed to identify the causes of abnormal body temperature during the prehospital interval and if in-field measures to prevent temperature variations might improve outcomes.
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Abstract
Airway management and ventilation are central to the resuscitation of the neurologically ill. These patients often have evolving processes that threaten the airway and adequate ventilation. Furthermore, intubation, ventilation, and sedative choices directly affect brain perfusion. Therefore, airway, ventilation, and sedation was chosen as an emergency neurological life support protocol. Topics include airway management, when and how to intubate with special attention to hemodynamics and preservation of cerebral blood flow, mechanical ventilation settings, and the use of sedative agents based on the patient's neurological status.
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Abstract
Maintenance of adequate oxygenation is a mainstay of intensive care, however, recommendations on the safety, accuracy, and the potential clinical utility of invasive and non-invasive tools to monitor brain and systemic oxygenation in neurocritical care are lacking. A literature search was conducted for English language articles describing bedside brain and systemic oxygen monitoring in neurocritical care patients from 1980 to August 2013. Imaging techniques e.g., PET are not considered. A total of 281 studies were included, the majority described patients with traumatic brain injury (TBI). All tools for oxygen monitoring are safe. Parenchymal brain oxygen (PbtO2) monitoring is accurate to detect brain hypoxia, and it is recommended to titrate individual targets of cerebral perfusion pressure (CPP), ventilator parameters (PaCO2, PaO2), and transfusion, and to manage intracranial hypertension, in combination with ICP monitoring. SjvO2 is less accurate than PbtO2. Given limited data, NIRS is not recommended at present for adult patients who require neurocritical care. Systemic monitoring of oxygen (PaO2, SaO2, SpO2) and CO2 (PaCO2, end-tidal CO2) is recommended in patients who require neurocritical care.
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Freeman JF, Ciarallo C, Rappaport L, Mandt M, Bajaj L. Use of capnographs to assess quality of pediatric ventilation with 3 different airway modalities. Am J Emerg Med 2015; 34:69-74. [PMID: 26508582 DOI: 10.1016/j.ajem.2015.09.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Accepted: 09/17/2015] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES Prehospital pediatric airway management is difficult and controversial. Options include bag-mask ventilation (BMV), endotracheal tube (ETT), and laryngeal mask airway (LMA). Emergency Medical Services personnel report difficulty assessing adequacy of BMV during transport. Capnography, and capnograph tracings in particular, provide a measure of real-time ventilation currently used in prehospital medicine but have not been well studied in pediatric patients or with BMV. Our objective was to compare pediatric capnographs created with 3 airway modalities. METHODS This was a prospective study of pediatric patients requiring ETT or LMA ventilation during elective surgical procedures. Data were collected during BMV using 2 bag types (flow-inflating and self-inflating). The ETT or LMA was placed and ventilation with each bag type repeated. Ten- to 14-second capnographs were reviewed by 2 blinded anesthesiologists who were asked to assess ventilation and identify the airway and bag type used. Descriptive statistics, κ, and risk ratios were calculated. RESULTS Twenty-nine patients were enrolled. Median age was 4.4 years (2 months to 16.8 years). One hundred sixteen capnographs were reviewed. Reviewers were unable to differentiate between airway modalities and agreed on adequacy of ventilation 77% of the time (κ = 0.6, P < .001). Bag-mask ventilation was rated inadequate more frequently than ETT or LMA ventilation. There were no difference between ETT and LMA ventilation and no difference between the 2 bag types. CONCLUSION Capnographs are generated during BMV and are virtually identical to those produced with ETT or LMA ventilation. Attention to capnographs could improve outcomes during emergency treatment and transport of critically ill pediatric patients requiring ventilation with any of these airway modalities.
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Affiliation(s)
- Julia Fuzak Freeman
- University of Colorado Denver, Department of Pediatrics, Section of Emergency Medicine, Children's Hospital Colorado, Aurora, CO.
| | - Christopher Ciarallo
- University of Colorado Denver, Department of Anesthesiology, Children's Hospital Colorado, Aurora, CO
| | - Lara Rappaport
- Denver Health Medical Center, Department of Emergency Medicine, Denver, CO
| | - Maria Mandt
- University of Colorado Denver, Department of Pediatrics, Section of Emergency Medicine, Children's Hospital Colorado, Aurora, CO
| | - Lalit Bajaj
- University of Colorado Denver, Department of Pediatrics, Section of Emergency Medicine, Children's Hospital Colorado, Aurora, CO
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Anaesthesiologist-provided prehospital airway management in patients with traumatic brain injury: an observational study. Eur J Emerg Med 2015; 21:418-23. [PMID: 24368407 PMCID: PMC4212878 DOI: 10.1097/mej.0000000000000103] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Background Guidelines recommend that patients with brain trauma with a Glasgow Coma Scale (GCS) score of less than 9 should have an airway established. Hypoxia, hypotension and hypertension as well as hypoventilation and hyperventilation may worsen outcome in these patients. Objectives The objectives were to investigate guideline adherence, reasons for nonadherence and the incidences of complications related to prehospital advanced airway management in patients with traumatic brain injury. Materials and methods We prospectively collected data from eight anaesthesiologist-staffed prehospital critical care teams in the Central Denmark Region according to the Utstein-style template. Results Among 1081 consecutive prehospital advanced airway management patients, we identified 54 with a traumatic brain injury and an initial GCS score of less than 9. Guideline adherence in terms of airway management was 92.6%. The reasons for nonadherence were the patient’s condition, anticipated difficult airway management and short distance to the emergency department. Following rapid sequence intubation (RSI), 11.4% developed oxygen saturation below 90%, 9.1% had a first post-RSI systolic blood pressure below 90 mmHg and 48.9% had a first post-RSI systolic blood pressure below 120 mmHg. The incidence of hypertension following prehospital RSI was 4.5%. The incidence of postendotracheal intubation hyperventilation was as high as 71.1%. Conclusion The guideline adherence was high. The incidences of post-RSI hypoxia and systolic blood pressure below 90 compare with the results reported from other physician-staffed prehospital services. The incidence of systolic blood pressure below 120 as well as that of hyperventilation following prehospital endotracheal intubation in patients with traumatic brain injury call for a change in our current practice.
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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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Goldberg SA, Rojanasarntikul D, Jagoda A. The prehospital management of traumatic brain injury. HANDBOOK OF CLINICAL NEUROLOGY 2015; 127:367-78. [PMID: 25702228 DOI: 10.1016/b978-0-444-52892-6.00023-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Traumatic brain injury (TBI) is an important cause of death and disability, particularly in younger populations. The prehospital evaluation and management of TBI is a vital link between insult and definitive care and can have dramatic implications for subsequent morbidity. Following a TBI the brain is at high risk for further ischemic injury, with prehospital interventions targeted at reducing this secondary injury while optimizing cerebral physiology. In the following chapter we discuss the prehospital assessment and management of the brain-injured patient. The initial evaluation and physical examination are discussed with a focus on interpretation of specific physical examination findings and interpretation of vital signs. We evaluate patient management strategies including indications for advanced airway management, oxygenation, ventilation, and fluid resuscitation, as well as prehospital strategies for the management of suspected or impending cerebral herniation including hyperventilation and brain-directed hyperosmolar therapy. Transport decisions including the role of triage models and trauma centers are discussed. Finally, future directions in the prehospital management of traumatic brain injury are explored.
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Affiliation(s)
- Scott A Goldberg
- Department of Emergency Medicine, Brigham & Women's Hospital, Boston, MA, USA
| | - Dhanadol Rojanasarntikul
- Department of Emergency Medicine, Mount Sinai School of Medicine, New York, NY, USA; Chulalongkorn University, Bangkok, Thailand
| | - Andrew Jagoda
- Department of Emergency Medicine, Mount Sinai School of Medicine, New York, NY, USA; Brain Trauma Foundation, New York, NY, USA.
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Kou K, Hou XY, Sun JD, Chu K. Current pre-hospital traumatic brain injury management in China. World J Emerg Med 2014; 5:245-54. [PMID: 25548596 DOI: 10.5847/wjem.j.issn.1920-8642.2014.04.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Accepted: 10/28/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Traumatic brain injury (TBI) is associated with most trauma-related deaths. Secondary brain injury is the leading cause of in-hospital deaths after traumatic brain injury. By early prevention and slowing of the initial pathophysiological mechanism of secondary brain injury, pre-hospital service can significantly reduce case-fatality rates of TBI. In China, the incidence of TBI is increasing and the proportion of severe TBI is much higher than that in other countries. The objective of this paper is to review the pre-hospital management of TBI in China. DATA SOURCES A literature search was conducted in January 2014 using the China National Knowledge Infrastructure (CNKI). Articles on the assessment and treatment of TBI in pre-hospital settings practiced by Chinese doctors were identified. The information on the assessment and treatment of hypoxemia, hypotension, and brain herniation was extracted from the identified articles. RESULTS Of the 471 articles identified, 65 met the selection criteria. The existing literature indicated that current practices of pre-hospital TBI management in China were sub-optimal and varied considerably across different regions. CONCLUSION Since pre-hospital care is the weakest part of Chinese emergency care, appropriate training programs on pre-hospital TBI management are urgently needed in China.
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Affiliation(s)
- Kou Kou
- School of Public Health and Social Work & Institute Health and Biomedical Innovation, Queensland University of Technology, Brisbane, QLD 4059, Australia
| | - Xiang-Yu Hou
- School of Public Health and Social Work & Institute Health and Biomedical Innovation, Queensland University of Technology, Brisbane, QLD 4059, Australia
| | - Jian-Dong Sun
- School of Public Health and Social Work & Institute Health and Biomedical Innovation, Queensland University of Technology, Brisbane, QLD 4059, Australia
| | - Kevin Chu
- Royal Brisbane and Women's Hospital Metro North Hospital and Health Service, Butterfield Street Herston QLD 4029, Australia
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Spaite DW, Bobrow BJ, Stolz U, Sherrill D, Chikani V, Barnhart B, Sotelo M, Gaither JB, Viscusi C, Adelson PD, Denninghoff KR. Evaluation of the impact of implementing the emergency medical services traumatic brain injury guidelines in Arizona: the Excellence in Prehospital Injury Care (EPIC) study methodology. Acad Emerg Med 2014; 21:818-30. [PMID: 25112451 PMCID: PMC4134700 DOI: 10.1111/acem.12411] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2013] [Revised: 02/18/2014] [Accepted: 02/28/2014] [Indexed: 11/28/2022]
Abstract
Traumatic brain injury (TBI) exacts a great toll on society. Fortunately, there is growing evidence that the management of TBI in the early minutes after injury may significantly reduce morbidity and mortality. In response, evidence-based prehospital and in-hospital TBI treatment guidelines have been established by authoritative bodies. However, no large studies have yet evaluated the effectiveness of implementing these guidelines in the prehospital setting. This article describes the background, design, implementation, emergency medical services (EMS) treatment protocols, and statistical analysis of a prospective, controlled (before/after), statewide study designed to evaluate the effect of implementing the EMS TBI guidelines-the Excellence in Prehospital Injury Care (EPIC) study (NIH/NINDS R01NS071049, "EPIC"; and 3R01NS071049-S1, "EPIC4Kids"). The specific aim of the study is to test the hypothesis that statewide implementation of the international adult and pediatric EMS TBI guidelines will significantly reduce mortality and improve nonmortality outcomes in patients with moderate or severe TBI. Furthermore, it will specifically evaluate the effect of guideline implementation on outcomes in the subgroup of patients who are intubated in the field. Over the course of the entire study (~9 years), it is estimated that approximately 25,000 patients will be enrolled.
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Affiliation(s)
- Daniel W Spaite
- The Arizona Emergency Medicine Research Center, College of Medicine, The University of Arizona, Tucson, AZ; The Department of Emergency Medicine, College of Medicine, The University of Arizona, Tucson, AZ
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Doğan NÖ, Şener A, Günaydın GP, İçme F, Çelik GK, Kavaklı HŞ, Temrel TA. The accuracy of mainstream end-tidal carbon dioxide levels to predict the severity of chronic obstructive pulmonary disease exacerbations presented to the ED. Am J Emerg Med 2014; 32:408-11. [DOI: 10.1016/j.ajem.2014.01.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2013] [Revised: 12/30/2013] [Accepted: 01/05/2014] [Indexed: 10/25/2022] Open
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Seder DB, Riker RR, Jagoda A, Smith WS, Weingart SD. Emergency neurological life support: airway, ventilation, and sedation. Neurocrit Care 2013; 17 Suppl 1:S4-20. [PMID: 22972019 DOI: 10.1007/s12028-012-9753-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Airway management is central to the resuscitation of the neurologically ill. These patients often have evolving processes that threaten the airway and adequate ventilation. Therefore, airway, ventilation, and sedation were chosen as an Emergency Neurological Life Support (ENLS) protocol. Reviewed topics include airway management; the decision to intubate; when and how to intubate with attention to cardiovascular status; mechanical ventilation settings; and the use of sedation, including how to select sedative agents based on the patient's neurological status.
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Affiliation(s)
- David B Seder
- Department of Critical Care Services, Maine Medical Center, Tufts University School of Medicine, Boston, MA, USA.
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Balancing the Potential Risks and Benefits of Out-of-Hospital Intubation in Traumatic Brain Injury: The Intubation/Hyperventilation Effect. Ann Emerg Med 2012; 60:732-6. [DOI: 10.1016/j.annemergmed.2012.06.017] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2011] [Revised: 06/11/2012] [Accepted: 06/25/2012] [Indexed: 11/20/2022]
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Yeh DD, Velmahos GC. Prehospital intubation for traumatic brain injury: do it correctly, or not at all. ANZ J Surg 2012; 82:484-5. [DOI: 10.1111/j.1445-2197.2012.06130.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Holmes J, Peng J, Bair A. Abnormal end-tidal carbon dioxide levels on emergency department arrival in adult and pediatric intubated patients. PREHOSP EMERG CARE 2012; 16:210-6. [PMID: 22217189 DOI: 10.3109/10903127.2011.640416] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND The utility of prehospital intubation is controversial, as uncontrolled studies in trauma patients suggest adverse outcomes with prehospital intubation, perhaps secondary to inappropriate ventilation once intubation is accomplished. OBJECTIVES The objectives were 1) to establish, immediately upon arrival to the emergency department (ED), the prevalence of abnormal end-tidal carbon dioxide (ETCO(2)) levels in patients with prehospital intubation and 2) to describe the relationship between abnormal ETCO(2) levels on ED arrival and mortality. METHODS This was a prospective, observational cohort study of patients with prehospital intubation. Patients were excluded if they underwent prehospital cardiopulmonary resuscitation (CPR). On ED arrival, the initial ETCO(2) measurement from the patient's endotracheal tube was immediately obtained prior to purposeful intervention in the patient's ventilation by using an Oridion Surestream Sure VentLine H Set with a Welch Allyn Propaq CS monitor. For each patient, the treating physician documented the ETCO(2) measurement, patient demographics, and details of the transport. The primary outcome was an abnormal ETCO(2) value (<30 mmHg or >45 mmHg). The secondary outcome was mortality. RESULTS One hundred eligible patients were enrolled, with a median age of 30 years (interquartile range [IQR] 15, 48 years). Esophageal intubations were identified in four cases, and those cases were excluded from further analysis. Mechanisms included trauma, 74; medical, 12; and burn, 10. The median ETCO(2) value was 32 mmHg (IQR 27, 38 mmHg), range 18-80 mmHg. Forty-six of 96 (48%, 95% confidence interval [CI] 38%, 58%) patients had abnormal ETCO(2) values, including 37 (39%, 95% CI 29%, 49%) with low ETCO(2) levels and nine (9%, 95% CI 4%, 17%) with high ETCO(2) levels. Death was higher in those trauma patients with abnormal ETCO(2) levels (10/33, 30%, 95% CI 16%, 49%) than in those with normal ETCO(2) levels (2/41, 5%, 95% CI 0.6%, 17%), relative risk = 6.2 (95% CI 1.5, 26.4), p = 0.004. CONCLUSION Nearly half of all patients transported by prehospital providers had abnormal ETCO(2) measurements on initial ED presentation, suggesting an area for potential improvement. Trauma patients with abnormal initial ETCO(2) levels were more likely to die.
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Affiliation(s)
- James Holmes
- Department of Emergency Medicine, UC Davis School of Medicine, Sacramento, California 95817, USA.
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Davis DP, Davis PW. A structural model of perfusion and oxygenation in low-flow states. Resuscitation 2011; 82:1444-52. [DOI: 10.1016/j.resuscitation.2011.05.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2011] [Revised: 05/11/2011] [Accepted: 05/18/2011] [Indexed: 10/18/2022]
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Davis DP, Koprowicz KM, Newgard CD, Daya M, Bulger EM, Stiell I, Nichol G, Stephens S, Dreyer J, Minei J, Kerby JD. The relationship between out-of-hospital airway management and outcome among trauma patients with Glasgow Coma Scale Scores of 8 or less. PREHOSP EMERG CARE 2011; 15:184-92. [PMID: 21309705 PMCID: PMC4091894 DOI: 10.3109/10903127.2010.545473] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Airway management remains a fundamental component of optimal care of the severely injured patient, with endotracheal intubation representing the definitive strategy for airway control. However, multiple studies document an association between out-of-hospital intubation and increased mortality for severe traumatic brain injury. OBJECTIVES To explore the relationship between out-of-hospital intubation attempts and outcome among trauma patients with Glasgow Coma Scale (GCS) scores ≤ 8 across sites participating in the Resuscitation Outcomes Consortium (ROC). METHODS The ROC Epistry-Trauma, an epidemiologic database of prehospital encounters with critically injured trauma victims, was used to identify emergency medical services (EMS)-treated patients with GCS scores ≤ 8. Multiple logistic regression was used to explore the association between intubation attempts and vital status at discharge, adjusting for the following covariates: age, gender, GCS score, hypotension, mechanism of injury, and ROC site. Sites were then stratified by frequency of intubation attempts and chi-square test for trend was used to associate the frequency of intubation attempts with outcome. RESULTS A total of 1,555 patients were included in this analysis; intubation was attempted in 758 of these. Patients in whom intubation was attempted had higher mortality (adjusted odds ratio [OR] 2.91, 95% confidence interval [CI] 2.13-3.98, p < 0.01). However, sites with higher rates of attempted intubation had lower mortality across all trauma victims with GCS scores ≤ 8 (OR 1.40, 95% CI 1.15-1.72, p < 0.01). CONCLUSIONS Patients in whom intubation is attempted have higher adjusted mortality. However, sites with a higher rate of attempted intubation have lower adjusted mortality across the entire cohort of trauma patients with GCS scores ≤ 8. Coma Scale score.
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Affiliation(s)
- Daniel P Davis
- Department of Emergency Medicine, UCSD Center for Resuscitation Science, San Diego, California 92103-8676, USA.
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Abstract
Prehospital trauma care developed over the last decades parallel in many countries. Most of the prehospital emergency medical systems relied on input or experiences from military medicine and were often modeled after the existing military procedures. Some systems were initially developed with the trauma patient in mind, while other systems were tailored for medical, especially cardiovascular, emergencies. The key components to successful prehospital trauma care are the well-known ABCs of trauma care: Airway, Breathing, Circulation. Establishing and securing the airway, ventilation, fluid resuscitation, and in addition, the quick transport to the best-suited trauma center represent the pillars of trauma care in the field. While ABC in trauma care has neither been challenged nor changed, new techniques, tools and procedures have been developed to make it easier for the prehospital provider to achieve these goals in the prehospital setting and thus improve the outcome of trauma patients.
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Affiliation(s)
- Kelvin Williamson
- Department of Anesthesiology and Pain Medicine, University of Washington/Harborview Medical Center, #359724, 325 Ninth Avenue, Seattle, WA 98104, USA
| | - Ramaiah Ramesh
- Department of Anesthesiology and Pain Medicine, University of Washington/Harborview Medical Center, #359724, 325 Ninth Avenue, Seattle, WA 98104, USA
| | - Andreas Grabinsky
- Department of Emergency and Trauma Anesthesia, University of Washington/Harborview Medical Center, #359724, 325 Ninth Avenue, Seattle, WA 98104, USA
- Department of King County Medic One, University of Washington/Harborview Medical Center, #359724, 325 Ninth Avenue, Seattle, WA 98104, USA
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Comparison of different methods (paCO2, petCO2, ptcCO2) to determine carbon dioxide partial pressure (pCO2) in mechanically ventilated patients from an intensive care unit. Resuscitation 2010. [DOI: 10.1016/j.resuscitation.2010.09.234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Abstract
PURPOSE OF REVIEW Recently, notable progress has been made in the field of anesthesia drugs and airway management. RECENT FINDINGS Anesthesia in prehospital emergencies and in the emergency department is reviewed and guidelines are discussed. SUMMARY Preoxygenation should be performed with high-flow oxygen delivered through a tight-fitting face mask with a reservoir. Ketamine may be the induction agent of choice in hemodynamically unstable patients. The rocuronium antagonist sugammadex may have the potential to make rocuronium a first-line neuromuscular blocking agent in emergency induction. Experienced healthcare providers may consider prehospital anesthesia induction. Moderately experienced healthcare providers should optimize oxygenation, hasten hospital transfer and only try to intubate a patient whose life is threatened. When intubation fails twice, ventilation should be performed with an alternative supraglottic airway or a bag-valve-mask device. Lesser experienced healthcare providers should completely refrain from intubation, optimize oxygenation, hasten hospital transfer and ventilate patients only in life-threatening circumstances with a supraglottic airway or a bag-valve-mask device. Senior help should be sought early. In a 'cannot ventilate-cannot intubate' situation, a supraglottic airway should be employed and, if ventilation is still unsuccessful, a surgical airway should be performed. Capnography should be used in every ventilated patient. Clinical practice is essential to retain anesthesia and airway management skills.
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Concordance between capnography and capnia in adults admitted for acute dyspnea in an ED. Am J Emerg Med 2010; 28:711-4. [PMID: 20637388 DOI: 10.1016/j.ajem.2009.04.028] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2009] [Accepted: 04/16/2009] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND End-tidal carbon dioxide pressure (etCO(2)) is widely used in anaesthesia and critical care in intubated patients. The aim of our preliminary study was to evaluate the feasibility of a simple device to predict capnia in spontaneously breathing patients in an emergency department (ED). PATIENTS AND METHODS This study was a prospective, nonblind study performed in our teaching hospital ED. We included nonintubated patients with dyspnea (> or =18 years) requiring measurement of arterial blood gases, as ordered by the emergency physician in charge. There were no exclusion criteria. End-tidal CO(2) was measured by an easy-to-use device connected to a microstream capnometer, which gave a continuous measurement and graphical display of the etCO(2) level of a patient's exhaled breath. RESULTS A total of 43 patients (48 measurements) were included, and the majority had pneumonia (n = 12), acute cardiac failure (n = 8), asthma (n = 7), or chronic obstructive pulmonary disease exacerbation (n = 6). Using simple linear regression, the correlation between etCO(2) and Paco(2) was good (R = 0.82). However, 18 measurements (38%) had a difference between etCO(2) and Paco(2) of 10 mm Hg or more. The mean difference between the Paco(2) and etCO(2) levels was 8 mm Hg. Using the Bland and Altman matrix, the limits of agreement were -10 to +26 mm Hg. CONCLUSION In our preliminary study, etCO(2) using a microstream method does not seem to accurately predict Paco(2) in patients presenting to an ED for acute dyspnea.
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Paal P, Herff H, Mitterlechner T, von Goedecke A, Brugger H, Lindner KH, Wenzel V. Anaesthesia in prehospital emergencies and in the emergency room. Resuscitation 2010; 81:148-54. [PMID: 19942337 DOI: 10.1016/j.resuscitation.2009.10.023] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2009] [Revised: 10/05/2009] [Accepted: 10/24/2009] [Indexed: 12/23/2022]
Abstract
AIMS To review anaesthesia in prehospital emergencies and in the emergency room, and to discuss guidelines for anaesthesia indication; pre-oxygenation; anaesthesia induction and drugs; airway management; anaesthesia maintenance and monitoring; side effects and training. METHODS A literature search in the PubMed database was performed and 87 articles were included in this non-systematic review. CONCLUSIONS For pre-oxygenation, high-flow oxygen should be delivered with a tight-fitting face-mask provided with a reservoir. In haemodynamically unstable patients, ketamine may be the induction agent of choice. The rocuronium antagonist sugammadex may have the potential to make rocuronium a first-line neuromuscular blocking agent in emergency induction. An experienced health-care provider may consider prehospital anaesthesia induction. A moderately experienced health-care provider should optimise oxygenation, fasten hospital transfer and only try to intubate a patient in extremis. If intubation fails twice, ventilation should be resumed with an alternative supra-glottic airway or a bag-valve-mask device. A lesser experienced health-care provider should completely refrain from intubation, optimise oxygenation, fasten hospital transfer and only in extremis ventilate with an alternative supra-glottic airway or a bag-valve-mask device. With an expected difficult airway, the patient should be intubated awake. With an unexpected difficult airway, bag-valve-mask ventilation should be resumed and an alternative supra-glottic airway device inserted. Senior help should be called early. In a "can-not-ventilate, can-not-intubate" situation an alternative airway should be tried and if unsuccessful because of severe upper airway pathology, a surgical airway should be performed. Ventilation should be monitored continuously with capnography. Clinical training is important to increase airway management skills.
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Affiliation(s)
- Peter Paal
- Department of Anesthesiology and Critical Care Medicine, Innsbruck Medical University, Anichstrasse 35, 6020 Innsbruck, Austria.
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Cudnik MT, Newgard CD, Daya M, Jui J. The Impact of Rapid Sequence Intubation on Trauma Patient Mortality in Attempted Prehospital Intubation. J Emerg Med 2010; 38:175-81. [DOI: 10.1016/j.jemermed.2008.01.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2007] [Revised: 12/10/2007] [Accepted: 01/27/2008] [Indexed: 11/30/2022]
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Sollid SJM, Lockey D, Lossius HM. A consensus-based template for uniform reporting of data from pre-hospital advanced airway management. Scand J Trauma Resusc Emerg Med 2009; 17:58. [PMID: 19925688 PMCID: PMC2785748 DOI: 10.1186/1757-7241-17-58] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2009] [Accepted: 11/20/2009] [Indexed: 11/11/2022] Open
Abstract
Background Advanced airway management is a critical intervention that can harm the patient if performed poorly. The available literature on this subject is rich, but it is difficult to interpret due to a huge variability and poor definitions. Several initiatives from large organisations concerned with airway management have recently propagated the need for guidelines and standards in pre-hospital airway management. Following the path of other initiatives to establish templates for uniform data reporting, like the many Utstein-style templates, we initiated and carried out a structured consensus process with international experts to establish a set of core data points to be documented and reported in cases of advanced pre-hospital airway management. Methods A four-step modified nominal group technique process was employed. Results The inclusion criterion for the template was defined as any patient for whom the insertion of an advanced airway device or ventilation was attempted. The data points were divided into three groups based on their relationship to the intervention, including system-, patient-, and post-intervention variables, and the expert group agreed on a total of 23 core data points. Additionally, the group defined 19 optional variables for which a consensus could not be achieved or the data were considered as valuable but not essential. Conclusion We successfully developed an Utstein-style template for documenting and reporting pre-hospital airway management. The core dataset for this template should be included in future studies on pre-hospital airway management to produce comparable data across systems and patient populations and will be implemented in systems that are influenced by the expert panel.
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Affiliation(s)
- Stephen J M Sollid
- Department of Research and Development, Norwegian Air Ambulance Foundation, Drøbak, Norway.
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Strote J, Roth R, Cone DC, Wang HE. Prehospital endotracheal intubation: the controversy continues. Am J Emerg Med 2009; 27:1142-7. [DOI: 10.1016/j.ajem.2008.08.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2008] [Revised: 08/07/2008] [Accepted: 08/09/2008] [Indexed: 11/28/2022] Open
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The measure of treatment agreement between portable and laboratory blood gas measurements in guiding protocol-driven ventilator management. ACTA ACUST UNITED AC 2009; 67:303-13; discussion 313-4. [PMID: 19667883 DOI: 10.1097/ta.0b013e3181a5f055] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Portable blood gas analyzer and monitor devices are increasingly being used to direct ventilator therapy. The purpose of this study was to evaluate the "measure of treatment agreement" between portable and laboratory blood gas measurements used in guiding protocol-driven ventilator management. MATERIALS AND METHODS Using National Institutes of Health Acute Respiratory Distress Syndrome network ventilator management guidelines to manage patient care, measurements taken from the Nonin 8500 M pulse oximeter (SpO2), the Novametrix-610 end-tidal CO2 (ETCO2) detector, and the i-STAT 1 (SaO2, PO2, pH, PCO2) were compared with the recommended treatment from paired laboratory ABL-725 (SaCO2, PO2, pH, PCO2) measurements. RESULTS Four hundred forty-six intubated adult intensive care unit patients were studied prospectively. Except for the ETCO2 (R2 = 0.460), correlation coefficients between portable and laboratory measurements were high (R2 > or = 0.755). Testing for equivalence, the Nonin-SpO2, iSTAT-PO2, iSTAT-pH, and iSTAT-PCO2 were deemed "equivalent" surrogates to paired ABL measurements. Testing for the limits of agreement found only the iSTAT-PCO2 to be an acceptable surrogate measurement. The measure of treatment agreement between the portable and paired laboratory blood gas measurements were Nonin-SpO2 (68%), iSTAT-SaO2 (73%), iSTAT-PO2 (97%), iSTAT-pH (88%), iSTAT-PCO2 (95%), and Novametrix-ETCO2 (60%). Only the iSTAT-PO2 and the iSTAT-PCO2 achieved the > or =95% treatment agreement threshold to be considered as acceptable surrogates to laboratory measurements. CONCLUSIONS : The iSTAT-PO2 and -PCO2 were portable device measurements acceptable as surrogates to standard clinical laboratory blood gas measurements in guiding protocol-directed ventilator management. The "measure of treatment agreement," based on standardized decisions and measurement thresholds of a protocol, provides a simple method for assessing clinical validity of surrogate measurements.
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Concordance of End-Tidal Carbon Dioxide and Arterial Carbon Dioxide in Severe Traumatic Brain injury. ACTA ACUST UNITED AC 2009; 67:526-30. [DOI: 10.1097/ta.0b013e3181866432] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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41
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Wang HE, Davis DP, O'Connor RE, Domeier RM. Drug-Assisted Intubation in the Prehospital Setting (Resource Document to NAEMSP Position Statement). PREHOSP EMERG CARE 2009; 10:261-71. [PMID: 16531387 DOI: 10.1080/10903120500541506] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Henry E Wang
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.
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42
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Davis DP, Fakhry SM, Wang HE, Bulger EM, Domeier RM, Trask AL, Bochicchio GV, Hauda WE, Robinson L. Paramedic Rapid Sequence Intubation for Severe Traumatic Brain Injury: Perspectives from an Expert Panel. PREHOSP EMERG CARE 2009; 11:1-8. [PMID: 17169868 DOI: 10.1080/10903120601021093] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Although early intubation has become standard practice in the prehospital management of severe traumatic brain injury (TBI), many patients cannot be intubated without neuromuscular blockade. Several emergency medical services (EMS) systems have implemented paramedic rapid sequence intubation (RSI) protocols, with published reports documenting apparently conflicting outcomes effects. In response, the Brain Trauma Foundation assembled a panel of experts to interpret the existing literature regarding paramedic RSI for severe TBI and offer guidance for EMS systems considering adding this skill to the paramedic scope of practice. The interpretation of this panel can be summarized as follows: (1) the existing literature regarding paramedic RSI is inconclusive, and apparent differences in outcome can be explained by use of different methodologies and variability in comparison groups; (2) the use of Glasgow Coma Scale score alone to identify TBI patients requiring RSI is limited, with additional research needed to refine our screening criteria; (3) suboptimal RSI technique as well as subsequent hyperventilation may account for some of the mortality increase reported with the procedure; (4) initial and ongoing training as well as experience with RSI appear to affect performance; and (5) the success of a paramedic RSI program is dependent on particular EMS and trauma system characteristics.
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Affiliation(s)
- Daniel P Davis
- Department of Emergency Medicine, University of California at San Diego, San Diego, California 92103-8676, and Trauma Services, Inova Regional Trauma Center, Inova Fairfax Hospital, Falls Church, VA, USA.
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Prehospital hypocapnia and poor outcome after severe traumatic brain injury. ACTA ACUST UNITED AC 2009; 66:1577-82; discussion 1583. [PMID: 19509617 DOI: 10.1097/ta.0b013e3181a3931d] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The Brain Trauma Foundation (BTF) Guidelines for prehospital management of traumatic brain injury (TBI) recommend a goal end-tidal carbon dioxide of 30 mm Hg to 35 mm Hg in patients without signs of herniation. METHODS We examined prehospital concordance with BTF Guidelines, selected demographic and physiologic variables and outcomes for 100 consecutive admissions to a well-established Level I regional trauma center. All patients had blunt TBI with Glasgow Coma Score < or = 8 without signs of herniation. All were transported by helicopter by flight paramedics experienced with BTF Guidelines and the continuous wave form capnometer. Patients resumed spontaneous ventilation after intubation. RESULTS Concordance (prehospital end-tidal carbon dioxide > 29 mm Hg) was achieved in 65 of 100 cases. Mortality was 29% (19 of 65) among those in whom guideline levels were achieved prehospital and 46% (16 of 35) in those in whom guideline levels were not achieved prehospital (odds ratio, 0.49; p = 0.10). The "achieved" group was younger (p = 0.02), with higher calculated probability of survival (p = 0.01). Intracranial pressure was maintained under intensive care within acceptable limits in the hospital in both groups but was significantly higher in the "not achieved" group (p = 0.05). CONCLUSIONS Our data, though not statistically significant, suggest that patients who are harder to keep within the guidelines in the field are more likely to die, because of more severe TBI or complication by other factors such as age or injury severity. Whether increased awareness of this phenomenon can improve outcomes is unknown but suggests an approach to future education and research.
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Schmid M, Mang H, Ey K, Schüttler J. Prehospital airway management on rescue helicopters in the United Kingdom. Anaesthesia 2009; 64:625-31. [PMID: 19453316 DOI: 10.1111/j.1365-2044.2008.05859.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Adequate equipment is one prerequisite for advanced, out of hospital, airway management. There are no data on current availability of airway equipment on UK rescue helicopters. An internet search revealed all UK rescue helicopters, and a questionnaire was sent to the bases asking for available airway management items. We identified 27 helicopter bases and 26 (96%) sent the questionnaire back. Twenty-four bases (92%) had at least one supraglottic airway device; 16 (62%) helicopters had material for establishing a surgical airway (e.g. a cricothyroidotomy set); 88% of the helicopters had CO(2) detection; 25 (96%) helicopters carried automatic ventilators; among these, four (15%) had sophisticated ventilators and seven (27%) helicopters carried special face masks suitable for non-invasive ventilation. We found a wide variation in the advanced airway management equipment that was carried routinely on air ambulances. Current guidelines for airway management are not met by all UK air ambulances.
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Affiliation(s)
- M Schmid
- Department of Anesthesiology, University Erlangen-Nuernberg, Erlangen, Germany.
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Abstract
The aim of this study was to review the current protocols of prehospital practice and their impact on outcome in the management of traumatic brain injury. A literature review of the National Library of Medicine encompassing the years 1980 to May 2008 was performed. The primary impact of a head injury sets in motion a cascade of secondary events that can worsen neurological injury and outcome. The goals of care during prehospital triage, stabilization, and transport are to recognize life-threatening raised intracranial pressure and to circumvent cerebral herniation. In that process, prevention of secondary injury and secondary insults is a major determinant of both short- and longterm outcome. Management of brain oxygenation, blood pressure, cerebral perfusion pressure, and raised intracranial pressure in the prehospital setting are discussed. Patient outcomes are dependent upon an organized trauma response system. Dispatch and transport timing, field stabilization, modes of transport, and destination levels of care are addressed. In addition, special considerations for mass casualty and disaster planning are outlined and recommendations are made regarding early response efforts and the ethical impact of aggressive prehospital resuscitation. The most sophisticated of emergency, operative, or intensive care units cannot reverse damage that has been set in motion by suboptimal protocols of triage and resuscitation, either at the injury scene or en route to the hospital. The quality of prehospital care is a major determinant of long-term outcome for patients with traumatic brain injury.
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Affiliation(s)
- Shirley I Stiver
- Department of Neurosurgery, School of Medicine, University of California San Francisco, California 94110-0899, USA.
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Uren B, Lowell MJ, Silbergleit R. Critical care transport of patients who have acute neurological emergencies. Emerg Med Clin North Am 2009; 27:17-26, vii. [PMID: 19218016 DOI: 10.1016/j.emc.2008.09.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
This article reviews the special questions and issues in critical care transport related specifically to the care of patients who have neurologic emergencies. It first considers potential indications for transport and reviews attempts to create a hierarchical stroke center system akin to that developed for trauma care. It then discusses therapeutic concerns relating to the transport environment and the use of specific interventions, including the effects of end-tidal CO(2) monitoring on intracranial pressure, patient outcomes after traumatic brain injury, and opportunities to initiate therapeutic hypothermia in comatose survivors of cardiac arrest during transport. Finally, the cost of critical care transport of patients who have neurologic emergencies is considered.
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Affiliation(s)
- Bradley Uren
- Department of Emergency Medicine and Survival Flight, University of Michigan, Ann Arbor, MI, USA.
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Accuracy and Precision of Three Different Methods to Determine Pco2 (Paco2 vs. Petco2 vs. Ptcco2) During Interhospital Ground Transport of Critically Ill and Ventilated Adults. ACTA ACUST UNITED AC 2008; 65:10-8. [DOI: 10.1097/ta.0b013e31815eba83] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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49
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Abstract
While airway and ventilatory compromise are significant concerns following traumatic brain injury (TBI), there is little data supporting an aggressive approach to airway management by prehospital personnel, and a growing number of reports suggesting an association between early intubation and increased mortality. Recent clinical and experimental data suggest that hyperventilation is an important contributor to these adverse outcomes in TBI patients. Various mechanisms appear to be responsible for the worsened outcomes, including hemodynamic, cerebrovascular, immunologic and cellular effects. Here, relevant experimental and clinical data regarding the impact of ventilation on TBI are reviewed. In addition, experimental data regarding potential mechanisms for the adverse effects of hyperventilation and hypocapnia on the injured brain are presented. Finally, the limited data regarding the impact of hypoventilation and hypercapnia on outcome from TBI are discussed.
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Affiliation(s)
- Daniel P Davis
- UC San Diego Department of Emergency Medicine, 200 West Arbor Drive, #8676, San Diego, CA 92103-8676, United States.
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Early ventilation in traumatic brain injury. Resuscitation 2008; 77:417-8; author reply 418. [PMID: 18308456 DOI: 10.1016/j.resuscitation.2007.11.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2007] [Accepted: 11/04/2007] [Indexed: 11/20/2022]
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