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Zhang Y, Miller M, Buttfield A, Burns B, Lawrie K, Gaston J, Ferguson I. Alfentanil versus fentanyl for emergency department rapid sequence induction with ketamine: A-FAKT, a pilot randomized trial. Am J Emerg Med 2024; 84:25-32. [PMID: 39059038 DOI: 10.1016/j.ajem.2024.07.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 06/12/2024] [Accepted: 07/14/2024] [Indexed: 07/28/2024] Open
Abstract
BACKGROUND Fentanyl is often administered during rapid sequence induction of anesthesia (RSI) in the emergency department (ED) to ameliorate the hypertensive response that may occur. Due to its more rapid onset, the use of alfentanil may be more consistent with both the onset time of the sedative and the commencement of laryngoscopy. As such, we compared the effect of alfentanil and fentanyl on post-induction hemodynamic changes when administered as part of a standardized induction regimen including ketamine and rocuronium in ED RSI. METHODS This was a double-blind pilot randomized controlled trial of adult patients requiring RSI in the ED of three urban Australian hospitals. Patients were randomized to receive either alfentanil or fentanyl in addition to ketamine and rocuronium for RSI. Non-invasive blood pressure and heart rate were measured immediately before and at two, four, and six minutes after induction. The primary outcome was the occurrence of at least one post-induction systolic blood pressure outside the pre-specified range of 100-160mmHg (with adjustment for patients with baseline hypertension). Secondary outcomes included hypertension, hypotension, hypoxia, first-pass intubation success, 30-day mortality, and the pattern of hemodynamic changes. RESULTS A total of 61 patients were included in the final analysis (31 in the alfentanil group and 30 in the fentanyl group). The primary outcome was met in 58% of the alfentanil group and 50% of the fentanyl group (difference 8%, 95% confidence interval: -17% to 33%). The 30-day mortality rate, first-pass success rate, and incidences of hypertension, hypotension, and hypoxia were similar between the groups. There were no significant differences in systolic blood pressure or heart rate between the groups at any of the measured time-points. CONCLUSION Alfentanil and fentanyl produced comparable post-induction hemodynamic changes when used as adjuncts to ketamine in ED RSI. Future studies could consider comparing different dosages of these opioids.
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Affiliation(s)
- Yichen Zhang
- South Western Sydney Clinical School, University of New South Wales, Warwick Farm, New South Wales, Australia.
| | - Matthew Miller
- Aeromedical Operations, New South Wales Ambulance, Bankstown Aerodrome, New South Wales, Australia; Department of Anaesthesia, St George Hospital, Kogarah, New South Wales, Australia; St George and Sutherland Clinical Schools, University of New South Wales, Kogarah, New South Wales, Australia
| | - Alexander Buttfield
- Emergency Department, Campbelltown Hospital, Campbelltown, New South Wales, Australia; School of Medicine, Western Sydney University, Campbelltown, New South Wales, Australia
| | - Brian Burns
- Aeromedical Operations, New South Wales Ambulance, Bankstown Aerodrome, New South Wales, Australia; Emergency Department, Northern Beaches Hospital, Frenchs Forest, New South Wales, Australia; Faculty of Medicine & Health, University of Sydney, Camperdown, New South Wales, Australia; Macquarie Medical School, Macquarie University, Macquarie Park, New South Wales, Australia
| | - Kimberley Lawrie
- Aeromedical Operations, New South Wales Ambulance, Bankstown Aerodrome, New South Wales, Australia; Emergency Department, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - James Gaston
- Emergency Department, Campbelltown Hospital, Campbelltown, New South Wales, Australia; School of Medicine, Western Sydney University, Campbelltown, New South Wales, Australia
| | - Ian Ferguson
- South Western Sydney Clinical School, University of New South Wales, Warwick Farm, New South Wales, Australia; Aeromedical Operations, New South Wales Ambulance, Bankstown Aerodrome, New South Wales, Australia; Emergency Department, Liverpool Hospital, Liverpool, New South Wales, Australia
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Endlich Y, Davies EL, Kelly J. The nature of the response to airway management incident reports in high income countries: A scoping review. Anaesth Intensive Care 2024; 52:283-301. [PMID: 39219018 DOI: 10.1177/0310057x241227238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
Adverse events associated with failed airway management may have catastrophic consequences, and despite many advances in knowledge, guidelines and equipment, airway incidents and patient harm continue to occur. Patient safety incident reporting systems have been established to facilitate a reduction in incidents. However, it has been found that corrective actions are inadequate and successful safety improvements scarce. The aim of this scoping review was to assess whether the same is true for airway incidents by exploring academic literature that describes system changes in airway management in high-income countries over the last 30 years, based on findings and recommendations from incident reports and closed claims studies. This review followed the most recent guidance from the Joanna Briggs Institute (JBI). PubMed, Ovid MEDLINE and Embase, the JBI database, SCOPUS, the Cochrane Library and websites for anaesthetic societies were searched for eligible articles. Included articles were analysed and data synthesised to address the review's aim. The initial search yielded 28,492 results, of which 111 articles proceeded to the analysis phase. These included 23 full-text articles, 78 conference abstracts and 10 national guidelines addressing a range of airway initiatives across anaesthesia, intensive care and emergency medicine. While findings and recommendations from airway incident analyses are commonly published, there is a gap in the literature regarding the resulting system changes to reduce the number and severity of adverse airway events. Airway safety management mainly focuses on Safety-I events and thereby does not consider Safety-II principles, potentially missing out on all the information available from situations where airway management went well.
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Affiliation(s)
- Yasmin Endlich
- School of Medicine, The University of Adelaide, Adelaide, Australia
- School of Nursing, The University of Adelaide, Adelaide, Australia
- Royal Adelaide Hospital, Department of Anaesthesia, Adelaide, Australia
| | - Ellen L Davies
- Adelaide Health Simulation, The University of Adelaide, Adelaide, Australia
| | - Janet Kelly
- School of Nursing, The University of Adelaide, Adelaide, Australia
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Tamsett Z, Douglas N, King C, Johnston T, Bentley C, Hao B, Prinsloo D, Bourke EM. Does the choice of induction agent in rapid sequence intubation in the emergency department influence the incidence of post-induction hypotension? Emerg Med Australas 2024; 36:340-347. [PMID: 38018391 DOI: 10.1111/1742-6723.14355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Revised: 10/26/2023] [Accepted: 11/14/2023] [Indexed: 11/30/2023]
Abstract
OBJECTIVE To describe the effects of different induction agents on the incidence of post-induction hypotension (PIH) and its associated interventions during rapid sequence intubation (RSI) in the ED. METHODS A single centre retrospective study of patients intubated between 2018 and 2021 was conducted in a regional Australian ED. The impact of induction agent choice, in addition to demographic and clinical factors on the incidence of PIH were determined using descriptive statistics and a multivariate analysis presented as adjusted odds ratios (aORs) and their 95% confidence intervals (CIs). RESULTS Ketamine and propofol, used either individually or in conjunction with fentanyl, were significantly associated with PIH (ketamine aOR 4.5, 95% CI 1.35-14.96; propofol aOR 4.88, 95% CI 1.46-16.29). Age >60 years was associated with a greater requirement for vasopressors (aOR 4.46, 95% CI 2.49-7.97) and a higher risk of mortality after RSI (aOR 4.2, 95% CI 1.87-9.40). Patients with a shock index >1.0 were significantly more likely to require vasopressors (aOR 5.13, 95% CI 2.35-11.2) and have a cardiac arrest within 15 min of RSI (aOR 3.56, 95% CI 1.07-11.8). CONCLUSIONS Exposure to both propofol and ketamine is significantly associated with PIH after RSI, alongside age and shock index. PIH is likely multifactorial in nature, and this data supports the sympatholytic effect of induction agents as the underlying cause of PIH rather than the choice of agent itself. Further prospective work including a randomised controlled trial between induction agents is justified to further clarify this important clinical question.
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Affiliation(s)
- Zacchary Tamsett
- Department of Emergency Medicine, Grampians Health, Ballarat, Victoria, Australia
| | - Ned Douglas
- Department of Anaesthesia, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
| | - Cathy King
- Department of Emergency Medicine, Grampians Health, Ballarat, Victoria, Australia
- School of Medicine, Deakin University, Geelong, Victoria, Australia
| | - Tanya Johnston
- Department of Emergency Medicine, Grampians Health, Ballarat, Victoria, Australia
| | - Connor Bentley
- Department of Emergency Medicine, Grampians Health, Ballarat, Victoria, Australia
| | - Brian Hao
- Department of Emergency Medicine, Grampians Health, Ballarat, Victoria, Australia
| | - Duron Prinsloo
- Department of Emergency Medicine, Grampians Health, Ballarat, Victoria, Australia
| | - Elyssia M Bourke
- Department of Emergency Medicine, Grampians Health, Ballarat, Victoria, Australia
- Department of Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Emergency Medicine, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
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Sastre JA, Gómez-Ríos MA, López T, Gutiérrez-Couto U, Casans-Francés R. Dynamic versus standard bougies for tracheal intubation with direct or indirect laryngoscopy in simulated or real scenarios: a systematic review and meta-analysis. Expert Rev Med Devices 2024; 21:427-438. [PMID: 38655581 DOI: 10.1080/17434440.2024.2344667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Accepted: 04/02/2024] [Indexed: 04/26/2024]
Abstract
INTRODUCTION This systematic review and meta-analysis aimed to compare the efficacy of dynamic versus standard bougies to achieve tracheal intubation. METHODS We searched MEDLINE, Embase, CENTRAL, Web of Science, Scopus and Google Scholar on 10 October 2023. We included clinical trials comparing both devices. The primary outcome was the first-attempt intubation success rate. The secondary outcome was the time required for tracheal intubation. RESULTS Eighteen studies were included. Dynamic bougies do not increase first-attempt success rate (RR 1.11; p = 0.06) or shorten tracheal intubation time (MD -0.30 sec; p = 0.84) in clinical trials in humans. In difficult airways, first-attempt success intubation rate was greater for dynamic bougies (RR 1.17; p = 0.002); Additionally, they reduced the time required for intubation (MD -4.80 sec; p = 0.001). First-attempt intubation success rate was higher (RR 1.15; p = 0.01) and time to achieve intubation was shorter when using Macintosh blades combined with dynamic bougies (MD -5.38 sec; p < 0.00001). Heterogeneity was high. CONCLUSION Dynamic bougies do not increase the overall first-pass success rate or shorten tracheal intubation time. However, dynamic bougies seem to improve first-attempt tracheal intubation rate in patients with difficult airways and in those intubated with a Macintosh blade. Further research is needed for definitive conclusions. REGISTRATION OF PROSPERO CRD42023472122.
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Affiliation(s)
- José A Sastre
- Department of Anesthesiology, Salamanca University Hospital, Salamanca, Spain
| | - Manuel A Gómez-Ríos
- Department of Anesthesiology and Perioperative Medicine, Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain
| | - Teresa López
- Department of Anesthesiology, Salamanca University Hospital, Salamanca, Spain
| | - Uxía Gutiérrez-Couto
- Department of Librarry Science and Documentation, Complejo Hospitalario Universitario de Ferrol, Ferrol, Spain
| | - Rubén Casans-Francés
- Department of Anesthesiology, Hospital Universitario Infanta Elena, Valdemoro, Madrid, Spain
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Bennett S, Alkhouri H, Badge H, Long E, Chan T, Vassiliadis J, Fogg T. Bed tilt and ramp positions are associated with increased first-pass success of adult endotracheal intubation in the emergency department: A registry study. Emerg Med Australas 2023; 35:983-990. [PMID: 37429648 DOI: 10.1111/1742-6723.14276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 06/01/2023] [Accepted: 06/19/2023] [Indexed: 07/12/2023]
Abstract
OBJECTIVE Successful endotracheal intubation in the ED requires optimum body positioning. In patients with obesity, the ramp position was suggested to achieve better intubating conditions. However, limited data are available on the airway management practices for patients with obesity in Australasian EDs. The aim of this study was to identify current patient positioning practices during endotracheal intubation and its association with first-pass success (FPS) at intubation and adverse event (AE) rates in obese and non-obese populations. METHODS Prospectively collected data from the Australia and New Zealand ED Airway Registry (ANZEDAR) between 2012 and 2019 were analysed. Patients were categorised into two groups according to their weight: <100 kg (non-obese) or ≥100 kg (obese). Four position categories were investigated; supine, pillow or occipital pad, bed tilt and ramp or head-up with relation to FPS and complication rate using logistic regression modelling. RESULTS A total of 3708 intubations from 43 EDs were included. Overall, the non-obese cohort had a greater FPS rate (85.9%) compared to the obese group (77.0%). The bed tilt position had the highest FPS rate (87.2%), whereas the supine position had the lowest (83.0%). AE rates were highest in the ramp position (31.2%) compared to all other positions (23.8%). Regression analysis showed ramp, or bed tilt positions and a consultant-level intubator were associated with higher FPS. Obesity, in addition to other factors, was independently associated with lower FPS. CONCLUSION Obesity was associated with lower FPS, which could be improved through performing a bed tilt or ramp positioning.
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Affiliation(s)
- Samantha Bennett
- Faculty of Medicine, The University of Notre Dame Australia, Sydney, New South Wales, Australia
- Sydney Children's Hospital, Sydney, New South Wales, Australia
| | - Hatem Alkhouri
- Emergency Care Institute, Agency for Clinical Innovation, Sydney, New South Wales, Australia
- Faculty of Medicine, The University of New South Wales, Sydney, New South Wales, Australia
| | - Helen Badge
- School of Allied Health, Faculty of Health Science, Australian Catholic University, Sydney, New South Wales, Australia
| | - Elliot Long
- The Royal Children's Hospital, Murdoch Children's Research Institute, The University of Melbourne, Melbourne, Victoria, Australia
| | - Trevor Chan
- Emergency Care Institute, Agency for Clinical Innovation, Sydney, New South Wales, Australia
- Emergency Department, St George Hospital, Sydney, New South Wales, Australia
| | - John Vassiliadis
- Emergency Department, Royal North Shore Hospital, Sydney, New South Wales, Australia
- Discipline of Emergency Medicine, Northern Clinical School, The University of Sydney Medical School, Sydney, New South Wales, Australia
| | - Toby Fogg
- Emergency Department, Royal North Shore Hospital, Sydney, New South Wales, Australia
- CareFlight, Sydney, New South Wales, Australia
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Solan T, Cudini D, Humar M, Forsyth N, Meadley B, St Clair T, Hodge D, Smith K, Babl FE, Long E. Characteristics of paediatric pre-hospital intubation by Intensive Care Paramedics. Emerg Med Australas 2023; 35:754-758. [PMID: 37019689 DOI: 10.1111/1742-6723.14207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 03/01/2023] [Accepted: 03/22/2023] [Indexed: 04/07/2023]
Abstract
OBJECTIVES Emergency intubation in children is an infrequent procedure both in the pre-hospital and hospital setting. The anatomical, physiological and situational challenges together with limited clinician exposure can make this a difficult procedure with high risk of adverse events. The aim of this collaborative study between a state-wide ambulance service and a tertiary children's hospital was to describe the characteristics of pre-hospital paediatric intubations by Intensive Care Paramedics. METHODS We conducted a retrospective review of state-wide ambulance service electronic patient care records (ePCRs) in Victoria, Australia, population: 6.5 million. Children aged 0-18 years who were attended by paramedics over a 12-month period that required advanced airway management were analysed for demographics and first-pass success rate. RESULTS Paramedics attended 2674 cases aged 0-18 years over the 12-month study period who received basic or advanced airway management. A total of 78 cases required advanced airway management. The median age of patients was 12 years (interquartile range 3-16) and most were male (60.2%). Sixty-eight patients (87.5%) were intubated successfully on the first attempt, first-pass success was lowest in children <1 year of age. The most common indications for pre-hospital intubation were closed head injury and cardiac arrest. It was not possible to report complication rates because of incomplete documentation. CONCLUSION Pre-hospital intubation in children is performed infrequently in an extremely unwell patient group. Continued high-level paramedic training is required to prevent adverse events and ensure patient safety.
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Affiliation(s)
- Tom Solan
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
- Paediatric Research in Emergency Departments International Collaborative (PREDICT), Melbourne, Victoria, Australia
- Emergency Department, The Royal Children's Hospital, Melbourne, Victoria, Australia
- Departments of Paediatrics and Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
| | - Daniel Cudini
- Ambulance Victoria, Melbourne, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Paramedicine, Monash University, Melbourne, Victoria, Australia
| | - Matthew Humar
- Ambulance Victoria, Melbourne, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Paramedicine, Monash University, Melbourne, Victoria, Australia
| | - Nathan Forsyth
- Emergency Department, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Ben Meadley
- Ambulance Victoria, Melbourne, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Paramedicine, Monash University, Melbourne, Victoria, Australia
| | - Toby St Clair
- Ambulance Victoria, Melbourne, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Paramedicine, Monash University, Melbourne, Victoria, Australia
| | - Darren Hodge
- Ambulance Victoria, Melbourne, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Paramedicine, Monash University, Melbourne, Victoria, Australia
| | - Karen Smith
- Ambulance Victoria, Melbourne, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Paramedicine, Monash University, Melbourne, Victoria, Australia
| | - Franz E Babl
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
- Paediatric Research in Emergency Departments International Collaborative (PREDICT), Melbourne, Victoria, Australia
- Emergency Department, The Royal Children's Hospital, Melbourne, Victoria, Australia
- Departments of Paediatrics and Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
| | - Elliot Long
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
- Paediatric Research in Emergency Departments International Collaborative (PREDICT), Melbourne, Victoria, Australia
- Emergency Department, The Royal Children's Hospital, Melbourne, Victoria, Australia
- Departments of Paediatrics and Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
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Dean P, Geis G, Hoehn EF, Lautz AJ, Edmunds K, Shah A, Zhang Y, Frey M, Boyd S, Nagler J, Miller KA, Neubrand TL, Cabrera N, Kopp TM, Wadih E, Kannikeswaran N, VanDeWall A, Hewett Brumberg EK, Donoghue A, Palladino L, O'Connell KJ, Mazzawi M, Tam DCF, Murray M, Kerrey B. High-risk criteria for the physiologically difficult paediatric airway: A multicenter, observational study to generate validity evidence. Resuscitation 2023; 190:109875. [PMID: 37327848 DOI: 10.1016/j.resuscitation.2023.109875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 06/07/2023] [Accepted: 06/08/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND Single-center studies have identified risk factors for peri-intubation cardiac arrest in the emergency department (ED). The study objective was to generate validity evidence from a more diverse, multicenter cohort of patients. METHODS We completed a retrospective cohort study of 1200 paediatric patients who underwent tracheal intubation in eight academic paediatric EDs (150 per ED). The exposure variables were 6 previously studied high-risk criteria for peri-intubation arrest: (1) persistent hypoxemia despite supplemental oxygen, (2) persistent hypotension, (3) concern for cardiac dysfunction, (4) post-return of spontaneous circulation (ROSC), (5) severe metabolic acidosis (pH < 7.1), and (6) status asthmaticus. The primary outcome was peri-intubation cardiac arrest. Secondary outcomes included extracorporeal membrane oxygenation (ECMO) cannulation and in-hospital mortality. We compared all outcomes between patients that met one or more versus no high-risk criteria, using generalized linear mixed models. RESULTS Of the 1,200 paediatric patients, 332 (27.7%) met at least one of 6 high-risk criteria. Of these, 29 (8.7%) suffered peri-intubation arrest compared to zero arrests in patients meeting none of the criteria. On adjusted analysis, meeting at least one high-risk criterion was associated with all 3 outcomes - peri-intubation arrest (AOR 75.7, 95% CI 9.7-592.6), ECMO (AOR 7.1, 95% CI 2.3-22.3) and mortality (AOR 3.4, 95% 1.9-6.2). Four of 6 criteria were independently associated with peri-intubation arrest: persistent hypoxemia despite supplemental oxygen, persistent hypotension, concern for cardiac dysfunction, and post-ROSC. CONCLUSIONS In a multicenter study, we confirmed that meeting at least one high-risk criterion was associated with paediatric peri-intubation cardiac arrest and patient mortality.
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Affiliation(s)
- Preston Dean
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States.
| | - Gary Geis
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States.
| | - Erin F Hoehn
- Division of Emergency Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States; Division of Emergency Medicine, Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, OH, United States.
| | - Andrew J Lautz
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States; Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States.
| | - Katherine Edmunds
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States.
| | - Ashish Shah
- Division of Emergency Medicine, Rady Children's Hospital, University of California San Diego, San Diego, CA, United States.
| | - Yin Zhang
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States.
| | - Mary Frey
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States.
| | - Stephanie Boyd
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States.
| | - Joshua Nagler
- Boston Children's Hospital, Harvard Medical School, Boston, MA, United States.
| | - Kelsey A Miller
- Boston Children's Hospital, Harvard Medical School, Boston, MA, United States.
| | - Tara L Neubrand
- Section of Emergency Medicine, Children's Hospital Colorado, Aurora, CO, United States; Department of Emergency Medicine, University of New Mexico, Albuquerque, NM, United States.
| | - Natasha Cabrera
- Section of Emergency Medicine, Children's Hospital Colorado, Aurora, CO, United States
| | - Tara M Kopp
- Division of Emergency Medicine, Norton Children's Hospital, University of Louisville School of Medicine, Louisville, KY, United States.
| | - Esper Wadih
- Division of Emergency Medicine, Norton Children's Hospital, University of Louisville School of Medicine, Louisville, KY, United States.
| | - Nirupama Kannikeswaran
- Division of Emergency Medicine, Children's Hospital of Michigan, Central Michigan University, Detroit, MI, United States.
| | - Audrey VanDeWall
- Division of Emergency Medicine, Children's Hospital of Michigan, Central Michigan University, Detroit, MI, United States.
| | - Elizabeth K Hewett Brumberg
- Division of Emergency Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States.
| | - Aaron Donoghue
- Division of Emergency Medicine, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States.
| | - Lauren Palladino
- Division of Emergency Medicine, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States.
| | - Karen J O'Connell
- Division of Emergency Medicine, Children's National Hospital, The George Washington University School of Medicine and Health Sciences, Washington, DC, United States.
| | - Malek Mazzawi
- Division of Emergency Medicine, Children's National Hospital, The George Washington University School of Medicine and Health Sciences, Washington, DC, United States.
| | - Derek Chi Fung Tam
- Division of Emergency Medicine, Rady Children's Hospital, University of California San Diego, San Diego, CA, United States.
| | - Matthew Murray
- Division of Emergency Medicine, Rady Children's Hospital, University of California San Diego, San Diego, CA, United States.
| | - Benjamin Kerrey
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States.
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Kibblewhite C, Todd VF, Howie G, Sanders J, Ellis C, Dittmer B, Garcia E, Swain A, Smith T, Dicker B. Out-of-Hospital emergency airway management practices: A nationwide observational study from Aotearoa New Zealand. Resusc Plus 2023; 15:100432. [PMID: 37547539 PMCID: PMC10400901 DOI: 10.1016/j.resplu.2023.100432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 06/29/2023] [Accepted: 07/10/2023] [Indexed: 08/08/2023] Open
Abstract
Background and Objectives Airway management is crucial for emergency care in critically ill patients outside the hospital setting. An Airway Registry is useful in providing essential information for quality improvement purposes. Therefore, this study aimed to develop an out-of-hospital airway registry and describe airway management practices in Aotearoa New Zealand (AoNZ). Methods Data from the Aotearoa New Zealand Paramedic Care Collection (ANZPaCC) database were used in a retrospective cohort study covering July 2020 to June 2021. All patients receiving airway interventions were included. An airway intervention was defined as one or more of the following: non-drug assisted endotracheal intubation (NDA-ETI), drug-assisted endotracheal intubation (DA-ETI; where a combination of paralytic agent and sedative were used to aid in intubation), laryngeal mask airway (LMA), oropharyngeal airway (OPA), nasopharyngeal airway (NPA), surgical airway (cricothyroidotomy), suction, jaw thrust. Descriptive statistics were analysed using Chi-Square and logistic regression modelling investigated the relationship between advanced airway success and patient characteristics. Results The study included 4,529 patients who underwent 7,779 airway interventions. Basic airway interventions were used most frequently: OPA (45.1%), NPA (29.3%), LMA (28.9%), suction (19.9%) and jaw thrust (17.6%). Advanced airway interventions were used less frequently: NDA-ETI (19.8%), DA-ETI (8.7%), and surgical airways (0.2%). The success rate for ETI (including both NDA-ETI and DA-ETI) was 89.4%, with NDA-ETI success at 85.8% and DA-ETI success at 97.7%. ETI first-pass success rates were significantly lower for males (aOR 0.65, 95%CI 0.48-0.87, p < 0.001) and higher for non-cardiac arrest injury patients (aOR 2.94, 95%CI 1.43-6.00, p < 0.001). In this cohort receiving airway interventions the 1-day mortality rate was 41.1%, demonstrating that a high proportion of these patients were severely clinically compromised. Conclusions Out-of-hospital airway management practices and success rates in AoNZ are comparable to those elsewhere. This research has determined the variables to be used as the AoNZ Paramedic Airway Registry ongoing and has demonstrated baseline outcomes in airway management for ongoing quality improvement using this registry.
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Affiliation(s)
- Chris Kibblewhite
- Clinical Audit and Research, Hato Hone St John New Zealand, Auckland, New Zealand
| | - Verity F. Todd
- Clinical Audit and Research, Hato Hone St John New Zealand, Auckland, New Zealand
- Paramedicine Research Unit, Paramedicine Department, Auckland University of Technology, Auckland, New Zealand
| | - Graham Howie
- Clinical Audit and Research, Hato Hone St John New Zealand, Auckland, New Zealand
- Paramedicine Research Unit, Paramedicine Department, Auckland University of Technology, Auckland, New Zealand
| | - Josh Sanders
- Clinical Audit and Research, Hato Hone St John New Zealand, Auckland, New Zealand
| | - Craig Ellis
- Clinical Audit and Research, Hato Hone St John New Zealand, Auckland, New Zealand
| | - Bryan Dittmer
- Clinical Audit and Research, Hato Hone St John New Zealand, Auckland, New Zealand
| | - Elena Garcia
- Clinical Audit and Research, Hato Hone St John New Zealand, Auckland, New Zealand
| | - Andy Swain
- Paramedicine Research Unit, Paramedicine Department, Auckland University of Technology, Auckland, New Zealand
- Wellington Free Ambulance, Wellington, New Zealand
| | - Tony Smith
- Clinical Audit and Research, Hato Hone St John New Zealand, Auckland, New Zealand
| | - Bridget Dicker
- Clinical Audit and Research, Hato Hone St John New Zealand, Auckland, New Zealand
- Paramedicine Research Unit, Paramedicine Department, Auckland University of Technology, Auckland, New Zealand
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9
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Venner C. Is it time for mandatory airway assessments for emergency medicine trainees? Emerg Med Australas 2023; 35:521-522. [PMID: 37005065 DOI: 10.1111/1742-6723.14210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 03/23/2023] [Indexed: 04/04/2023]
Affiliation(s)
- Caroline Venner
- Gladstone Hospital, Gladstone, Queensland, Australia
- Children's Health Queensland Retrieval Service, Brisbane, Queensland, Australia
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10
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Tamilarasu KP, Aazmi A, Vinayagam S, Rajendran G, Patel S, Aazmi B. A Prospective Observational Study of Endotracheal Intubation Practices in an Academic Emergency Department of a Tertiary Care Hospital in South India. Cureus 2023; 15:e36072. [PMID: 37065283 PMCID: PMC10096852 DOI: 10.7759/cureus.36072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2023] [Indexed: 03/14/2023] Open
Abstract
INTRODUCTION Airway management is the first critical step to be addressed in the airway, breathing, and circulation algorithm for stabilizing critically ill patients. Since the emergency department (ED) is the primary contact of these patients in health care, doctors in the ED should be trained to perform advanced airway management. In India, emergency medicine has been recognized as a new specialty by the Medical Council of India (now the National Medical Commission) since 2009. Data related to airway management in the ED in India is sparse. METHODS We conducted a one-year prospective observational study to establish descriptive data regarding endotracheal intubations performed in our ED. Descriptive data related to intubation was collected using a standardized proforma that was filled by the physician performing intubation. RESULTS A total of 780 patients were included, of which 58.8% were intubated in the first attempt. The majority (60.4%) of the intubations were performed in non-trauma patients and the remaining 39.6% in trauma patients. Oxygenation failure was the most common indication (40%) for intubation followed by a low Glasgow coma scale (GCS) score (35%). Rapid sequence intubation (RSI) was performed in 36.9% of patients, and intubation was done with sedation only in 36.9% of patients. Midazolam was the most commonly used drug - either alone or in combination with other drugs. We found a strong association of first-pass success (FPS) with the method of intubation, Cormack-Lehane grading, predicted difficulty in intubation, and experience of the physician performing the first attempt of intubation (P<0.05). Hypoxemia (34.6%) and airway trauma (15.6%) were the most commonly encountered complications. CONCLUSION Our study showed an FPS of 58.8%. Complications were seen in 49% of intubations. Our study highlights the areas for quality improvement in intubation practices in our ED, like the use of videolaryngoscopy, RSI, airway adjuncts like stylet and bougie, and intubation by more experienced physicians in patients with anticipated difficult intubation.
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11
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Meulendyks S, Korpal D, Jin HJ, Mal S, Pace J. Airway registries in primarily adult, emergent endotracheal intubation: a scoping review. Scand J Trauma Resusc Emerg Med 2023; 31:11. [PMID: 36890554 PMCID: PMC9993388 DOI: 10.1186/s13049-023-01075-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 02/28/2023] [Indexed: 03/10/2023] Open
Abstract
BACKGROUND Emergency Department (ED) airway registries are formalized methods to collect and document airway practices and outcomes. Airway registries have become increasingly common in EDs globally; yet there is no consensus of airway registry methodology or intended utility. This review builds on previous literature and aims to provide a thorough description of international ED airway registries and discuss how airway registry data is utilized. METHODS A search of Medline, Embase, Scopus, Cochrane Libraries, Web of Science, and Google Scholar was performed with no date limitations applied. English language full-text publications and grey literature from centres implementing an ongoing airway registry to monitor intubations performed in mainly adult patients in an ED setting were included. Non-English publications and publications describing airway registries to monitor intubation practices in predominantly paediatric patients or settings outside of the ED were excluded. Study screening for eligibility was performed by two team members individually, with any disagreements resolved by a third team member. Data was charted using a standardized data charting tool created for this review. RESULTS Our review identified 124 eligible studies from 22 airway registries with a global distribution. We found that airway registry data is used for quality assurance, quality improvement, and clinical research regarding intubation practices and contextual factors. This review also demonstrates that there is a great deal of heterogeneity in definitions of first-pass success and adverse events in the peri-intubation period. CONCLUSIONS Airway registries are used as a crucial tool to monitor and improve intubation performance and patient care. ED airway registries inform and document the efficacy of quality improvement initiatives to improve intubation performance in EDs globally. Standardized definitions of first-pass success and peri-intubation adverse events, such as hypotension and hypoxia, may allow for airway management performance to be compared on a more equivalent basis and allow for the development of more reliable international benchmarks for first-pass success and rates of adverse events in the future.
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Affiliation(s)
- Sarah Meulendyks
- Schulich School of Medicine and Dentistry, 1151 Richmond St, London, ON, N6A 5C1, Canada.
| | - Daniel Korpal
- Department of Emergency Medicine, London Health Sciences Centre, 800 Commissioners Rd E, London, ON, N6A 5W9, Canada
| | - Helen Jingshu Jin
- Schulich School of Medicine and Dentistry, 1151 Richmond St, London, ON, N6A 5C1, Canada
| | - Sameer Mal
- Department of Emergency Medicine, London Health Sciences Centre, 800 Commissioners Rd E, London, ON, N6A 5W9, Canada
| | - Jacob Pace
- Department of Emergency Medicine, London Health Sciences Centre, 800 Commissioners Rd E, London, ON, N6A 5W9, Canada
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12
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Robinson AE, Driver BE, Prekker ME, Reardon RF, Horton G, Stang JL, Collins JD, Carlson JN. First attempt success with continued versus paused chest compressions during cardiac arrest in the emergency department. Resuscitation 2023; 186:109726. [PMID: 36764570 DOI: 10.1016/j.resuscitation.2023.109726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 01/31/2023] [Accepted: 02/02/2023] [Indexed: 02/11/2023]
Abstract
AIM Tracheal intubation is associated with interruption in cardiopulmonary resuscitation (CPR). Current knowledge of tracheal intubation during active CPR focuses on the out-of-hospital environment. We aim to describe characteristics of tracheal intubation during active CPR in the emergency department (ED) and determine whether first attempt success was associated with CPR being continued vs paused. MEASUREMENTS We reviewed overhead video from adult ED patients receiving chest compressions at the start of the orotracheal intubation attempt. We recorded procedural detail including method of CPR, whether CPR was continued vs paused, and first attempt intubation success (primary outcome). We performed logistic regression to determine whether continuing CPR was associated with first attempt success. RESULTS We reviewed 169 instances of tracheal intubation, including 143 patients with continued CPR and 26 patients with paused CPR. Those with paused CPR were more likely to be receiving manual rather than mechanical chest compressions. Video laryngoscopy and bougie use were common. First attempt success was higher in the continued CPR group (87%, 95% CI 81% to 92%) than the interrupted CPR group (65%, 95% CI 44% to 83%, difference 22% [95% CI 3% to 41%]). The multivariable model demonstrated an adjusted odds ratio of 0.67 (95% CI 0.17 to 2.60) for first attempt intubation success when CPR was interrupted vs continued. CONCLUSIONS It was common to continue CPR during tracheal intubation, with success comparable to that achieved in patients without cardiac arrest. It is reasonable to attempt tracheal intubation without interrupting CPR, pausing only if necessary.
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Affiliation(s)
- Aaron E Robinson
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN 55404, United States; Department of Emergency Medicine, University of Minnesota Medical School, Minneapolis, MN 55455, United States.
| | - Brian E Driver
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN 55404, United States; Department of Emergency Medicine, University of Minnesota Medical School, Minneapolis, MN 55455, United States
| | - Matthew E Prekker
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN 55404, United States; Department of Emergency Medicine, University of Minnesota Medical School, Minneapolis, MN 55455, United States
| | - Robert F Reardon
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN 55404, United States; Department of Emergency Medicine, University of Minnesota Medical School, Minneapolis, MN 55455, United States
| | - Gabriella Horton
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN 55404, United States
| | - Jamie L Stang
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN 55404, United States; Department of Emergency Medicine, University of Minnesota Medical School, Minneapolis, MN 55455, United States
| | - Jacob D Collins
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN 55404, United States
| | - Jestin N Carlson
- Department of Emergency Medicine, Allegheny Health Network, Pittsburgh, PA 15222, United States
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13
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Göksu E, Yildirim M, El Warea M. Evaluation of endotracheal intubations in the emergency department of a tertiary care facility. Turk J Emerg Med 2023; 23:82-87. [PMID: 37169036 PMCID: PMC10166293 DOI: 10.4103/tjem.tjem_268_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 03/02/2023] [Accepted: 03/06/2023] [Indexed: 03/29/2023] Open
Abstract
OBJECTIVE In this study, we aimed to evaluate the performance of emergency department intubations for 1 year. METHODS This was a retrospective analysis of prospectively collected data. The collected variables were patient demographics, indication for intubation, preintubation hemodynamics, preoxygenation methods, medications used for premedication, induction and paralysis, type of laryngoscope used, Cormack-Lehane (C-L) grades, number of intubation attempts, and peri-intubation adverse events. RESULTS A total of 194 patients were included. The median age of the population was 66.5 years (53.75-79); 61.9% of the patients were male. The majority of the patients were intubated due to medical conditions. The main indication for endotracheal intubation was respiratory failure in 38.6% of the patients. Preoxygenation before intubation was performed in 87.2% of the patients. Fifty-eight percent of the population were hemodynamically stable before the intubation. Fentanyl was the agent used for premedication, induction agents of choice were ketamine and midazolam, and rocuronium was the neuromuscular blocking agent. The C-L grades 1 and 2 were detected in 87.6% of the patients. The first-pass success rate was 72.8%. The peri-intubation adverse events were mainly hypotension and desaturation observed in 82 (42%) patients. The patients with higher C-L grades needed more intubation attempts (P < 0.001). Peri-intubation adverse events were associated with the increased number of intubation attempts (P < 0.001). CONCLUSION This and similar studies or an airway registry on a national level may help improve the quality of service given and delineate the deficiencies of the airway-related procedures in the emergency department.
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14
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Lee GT, Park JE, Woo SY, Shin TG, Jeong D, Kim T, Lee SU, Yoon H, Hwang SY. Defining the learning curve for endotracheal intubation in the emergency department. Sci Rep 2022; 12:14903. [PMID: 36050439 PMCID: PMC9437073 DOI: 10.1038/s41598-022-19337-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 08/29/2022] [Indexed: 11/09/2022] Open
Abstract
To determine the minimum number of endotracheal intubation (ETI) attempts necessary for a novice emergency medicine (EM) trainee to become proficient with this procedure. This single-center study retrospectively analyzed data obtained from the institutional airway registry during the period from April 2014 to March 2021. All ETI attempts made by EM trainees starting their residency programs between 2014 and 2018 were evaluated. We used a first attempt success (FAS) rate of 85% as a proxy for ETI proficiency. Generalized linear mixed models were used to evaluate the association between FAS and cumulative ETI experience. The number of ETI attempts required to achieve an FAS rate of ≥ 85% was estimated using the regression coefficients obtained from the model. The study period yielded 2077 ETI cases from a total of 1979 patients. The FAS rate was 78.6% (n = 1632/2077). After adjusting for confounding factors, the cumulative number of ETI cases was associated with increased FAS (adjusted odds ratio, 1.010 per additional ETI case; 95% confidence interval 1.006-1.013; p < 0.001). A minimum of 119 ETI cases were required to establish a ≥ 85% likelihood of FAS. At least 119 ETI cases were required for EM trainees to achieve an FAS rate of ≥ 85% in the emergency department.
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Affiliation(s)
- Gun Tak Lee
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-Ro, Gangnam-Gu, Seoul, 06351, Korea
- Department of Emergency Medicine, College of Medicine, Kangwon National University, Chuncheon, Gangwon-Do, Korea
| | - Jong Eun Park
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-Ro, Gangnam-Gu, Seoul, 06351, Korea
- Department of Emergency Medicine, College of Medicine, Kangwon National University, Chuncheon, Gangwon-Do, Korea
| | - Sook-Young Woo
- Biomedical Statistics Center, Data Science Research Institute, Samsung Medical Center, Samsung Medical Center, Seoul, Korea
| | - Tae Gun Shin
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-Ro, Gangnam-Gu, Seoul, 06351, Korea
| | - Daun Jeong
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-Ro, Gangnam-Gu, Seoul, 06351, Korea
| | - Taerim Kim
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-Ro, Gangnam-Gu, Seoul, 06351, Korea
| | - Se Uk Lee
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-Ro, Gangnam-Gu, Seoul, 06351, Korea
| | - Hee Yoon
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-Ro, Gangnam-Gu, Seoul, 06351, Korea
| | - Sung Yeon Hwang
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-Ro, Gangnam-Gu, Seoul, 06351, Korea.
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15
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Endlich Y, Hore PJ, Baker PA, Beckmann LA, Bradley WP, Chan KLE, Chapman GA, Jephcott CGA, Kruger PS, Newton A, Roessler P. Updated guideline on equipment to manage difficult airways: Australian and New Zealand College of Anaesthetists. Anaesth Intensive Care 2022; 50:430-446. [PMID: 35722809 DOI: 10.1177/0310057x221082664] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The Australian and New Zealand College of Anaesthetists (ANZCA) recently reviewed and updated the guideline on equipment to manage a difficult airway. An ANZCA-established document development group, which included representatives from the Australasian College for Emergency Medicine and the College of Intensive Care Medicine of Australia and New Zealand, performed the review, which is based on expert consensus, an extensive literature review, and bi-nationwide consultation. The guideline (PG56(A) 2021, https://www.anzca.edu.au/getattachment/02fe1a4c-14f0-4ad1-8337-c281d26bfa17/PS56-Guideline-on-equipment-to-manage-difficult-airways) is accompanied by a detailed background paper (PG56(A)BP 2021, https://www.anzca.edu.au/getattachment/9ef4cd97-2f02-47fe-a63a-9f74fa7c68ac/PG56(A)BP-Guideline-on-equipment-to-manage-difficult-airways-Background-Paper), from which the current recommendations are reproduced on behalf of, and with the permission of, ANZCA. The updated 2021 guideline replaces the 2012 version and aims to provide an updated, objective, informed, transparent, and evidence-based review of equipment to manage difficult airways.
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Affiliation(s)
- Yasmin Endlich
- Department of Anaesthesia and Acute Pain Medicine, Royal Adelaide Hospital, Adelaide, Australia.,Department of Paediatric Anaesthesia, Women's and Children's Hospital, North Adelaide, Australia.,Faculty of Anaesthesia, University of Adelaide, Adelaide, Australia
| | - Phillipa J Hore
- Department of Anaesthesia and Acute Pain Medicine, St Vincent's Hospital, Melbourne, Australia
| | - Paul A Baker
- Department of Anaesthesiology, University of Auckland, Auckland, New Zealand.,Department of Anaesthesia, Starship Children's Hospital, Auckland, New Zealand
| | - Linda A Beckmann
- Department of Anaesthesia and Acute Pain Medicine, Royal Brisbane and Women's Hospital, Herston, Australia
| | - William P Bradley
- Department of Anaesthesia and Perioperative Medicine, The Alfred, Melbourne, Australia.,Faculty of Anaesthesia, Monash University, Melbourne, Australia
| | - Kah L E Chan
- Department of Anaesthesia and Acute Pain Medicine, Royal Brisbane and Women's Hospital, Herston, Australia
| | - Gordon A Chapman
- Department of Anaesthesia, Royal Perth Hospital, Perth, Australia.,Faculty of Anaesthesia, University of Western Australia, Perth, Australia
| | | | - Peter S Kruger
- Department of Intensive Care Medicine, Princess Alexandra Hospital, Brisbane, Australia
| | - Alastair Newton
- Department of Emergency Medicine, The Prince Charles Hospital, Brisbane, Australia.,Retrieval Services Queensland, Brisbane, Australia
| | - Peter Roessler
- Safety and Advocacy Unit, Australian and New Zealand College of Anaesthetists, Melbourne, Australia
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16
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Julliard D, Vassiliadis J, Bowra J, Gillett M, Knipp R, Krishnamohan A, Fogg T. Comparison of supine and upright face-to-face cadaver intubation. Am J Emerg Med 2022; 56:87-91. [DOI: 10.1016/j.ajem.2022.03.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 03/14/2022] [Accepted: 03/15/2022] [Indexed: 11/27/2022] Open
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17
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Umana E, Foley J, Grossi I, Deasy C, O'Keeffe F. National Emergency Resuscitation Airway Audit (NERAA): a pilot multicentre analysis of emergency intubations in Irish emergency departments. BMC Emerg Med 2022; 22:91. [PMID: 35643431 PMCID: PMC9148500 DOI: 10.1186/s12873-022-00644-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 04/18/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND There is paucity of literature on why and how patients are intubated, and by whom, in Irish Emergency Departments (EDs). The aim of this pilot study was to characterise emergency airway management (EAM) of critically unwell patients presenting to Irish EDs. METHODS A multisite prospective pilot study was undertaken from February 10 to May 10, 2020. This project was facilitated through the Irish Trainee Emergency Research Network (ITERN). All patients over 16 years of age requiring EAM were included. Eleven EDs participated in the project. Data recorded included patients' demographics, indication for intubation, technique of airway management, medications used to facilitate intubation, level of training and specialty of the intubating clinician, number of attempts, success/complications rates and variation across centres. RESULTS Over a 3-month period, 118 patients underwent 131 intubation attempts across 11 EDs. The median age was 57 years (IQR: 40-70). Medical indications were reported in 83% of patients compared to 17% for trauma. Of the 118 patients intubated, Emergency Medicine (EM) doctors performed 54% of initial intubations, while anaesthesiology/intensive care medicine (ICM) doctors performed 46%. The majority (90%) of intubating clinicians were at registrar level. Emergency intubation check lists, video laryngoscopy and bougie were used in 55, 53 and 64% of first attempts, respectively. The first pass success rate was 89%. Intubation complications occurred in 19% of patients. EM doctors undertook a greater proportion of intubations in EDs with > 50,000 attendance (65%) compared to EDs with < 50,000 attendances (16%) (p < 0.000). CONCLUSION This is the first study to describe EAM in Irish EDs, and demonstrates comparable first pass success and complication rates to international studies. This study highlights the need for continuous EAM surveillance and could provide a vector for developing national standards for EAM and EAM training in Irish EDs.
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Affiliation(s)
- Etimbuk Umana
- Department of Emergency Medicine, Connolly Hospital Blanchardstown, Mill Road, Abbotstown, Dublin, Ireland.
- Irish Trainee Emergency Research Network (ITERN), Dublin, Ireland.
| | - James Foley
- Irish Trainee Emergency Research Network (ITERN), Dublin, Ireland
- Department of Emergency Medicine, University Hospital Waterford, Waterford, Ireland
| | - Irene Grossi
- Department of Emergency Medicine, University Hospital Limerick, Limerick, Ireland
| | - Conor Deasy
- Irish Trainee Emergency Research Network (ITERN), Dublin, Ireland
- Department of Emergency Medicine, Cork University Hospital, Cork, Ireland
| | - Francis O'Keeffe
- Department of Emergency Medicine, Mater Misericordiae University Hospital, Dublin, Ireland
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18
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Tessarolo E, Alkhouri H, Lelos N, Sarrami P, McCarthy S. Review article: Effectiveness and risks of cricoid pressure during rapid sequence induction for endotracheal intubation in the emergency department: A systematic review. Emerg Med Australas 2022; 34:484-491. [PMID: 35577760 DOI: 10.1111/1742-6723.13993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 02/26/2022] [Accepted: 04/08/2022] [Indexed: 11/28/2022]
Abstract
The use of cricoid pressure (CP) to prevent aspiration during rapid sequence induction (RSI) has become controversial, although CP is considered central to the practice of RSI. There is insufficient research to support its efficacy in reducing aspiration, and emerging concerns it reduces the first-pass success (FPS) of intubation. This systematic review aims to assess the safety and efficacy of CP during RSI in EDs by investigating its effect on FPS and the incidence of complications, including gastric regurgitation and aspiration. A systematic review of four databases was performed for all primary research investigating CP during RSI in EDs. The primary outcome was FPS; secondary outcomes included complications such as gastric regurgitation, aspiration, hypoxia, hypotension and oesophageal intubation. After screening 4208 citations, three studies were included: one randomised controlled trial (n = 54) investigating the incidence of aspiration during the application of CP and two registry studies (n = 3710) comparing the rate of FPS of RSI with and without CP. The results of these individual studies are not sufficient to draw concrete conclusions but do suggest that aspiration occurs regardless of the application of CP, and that FPS is not reduced by the application of CP. There is insufficient evidence to conclude whether applying CP during RSI in EDs affects the rate of FPS or the incidence of complications such as aspiration. Further research in the ED, including introducing CP usage into other existing airway registries, is needed.
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Affiliation(s)
- Ella Tessarolo
- Faculty of Medicine, The University of Notre Dame Australia, Sydney, New South Wales, Australia
| | - Hatem Alkhouri
- Emergency Care Institute, Agency for Clinical Innovation, Sydney, New South Wales, Australia.,Faculty of Medicine, The University of New South Wales, Sydney, New South Wales, Australia
| | - Nicholas Lelos
- Emergency Department, Bankstown Hospital, Sydney, New South Wales, Australia
| | - Pooria Sarrami
- Institute of Trauma and Injury Management, Agency for Clinical Innovation, Sydney, New South Wales, Australia.,South Western Sydney Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
| | - Sally McCarthy
- Faculty of Medicine, The University of New South Wales, Sydney, New South Wales, Australia.,Emergency Department, Prince of Wales Hospital, Sydney, New South Wales, Australia
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19
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Wilhelms SB, Wilhelms DB. Airway management procedures in Swedish emergency department patients - a national retrospective study. BMC Emerg Med 2022; 22:67. [PMID: 35448960 PMCID: PMC9026936 DOI: 10.1186/s12873-022-00627-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 04/12/2022] [Indexed: 11/28/2022] Open
Abstract
Background With the on-going debate about which specialty should be responsible for intubations in the emergency department in mind, the aim of this study was to describe the prevalence of endotracheal intubation and other airway management procedures in emergency department patients in Sweden. Methods All patients registered in the Swedish Intensive Care Registry with admission date from January 1 2013 until June 7 2018 and reported admission type “from the emergency department” or “emergency department” reported in the SAPS3 scoring were included. All patients missing codes for procedures were excluded. Results A total of 110,072 admissions from an emergency department to an ICU were registered during the study period. Of these, 41,619 admissions (37.8%) were excluded due to lack of codes for medical procedures. The remaining 68,453 admissions (62.2%) were included, and 31,888 emergency airway procedures (within 3 h from admission time to the intensive care unit) were registered. Invasive emergency airway procedures were the most common type of airway procedure (n = 23,446), followed by non-invasive airway procedures (n = 8377) and high-flow nasal cannula (n = 880). In 2017 a total of 4720 invasive emergency airway management procedures were registered. Conclusions The frequency of invasive airway management procedures in Swedish EDs is low. With approximately 1.9 million adult ED visits per year, this gives an estimated incidence of 2.4 invasive airway management procedures per thousand ED visits in 2017. Trial registration Not applicable.
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Affiliation(s)
- Susanne B Wilhelms
- Department of Anaesthesia and Intensive Care in Linköping, Linköping, Sweden. .,Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden. .,Department of Clinical Physiology in Linköping, Linköping, Sweden. .,Department of Medical and Health Sciences, Linköping University, Linköping, Sweden.
| | - Daniel B Wilhelms
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden.,Department of Emergency Medicine in Linköping, Linköping, Sweden
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20
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Mousavi SM, Sayyari Doughabadi M, Alamdaran SA, Sadrzadeh SM, Zakeri H, VafadarMoradi E. Diagnostic Accuracy of Suprasternal Versus Subxiphoid Ultrasonography for Endotracheal Intubation. Anesth Pain Med 2022; 12:e118592. [PMID: 35433372 PMCID: PMC8995869 DOI: 10.5812/aapm.118592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Revised: 02/20/2022] [Accepted: 02/20/2022] [Indexed: 11/16/2022] Open
Abstract
Background Airway management is an important skill for emergency physicians, and confirmation of correct endotracheal tube (ETT) placement is a crucial component of airway management. Objectives Due to the occurrence of incorrect ETT positioning in emergency departments, the present study aimed to compare the diagnostic sensitivity of ultrasound using suprasternal and subxiphoid methods for confirming the correct placement of ETT compared to capnography. Methods This cross-sectional study was conducted by examining patients requiring intubation. Ultrasound was performed by two independent emergency medical assistants using two suprasternal and subxiphoid methods to confirm correct ETT placement; the results were then interpreted. To observe the tube passage through the vocal cords, capnography and lung auscultation were applied as the gold standards, and the results of two ultrasound methods were compared. Results A total of 66 patients, who were intubated in the emergency department, participated in this study. The positive and negative predictive values, sensitivity, and specificity of supernatural ultrasound were 96.72%, 80%, 98.33%, and 66.67%, respectively. Also, positive and negative predictive values, sensitivity, and specificity of subxiphoid ultrasound were 97.95%, 29.41%, 80%, and 83.33%, respectively. The diagnostic odds ratios of suprasternal and subxiphoid ultrasounds were 1.026 and 1.024 compared to capnography, respectively. Conclusions Ultrasonography using the suprasternal method was feasible. Considering the high sensitivity and specificity of this method in confirming correct ETT placement, it produced reliable results. Overall, this modality can be used as one of the main methods to verify correct ETT placement in emergency departments.
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Affiliation(s)
- Seyed Mohammad Mousavi
- Department of Emergency Medicine, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Maryam Sayyari Doughabadi
- Department of Emergency Medicine, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Seyed Ali Alamdaran
- Radiology Department, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Sayyed Majid Sadrzadeh
- Department of Emergency Medicine, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Hosein Zakeri
- Department of Emergency Medicine, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Elnaz VafadarMoradi
- Department of Emergency Medicine, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
- Corresponding Author: Department of Emergency Medicine, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.
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21
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Ferguson I, Buttfield A, Burns B, Reid C, Shepherd S, Milligan J, Harris IA, Aneman A. Fentanyl versus placebo with ketamine and rocuronium for patients undergoing rapid sequence intubation in the emergency department: The FAKT study-A randomized clinical trial. Acad Emerg Med 2022; 29:719-728. [PMID: 35064992 PMCID: PMC9314707 DOI: 10.1111/acem.14446] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 11/30/2021] [Accepted: 01/10/2022] [Indexed: 01/21/2023]
Abstract
Objective The objective was to determine whether the use of fentanyl with ketamine for emergency department (ED) rapid sequence intubation (RSI) results in fewer patients with systolic blood pressure (SBP) measurements outside the pre‐specified target range of 100–150 mm Hg following the induction of anesthesia. Methods This study was conducted in the ED of five Australian hospitals. A total of 290 participants were randomized to receive either fentanyl or 0.9% saline (placebo) in combination with ketamine and rocuronium, according to a weight‐based dosing schedule. The primary outcome was the proportion of patients in each group with at least one SBP measurement outside the prespecified range of 100–150 mm Hg (with adjustment for baseline abnormality). Secondary outcomes included first‐pass intubation success, hypotension, hypertension and hypoxia, mortality, and ventilator‐free days 30 days following enrollment. Results A total of 142 in the fentanyl group and 148 in the placebo group commenced the protocol. A total of 66% of patients receiving fentanyl and 65% of patients receiving placebo met the primary outcome (difference = 1%, 95% CI = −10 to 12). Hypotension (SBP ≤ 99 mm Hg) was more common with fentanyl (29% vs. 16%; difference = 13%, 95% CI = 3% to 23%), while hypertension (≥150 mm Hg) occurred more with placebo (69% vs. 55%; difference = 14%, 95% CI = 3 to 24). First‐pass success rate, 30 day mortality, and ventilator‐free days were similar. Conclusions and Relevance There was no difference in the primary outcome between groups, although lower blood pressures were more common with fentanyl. Clinicians should consider baseline hemodynamics and postinduction targets when deciding whether to use fentanyl as a coinduction agent with ketamine.
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Affiliation(s)
- Ian Ferguson
- South West Clinical School University of New South Wales Sydney New South Wales Australia
- Emergency Department Liverpool Hospital Sydney New South Wales Australia
- GSA‐HEMS, NSW Ambulance Bankstown Aerodrome Sydney New South Wales Australia
| | - Alexander Buttfield
- University of Western Sydney Sydney New South Wales Australia
- Campbelltown Hospital Sydney New South Wales Australia
| | - Brian Burns
- GSA‐HEMS, NSW Ambulance Bankstown Aerodrome Sydney New South Wales Australia
- University of Sydney, Discipline of Emergency Medicine Sydney New South Wales Australia
- Northern Beaches Hospital Sydney New South Wales Australia
| | - Cliff Reid
- GSA‐HEMS, NSW Ambulance Bankstown Aerodrome Sydney New South Wales Australia
- University of Sydney, Discipline of Emergency Medicine Sydney New South Wales Australia
- Northern Beaches Hospital Sydney New South Wales Australia
| | - Shamus Shepherd
- Orange Health Service Orange New South Wales Australia
- University of New South Wales Rural Clinical School Orange New South Wales Australia
| | - James Milligan
- Royal North Shore Hospital, St Leonards Sydney New South Wales Australia
- CareFlight Ltd Sydney New South Wales Australia
| | - Ian A. Harris
- South West Clinical School University of New South Wales Sydney New South Wales Australia
- Ingham Institute for Applied Medical Research Liverpool New South Wales Australia
| | - Anders Aneman
- South West Clinical School University of New South Wales Sydney New South Wales Australia
- Intensive Care Unit, Liverpool Hospital Liverpool New South Wales Australia
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22
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Groombridge CJ, Maini A, Johnny C, McCreary D, Kim Y, Smit DV, Fitzgerald M. Randomised controlled trial in cadavers investigating methods for intubation via a supraglottic airway device: Comparison of flexible airway scope guided versus a retrograde technique. Emerg Med Australas 2021; 34:411-416. [PMID: 34837890 DOI: 10.1111/1742-6723.13908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 11/06/2021] [Accepted: 11/09/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE A supraglottic airway device (SAD) may be utilised for rescue re-oxygenation following a failed attempt at endotracheal intubation with direct or video laryngoscopy. However, the choice of subsequent method to secure a definitive airway is not clearly established. The aim of the present study was to compare two techniques for securing a definitive airway via the in-situ SAD. METHODS A randomised controlled trial was undertaken. The population studied was emergency physicians (EPs) attending a cadaveric airway course. The intervention was intubation through a SAD using a retrograde intubation technique (RIT). The comparison was intubation through a SAD guided by a flexible airway scope (FAS). The primary outcome was time to intubation. The trial was registered with ANZCTR.org.au (ACTRN12621000995875). RESULTS Four EPs completed intubations using both methods on four cadavers for a total of 32 experiments. The mean time to intubation was 18.2 s (standard deviation 8.8) in the FAS group compared with 52.9 s (standard deviation 11.7) in the RIT group; a difference of 34.7 s (95% confidence interval 27.1-42.3, P < 0.001). All intubations were completed within 2 min and there were no equipment failures or evidence of airway trauma. CONCLUSION Successful tracheal intubation of cadavers by EPs is achievable, without iatrogenic airway trauma, via a SAD using either a FAS or RIT, but was 35 s quicker with the FAS.
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Affiliation(s)
- Christopher J Groombridge
- National Trauma Research Institute, Melbourne, Victoria, Australia.,Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia.,Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Amit Maini
- National Trauma Research Institute, Melbourne, Victoria, Australia.,Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Cecil Johnny
- National Trauma Research Institute, Melbourne, Victoria, Australia.,Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia
| | - David McCreary
- Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia.,Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Yesul Kim
- National Trauma Research Institute, Melbourne, Victoria, Australia.,Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - De Villiers Smit
- National Trauma Research Institute, Melbourne, Victoria, Australia.,Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Mark Fitzgerald
- National Trauma Research Institute, Melbourne, Victoria, Australia.,Central Clinical School, Monash University, Melbourne, Victoria, Australia
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23
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Sulistio S, Habib H, Mulyana RM, Albar IA. Emergency intubation practices in a tertiary teaching hospital in Jakarta, Indonesia: A prospective observational study. Emerg Med Australas 2021; 34:347-354. [PMID: 34749439 DOI: 10.1111/1742-6723.13890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 10/04/2021] [Accepted: 10/12/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Intubation is an important competency for emergency doctors. Emergency patients are often unstable, with undifferentiated conditions. There is little time to prepare these patients prior to intubation and so ED intubation may differ from intubation in intensive care units and operating theatres. The present study aims to describe the characteristics of emergency intubation after an administrative policy change within a tertiary teaching hospital in Jakarta, allowing non-anaesthetists to perform intubation in the ED. METHODS Prospective data were collected regarding patients of all age groups who were intubated at the ED of Cipto Mangunkusumo General Hospital, Jakarta, from February 2018 to January 2019. Patient characteristics, intubation attempts, medications used, complications, and disposition were recorded in a self-reported airway registry based on the Australian and New Zealand Emergency Department Airway Registry (ANZEDAR) form. RESULTS During the 12-month study period, 231 patients, or 41.5% of ED intubated patients were enrolled in the study, and there were 268 intubation attempts on these enrolled patients. The first-pass success rate was 207 out of 231 patients, or 89.6%, with anaesthetist (88.9%), better than emergency doctors (55.4%). Complications were reported in 51 patients, or 22.0%, with desaturation and hypotension being the most common. Thirty-three patients, or 14.3%, died in the ED before being transferred to another unit. CONCLUSIONS The first-pass success rate is comparable with international data. Non-anaesthetic physicians must improve their experience to achieve a favourable success rate. The data on complications highlight the need for improvement in Indonesian ED intubation practices.
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Affiliation(s)
- Septo Sulistio
- Emergency Department, Cipto Mangunkusumo General Hospital, Jakarta, Indonesia.,Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Hadiki Habib
- Emergency Department, Cipto Mangunkusumo General Hospital, Jakarta, Indonesia.,Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Radi Muharris Mulyana
- Emergency Department, Cipto Mangunkusumo General Hospital, Jakarta, Indonesia.,Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Imamul Aziz Albar
- Emergency Department, Cipto Mangunkusumo General Hospital, Jakarta, Indonesia.,Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
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24
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Miller R, Bell S, TenEyck L, Topping M. A retrospective observational study of critically unwell patients retrieved from Thames Hospital between April 2018 and December 2020. J Prim Health Care 2021; 13:231-237. [PMID: 34588107 DOI: 10.1071/hc21058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 07/20/2021] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION In New Zealand, critically ill patients who present to rural hospitals are typically treated, stabilised and transferred to facilities where more appropriate resources are available. AIM The aim of this study was to describe patients who presented critically unwell and required retrieval from Thames Hospital in the Waikato region. METHODS Notes were reviewed retrospectively for patients who were retrieved from Thames Hospital between 1 April 2018 and 31 December 2020. Patients were excluded if they were retrieved from the offsite birthing centre or their notes were not available to the authors. RESULTS During the study period, 56 patients were retrieved by intensive care teams based at Waikato, Starship or Auckland Hospitals. Patients had a median age of 57 years and most were female (60.7%). Māori patients were over-represented in the retrieval cohort compared with the population presenting to the emergency department (30.4% vs. 20.1%, P < 0.001). We found that 41% of patients presented after-hours when there was only one senior medical officer available on site and 70 procedures were performed, including rapid sequence induction, which was required by 19.6% of patients. DISCUSSION This study describes a population of critically unwell patients who were retrieved from a rural hospital. The key finding is that nearly half of these patients presented after-hours when there was only one senior medical officer available on site. This doctor also has sole responsibility for all other patients in the hospital. We recommend that referral centres streamline the retrieval processes for rural hospitals.
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Affiliation(s)
- Rory Miller
- Thames Hospital, 601 Mackay Street, Thames, New Zealand; and Corresponding author.
| | - Samuel Bell
- Waitemata District Health Board, Auckland, New Zealand
| | - Lisa TenEyck
- Thames Hospital, 601 Mackay Street, Thames, New Zealand
| | - Meg Topping
- University of Otago Christchurch, Christchurch, New Zealand
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25
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Yau SY, Chang YC, Wu MY, Liao SC. Does seniority always correlate with simulated intubation performance? Comparing endotracheal intubation performance across medical students, residents, and physicians using a high-fidelity simulator. PLoS One 2021; 16:e0257969. [PMID: 34559834 PMCID: PMC8462689 DOI: 10.1371/journal.pone.0257969] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 09/14/2021] [Indexed: 02/01/2023] Open
Abstract
Background Endotracheal intubation is crucial in emergency medical care and anaesthesia. Our study employed a high-fidelity simulator to explore differences in intubation success rate and other skills between junior and senior physicians. Methods We examined the performance of 50 subjects, including undergraduate students (UGY), postgraduate trainees (PGY), residents (R), and attending physicians (VS). Each participant performed 12 intubations (i.e. 3 devices x 4 scenarios) on a high-fidelity simulator. Main outcome measures included success rate, time for intubation, force applied on incisor and tongue, and Cormack Lehane grades. Results There was no primary effect of seniority on any outcome measure except success rate and Cormack Lehane grades. However, VS demonstrated shorter duration than medical students using Glidescope and direct laryngoscopy, whereas VS and R applied significantly more force on the incisor in the normal airway and rigid neck scenario respectively. Discussion Seniority does not always correlate with skill perfection in detailed processes. Our study suggests that the use of video laryngoscopy enhances the intubation success rate and speed, but the benefit only accrues to senior learners, whereby they applied more force on the incisor at a single peak under difficult scenarios. These findings are discussed in terms of psychological and cognitive perspectives. Conclusion Speed and safety are essential for high quality critical medical procedures. A tool should be designed and implemented to educate junior physicians with an emphasis on practice and efficiency, which should also contribute to updating senior physicians’ knowledge and competence by providing instant feedback on their performance. This type of fine-grained feedback could serve as a complement to traditional training and provide a sustainable learning model for medical education.
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Affiliation(s)
- Sze-Yuen Yau
- Chang Gung Medical Education Research Center (CGMERC), Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Yu-Che Chang
- Chang Gung Medical Education Research Center (CGMERC), Chang Gung Memorial Hospital, Linkou, Taiwan
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Linkou, Taiwan
- Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Meng-Yu Wu
- Chang Gung Medical Education Research Center (CGMERC), Chang Gung Memorial Hospital, Linkou, Taiwan
- Chang Gung University College of Medicine, Taoyuan, Taiwan
- Department of Cardiac Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Shu-Chen Liao
- Chang Gung Medical Education Research Center (CGMERC), Chang Gung Memorial Hospital, Linkou, Taiwan
- Chang Gung University College of Medicine, Taoyuan, Taiwan
- Department of Emergency Medicine, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan
- * E-mail:
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26
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Freeman J, Alkhouri H, Knipp R, Fogg T, Gillett M. Mapping haemodynamic changes with rapid sequence induction agents in the emergency department. Emerg Med Australas 2021; 34:237-243. [PMID: 34553502 DOI: 10.1111/1742-6723.13867] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 08/27/2021] [Accepted: 08/30/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Patients intubated in the ED are at an increased risk of post-intubation hypotension. However, evidence regarding the most appropriate induction agent is lacking. The present study aims to describe and compare the haemodynamic effect of propofol, ketamine and thiopentone during rapid sequence induction. METHODS This is an observational study using data prospectively collected from the Australian and New Zealand Emergency Department Airway Registry between June 2012 and March 2019. The distribution of induction agents across medical and trauma patients were obtained with descriptive statistics. The relationship between induction agent, dose and change in pre- and post-intubation systolic blood pressure (SBP) was described using multivariable logistic regression. The SBP pre- and post-intubation was the primary measure of haemodynamic stability. RESULTS From the 5063 intubation episodes, 2229 met the inclusion criteria. Of those, 785 (35.2%) patients were induced with thiopentone, 773 (34.7%) with propofol and 671 (30.1%) with ketamine. Of the included population, 396 (17.8%) patients experienced a reduction in pre-intubation SBP exceeding 20%. Both propofol (P = 0.01) and ketamine (P = 0.01) had an independent and dose-dependent association with hypotension, noting that a higher proportion of patients induced with ketamine had a shock index exceeding 0.9. CONCLUSION Propofol was associated with post-intubation hypotension and it is recommended clinicians consider using the lowest effective dose to reduce this risk. Reflecting its perceived haemodynamic stability, patients who received ketamine were more likely to have a higher shock index; however, there was also an association with post-intubation hypotension.
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Affiliation(s)
- Jessica Freeman
- Emergency Department, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Hatem Alkhouri
- Emergency Care Institute, Agency for Clinical Innovation, Sydney, New South Wales, Australia.,Faculty of Medicine, The University of New South Wales, Sydney, New South Wales, Australia
| | - Robert Knipp
- Emergency Department, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Toby Fogg
- Emergency Department, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Mark Gillett
- Emergency Department, Royal North Shore Hospital, Sydney, New South Wales, Australia
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Groombridge CJ, Maini A, Olaussen A, Kim Y, Fitzgerald M, Smit DV. Unintended consequences: The impact of airway management modifications introduced in response to COVID-19 on intubations in a tertiary centre emergency department. Emerg Med Australas 2021; 33:728-733. [PMID: 34080299 PMCID: PMC8209873 DOI: 10.1111/1742-6723.13809] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 04/01/2021] [Accepted: 05/16/2021] [Indexed: 11/27/2022]
Abstract
Objective In response to COVID‐19, we introduced and examined the effect of a raft of modifications to standard practice on adverse events and first‐attempt success (FAS) associated with ED intubation. Methods An analysis of prospectively collected registry data of all ED intubations over a 3‐year period at an Australian Major Trauma Centre. During the first 6 months of the COVID‐19 pandemic in Australia, we introduced modifications to standard practice to reduce the risk to staff including: aerosolisation reduction, comprehensive personal protective equipment for all intubations, regular low fidelity simulation with ‘sign‐off’ for all medical and nursing staff, senior clinician laryngoscopist and the introduction of pre‐drawn medications. Results There were 783 patients, 136 in the COVID‐19 era and 647 in the pre‐COVID‐19 comparator group. The rate of hypoxia was higher during the COVID‐19 era compared to pre‐COVID‐19 (18.4% vs 9.6%, P < 0.005). This occurred despite the FAS rate remaining very high (95.6% vs 93.8%, P = 0.42) and intubation being undertaken by more senior laryngoscopists (consultant 55.9% during COVID‐19 vs 22.6% pre‐COVID‐19, P < 0.001). Other adverse events were similar before and during COVID‐19 (hypotension 12.5% vs 7.9%, P = 0.082; bradycardia 1.5% vs 0.5%, P = 0.21). Video laryngoscopy was more likely to be used during COVID‐19 (95.6% vs 82.5%, P < 0.001) and induction of anaesthesia more often used ketamine (66.9% vs 42.3%, P < 0.001) and rocuronium (86.8% vs 52.1%, P < 0.001). Conclusions This raft of modifications to ED intubation was associated with significant increase in hypoxia despite a very high FAS rate and more senior first laryngoscopist.
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Affiliation(s)
- Christopher J Groombridge
- National Trauma Research Institute, Melbourne, Victoria, Australia.,Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia.,Department of Surgery, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Amit Maini
- National Trauma Research Institute, Melbourne, Victoria, Australia.,Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Alexander Olaussen
- National Trauma Research Institute, Melbourne, Victoria, Australia.,Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia.,Department of Paramedicine, Monash University, Melbourne, Victoria, Australia
| | - Yesul Kim
- National Trauma Research Institute, Melbourne, Victoria, Australia.,Department of Surgery, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Mark Fitzgerald
- National Trauma Research Institute, Melbourne, Victoria, Australia.,Department of Surgery, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - De Villiers Smit
- National Trauma Research Institute, Melbourne, Victoria, Australia.,Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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28
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Alkhouri H, Richards C, Miers J, Fogg T, McCarthy S. Case series and review of emergency front-of-neck surgical airways from The Australian and New Zealand Emergency Department Airway Registry. Emerg Med Australas 2021; 33:499-507. [PMID: 33179449 DOI: 10.1111/1742-6723.13678] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 10/12/2020] [Accepted: 10/16/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND An emergency front-of-neck access (eFONA), also called can't intubate, can't oxygenate (CICO) rescue, is a rare event. Little is known about the performance of surgical or percutaneous airways in EDs across Australia and New Zealand. OBJECTIVE To describe the management of cases resulting in an eFONA, and recorded in The Australian and New Zealand Emergency Department Airway Registry (ANZEDAR). METHODS A retrospective case series and review of ED patients undergoing surgical or percutaneous airways. Data were collected prospectively over 60 months between 2010 and 2015 from 44 participating EDs. RESULTS An eFONA/CICO rescue airway was performed on 15 adult patients: 14 cricothyroidotomies (0.3% of registry intubations) and one tracheostomy. The indication for intubation was 60% trauma and 40% medical aetiologies. The intubator specialty was emergency medicine in eight (53.3%) episodes. Thirteen (86.7%) cricothyroidotomies and the sole tracheostomy (6.7%) were performed at major referral hospitals with 12 (80%) surgical airways out of hours. In four (26.7%) cases, cricothyroidotomy was performed as the primary intubation method. Pre-oxygenation techniques were used in 14 (93.3%) episodes; apnoeic oxygenation in four (26.7%). CONCLUSIONS Most cases demonstrated deviations from standard difficult airway practice, which may have increased the likelihood of performance of a surgical airway, and its increased likelihood out of hours. Our findings may inform training strategies to improve care for ED patients requiring this critical intervention. We recommend further discussion of proposed standard terminology for emergency surgical or percutaneous airways, to facilitate clear crisis communication.
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Affiliation(s)
- Hatem Alkhouri
- Emergency Care Institute, Agency for Clinical Innovation, Sydney, New South Wales, Australia
- Faculty of Medicine, The University of New South Wales, Sydney, New South Wales, Australia
- The Simpson Centre for Health Services Research (SWS Clinical School), The University of New South Wales, Ingham Institute of Applied Medical Research, Sydney, New South Wales, Australia
| | - Clare Richards
- Emergency Care Institute, Agency for Clinical Innovation, Sydney, New South Wales, Australia
- Emergency Department, Gosford Hospital, Gosford, New South Wales, Australia
| | - James Miers
- Emergency Care Institute, Agency for Clinical Innovation, Sydney, New South Wales, Australia
- Emergency Department, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Toby Fogg
- Emergency Department, Royal North Shore Hospital, Sydney, New South Wales, Australia
- CareFlight, Sydney, New South Wales, Australia
| | - Sally McCarthy
- Emergency Care Institute, Agency for Clinical Innovation, Sydney, New South Wales, Australia
- Faculty of Medicine, The University of New South Wales, Sydney, New South Wales, Australia
- Emergency Department, Prince of Wales Hospital, Sydney, New South Wales, Australia
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29
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Driver B, Semler MW, Self WH, Ginde AA, Gandotra S, Trent SA, Smith LM, Gaillard JP, Page DB, Whitson MR, Vonderhaar DJ, Joffe AM, West JR, Hughes C, Landsperger JS, Howell MP, Russell DW, Gulati S, Bentov I, Mitchell S, Latimer A, Doerschug K, Koppurapu V, Gibbs KW, Wang L, Lindsell CJ, Janz D, Rice TW, Prekker ME, Casey JD. BOugie or stylet in patients UnderGoing Intubation Emergently (BOUGIE): protocol and statistical analysis plan for a randomised clinical trial. BMJ Open 2021; 11:e047790. [PMID: 34035106 PMCID: PMC8154972 DOI: 10.1136/bmjopen-2020-047790] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Intubation-related complications are less frequent when intubation is successful on the first attempt. The rate of first attempt success in the emergency department (ED) and intensive care unit (ICU) is typically less than 90%. The bougie, a semirigid introducer that can be placed into the trachea to facilitate a Seldinger-like technique of tracheal intubation and is typically reserved for difficult or failed intubations, might improve first attempt success. Evidence supporting its use, however, is from a single academic ED with frequent bougie use. Validation of these findings is needed before widespread implementation. METHODS AND ANALYSIS The BOugie or stylet in patients Undergoing Intubation Emergently trial is a prospective, multicentre, non-blinded randomised trial being conducted in six EDs and six ICUs in the USA. The trial plans to enrol 1106 critically ill adults undergoing orotracheal intubation. Eligible patients are randomised 1:1 for the use of a bougie or use of an endotracheal tube with stylet for the first intubation attempt. The primary outcome is successful intubation on the first attempt. The secondary outcome is severe hypoxaemia, defined as an oxygen saturation less than 80% between induction until 2 min after completion of intubation. Enrolment began on 29 April 2019 and is expected to be completed in 2021. ETHICS AND DISSEMINATION The trial protocol was approved with waiver of informed consent by the Central Institutional Review Board at Vanderbilt University Medical Center or the local institutional review board at an enrolling site. The results will be submitted for publication in a peer-reviewed journal and presented at scientific conferences. TRIAL REGISTRATION NUMBER ClinicalTrials.gov Registry (NCT03928925).
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Affiliation(s)
- Brian Driver
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA
| | - Matthew W Semler
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Wesley H Self
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Adit A Ginde
- Department of Emergency Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
| | - Sheetal Gandotra
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, The University of Alabama at Birmingham, Birmingham, Alabama, USA
- Pulmonary Section, Birmingham Veteran's Affairs Medical Center, Birmingham, Alabama, USA
| | - Stacy A Trent
- Department of Emergency Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
- Department of Emergency Medicine, Denver Health Medical Center, Denver, Colorado, USA
| | - Lane M Smith
- Department of Emergency Medicine, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
| | - John P Gaillard
- Department of Emergency Medicine, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
| | - David B Page
- Department of Emergency Medicine, The University of Alabama at Birmingham, Birmingham, Alabama, USA
- Department of Medicine, Division of Pulmonary, Allergy & Critical Care Medicine, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Micah R Whitson
- Department of Emergency Medicine, The University of Alabama at Birmingham, Birmingham, Alabama, USA
- Department of Medicine, Division of Pulmonary, Allergy & Critical Care Medicine, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Derek J Vonderhaar
- Department of Pulmonary/Critical Care Medicine, Ochsner Health System, New Orleans, Louisiana, USA
| | - A M Joffe
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington, USA
| | - Jason R West
- Department of Emergency Medicine, Lincoln Medical Center, Bronx, New York, USA
| | - Christopher Hughes
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Janna S Landsperger
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Michelle P Howell
- Department of Emergency Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
| | - Derek W Russell
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, The University of Alabama at Birmingham, Birmingham, Alabama, USA
- Pulmonary Section, Birmingham Veteran's Affairs Medical Center, Birmingham, Alabama, USA
| | - Swati Gulati
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, The University of Alabama at Birmingham, Birmingham, Alabama, USA
- Pulmonary Section, Birmingham Veteran's Affairs Medical Center, Birmingham, Alabama, USA
| | - Itay Bentov
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington, USA
| | - Steven Mitchell
- Department of Emergency Medicine, University of Washington, Seattle, Washington, USA
| | - Andrew Latimer
- Department of Emergency Medicine, University of Washington, Seattle, Washington, USA
| | - Kevin Doerschug
- Department of Internal Medicine, University of Iowa Hospitals and Clinics Pathology, Iowa City, Iowa, USA
| | - Vikas Koppurapu
- Department of Internal Medicine, University of Iowa Hospitals and Clinics Pathology, Iowa City, Iowa, USA
| | - Kevin W Gibbs
- Department of Medicine, Section of Pulmonary, Critical Care, Allergy and Immunologic Disease, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Li Wang
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | - David Janz
- Section of Pulmonary/Critical Care Medicine & Allergy/Immunology, Louisiana State University, New Orleans, Louisiana, USA
| | - Todd W Rice
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Matthew E Prekker
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA
- Department of Medicine, Division of Pulmonary/Critical Care Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA
| | - Jonathan D Casey
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
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Avery P, Morton S, Raitt J, Lossius HM, Lockey D. Rapid sequence induction: where did the consensus go? Scand J Trauma Resusc Emerg Med 2021; 29:64. [PMID: 33985541 PMCID: PMC8116824 DOI: 10.1186/s13049-021-00883-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 04/28/2021] [Indexed: 12/15/2022] Open
Abstract
Background Rapid Sequence Induction (RSI) was introduced to minimise the risk of aspiration of gastric contents during emergency tracheal intubation. It consisted of induction with the use of thiopentone and suxamethonium with the application of cricoid pressure. This narrative review describes how traditional RSI has been modified in the UK and elsewhere, aiming to deliver safe and effective emergency anaesthesia outside the operating room environment. Most of the key aspects of traditional RSI – training, technique, drugs and equipment have been challenged and often significantly changed since the procedure was first described. Alterations have been made to improve the safety and quality of the intervention while retaining the principles of rapidly securing a definitive airway and avoiding gastric aspiration. RSI is no longer achieved by an anaesthetist alone and can be delivered safely in a variety of settings, including in the pre-hospital environment. Conclusion The conduct of RSI in current emergency practice is far removed from the original descriptions of the procedure. Despite this, the principles – rapid delivery of a definitive airway and avoiding aspiration, are still highly relevant and the indications for RSI remain relatively unchanged.
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Affiliation(s)
- Pascale Avery
- Southmead Hospital, North Bristol NHS Trust, Bristol, BS10 5NB, UK.
| | - Sarah Morton
- Essex & Herts Air Ambulance, Flight House, Earls Colne, Colchester, Essex, CO6 2NS, UK
| | - James Raitt
- Thames Valley Air Ambulance Stokenchurch House, Oxford Rd, Stokenchurch, High Wycombe, HP14 3SX, UK
| | | | - David Lockey
- Southmead Hospital, North Bristol NHS Trust, Bristol, BS10 5NB, UK.,Blizard Institute, Queen Mary University, Whitechapel, London, E1 2AT, UK
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Shinohara M, Iwashita M, Abe T, Takeuchi I. Risk factors associated with symptoms of post-extubation upper airway obstruction in the emergency setting. J Int Med Res 2021; 48:300060520926367. [PMID: 32468931 PMCID: PMC7263151 DOI: 10.1177/0300060520926367] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective Post-extubation stridor and hoarseness are important clinical manifestations that indicate laryngeal edema due to intubation. In previous studies the incidence of post-extubation stridor and hoarseness ranged from 1.5% to 26.3% in postoperative patients and patients in the intensive care unit. Female sex and prolonged intubation are reportedly risk factors for post-extubation stridor. However, the risk factors for post-extubation stridor and the appropriate endotracheal tube size in emergency settings remain unknown. This study was performed to identify the risk factors for post-extubation laryngeal edema after emergency intubation. Methods A prospective observational study was conducted in a tertiary emergency medical center/trauma center. The primary outcome was post-extubation stridor and hoarseness. Results During the study period, 482 emergency intubations and 227 extubations were performed in adult patients. In total, 29% of the patients presented symptoms of stridor and/or hoarseness. Female sex (odds ratio, 2.65; 95% confidence interval, 1.21–5.81) and the duration of intubation (odds ratio, 1.18; 95% confidence interval, 1.05–1.32) were associated with stridor and/or hoarseness. Conclusions Patients who undergo emergency intubation have a higher risk of post-extubation upper airway obstruction symptoms than postoperative patients and patients in the intensive care unit, and female sex is associated with these symptoms.
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Affiliation(s)
- Mafumi Shinohara
- Advanced Critical Care and Emergency Center, Yokohama City University Medical Center; Department of Emergency Medicine, Yokohama City University, Yokohama City, Kanagawa, Japan
| | - Masayuki Iwashita
- Advanced Critical Care and Emergency Center, Yokohama City University Medical Center; Department of Emergency Medicine, Yokohama City University, Yokohama City, Kanagawa, Japan
| | - Takeru Abe
- Advanced Critical Care and Emergency Center, Yokohama City University Medical Center; Department of Emergency Medicine, Yokohama City University, Yokohama City, Kanagawa, Japan
| | - Ichiro Takeuchi
- Advanced Critical Care and Emergency Center, Yokohama City University Medical Center; Department of Emergency Medicine, Yokohama City University, Yokohama City, Kanagawa, Japan
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Grant S, Pellatt RA, Shirran M, Sweeny AL, Perez SR, Khan F, Keijzers G. Safety of rapid sequence intubation in an emergency training network. Emerg Med Australas 2021; 33:857-867. [PMID: 33565240 DOI: 10.1111/1742-6723.13742] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 11/18/2020] [Accepted: 01/18/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Rapid sequence intubation (RSI) is a core critical care skill. Emergency medicine trainees are exposed to relatively low numbers of RSIs. We aimed to improve patient outcomes by implementing an RSI checklist, electronic learning and audit, in line with current best evidence. METHODS Prospective observational study of RSIs performed in the EDs of two Queensland hospitals between January 2014 and December 2016. Data collected included: first-pass success (FPS), predicted difficulty, indication for intubation, drugs used, positioning, number of attempts, checklist use and complications. Descriptive statistics and multivariable modelling were used to describe differences in FPS, and complications. RESULTS Six hundred and fifty-five patients underwent RSI with FPS of 86.6%. Complications were reported in 15.9%, mainly hypotension (10.9%) and desaturation (4.0%). FPS improved with bougie use (88.9% vs 73.0% without bougie, P < 0.001) and video-laryngoscopy (88.2% vs 72.9% using standard laryngoscopy, P < 0.001). New desaturation was reduced with apnoeic oxygenation (2.0% vs 22.2%, P < 0.001), bougie use (2.8% vs 8.9%, P < 0.001), checklist use (2.3% vs 22.7%, P < 0.001) and achieving FPS (2.1% vs 16.3%, P < 0.001). Complications were reduced with checklist use (13.3% vs 43.2%, P < 0.001) and apnoeic oxygenation use (3.9% vs 31.1%, P < 0.001). Logistic regression found checklist use was associated with reduced desaturation (OR 0.1, 95% CI 0.04-0.27) and the composite variable of any complication (OR 0.39, 95% CI 0.17-0.89). CONCLUSIONS Implementation of an evidence-based care bundle and audit of practice has created a safe environment for trainees to learn the core critical care skill of RSI. In our setting, checklist use was associated with fewer complications.
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Affiliation(s)
- Steven Grant
- Emergency Department, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Richard Af Pellatt
- Emergency Department, Gold Coast University Hospital, Gold Coast, Queensland, Australia.,LifeFlight Retrieval Medicine, Brisbane, Queensland, Australia.,Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia.,School of Medicine, Griffith University, Gold Coast, Queensland, Australia
| | - Mark Shirran
- Emergency Department, Gold Coast University Hospital, Gold Coast, Queensland, Australia.,School of Medicine, Griffith University, Gold Coast, Queensland, Australia.,Queensland Ambulance Service, Brisbane, Queensland, Australia
| | - Amy L Sweeny
- Emergency Department, Gold Coast University Hospital, Gold Coast, Queensland, Australia.,School of Medicine, Griffith University, Gold Coast, Queensland, Australia
| | - Siegfried R Perez
- Emergency Department, Logan Hospital, Logan City, Queensland, Australia.,Department of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Faisal Khan
- School of Medicine, Griffith University, Gold Coast, Queensland, Australia.,Anaesthetics Department, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Gerben Keijzers
- Emergency Department, Gold Coast University Hospital, Gold Coast, Queensland, Australia.,Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia.,School of Medicine, Griffith University, Gold Coast, Queensland, Australia
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Arnold I, Alkhouri H, Badge H, Fogg T, McCarthy S, Vassiliadis J. Current airway management practices after a failed intubation attempt in Australian and New Zealand emergency departments. Emerg Med Australas 2021; 33:808-816. [PMID: 33543598 DOI: 10.1111/1742-6723.13729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 01/05/2021] [Accepted: 01/10/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The aims of the present study were to describe current airway management practices after a failed intubation attempt in Australian and New Zealand EDs and to explore factors associated with second attempt success. METHODS Data were collected from a multicentre airway registry (The Australian and New Zealand Emergency Department Airway Registry). All intubation episodes that required a second attempt between March 2010 and November 2015 were analysed. Analysis for association with success at the second attempt was undertaken for patient factors including predicted difficulty of laryngoscopy, as well as for changes in laryngoscope type, adjunct devices, intubator and intubating manoeuvres. RESULTS Of the 762 patients with a failed first intubation attempt, 603 (79.1%) were intubated successfully at the second attempt. The majority of second attempts were undertaken by emergency consultants (36.8%) and emergency registrars (34.2%). A change in intubator occurred in 56.5% of intubation episodes and was associated with higher second attempt success (unadjusted odds ratio [OR] 1.85; 95% confidence interval [CI] 1.29-2.65). In 69.7% of second attempts at intubation, there was no change in laryngoscope type. Changes in laryngoscope type, adjunct devices and intubation manoeuvres were not significantly associated with success at the second attempt. In adjusted analyses, second attempt success was higher for a change from a non-consultant intubator to a consultant intubator from any specialty (adjusted OR 2.31; 95% CI 1.35-3.95) and where laryngoscopy was not predicted to be difficult (adjusted OR 2.58; 95% CI 1.58-4.21). CONCLUSIONS The majority of second intubation attempts were undertaken by emergency consultants and registrars. A change from a non-consultant intubator to a consultant intubator of any specialty for the second attempt and intubation episodes where laryngoscopy was predicted to be non-difficult were associated with a higher success rate at intubation. Participation in routine collection and monitoring of airway management practices via a Registry may enable the introduction of appropriate improvements in airway procedures and reduce complication rates.
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Affiliation(s)
- Isaac Arnold
- Faculty of Medicine, The University of New South Wales, Sydney, New South Wales, Australia
| | - Hatem Alkhouri
- Faculty of Medicine, The University of New South Wales, Sydney, New South Wales, Australia.,Emergency Care Institute, Agency for Clinical Innovation, Sydney, New South Wales, Australia.,Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
| | - Helen Badge
- Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia.,School of Allied Health, Faculty of Health Science, Australian Catholic University, Sydney, New South Wales, Australia
| | - Toby Fogg
- Emergency Department, Royal North Shore Hospital, Sydney, New South Wales, Australia.,CareFlight, Sydney, New South Wales, Australia
| | - Sally McCarthy
- Faculty of Medicine, The University of New South Wales, Sydney, New South Wales, Australia.,Emergency Care Institute, Agency for Clinical Innovation, Sydney, New South Wales, Australia.,Emergency Department, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - John Vassiliadis
- Emergency Department, Royal North Shore Hospital, Sydney, New South Wales, Australia.,Discipline of Emergency Medicine, Northern Clinical School, The University of Sydney Medical School, Sydney, New South Wales, Australia
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34
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Law JA, Duggan LV, Asselin M, Baker P, Crosby E, Downey A, Hung OR, Jones PM, Lemay F, Noppens R, Parotto M, Preston R, Sowers N, Sparrow K, Turkstra TP, Wong DT, Kovacs G. Canadian Airway Focus Group updated consensus-based recommendations for management of the difficult airway: part 1. Difficult airway management encountered in an unconscious patient. Can J Anaesth 2021; 68:1373-1404. [PMID: 34143394 PMCID: PMC8212585 DOI: 10.1007/s12630-021-02007-0] [Citation(s) in RCA: 56] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 03/11/2021] [Accepted: 03/14/2021] [Indexed: 02/08/2023] Open
Abstract
PURPOSE Since the last Canadian Airway Focus Group (CAFG) guidelines were published in 2013, the literature on airway management has expanded substantially. The CAFG therefore re-convened to examine this literature and update practice recommendations. This first of two articles addresses difficulty encountered with airway management in an unconscious patient. SOURCE Canadian Airway Focus Group members, including anesthesia, emergency medicine, and critical care physicians, were assigned topics to search. Searches were run in the Medline, EMBASE, Cochrane Central Register of Controlled Trials, and CINAHL databases. Results were presented to the group and discussed during video conferences every two weeks from April 2018 to July 2020. These CAFG recommendations are based on the best available published evidence. Where high-quality evidence was lacking, statements are based on group consensus. FINDINGS AND KEY RECOMMENDATIONS Most studies comparing video laryngoscopy (VL) with direct laryngoscopy indicate a higher first attempt and overall success rate with VL, and lower complication rates. Thus, resources allowing, the CAFG now recommends use of VL with appropriately selected blade type to facilitate all tracheal intubations. If a first attempt at tracheal intubation or supraglottic airway (SGA) placement is unsuccessful, further attempts can be made as long as patient ventilation and oxygenation is maintained. Nevertheless, total attempts should be limited (to three or fewer) before declaring failure and pausing to consider "exit strategy" options. For failed intubation, exit strategy options in the still-oxygenated patient include awakening (if feasible), temporizing with an SGA, a single further attempt at tracheal intubation using a different technique, or front-of-neck airway access (FONA). Failure of tracheal intubation, face-mask ventilation, and SGA ventilation together with current or imminent hypoxemia defines a "cannot ventilate, cannot oxygenate" emergency. Neuromuscular blockade should be confirmed or established, and a single final attempt at face-mask ventilation, SGA placement, or tracheal intubation with hyper-angulated blade VL can be made, if it had not already been attempted. If ventilation remains impossible, emergency FONA should occur without delay using a scalpel-bougie-tube technique (in the adult patient). The CAFG recommends all institutions designate an individual as "airway lead" to help institute difficult airway protocols, ensure adequate training and equipment, and help with airway-related quality reviews.
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Affiliation(s)
- J. Adam Law
- grid.55602.340000 0004 1936 8200Department of Anesthesia, Pain Management and Perioperative Medicine, QEII Health Sciences Centre, Dalhousie University, Halifax Infirmary Site, 1796 Summer Street, Room 5452, Halifax, NS B3H 3A7 Canada
| | - Laura V. Duggan
- grid.28046.380000 0001 2182 2255Department of Anesthesiology and Pain Medicine, The Ottawa Hospital Civic Campus, University of Ottawa, Room B307, 1053 Carling Avenue, Mail Stop 249, Ottawa, ON K1Y 4E9 Canada
| | - Mathieu Asselin
- grid.23856.3a0000 0004 1936 8390Département d’anesthésiologie et de soins intensifs, Université Laval, 2325 rue de l’Université, Québec, QC G1V 0A6 Canada ,grid.411081.d0000 0000 9471 1794Département d’anesthésie du CHU de Québec, Hôpital Enfant-Jésus, 1401 18e rue, Québec, QC G1J 1Z4 Canada
| | - Paul Baker
- grid.9654.e0000 0004 0372 3343Department of Anaesthesiology, Faculty of Medical and Health Science, University of Auckland, Private Bag 92019, Auckland, 1142 New Zealand
| | - Edward Crosby
- grid.28046.380000 0001 2182 2255Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, University of Ottawa, Suite CCW1401, 501 Smyth Road, Ottawa, ON K1H 8L6 Canada
| | - Andrew Downey
- grid.1055.10000000403978434Department of Anaesthesia, Perioperative and Pain Medicine, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Orlando R. Hung
- grid.55602.340000 0004 1936 8200Department of Anesthesia, Pain Management and Perioperative Medicine, QEII Health Sciences Centre, Dalhousie University, 1796 Summer Street, Halifax, NS B3H 3A7 Canada
| | - Philip M. Jones
- grid.39381.300000 0004 1936 8884Department of Anesthesia & Perioperative Medicine, Department of Epidemiology & Biostatistics, Schulich School of Medicine & Dentistry, University of Western Ontario, LHSC- University Hospital, 339 Windermere Rd., London, ON N6A 5A5 Canada
| | - François Lemay
- grid.417661.30000 0001 2190 0479Département d’anesthésiologie, CHU de Québec – Université Laval, Hôtel-Dieu de Québec, 11, Côte du Palais, Québec, QC G1R 2J6 Canada
| | - Rudiger Noppens
- grid.39381.300000 0004 1936 8884Department of Anesthesia & Perioperative Medicine, Schulich School of Medicine & Dentistry, University of Western Ontario, LHSC- University Hospital, 339 Windermere Road, London, ON N6A 5A5 Canada
| | - Matteo Parotto
- grid.17063.330000 0001 2157 2938Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto General Hospital, Toronto, ON Canada ,grid.17063.330000 0001 2157 2938Interdepartmental Division of Critical Care Medicine, University of Toronto, EN 442 200 Elizabeth St, Toronto, ON M5G 2C4 Canada
| | - Roanne Preston
- grid.413264.60000 0000 9878 6515Department of Anesthesia, BC Women’s Hospital, 4500 Oak Street, Vancouver, BC V6H 3N1 Canada
| | - Nick Sowers
- grid.55602.340000 0004 1936 8200Department of Emergency Medicine, QEII Health Sciences Centre, Dalhousie University, 1796 Summer Street, Halifax, NS B3H 3A7 Canada
| | - Kathryn Sparrow
- grid.25055.370000 0000 9130 6822Discipline of Anesthesia, St. Clare’s Mercy Hospital, Memorial University of Newfoundland, 300 Prince Phillip Drive, St. John’s, NL A1B V6 Canada
| | - Timothy P. Turkstra
- grid.39381.300000 0004 1936 8884Department of Anesthesia & Perioperative Medicine, Schulich School of Medicine & Dentistry, University of Western Ontario, LHSC- University Hospital, 339 Windermere Road, London, ON N6A 5A5 Canada
| | - David T. Wong
- grid.17063.330000 0001 2157 2938Department of Anesthesia, Toronto Western Hospital, University Health Network, University of Toronto, 399, Bathurst St, Toronto, ON M5T2S8 Canada
| | - George Kovacs
- grid.55602.340000 0004 1936 8200Department of Emergency Medicine, QEII Health Sciences Centre, Dalhousie University, 1796 Summer Street, Halifax, NS B3H 3A7 Canada
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Roshan R, Dhanapal SG, Joshua V, Madhiyazhagan M, Amirtharaj J, Priya G, Abhilash KP. Aspiration during Rapid Sequence Induction: Prevalence and Risk Factors. Indian J Crit Care Med 2021; 25:140-145. [PMID: 33707890 PMCID: PMC7922444 DOI: 10.5005/jp-journals-10071-23714] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Securing definitive airway with minimal complications is a challenging task for high-volume emergency departments (ED) that deal with patients with compromised airway. Materials and methods We conducted a prospective observational study between September 2019 and March 2020. Cohort of adults presenting to the ED requiring rapid sequence induction (RSI) were recruited to determine the prevalence and risk factors for the development of aspiration pneumonia(AP) in patients intubated in the ED. Results During the study period, a total of 154 patients with a mean age of 44.5 years required RSI in the ED. Male (61%) predominance was noted among the study cohorts. We did not find any association between RSI performed in the ED and the risk of developing AP. The first attempt success rate of RSI was 76.7%, and 33(21.4%) patients had immediate adverse events following RSI. Rescue intubation was required for 11(7.1%) patients. The prevalence of AP following RSI in the ED was 13.4%. Endotracheal tube (ET) aspirate pepsin was positive in 45(29.2%) samples collected. The ET aspirate pepsin assay had low sensitivity (44.44%), specificity (73.53%), positive predictive value (18%), and negative predictive value (91%) in predicting the occurrence of AP. On multivariate logistic regression analysis, male gender (AOR: 7.29, 95%CI: 1.51-35.03, p = 0.013) and diabetes mellitus (AOR: 3.75, 95%CI: 1.23-11.51, p = 0.02) were found to be independent risk factors for developing AP. Conclusion We identified male gender and diabetes mellitus to be independent predictors of risk of developing AP after RSI in the ED. ET aspirate pepsin levels proved to be neither sensitive nor specific in the diagnosis of AP. How to cite this article Roshan R, Sudhakar GD, Vijay J, Mamta M, Amirtharaj J, Priya G, et al. Aspiration during Rapid Sequence Induction: Prevalence and Risk Factors. Indian J Crit Care Med 2021;25(2):140-145.
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Affiliation(s)
- Ramgopal Roshan
- Department of Emergency Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | - Sudhakar G Dhanapal
- Department of Emergency Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | - Vijay Joshua
- Department of Emergency Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | - Mamta Madhiyazhagan
- Department of Emergency Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | - Jayakumar Amirtharaj
- Department of Clinical Biochemistry, Christian Medical College, Vellore, Tamil Nadu, India
| | - Ganesan Priya
- Department of Emergency Medicine, Christian Medical College, Vellore, Tamil Nadu, India
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Latimer AJ, Harrington B, Counts CR, Ruark K, Maynard C, Watase T, Sayre MR. Routine Use of a Bougie Improves First-Attempt Intubation Success in the Out-of-Hospital Setting. Ann Emerg Med 2020; 77:296-304. [PMID: 33342596 DOI: 10.1016/j.annemergmed.2020.10.016] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 09/28/2020] [Accepted: 10/05/2020] [Indexed: 11/25/2022]
Abstract
STUDY OBJECTIVE The bougie is typically treated as a rescue device for difficult airways. We evaluate whether first-attempt success rate during paramedic intubation in the out-of-hospital setting changed with routine use of a bougie. METHODS A prospective, observational, pre-post study design was used to compare first-attempt success rate during out-of-hospital intubation with direct laryngoscopy for patients intubated 18 months before and 18 months after a protocol change that directed the use of the bougie on the first intubation attempt. We included all patients with a paramedic-performed intubation attempt. Logistic regression was used to examine the association between routine bougie use and first-attempt success rate. RESULTS Paramedics attempted intubation in 823 patients during the control period and 771 during the bougie period. The first-attempt success rate increased from 70% to 77% (difference 7.0% [95% confidence interval 3% to 11%]). Higher first-attempt success rate was observed during the bougie period across Cormack-Lehane grades, with rates of 91%, 60%, 27%, and 6% for Cormack-Lehane grade 1, 2, 3, and 4 views, respectively, during the control period and 96%, 85%, 50%, and 14%, respectively, during the bougie period. Intubation during the bougie period was independently associated with higher first-attempt success rate (adjusted odds ratio 2.82 [95% confidence interval 1.96 to 4.01]). CONCLUSION Routine out-of-hospital use of the bougie during direct laryngoscopy was associated with increased first-attempt intubation success rate.
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Affiliation(s)
- Andrew J Latimer
- Department of Emergency Medicine, University of Washington, Seattle, WA; Seattle Fire Department, Seattle, WA.
| | - Brenna Harrington
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Catherine R Counts
- Department of Emergency Medicine, University of Washington, Seattle, WA; Seattle Fire Department, Seattle, WA
| | - Katelyn Ruark
- University of North Dakota College of Medicine, Grand Forks, ND
| | - Charles Maynard
- Department of Health Services, University of Washington, Seattle, WA
| | - Taketo Watase
- Department of Emergency Medicine, University of Washington, Seattle, WA
| | - Michael R Sayre
- Department of Emergency Medicine, University of Washington, Seattle, WA; Seattle Fire Department, Seattle, WA
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Perera A, Alkhouri H, Fogg T, Vassiliadis J, Mackenzie J, Wimalasena Y. Apnoeic oxygenation was associated with decreased desaturation rates during rapid sequence intubation in multiple Australian and New Zealand emergency departments. Emerg Med J 2020; 38:118-124. [PMID: 33298602 DOI: 10.1136/emermed-2019-208424] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 10/19/2020] [Accepted: 10/31/2020] [Indexed: 11/04/2022]
Abstract
Apnoeic oxygenation (ApOx) has been demonstrated to reduce the incidence of desaturation, although evidence of benefit has been conflicting depending on the technique used. The aim of this study was to compare the incidence of desaturation between patients who received ApOx via conventional nasal cannula (NC) and those who did not, using a large, multicentre airway registry. METHODS This study is an analysis of 24 months of prospectively collected data in the Australia and New Zealand Emergency Department Airway Registry (June 2013-June 2015). The registry includes information on all intubated adults from 43 emergency departments. Patients intubated during cardiac arrest (n=393), those who received active ventilation prior to the first intubation attempt (n=486), and where the use of ApOx was not recorded either way (n=312) were excluded. The proportion of patients who desaturated (Sa02 <93) in the group that received ApOx and those that did not were compared. To evaluate the association of ApOx with patient desaturation, a logistic regression model based on factors expected to influence desaturation was performed. RESULTS Of 2519 patients analysed, 1669 (66.3%) received ApOx via NC while 850 (33.7%) did not. Desaturation in the cohort receiving ApOx was 10.4% compared with standard care (no ApOx) 13.7%. ApOx had a protective effect for desaturation (OR 0.71 95% CI 0.53 to 0.95). Single intubation attempt was associated with reduced risk of desaturation of (OR 0.10, 95% CI 0.06 to 0.17); this was increased on second attempt (OR 0.37, 95% CI 0.21 to 0.68). Desaturation was also associated with the physician recording that they had anticipated a difficult airway (OR 1.83, 95% CI 1.34 to 2.48). CONCLUSION This large multicentre registry study provides evidence that ApOx delivered through a conventional NC is associated with a lower incidence of desaturation in patients undergoing rapid sequence intubation. TRIAL REGISTRATION NUMBER ACTRN12613001052729.
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Affiliation(s)
- Adrian Perera
- Intensive Care, Royal Free London NHS Foundation Trust, London, UK
| | - Hatem Alkhouri
- Emergency Care Institute, Agency for Clinical Innovation, Sydney, New South Wales, Australia.,Faculty of Medicine, The University of New South Wales, Sydney, New South Wales, Australia
| | - Toby Fogg
- Emergency Department, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - John Vassiliadis
- Emergency Department, Royal North Shore Hospital, Sydney, New South Wales, Australia.,Medical Education, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - John Mackenzie
- Acute Care Adult and Paediatrics, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Yashvi Wimalasena
- Emergency Medicine, University Hospitals Coventry & Warwickshire NHS Trust, Birmingham, West Midlands, UK.,GSA HEMS, NSW Ambulance Service, Sydney, New South Wales, Australia.,Emergency Department, Lismore Base Hospital, Lismore, New South Wales, Australia
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Dean PN, Hoehn EF, Geis GL, Frey ME, Cabrera‐Thurman MK, Kerrey BT, Zhang Y, Stalets EL, Zackoff MW, Maxwell AR, Pham TM, Lautz AJ. Identification of the Physiologically Difficult Airway in the Pediatric Emergency Department. Acad Emerg Med 2020; 27:1241-1248. [PMID: 32896033 DOI: 10.1111/acem.14128] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 08/27/2020] [Accepted: 09/01/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND The risk factors for peri-intubation cardiac arrest in critically ill children are incompletely understood. The study objective was to derive physiologic risk factors for deterioration during tracheal intubation in a pediatric emergency department (PED). METHODS This was a retrospective cohort study of patients undergoing emergency tracheal intubation in a PED. Using the published literature and expert opinion, a multidisciplinary team developed high-risk criteria for peri-intubation arrest: 1) hypotension, 2) concern for cardiac dysfunction, 3) persistent hypoxemia, 4) severe metabolic acidosis (pH < 7.1), 5) post-return of spontaneous circulation (ROSC), and 6) status asthmaticus. We completed a structured review of the electronic health record for a historical cohort of patients intubated in the PED. The primary outcome was peri-intubation arrest. Secondary outcomes included tracheal intubation success rate, extracorporeal membrane oxygenation (ECMO) activation, and in-hospital mortality. We compared outcomes between patients meeting one or more versus no high-risk criteria. RESULTS Peri-intubation cardiac arrest occurred in 5.6% of patients who met at least one high-risk criterion compared to 0% in patients meeting none (5.6% difference, 95% confidence interval [CI] = 1.0 to 18.1, p = 0.028). Patients meeting at least one criterion had higher rates of any postintubation cardiac arrest in the PED (11.1% vs. 0%, 11.1% difference, 95% CI = 4.1 to 25.3, p = 0.0007), in-hospital mortality (25% vs. 2.3%, 22.7% difference, 95% CI = 11.0 to 38.9, p < 0.0001), ECMO activation (8.3% vs. 0%, 8.3% difference, 95% CI = 2.5 to 21.8, p = 0.004), and lower likelihood of first-pass intubation success (47.2% vs. 66.1%, -18.9% difference, 95% CI = -35.5 to -1.5, p = 0.038), respectively. CONCLUSIONS We have developed criteria that successfully identify physiologically difficult airways in the PED. Children with hypotension, persistent hypoxemia, concern for cardiac dysfunction, severe metabolic acidosis, status asthmaticus or who are post-ROSC are at higher risk for peri-intubation cardiac arrest and in-hospital mortality. Further multicenter investigation is needed to validate our findings.
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Affiliation(s)
- Preston N. Dean
- From the Division of Emergency Medicine Cincinnati Children's Hospital Medical Center CincinnatiOHUSA
- the Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OHUSA
| | - Erin F. Hoehn
- From the Division of Emergency Medicine Cincinnati Children's Hospital Medical Center CincinnatiOHUSA
- the Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OHUSA
- the Division of Emergency Medicine Children's Hospital of Pittsburgh of UPMC Pittsburgh PAUSA
| | - Gary L. Geis
- From the Division of Emergency Medicine Cincinnati Children's Hospital Medical Center CincinnatiOHUSA
- the Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OHUSA
| | - Mary E. Frey
- From the Division of Emergency Medicine Cincinnati Children's Hospital Medical Center CincinnatiOHUSA
| | - Mary K. Cabrera‐Thurman
- From the Division of Emergency Medicine Cincinnati Children's Hospital Medical Center CincinnatiOHUSA
| | - Benjamin T. Kerrey
- From the Division of Emergency Medicine Cincinnati Children's Hospital Medical Center CincinnatiOHUSA
- the Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OHUSA
| | - Yin Zhang
- the Division of Biostatistics and EpidemiologyCincinnati Children's Hospital Medical Center CincinnatiOHUSA
| | - Erika L. Stalets
- the Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OHUSA
- and the Division of Critical Care Medicine Cincinnati Children's Hospital Medical Center Cincinnati OHUSA
| | - Matthew W. Zackoff
- the Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OHUSA
- and the Division of Critical Care Medicine Cincinnati Children's Hospital Medical Center Cincinnati OHUSA
| | - Andrea R. Maxwell
- the Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OHUSA
- and the Division of Critical Care Medicine Cincinnati Children's Hospital Medical Center Cincinnati OHUSA
| | - Tena M. Pham
- and the Division of Critical Care Medicine Cincinnati Children's Hospital Medical Center Cincinnati OHUSA
| | - Andrew J. Lautz
- the Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OHUSA
- and the Division of Critical Care Medicine Cincinnati Children's Hospital Medical Center Cincinnati OHUSA
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Oliver M, Caputo ND, West JR, Hackett R, Sakles JC. Emergency physician use of end-tidal oxygen monitoring for rapidsequence intubation. J Am Coll Emerg Physicians Open 2020; 1:706-713. [PMID: 33145509 PMCID: PMC7593475 DOI: 10.1002/emp2.12260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 09/02/2020] [Accepted: 09/03/2020] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND End-tidal oxygen (ETO2) monitoring is used by anesthesiologists to quantify the efficacy of preoxygenation before intubation but is generally not used in emergency departments (EDs). We have previously published our findings describing preoxygenation practices in the ED during blinded use of ETO2. The purpose of this investigation is to determine whether the unblinded use of ETO2 monitoring led to improvements in preoxygenation during rapid sequence intubation in the ED and also the oxygen device or technique changes that were used to achieve higher ETO2 levels. METHODS We conducted an interventional study at 2 academic EDs in Sydney, Australia and New York City, New York using ETO2 monitoring to investigate the preoxygenation process and effectiveness. We used data collected during a previous descriptive study for the control group, in which care teams in the same 2 EDs were blinded to the ETO2 value. In the study group, clinicians could utilize ETO2 to improve preoxygenation. Following an education process, clinicians were able to choose the method of preoxygenation and the techniques required to attempt to achieve an ETO2 level >85%. The primary outcome was the difference in ETO2 levels at the time of induction between the control and study group and the secondary outcome included the methods that were attempted to improve preoxygenation. RESULTS A convenience sample of 100 patients was enrolled in each group. The median ETO2 level achieved at the time of induction was 80% (interquartile range 61 to 86, overall range 73) in the control group and 90% in the study group (interquartile range 83 to 92, overall range 41); the median difference was 12 (95% confidence interval: 8, 16, P = < 0.001). The majority of oxygen device changes were from non-rebreather mask to bag-valve-mask (BVM) (15%, n = 15) and changes in technique from improvements in mask seal (54%, n = 34). The final device used in the study group was BVM in 87% of cases. CONCLUSIONS In 2 clinical studies of ETO2 in academic EDs, we have demonstrated that the use of ETO2 is feasible and associated with specific and potentially improved approaches to preoxygenation. A clinical trial is needed to further study the impact of ETO2 on the preoxygenation process and the rate of hypoxemia.
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Affiliation(s)
- Matthew Oliver
- Department of Emergency MedicineRoyal Prince Alfred HospitalSydneyAustralia
- Sydney Medical SchoolUniversity of SydneySydneyAustralia
| | | | - Jason R. West
- Department of Emergency MedicineLincoln Medical CenterBronxNew YorkUSA
| | - Robert Hackett
- Department of AnaesthesiaRoyal Prince Alfred HospitalSydneyAustralia
| | - John C. Sakles
- Department of Emergency MedicineUniversity of Arizona College of MedicineArizonaTucsonUSA
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George S, Long E, Gelbart B, Dalziel SR, Babl FE, Schibler A. Intubation practices for children in emergency departments and intensive care units across Australia and New Zealand: A survey of medical staff. Emerg Med Australas 2020; 32:1052-1058. [PMID: 32969150 DOI: 10.1111/1742-6723.13620] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 05/28/2020] [Accepted: 08/06/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Intubation of children in the emergency setting is a high-risk, low incidence event. Standardisation of clinical practice has been hampered by a lack of high-quality evidence to support one technique over another. The aim of the present study is to determine clinician preference in intubation practice of children in EDs and ICUs in Australia and New Zealand to provide baseline information to allow future targeted research focused on improving the safety and efficacy of paediatric emergency airway management. METHODS The present study was a voluntary questionnaire undertaken by medical staff at registrar level or above in EDs and ICUs associated with the Paediatric Research in Emergency Departments International Collaborative (PREDICT) and Australia and New Zealand Intensive Care Society Paediatric Study Group (ANZICS PSG) research networks. Respondents reported on their individual intubation practices, with a focus on pre-oxygenation and apnoeic oxygenation techniques, and the use of video laryngoscopy. RESULTS A total of 502 clinicians were invited to complete the survey between May and October 2018 with 336 (66.9%) responded. There was marked variation in practice between ED clinicians and ICU clinicians in the techniques used for pre-oxygenation, the frequency of use of apnoeic oxygenation and the reported use of video laryngoscopy. CONCLUSIONS Within Australia and New Zealand there is considerable variation in paediatric emergency airway clinical practice, in particular with respect to pre-oxygenation, apnoeic oxygenation and use of video laryngoscopy. Definitive clinical trials are required to best inform clinical practice in this area.
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Affiliation(s)
- Shane George
- Department of Emergency Medicine, Gold Coast University Hospital, Gold Coast, Queensland, Australia.,Department of Children's Critical Care, Gold Coast University Hospital, Gold Coast, Queensland, Australia.,Paediatric Critical Care Research Group, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia.,School of Medicine, Griffith University, Brisbane, Queensland, Australia
| | - Elliot Long
- Department of Emergency Medicine, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics and Centre for Integrated Critical Care, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Ben Gelbart
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics and Centre for Integrated Critical Care, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia.,Paediatric Intensive Care, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Stuart R Dalziel
- Emergency Department, Starship Children's Hospital, Auckland, New Zealand.,Department of Surgery, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand.,Department of Paediatrics Child and Youth Health, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Franz E Babl
- Department of Emergency Medicine, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics and Centre for Integrated Critical Care, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Andreas Schibler
- Paediatric Critical Care Research Group, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia.,Paediatric Intensive Care Unit, Queensland Children's Hospital, Brisbane, Queensland, Australia
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Groombridge C, Maini A, Olaussen A, Kim Y, Fitzgerald M, Mitra B, Smit DV. Impact of a targeted bundle of audit with tailored education and an intubation checklist to improve airway management in the emergency department: an integrated time series analysis. Emerg Med J 2020; 37:576-580. [PMID: 32554746 DOI: 10.1136/emermed-2019-208935] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 04/21/2020] [Accepted: 04/29/2020] [Indexed: 11/04/2022]
Abstract
BACKGROUND Endotracheal intubation (ETI) is a commonly performed but potentially high-risk procedure in the emergency department (ED). Requiring more than one attempt at intubation has been shown to increase adverse events and interventions improving first-attempt success rate should be identified to make ETI in the ED safer. We introduced and examined the effect of a targeted bundle of airway initiatives on first-attempt success and adverse events associated with ETI. METHODS This prospective, interventional cohort study was conducted over a 2-year period at an Australian Major Trauma Centre. An online airway registry was established at the inception of the study to collect information related to all intubations. After 6 months, we introduced a bundle of initiatives including monthly audit, monthly airway management education and an airway management checklist. A time series analysis model was used to compare standard practice (ie, first 6 months) to the postintervention period. RESULTS There were 526 patients, 369 in the intervention group and 157 in the preintervention comparator group. A total of 573 intubation attempts were performed. There was a significant improvement in first-attempt success rates between preintervention and postintervention groups (88.5% vs 94.6%, relative risk 1.07; 95% CI 1.00 to 1.14, p=0.014). After the introduction of the intervention the first-attempt success rate increased significantly, by 13.4% (p=0.006) in the first month, followed by a significant increase in the monthly trend (relative to the preintervention trend) of 1.71% (p<0.001). The rate of adverse events were similar preintervention and postintervention (hypoxia 8.3% vs 8.9% (p=0.81); hypotension 8.3% vs 7.0% (p=0.62); any complication 27.4% vs 23.6% (p=0.35)). CONCLUSIONS This bundle of airway management initiatives was associated with significant improvement in the first-attempt success rate of ETI. The introduction of a regular education programme based on the audit of a dedicated airway registry, combined with a periprocedure checklist is a worthwhile ED quality improvement initiative.
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Affiliation(s)
- Christopher Groombridge
- National Trauma Research Institute, Melbourne, Victoria, Australia .,Emergency & Trauma Centre, Alfred Health, Melbourne, Victoria, Australia.,Monash University, Melbourne, Victoria, Australia.,Trauma Service, Alfred Hospital, Melbourne, Victoria, Australia
| | - Amit Maini
- National Trauma Research Institute, Melbourne, Victoria, Australia.,Emergency & Trauma Centre, Alfred Health, Melbourne, Victoria, Australia.,Monash University, Melbourne, Victoria, Australia
| | | | - Yen Kim
- National Trauma Research Institute, Melbourne, Victoria, Australia.,Monash University, Melbourne, Victoria, Australia
| | - Mark Fitzgerald
- National Trauma Research Institute, Melbourne, Victoria, Australia.,Monash University, Melbourne, Victoria, Australia.,Trauma Service, Alfred Hospital, Melbourne, Victoria, Australia
| | - Biswadev Mitra
- National Trauma Research Institute, Melbourne, Victoria, Australia.,Emergency & Trauma Centre, Alfred Health, Melbourne, Victoria, Australia.,Monash University, Melbourne, Victoria, Australia
| | - De Villiers Smit
- National Trauma Research Institute, Melbourne, Victoria, Australia.,Emergency & Trauma Centre, Alfred Health, Melbourne, Victoria, Australia.,Monash University, Melbourne, Victoria, Australia
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Ghedina N, Alkhouri H, Badge H, Fogg T, McCarthy S. Paediatric intubation in Australasian emergency departments: A report from the ANZEDAR. Emerg Med Australas 2019; 32:401-408. [DOI: 10.1111/1742-6723.13416] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 10/17/2019] [Accepted: 10/18/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Nicole Ghedina
- Emergency DepartmentSt John of God Midland Public Hospital Perth Western Australia Australia
- Royal Flying Doctor Service Western Operations Perth Western Australia Australia
| | - Hatem Alkhouri
- Agency for Clinical InnovationEmergency Care Institute Sydney New South Wales Australia
- Faculty of MedicineThe University of New South Wales Sydney New South Wales Australia
| | - Helen Badge
- Agency for Clinical InnovationEmergency Care Institute Sydney New South Wales Australia
- Faculty of MedicineThe University of New South Wales Sydney New South Wales Australia
| | - Toby Fogg
- Emergency DepartmentRoyal North Shore Hospital Sydney New South Wales Australia
- CareFlight/NSW Ambulance Service Sydney New South Wales Australia
| | - Sally McCarthy
- Emergency DepartmentPrince of Wales Hospital Sydney New South Wales Australia
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Girrbach F, Bercker S, Hinkelbein J. Alternative Hilfsmittel zum Atemwegsmanagement in der Notfallmedizin: Pro und Kontra. Notf Rett Med 2019. [DOI: 10.1007/s10049-019-00658-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Stoecklein HH, Kelly C, Kaji AH, Fantegrossi A, Carlson M, Fix ML, Madsen T, Walls RM, Brown CA. Multicenter Comparison of Nonsupine Versus Supine Positioning During Intubation in the Emergency Department: A National Emergency Airway Registry (NEAR) Study. Acad Emerg Med 2019; 26:1144-1151. [PMID: 31116893 DOI: 10.1111/acem.13805] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 05/11/2019] [Accepted: 05/18/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Head-up positioning for preoxygenation and ramping for morbidly obese patients are well-accepted techniques, but the effect of head-up positioning with full torso elevation for all intubations is controversial. We compared first-pass success, adverse events, and glottic view between supine (SP) and nonsupine (NSP) positioning for emergency department (ED) patients undergoing orotracheal intubation. METHODS We performed a retrospective analysis of prospectively collected data for ED intubations over a 2-year period from 25 participating centers in the National Emergency Airway Registry (NEAR). We compared characteristics and outcomes for adult patients intubated orotracheally in SP and NSP positions with either a direct or video laryngoscope. We report odds ratios (OR) with 95% confidence interval (CI) for categorical variables and interquartile ranges with 95% CI for continuous variables. Our primary outcome was first-attempt intubation success and secondary outcomes were glottic views and peri-intubation adverse events. RESULTS Of 11,480 total intubations, 5.8% were performed in NSP. The NSP group included significantly more obese patients (OR = 2.2 [95% CI = 1.9-2.6]) and patients with a suspected difficult airway (OR = 1.8 [95% CI = 1.6-2.2]). First-pass success (adjusted OR = 1.1 [95% CI = 0.9-1.4]) and overall rate of grade I glottic views (OR = 1.1 [95% CI = 0.9-1.2]) were similar between groups while NSP had a significantly higher rate of grade I views when direct laryngoscopy was employed (OR = 1.27 [95% CI = 1.04-1.54]). NSP was associated with higher odds of any adverse event (OR = 1.4 [95% CI = 1.1-1.7]). CONCLUSIONS ED providers utilized SP in most ED intubations but were more likely to use NSP for patients who were obese or in whom they predicted a difficult airway. We found no differences in first-pass success between groups but total adverse events were more likely in NSP. A randomized trial comparing patient positioning during intubation in the ED is warranted.
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Affiliation(s)
| | | | - Amy H. Kaji
- Department of Emergency Medicine Harbor–UCLA Torrance CA
| | | | - Margaret Carlson
- Division of Emergency Medicine University of Utah Salt Lake City UT
| | - Megan L. Fix
- Division of Emergency Medicine University of Utah Salt Lake City UT
| | - Troy Madsen
- Division of Emergency Medicine University of Utah Salt Lake City UT
| | - Ron M. Walls
- Department of Emergency Medicine Brigham and Women's Hospital Boston MA
| | - Calvin A. Brown
- Department of Emergency Medicine Brigham and Women's Hospital Boston MA
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Mackie S, Moy F, Kamona S, Jones P. Effect of the introduction of C-MAC videolaryngoscopy on first-pass intubation success rates for emergency medicine registrars. Emerg Med Australas 2019; 32:25-32. [PMID: 31257718 DOI: 10.1111/1742-6723.13329] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 05/09/2019] [Accepted: 05/10/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The present study investigated the impact of introducing C-MAC videolaryngoscopy as the standard method of visualising glottic structures on first-pass intubation success of emergency medicine (EM) registrars in a large tertiary academic hospital in New Zealand. METHODS In this retrospective cohort study, all patients receiving attempted orotracheal intubation in Auckland City Hospital ED 1 year prior to and 1 year after the introduction of C-MAC videolaryngoscopy were compared. The primary outcome was first-pass intubation success rates by EM registrars. Secondary outcomes were first-pass success rates by all intubators, and incidence of any complication of intubation. RESULTS There were 163 intubations by EM registrars from June 2015 to August 2017. There was a clinically important and statistically significant improvement in first-pass success from 59.2% (95% confidence interval [CI] 44.1-68.8%) to 85.1% (95% CI 76.0-91.2%, P < 0.001) after the introduction of C-MAC. In multivariate analysis, the independent predictors of success were: Airway Not Predicted Difficult, odds ratio (OR) 2.49 (95% CI 1.06-5.85, P = 0.037); and use of videolaryngoscope, OR 4.49 (95% CI 1.85-10.91, P = 0.001). Overall, complications of intubation improved significantly after introduction of C-MAC (28.9%, 95% CI 19.9-40.0% prior to C-MAC introduction; 16.1%, 95% CI 9.7-25.3% after; P = 0.048). CONCLUSION This is the first published study specifically addressing EM registrar intubation success rates in New Zealand, adding to the existing body of data suggesting that videolaryngoscopy may improve success rates for novice intubators.
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Affiliation(s)
- Stephanie Mackie
- Adult Emergency Department, Auckland City Hospital, Auckland, New Zealand
| | - Fen Moy
- Adult Emergency Department, Auckland City Hospital, Auckland, New Zealand
| | - Sinan Kamona
- Adult Emergency Department, Auckland City Hospital, Auckland, New Zealand
| | - Peter Jones
- Adult Emergency Department, Auckland City Hospital, Auckland, New Zealand.,Department of Surgery, The University of Auckland, Auckland, New Zealand
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Inoue A, Okamoto H, Hifumi T, Goto T, Hagiwara Y, Watase H, Hasegawa K. The incidence of post-intubation hypertension and association with repeated intubation attempts in the emergency department. PLoS One 2019; 14:e0212170. [PMID: 30742676 PMCID: PMC6370241 DOI: 10.1371/journal.pone.0212170] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Accepted: 01/29/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Studies in the non-emergency department (ED) settings have reported the relationships of post-intubation hypertension with poor patient outcomes. While ED-based studies have examined post-intubation hypotension and its sequelae, little is known about, post-intubation hypertension and its risk factors in the ED settings. In this context, we aimed to identify the incidence of post-intubation hypertension in the ED, and to test the hypothesis that repeated intubation attempts are associated with an increased risk of post-intubation hypertension. METHODS This study is a secondary analysis of the data from a multicenter prospective observational study of emergency intubations in 15 EDs from 2012 through 2016. The analytic cohort comprised all adult non-cardiac-arrest patients undergoing orotracheal intubation without pre-intubation hypotension. The primary exposure was the repeated intubation attempts, defined as ≥2 laryngoscopic attempts. The outcome was post-intubation hypertension defined as an increase in systolic blood pressure (sBP) of >20% along with a post-intubation sBP of >160 mmHg. To investigate the association of repeated intubation attempts with the risk of post-intubation hypertension, we fit multivariable logistic regression models adjusting for ten potential confounders and patient clustering within the EDs. RESULTS Of 3,097 patients, the median age was 69 years, 1,977 (64.0%) were men, and 991 (32.0%) underwent repeated intubation attempts. Post-intubation hypertension was observed in 276 (8.9%). In the unadjusted model, the incidence of post-intubation hypertension did not differ between the patients with single intubation attempt and those with repeated attempts (8.5% versus 9.8%, unadjusted P = 0.24). By contrast, after adjusting for potential confounders and patient clustering in the random-effects model, the patients who underwent repeated intubation attempts had a significantly higher risk of post-intubation hypertension (OR, 1.56; 95% CI, 1.11-2.18; adjusted P = 0.01). CONCLUSIONS We found that 8.9% of patients developed post-intubation hypertension, and that repeated intubation attempts were significantly associated with a significantly higher risk of post-intubation hypertension in the ED.
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Affiliation(s)
- Akihiko Inoue
- Department of Emergency and Critical Care Medicine, Hyogo Emergency Medical Center, Kobe, Hyogo, Japan
- Faculty of Medicine, Graduate School of Medicine, Kagawa University, Miki, Kita, Kagawa, Japan
- * E-mail:
| | - Hiroshi Okamoto
- Center for Clinical Epidemiology, St. Luke’s International University, Chuo-ku, Tokyo, Japan
| | - Toru Hifumi
- Emergency and Critical Care medicine, St. Luke's International Hospital, Chuo-ku, Tokyo, Japan
| | - Tadahiro Goto
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Yusuke Hagiwara
- Department of Pediatric Emergency and Critical Care Medicine, Tokyo Metropolitan Children's Medical Center, Fuchu, Tokyo, Japan
| | - Hiroko Watase
- Department of Surgery, University of Washington, Seattle, Washington, United States of America
| | - Kohei Hasegawa
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
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[Systematic analysis of airway registries in emergency medicine]. Anaesthesist 2018; 67:664-673. [PMID: 30105516 DOI: 10.1007/s00101-018-0476-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2018] [Revised: 07/07/2018] [Accepted: 07/16/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND A myriad of publications have contributed to an evidence-based approach to airway management in emergency services and admissions in recent years; however, it remains unclear which international registries on airway management in emergency medicine currently exist and how they are characterized concerning inclusion criteria, patient characteristics and definition of complications. METHODS A systematic literature research was carried out in PubMed with respect to publications from 2007-2017. All publications from airway registries collecting data on prehospital or emergency department (ED) airway management were included. Publications from pediatric intensive care units (PICU) were also included as long as they were the primary place of pediatric emergency care. RESULTS A total of eleven emergency airway registries (EAR) were identified that were primarily concerned with airway management. Furthermore, reported data on emergency airway management were extracted from different, national resuscitation registries. There was only one multinational EAR which exclusively collects data on pediatric emergency airway management (NEAR4KIDS, National Emergency Airway Registry for Kids). Additionally, all emergency department airway registries identified include data on pediatric emergency airway management to varying degrees (0.2-10.5%). Published observation periods were also highly variable with a minimum of 18 months and a maximum of 156 months. The ANZEDAR (Australia and New Zealand Emergency Airway Registry) is currently the largest EAR with data from 43 participating institutions in 2 different countries, while the NEAR III (National Emergency Airway Registry) includes data on 21,374 emergency intubations over a 10-year period and thus has the largest number of emergency interventions. Reported rapid sequence induction (RSI) rates in the registries are between 27.5% and 100%. First-pass success rates vary between 69% and 89%, while the reported use of video laryngoscopy is 0-73%. CONCLUSION This study identified eleven EARs that sometimes widely differed concerning inclusion periods, inclusion criteria, definition of complications and application of newer methods of emergency airway management. Thus, comparability of the reported results and first-pass success rates is only possible to a limited extent. The authors therefore advocate the initiation of an airway registry in emergency medicine in German-speaking countries.
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Kendall MC. Re: Influence of prehospital airway management on neurological outcome in patients transferred to a heart attack centre following out-of-hospital cardiac arrest. Emerg Med Australas 2018; 30:732. [PMID: 30068018 DOI: 10.1111/1742-6723.13128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 06/12/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Mark C Kendall
- Department of Anesthesiology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
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Ferguson I, Alkhouri H, Fogg T, Aneman A. Ketamine use for rapid sequence intubation in Australian and New Zealand emergency departments from 2010 to 2015: A registry study. Emerg Med Australas 2018; 31:205-210. [PMID: 29888875 DOI: 10.1111/1742-6723.13114] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Revised: 05/03/2018] [Accepted: 05/10/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVE This study aimed to quantify the proportion of patients undergoing rapid sequence intubation using ketamine in Australian and New Zealand EDs between 2010 and 2015. METHODS The Australian and New Zealand Emergency Department Airway Registry is a multicentre airway registry prospectively capturing data from 43 sites. Data on demographics and physiology, the attending staff and indication for intubation were recorded. The primary outcome was the annual percentage of patients intubated with ketamine. A logistic regression analysis was conducted to evaluate the factors associated with ketamine use. RESULTS A total of 4658 patients met inclusion criteria. The annual incidence of ketamine use increased from 5% to 28% over the study period (P < 0.0001). In the logistic regression analysis, the presence of an emergency physician as a team leader was the strongest predictor of ketamine use (odds ratio [OR] 1.83, 95% confidence interval [CI] 1.44-2.34). The OR for an increase in one point on the Glasgow Coma Scale was 1.10 (95% CI 1.07-1.12), whereas an increase of 1 mmHg of systolic blood pressure had an OR of 0.98 (95% CI 0.98-0.99). Intubation occurring in a major referral hospital had an OR of 0.68 (95% CI 0.56-0.82), while trauma conferred an OR of 1.38 (95% CI 1.25-1.53). CONCLUSIONS Ketamine use increased between 2010 and 2015. Lower systolic blood pressure, the presence of an emergency medicine team leader, trauma and a higher Glasgow Coma Scale were associated with increased odds of ketamine use. Intubation occurring in a major referral centre was associated with lower odds of ketamine use.
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Affiliation(s)
- Ian Ferguson
- Emergency Medicine Research Unit, Liverpool Hospital, Sydney, New South Wales, Australia.,South Western Sydney Clinical School, The University of New South Wales, Sydney, New South Wales, Australia.,GSA-HEMS, Ambulance Service of New South Wales, Sydney, New South Wales, Australia
| | - Hatem Alkhouri
- Emergency Care Institute, Agency for Clinical Innovation, Sydney, New South Wales, Australia
| | - Toby Fogg
- Emergency Department, Royal North Shore Hospital, Sydney, New South Wales, Australia.,CareFlight, Sydney, New South Wales, Australia
| | - Anders Aneman
- South Western Sydney Clinical School, The University of New South Wales, Sydney, New South Wales, Australia.,Intensive Care Unit, Liverpool Hospital, Sydney, New South Wales, Australia
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Duggan LV, Lockhart SL, Cook TM, O'Sullivan EP, Dare T, Baker PA. The Airway App: exploring the role of smartphone technology to capture emergency front-of-neck airway experiences internationally. Anaesthesia 2018. [DOI: 10.1111/anae.14247] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- L. V. Duggan
- Department of Anesthesiology, Pharmacology and Therapeutics; University of British Columbia; Vancouver Canada
| | - S. L. Lockhart
- Department of Anesthesiology, Pharmacology and Therapeutics; University of British Columbia; Vancouver Canada
| | - T. M. Cook
- Department of Anaesthesia; Royal United Hospitals Bath NHS Foundation Trust; Bath UK
| | - E. P. O'Sullivan
- Department of Anaesthetics; St. James's Hospital; Dublin Republic of Ireland
| | - T. Dare
- Department of Philosophy; Auckland University; Auckland New Zealand
| | - P. A. Baker
- Department of Paediatric Anaesthesia; Starship Children's Health; Auckland New Zealand
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