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Teym A, Melese M, Fenta E, Ayenew T, Fentahun F, Tegegne E, Alamneh AA. Patterns, Clinical Outcome, and Factors Associated with Poisoning Outcomes among Poisoned Patients in Northwest Ethiopia. SAGE Open Nurs 2024; 10:23779608231226081. [PMID: 38222268 PMCID: PMC10785725 DOI: 10.1177/23779608231226081] [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: 04/13/2023] [Revised: 11/19/2023] [Accepted: 12/22/2023] [Indexed: 01/16/2024] Open
Abstract
Introduction Poison is a substance that can hurt or cause dysfunction in the body due to its chemical action. Poisoning related to pesticides used in agriculture is a major public health issue in developing countries. However, there is a limited epidemiological data on poisoning in Ethiopia. Objective The aim of this study was to determine poisoning patterns, clinical outcome, and factors associated with poisoned patients in Northwest Ethiopia. Methods A cross-sectional study was conducted in July 2021 to include data of 1 year period. Data of all poisoned patients were collected using a standardized checklist from the registration book and patient medical records. The association between variables and outcomes was analyzed using a multivariable logistic regression model. A p-value of < 0.05 was considered to declare a statistically significant association. Result Over one-third of the poisoning cases (35.9%) were seen in the spring, according to a survey of 315 patient medical data. The majority of patients were in the age group of 21-30 years (44.1%). The most common form of poison consumed was organophosphate (OP), which accounts for 61.3% of all visits, and the least common was food poisoning, which accounts for 1.9%. About 82.5% of poisoning cases survived, while the remaining 17.5% were died. Time of arrival to the hospital ≥1 h (adjusted odds ratio (AOR) = 7.02; 95% confidence interval (CI): 1.16, 11.40), lack of oxygen support (AOR = 6.64; 95% CI: 3.56-6.78), and lack of adrenaline/dopamine medication (AOR = 3.57; 95% CI: 1.17-5.78) were all substantially linked with death of poisoned cases. Conclusions Three-fourth of poisoning cases survived, while the remaining one-fourth died. Ingestion of OPs is the most prevalent type of poisoning, and most cases are intentional. Delayed arrival ≥1 h, lack of oxygen support, and adrenaline/dopamine treatment were all linked to death. On-time arrival, oxygen assistance, and adrenaline/dopamine treatment in a healthcare setting are all recommended.
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Affiliation(s)
- Abraham Teym
- Department of Environmental Health, College of Medicine and Health Sciences, Debre Markos University, Debre Markos, Ethiopia
| | - Mebrat Melese
- School of Medicine, College of Medicine and Health Sciences, Debre Markos University, Debre Markos, Ethiopia
| | - Enyew Fenta
- School of Medicine, College of Medicine and Health Sciences, Debre Markos University, Debre Markos, Ethiopia
| | - Temesgen Ayenew
- Department of Nursing, College of Health Sciences, Debre Markos University, Debre Markos, Ethiopia
| | - Firehiwot Fentahun
- Department of Public Health, College of Medicine and Health Sciences, Debre Markos University, Debre Markos, Ethiopia
| | - Eniyew Tegegne
- Department of Environmental Health, College of Medicine and Health Sciences, Debre Markos University, Debre Markos, Ethiopia
| | - Alehegn Aderaw Alamneh
- Department of Human Nutrition, College of Medicine and Health Sciences, Debre Markos University, Debre Markos, Ethiopia
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Maguire S, Schmitt PR, Sternlicht E, Kofron CM. Endotracheal Intubation of Difficult Airways in Emergency Settings: A Guide for Innovators. MEDICAL DEVICES-EVIDENCE AND RESEARCH 2023; 16:183-199. [PMID: 37483393 PMCID: PMC10362894 DOI: 10.2147/mder.s419715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 07/05/2023] [Indexed: 07/25/2023] Open
Abstract
Over 400,000 Americans are intubated in emergency settings annually, with indications ranging from respiratory failure to airway obstructions to anaphylaxis. About 12.7% of emergency intubations are unsuccessful on the first attempt. Failure to intubate on the first attempt is associated with a higher likelihood of adverse events, including oxygen desaturation, aspiration, trauma to soft tissue, dysrhythmia, hypotension, and cardiac arrest. Difficult airways, as classified on an established clinical scale, are found in up to 30% of emergency department (ED) patients and are a significant contributor to failure to intubate. Difficult intubations have been associated with longer lengths of stay and significantly greater costs than standard intubations. There exists a wide range of airway management devices, both invasive and noninvasive, which are available in the emergency setting to accommodate difficult airways. Yet, first-pass success rates remain variable and leave room for improvement. In this article, we review the disease states most correlated with intubation, the current landscape of emergency airway management technologies, and the market potential for innovation. The aim of this review is to inspire new technologies to assist difficult airway management, given the substantial opportunity for translation due to two key-value signposts of medical innovation: the potential to decrease cost and the potential to improve clinical outcomes.
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Affiliation(s)
- Samantha Maguire
- Center for Biomedical Engineering, School of Engineering, Brown University, Providence, RI, USA
| | - Phillip R Schmitt
- Center for Biomedical Engineering, School of Engineering, Brown University, Providence, RI, USA
| | - Eliza Sternlicht
- Center for Biomedical Engineering, School of Engineering, Brown University, Providence, RI, USA
| | - Celinda M Kofron
- Center for Biomedical Engineering, School of Engineering, Brown University, Providence, RI, USA
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Li Y, Li J, Zhong L, Zeng Z. Development and Internal Validation of a Prediction Model for Difficult Laryngoscopy Using Ultrasound-Derived Factor in Comatose Patients. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2023; 42:1567-1576. [PMID: 36649198 DOI: 10.1002/jum.16177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 10/19/2022] [Accepted: 12/27/2022] [Indexed: 06/17/2023]
Abstract
OBJECTIVES The distance from skin to the hyoid bone (DSHB) and skin to the anterior commissure of vocal cords (DSAC) are reliable parameters for pre-operative airway ultrasound assessment in awake patients and can be assessed in comatose patients. This study aimed to inspect its feasibility and accuracy in predicting difficult laryngoscopy for comatose patients. METHODS A prospective cohort study included patients with a Glasgow Coma Scale (GCS) of ≤8 who underwent emergency tracheal intubation between November 2019 and August 2020. The outcome was difficult laryngoscopy and classified according to the Cormack-Lehane grading. RESULTS A total of 151 patients were included in the study. Fifty-two (34.4%) patients were categorized as having difficult laryngoscopy. The DSHB add DSAC (hereinafter referred to as the "DSBAC") was superior to either parameter alone in the predictive performance, and the optimal cut-off value was 1.90. To optimize the predictive value, DSBAC (adjusted odds ratio [OR]: 7.76; 95% confidence interval [CI]: 2.88-20.94; P < .001), GCS (adjusted OR: 1.39; 95% CI: 3.93-26.28; P = .039), mandibular retraction (adjusted OR: 8.20; 95% CI: 1.92-35.09; P = .005) and edentulous (adjusted OR: 4.23; 95% CI: 1.40-12.80; P = .011) were included in a multivariable model and constructed a nomogram. Discrimination and calibration statistics were satisfactory, with C-index above 0.80 from both model development and internal validation. CONCLUSIONS Ultrasound-derived factor, DSBAC, can be easily assessed and help predict difficult laryngoscopy among comatose patients. A simple nomogram including only four clinical items exhibited excellent discrimination performance and was useful when comatose patients underwent emergency tracheal intubation.
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Affiliation(s)
- Yueying Li
- Department of Anesthesiology, Meizhou People's Hospital, Meizhou, China
| | - Jingye Li
- Department of Anesthesiology, Meizhou People's Hospital, Meizhou, China
| | - Liping Zhong
- Department of Anesthesiology, Meizhou People's Hospital, Meizhou, China
| | - Zhiwen Zeng
- Department of Anesthesiology, Meizhou People's Hospital, Meizhou, China
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Nagashima K, Hosono H, Watanabe M. Relationship between tracheal intubation and the drugs used by patients with drug overdose due to self-harm. J Pharm Health Care Sci 2022; 8:2. [PMID: 34980270 PMCID: PMC8722335 DOI: 10.1186/s40780-021-00234-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 11/29/2021] [Indexed: 12/04/2022] Open
Abstract
Background Tracheal intubation may be performed in patients with drug overdose due to self-harm; however, the details of the causative drug are unknown. The purpose of this study was to clarify the relationship between drugs or its blood levels of patients with drug overdose and the need for tracheal intubation based on the actual measurement results. Methods From October 2018 to March 2020, 132 patients with drug overdose due to self-harm who were transported to the emergency department (ED) were studied. Patient drugs were measured using gas chromatography–mass spectrometry (GC-MS) and were analyzed on the basis of the GC/MS Forensic Toxicological Database. Logistic analysis was performed by combining patient information and GC-MS information. Results The Glasgow Coma Scale (GCS) and Japan Coma Scale (JCS) efficiently predicted tracheal intubation in patients with drug overdose during transport triage; GCS (cut-off value: 12, area under the curve (AUC): 0.81, 95% confidence interval (CI): 0.71–0.88, sensitivity: 0.85, specificity: 0.71, P < 0.05) and JCS (cut-off value: 3, AUC: 0.74, 95% CI: 0.60–0.84, sensitivity: 0.60, specificity: 0.84, P < 0.05). The drugs detected in all patients with drug overdose in order were benzodiazepine receptor agonists (BZs; 43.9%), anticonvulsants (38.6%), antipsychotics (25.0%), and antidepressants (9.8%). In univariate logistic analysis, antipsychotics (odds ratio (OR) 2.46, 95% CI 1.19–5.20, P < 0.05), anticonvulsants (OR 2.71, 95% CI 1.26–5.98, P < 0.05), and anticonvulsants above alert blood levels (OR 27.8, 95% CI 2.92–264.1, P < 0.05) were significantly associated with tracheal intubation in patients with drug overdose, but not BZs and antidepressants. Also, in multivariate logistic analysis, antipsychotics (OR 2.27, 95% CI 1.07–4.83, P < 0.05), anticonvulsants (OR 2.50, 95% CI 1.14–5.64, P < 0.05) and in multivariate logistic analysis of blood levels, anticonvulsants above the alert blood levels (OR 24.9, 95% CI 2.56–241.6, P < 0.05) were significantly associated with tracheal intubation in patients with drug overdose respectively. Conclusions Logistic analysis revealed that the use of anticonvulsants and antipsychotics were significantly associated with an increased OR in the tracheal intubation of patients with drug overdose due to self-harm.
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Affiliation(s)
- Kazuki Nagashima
- Laboratory of Clinical Pharmaceutics, Faculty of Pharma-Science, Teikyo University, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-8605, Japan.
| | - Hiroyuki Hosono
- Laboratory of Clinical Pharmaceutics, Faculty of Pharma-Science, Teikyo University, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-8605, Japan
| | - Machiko Watanabe
- Laboratory of Clinical Pharmaceutics, Faculty of Pharma-Science, Teikyo University, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-8605, Japan.
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Burket GA, Horowitz BZ, Hendrickson RG, Beauchamp GA. Endotracheal Intubation in the Pharmaceutical-Poisoned Patient: a Narrative Review of the Literature. J Med Toxicol 2021; 17:61-69. [PMID: 32394224 PMCID: PMC7785763 DOI: 10.1007/s13181-020-00779-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 04/08/2020] [Accepted: 04/16/2020] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION Endotracheal intubation (ETI) is an essential component of the supportive care provided to the critically ill patient with pharmaceutical poisoning; however, specific nuances surrounding intubation including techniques and complications in the context of pharmaceutical poisoning have not been well elucidated. DISCUSSION A search of the available literature on ETI in pharmaceutical-poisoned patients was undertaken using Medline, ERIC, Cochrane database, and PsycINFO using the following MeSH and keyword terms: ("toxicology" OR "poisons" OR "drug overdose" OR "poisoning") AND ("intubation, intratracheal" OR "intubation, endotracheal" OR "airway management" OR "respiration, artificial"). A hand-search was also performed when the literature in the above search required additional conceptual clarification, including using the "Similar Articles" feature of PubMed, along with reviewing articles' reference lists that discussed intubation in the context of a poisoning scenario. Articles with any discussion around the ETI process in the context of a pharmaceutical poisoning were then included. Intubation may be performed in patients poisoned with pharmaceuticals in the context of both single and multiple organ dysfunction including central and peripheral nervous system, pulmonary, or cardiovascular toxicity with hemodynamic instability, or localized effects resulting in mechanical airway obstruction. Certain classes of poisonings may require modifications to the standard rapid sequence induction airway management algorithm. CONCLUSIONS ETI is a key component of the supportive care provided to the patient poisoned by a pharmaceutical agent. Clinicians should be aware of the spectrum of toxicities that can necessitate intubation, as well as airway management nuances that are specific to various poisoning presentations.
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Affiliation(s)
- Glenn A Burket
- SCL Health St Mary's Medical Center, 2635 North 7th Street, Grand Junction, CO, 81501, USA
- Mesa County EMS, 215 Rice St, Grand Junction, CO, 81501, USA
| | - B Zane Horowitz
- Oregon Health and Science University, 3181 S.W. Sam Jackson Park Rd, Portland, OR, 97239, USA
- Oregon Poison Center, 3181 S.W. Sam Jackson Park Rd, Portland, OR, 97239, USA
| | - Robert G Hendrickson
- Oregon Health and Science University, 3181 S.W. Sam Jackson Park Rd, Portland, OR, 97239, USA
- Oregon Poison Center, 3181 S.W. Sam Jackson Park Rd, Portland, OR, 97239, USA
| | - Gillian A Beauchamp
- Lehigh Valley Health Network Department of Emergency and Hospital Medicine, Division of Medical Toxicology, USF Morsani College of Medicine, Lehigh Valley Campus, Cedar Crest Boulevard & I-78, Allentown, PA, 18101, USA.
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Mégarbane B, Oberlin M, Alvarez JC, Balen F, Beaune S, Bédry R, Chauvin A, Claudet I, Danel V, Debaty G, Delahaye A, Deye N, Gaulier JM, Grossenbacher F, Hantson P, Jacobs F, Jaffal K, Labadie M, Labat L, Langrand J, Lapostolle F, Le Conte P, Maignan M, Nisse P, Sauder P, Tournoud C, Vodovar D, Voicu S, Claret PG, Cerf C. Management of pharmaceutical and recreational drug poisoning. Ann Intensive Care 2020; 10:157. [PMID: 33226502 PMCID: PMC7683636 DOI: 10.1186/s13613-020-00762-9] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Accepted: 10/09/2020] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Poisoning is one of the leading causes of admission to the emergency department and intensive care unit. A large number of epidemiological changes have occurred over the last years such as the exponential growth of new synthetic psychoactive substances. Major progress has also been made in analytical screening and assays, enabling the clinicians to rapidly obtain a definite diagnosis. METHODS A committee composed of 30 experts from five scientific societies, the Société de Réanimation de Langue Française (SRLF), the Société Française de Médecine d'Urgence (SFMU), the Société de Toxicologie Clinique (STC), the Société Française de Toxicologie Analytique (SFTA) and the Groupe Francophone de Réanimation et d'Urgences Pédiatriques (GFRUP) evaluated eight fields: (1) severity assessment and initial triage; (2) diagnostic approach and role of toxicological analyses; (3) supportive care; (4) decontamination; (5) elimination enhancement; (6) place of antidotes; (7) specificities related to recreational drug poisoning; and (8) characteristics of cardiotoxicant poisoning. Population, Intervention, Comparison, and Outcome (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. Analysis of the literature and formulation of recommendations were then conducted according to the GRADE® methodology. RESULTS The SRLF-SFMU guideline panel provided 41 statements concerning the management of pharmaceutical and recreational drug poisoning. Ethanol and chemical poisoning were excluded from the scope of these recommendations. After two rounds of discussion and various amendments, a strong consensus was reached for all recommendations. Six of these recommendations had a high level of evidence (GRADE 1±) and six had a low level of evidence (GRADE 2±). Twenty-nine recommendations were in the form of expert opinion recommendations due to the low evidences in the literature. CONCLUSIONS The experts reached a substantial consensus for several strong recommendations for optimal management of pharmaceutical and recreational drug poisoning, mainly regarding the conditions and effectiveness of naloxone and N-acetylcystein as antidotes to treat opioid and acetaminophen poisoning, respectively.
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Affiliation(s)
- Bruno Mégarbane
- Department of Medical and Toxicological Critical Care, Federation of Toxicology, Lariboisière Hospital, AP-HP, INSERM MURS-1144, University of Paris, 2 Rue Ambroise Paré, Paris, 75010 France
| | - Mathieu Oberlin
- Emergency Department, HuManiS Laboratory (EA7308), University Hospital, Strasbourg, France
| | - Jean-Claude Alvarez
- Department of Pharmacology and Toxicology, Inserm U-1173, FHU Sepsis, Raymond Poincaré Hospital, AP-HP, Paris-Saclay University, Garches, France
| | - Frederic Balen
- Emergency Department, Toulouse University Hospital, Toulouse, France
| | - Sébastien Beaune
- Department of Emergency Medicine, Ambroise Paré Hospital, AP-HP, INSERM UMRS-1144, Paris-Saclay University, Boulogne-Billancourt, France
| | - Régis Bédry
- Hospital Secure Unit, Pellegrin University Hospital, Bordeaux, France
| | - Anthony Chauvin
- Emergency Department, Hôpital Lariboisière, AP-HP, Paris, France
| | - Isabelle Claudet
- Pediatric Emergency Department Children’s Hospital CHU Toulouse, Toulouse, France
| | - Vincent Danel
- Department of Emergency Medicine, University Hospital of Grenoble, Grenoble, France
| | - Guillaume Debaty
- 5525, University Grenoble Alps/CNRS/CHU de Grenoble Alpes/TIMC-IMAG UMR, Grenoble, France
| | | | - Nicolas Deye
- Department of Medical and Toxicological Critical Care, Federation of Toxicology, Lariboisière Hospital, AP-HP, INSERM U942, University of Paris, Paris, France
| | - Jean-Michel Gaulier
- Laboratory of Toxicology, EA 4483 - IMPECS - IMPact de L’Environnement Chimique Sur La Santé Humaine, University of Lille, Lille, France
| | | | - Philippe Hantson
- Intensive Care Department, Cliniques Universitaires St-Luc, Brussels, Belgium
| | - Frédéric Jacobs
- Polyvalent Intensive Care Unit, Antoine Béclère Hospital, Assistance Publique-Hôpitaux de Paris, Paris-Sud University, Clamart, France
| | - Karim Jaffal
- Department of Medical and Toxicological Critical Care, Federation of Toxicology, Lariboisière Hospital, AP-HP, INSERM MURS-1144, University of Paris, 2 Rue Ambroise Paré, Paris, 75010 France
| | - Magali Labadie
- Poison Control Centre of Bordeaux, University Hospital of Bordeaux, Bordeaux, France
| | - Laurence Labat
- Laboratory of Toxicology, Federation of Toxicology APHP, Lariboisière Hospital, INSERM UMRS-1144, University of Paris, Paris, France
| | - Jérôme Langrand
- Poison Control Center of Paris, Federation of Toxicology, Fernand-Widal-Lariboisière Hospital, AP-HP, INSERM UMRS-1144, University of Paris, Paris, France
| | - Frédéric Lapostolle
- SAMU 93-UF Recherche-Enseignement-Qualité, Inserm, U942, Avicenne Hospital, AP-HP, Paris-13 University, Bobigny, France
| | - Philippe Le Conte
- Department of Emergency Medicine, University Hospital of Nantes, Nantes, France
| | - Maxime Maignan
- Emergency Department, Grenoble University Hospital, INSERM U1042, Grenoble Alpes University, Grenoble, France
| | - Patrick Nisse
- Poison Control Centre, University Hospital of Lille, Lille, France
| | - Philippe Sauder
- Intensive Care Unit, University Hospital of Strasbourg, Strasbourg, France
| | | | - Dominique Vodovar
- Poison Control Center of Paris, Federation of Toxicology, Fernand-Widal-Lariboisière Hospital, AP-HP, INSERM UMRS-1144, University of Paris, Paris, France
| | - Sebastian Voicu
- Department of Medical and Toxicological Critical Care, Federation of Toxicology, Lariboisière Hospital, AP-HP, INSERM MURS-1144, University of Paris, 2 Rue Ambroise Paré, Paris, 75010 France
| | - Pierre-Géraud Claret
- Department of Anesthesia Resuscitation Pain Emergency Medicine, Nîmes University Hospital, Nîmes, France
| | - Charles Cerf
- Intensive Care Unit, Foch Hospital, Suresnes, France
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Abstract
How to cite this article: Chandran J, Krishna B. Initial Management of Poisoned Patient. Indian J Crit Care Med 2019;23(Suppl 4):S234-S240.
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Affiliation(s)
- Jagadish Chandran
- Department of Critical Care Medicine, St. John's Medical College and Hospital, Bengaluru, Karnataka, India
| | - Bhuvana Krishna
- Department of Critical Care Medicine, St. John's Medical College and Hospital, Bengaluru, Karnataka, India
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Poisonings Associated with Intubation: US National Poison Data System Exposures 2000-2013. J Med Toxicol 2017; 12:157-64. [PMID: 26646419 DOI: 10.1007/s13181-015-0528-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Patients may be intubated after exposure to a variety of substances because of respiratory failure, CNS sedation, pulmonary pathology, or cardiovascular instability. However, there is little data describing the types of substances that are associated with endotracheal intubation or the rates of intubation after these exposures. Evaluation of this association may inform future research on intubation after exposures to specific substances and guide poison prevention education. Our objective was to determine which exposures were commonly associated with intubation using the data from National Poison Data System (NPDS). The NPDS tracks data from potential exposures to substances reported to all American Association of Poison Control Centers. We performed a retrospective analysis of NPDS data from January 1st, 2000 to December 31st, 2013 to identify human exposures to substances that were associated with endotracheal intubation. Descriptive statistics were used to analyze the data. There were 93,474 single substance exposures and 228,507 multiple substance exposures that were associated with intubation. The most common exposures to substances that were associated with intubation were atypical antipsychotics (7.4 %) for single exposures and benzodiazepines (27.4 %) for multiple exposures. Within each age group, the most common known exposures to substances were for patients under 6 years, clonidine for single and multiple exposures; for patients aged 6-12 years, clonidine for single exposures and atypical antipsychotics for multiple exposures; for patients aged 13-19 years, atypical antipsychotics for single and multiple exposures; and for patients over 19 years, atypical antipsychotics for single exposures and benzodiazepines for multiple exposures. From 2000-2013, the exposures to substances most commonly associated with intubation varied by single versus multiple exposures and by age. This study helps clarify the exposures to substances that are associated with intubation reported to poison centers in the USA.
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Hua A, Haight S, Hoffman RS, Manini AF. Endotracheal Intubation after Acute Drug Overdoses: Incidence, Complications, and Risk Factors. J Emerg Med 2017; 52:59-65. [PMID: 27717590 PMCID: PMC5203803 DOI: 10.1016/j.jemermed.2016.07.114] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Revised: 07/22/2016] [Accepted: 07/29/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Drug overdose is the leading cause of injury-related fatality in the United States, and respiratory failure remains a major source of morbidity and mortality. OBJECTIVES We aimed to identify the incidence and risk factors for endotracheal intubation after acute drug overdose. METHODS This secondary data analysis was performed on a 5-year prospective cohort at two urban tertiary-care hospitals. The present study analyzed adult patients with suspected acute drug overdose to derive independent clinical predictors of endotracheal intubation. RESULTS We analyzed 2497 patients with acute drug overdose, of whom 87 (3.5%) underwent endotracheal intubation. Independent clinical risk factors for endotracheal intubation were: younger age (odds ratio [OR] 0.97, 95% confidence interval [CI] 0.96-0.98), and history of obstructive lung disease (OR 6.6, 95% CI 3.5-12.3); however, heart failure had no association. Patients with obstructive lung disease had significantly more hypercapnia (mean difference 6.8 mm Hg, 95% CI 2.3-11.3) and a higher degree of acidemia (mean pH difference 0.04, 95% CI 0.01-0.07) than patients without obstructive lung disease. Lack of rapid sequence sedative/paralytic was associated with in-hospital fatality. Early complications of endotracheal intubation itself included desaturation (3.4%) and bradycardia (1%). CONCLUSIONS Endotracheal intubation was infrequently performed on patients with acute drug overdose, and complications were rare when performed. Risk factors associated with endotracheal intubation included younger age and prior obstructive lung disease.
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Affiliation(s)
- Angela Hua
- Emergency Medicine Residency, Icahn School of Medicine at Mount Sinai, NY, NY, USA
| | - Stephen Haight
- University at Buffalo School of Medicine and Biomedical Sciences, Buffalo, NY, USA
| | - Robert S. Hoffman
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, NYU School of Medicine, NY, NY, USA
| | - Alex F. Manini
- Division of Medical Toxicology, Icahn School of Medicine at Mount Sinai, Elmhurst Hospital Center, NY, NY, USA
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Beauchamp GA, Hendrickson RG, Hatten BW. Endotracheal Intubation for Toxicologic Exposures: A Retrospective Review of Toxicology Investigators Consortium (ToxIC) Cases. J Emerg Med 2016; 51:382-388.e11. [PMID: 27480352 DOI: 10.1016/j.jemermed.2016.05.056] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2016] [Revised: 04/30/2016] [Accepted: 05/06/2016] [Indexed: 01/21/2023]
Abstract
BACKGROUND Endotracheal intubation remains a cornerstone of early resuscitation of the poisoned patient, but little is known about which substances are associated with intubation. OBJECTIVES Our objective was to describe patient exposures to substances reported to the American College of Medical Toxicology (ACMT) Toxicology Investigators Consortium (ToxIC) that were managed with intubation between 2010 and 2014. METHODS We performed a retrospective review of cases managed with endotracheal intubation in the ACMT ToxIC Registry from January 1, 2010 through December 31, 2014. Descriptive statistics were used to describe patient exposures. RESULTS A total of 2724 exposures to substances were managed with endotracheal intubation. Intubated patients were 52% male and 82% adults. For all ages taken together, the most common known single-substance exposures managed with intubation were sedative hypnotics (9.8%), antidepressants (8.7%), and opioids (8.0%). The most common single ingestions associated with intubation in various age groups were: opioids (<2 years old), alpha-2 agonists (2-6 years old), antidepressants (7-18 years old), sedative-hypnotics (19-65 years old), and cardiac medications (>65 years old). Multiple substances were involved in 29.0% of exposures. Decontamination and elimination processes were used in 12.8% of patients. CONCLUSIONS The most common substances involved in single- and multiple-substance exposures managed with intubation varied by age group. Most patients were managed with supportive care. Knowledge of substances commonly involved in exposures managed with intubation may inform triage and resource planning in the emergency department resuscitation of critically ill poisoned patients.
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Affiliation(s)
- Gillian A Beauchamp
- Oregon and Alaska Poison Center, Oregon Health & Science University Hospital, Portland, Oregon
| | - Robert G Hendrickson
- Oregon and Alaska Poison Center, Oregon Health & Science University Hospital, Portland, Oregon
| | - Benjamin W Hatten
- Section of Medical Toxicology, Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado; Rocky Mountain Poison and Drug Center, Denver Health and Hospital Authority, Denver, Colorado
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[Sedation and analgesia in emergency structure. Which sedation and/or analgesia for tracheal intubation?]. ACTA ACUST UNITED AC 2012; 31:313-21. [PMID: 22440814 DOI: 10.1016/j.annfar.2012.01.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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12
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Early laryngeal injury and complications because of endotracheal intubation in acutely poisoned patients: a prospective observational study. Clin Toxicol (Phila) 2010; 48:331-6. [PMID: 20507244 DOI: 10.3109/15563651003801117] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Tracheal intubation may represent a life-saving supportive measure in many acutely poisoned patients. Although considered as a safe procedure, intubation may rapidly damage laryngeal mucosa. The incidence and nature of short-duration intubation-associated laryngeal injuries are unknown in the population of poisoned patients. METHODS We designed a prospective clinical investigation to study intubation-related laryngeal complications in poisonings. All consecutive intubated poisoned patients admitted over a 20-month period in our toxicological intensive care unit in a teaching hospital were included in this study. Daily clinical observation and laryngeal fiberscopic evaluation were performed to assess intubation-related laryngeal complications. RESULTS We included 266 consecutive poisoned patients who had been intubated [116M/150F; age 41 years (31-53); median (25-75% percentiles); simplified acute physiology score II 43 (32-51); intubation time 24 h (13-52)]. Intubation was mainly performed at the scene (69%) and depended on the level of coma (89%). Complications included postextubation laryngeal dyspnea (9%) requiring mandatory reintubation (2%). Laryngoscopy was performed in 209 patients (79%) within 24 h after extubation. Eighty percent of patients presented significant initial laryngeal lesions. Stepwise logistic regression showed that two variables were predictive of injuries: female gender (odds ratio: 2.6; 95% confidence interval: 1.3-5.3) and intubation time > or =72 h (odds ratio: 6.4; confidence interval: 1.5-27.6). Overall, injuries were independent of age, severity of illness, coma level, vital signs, intoxicants, and intubation modalities. The most severe injuries were significantly associated with intubation time (p < 0.001) and simplified acute physiology score II (p = 0.04). Within 24 h following extubation, persistent dysphonia (p < 0.0001), dysphagia (p < 0.0001), or pharyngeal pain (p = 0.02) were predictive of laryngeal injury. CONCLUSIONS Despite short-duration intubation, poisoned patients are at high risk of initial laryngeal injury.
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13
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Rusan M, Sende J, Dhonneur G, Jabre P, Chollet-Xémard C, Margenet A, Marty J, Combes X. Enquête nationale sur la prise en charge de l’intubation difficile en médecine d’urgence préhospitalière. ACTA ACUST UNITED AC 2009; 28:302-6. [DOI: 10.1016/j.annfar.2009.01.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2008] [Accepted: 01/28/2009] [Indexed: 10/21/2022]
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14
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Sam KG, Kondabolu K, Pati D, Kamath A, Pradeep Kumar G, Rao PGM. Poisoning severity score, APACHE II and GCS: effective clinical indices for estimating severity and predicting outcome of acute organophosphorus and carbamate poisoning. J Forensic Leg Med 2009; 16:239-47. [PMID: 19481704 DOI: 10.1016/j.jflm.2008.12.004] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2007] [Revised: 09/23/2008] [Accepted: 12/09/2008] [Indexed: 11/25/2022]
Abstract
Self-poisoning with organophosphorus (OP) compounds is a major cause of morbidity and mortality across South Asian countries. To develop uniform and effective management guidelines, the severity of acute OP poisoning should be assessed through scientific methods and a clinical database should be maintained. A prospective descriptive survey was carried out to assess the utility of severity scales in predicting the outcome of 71 organophosphate (OP) and carbamate poisoning patients admitted during a one year period at the Kasturba Hospital, Manipal, India. The Glasgow coma scale (GCS) scores, acute physiology and chronic health evaluation II (APACHE II) scores, predicted mortality rate (PMR) and Poisoning severity score (PSS) were estimated within 24h of admission. Significant correlation (P<0.05) between PSS and GCS and APACHE II and PMR scores were observed with the PSS scores predicting mortality significantly (P< or =0.001). A total of 84.5% patients improved after treatment while 8.5% of the patients were discharged with severe morbidity. The mortality rate was 7.0%. Suicidal poisoning was observed to be the major cause (80.2%), while other reasons attributed were occupational (9.1%), accidental (6.6%), homicidal (1.6%) and unknown (2.5%) reasons. This study highlights the application of clinical indices like GCS, APACHE, PMR and severity scores in predicting mortality and may be considered for planning standard treatment guidelines.
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Affiliation(s)
- Kishore Gnana Sam
- Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal, Karnataka, India.
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15
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Intubation difficile : quelles techniques d’anesthésie ? Place en fonction du contexte. ACTA ACUST UNITED AC 2008; 27:26-32. [DOI: 10.1016/j.annfar.2007.10.024] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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16
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Jérémie N, Seltzer S, Lenfant F, Ricard-Hibon A, Facon A, Cabrita B, Messant I, d'Athis P, Freysz M. Rapid sequence induction: a survey of practices in three French prehospital mobile emergency units. Eur J Emerg Med 2006; 13:148-55. [PMID: 16679879 DOI: 10.1097/01.mej.0000209052.85881.e2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES This prospective study was conducted in three mobile emergency and intensive care units. METHODS The patients were over 15 years of age and were not in cardiac arrest. The study was to compare practices in the three units with the guidelines drawn up by the Commission of Experts so as to define the main parameters for quality assurance. All of the patients involved were considered to have full stomachs and required rapid sequence induction. RESULTS This procedure comply the guidelines only in 45% of cases; in the other cases succinylcholine should have been administered (mobile emergency and intensive care unit A) and the Sellick manoeuvre should have been used (mobile emergency and intensive care unit A and B). Notwithstanding, these two centres treated more traumatized patients than mobile emergency and intensive care unit C, and use of the Sellick manoeuvre in such circumstances is questionable. CONCLUSIONS More training and greater diffusion of the protocols are required, especially with regard to doctors who intervene intermittently.
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Affiliation(s)
- Nicolas Jérémie
- Département d'Anesthésie Réanimation, SAMU 21, Hôpital Général, Dijon Cedex, France
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17
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Levitan RM, Everett WW, Ochroch EA. Limitations of difficult airway prediction in patients intubated in the emergency department. Ann Emerg Med 2004; 44:307-13. [PMID: 15459613 DOI: 10.1016/j.annemergmed.2004.05.006] [Citation(s) in RCA: 86] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
STUDY OBJECTIVE Physiognomic assessment of difficult laryngoscopy before rapid sequence intubation has been advocated for all emergency department (ED) intubations. The study objectives were to evaluate whether Mallampati scores, thyromental distance, and neck mobility could have been assessed in non-cardiac arrest ED-intubated patients and determine whether such tests would have been feasible in our rapid sequence intubation-associated laryngoscopy failures. METHODS We retrospectively reviewed 37 months of ED intubations using prospectively collected data from electronic medical records, critical care flow sheets, and a trauma registry. All non-cardiac arrest ED-intubated patients were included for analysis. Mallampati scoring was deemed unobtainable if patients could not follow simple commands. Neck mobility and thyromental measurement were deemed unobtainable with cervical spine precautions. RESULTS Eight hundred fifty intubations met the inclusion criteria, and 838 patients underwent rapid sequence intubation. Laryngoscopy failed in 3 patients who underwent rapid sequence intubation. Eight patients had awake nasal intubation, and 4 oral intubations were done without rapid sequence intubation. Four hundred fifty-two (53%) patients could not follow simple commands, and cervical spine immobilization was present in 370 (44%) patients. Only 32% of patients could follow simple commands and were not cervical spine immobilized. Among the 3 rapid sequence intubation laryngoscopy failures, no patients were following commands. CONCLUSION Mallampati scoring, neck mobility testing, and measurement of thyromental distance could have been done in only one third of our non-cardiac arrest ED intubations and in none of the rapid sequence intubation failures. The inability to widely obtain these assessment tools, coupled with the low incidence of failed rapid sequence intubation, indicates limitations to using these screening tests in the ED setting.
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Affiliation(s)
- Richard M Levitan
- Department of Emergency Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA.
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Ricard-Hibon A, Chollet C, Belpomme V, Duchateau FX, Marty J. Epidemiology of adverse effects of prehospital sedation analgesia. Am J Emerg Med 2003; 21:461-6. [PMID: 14574652 DOI: 10.1016/s0735-6757(03)00095-0] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The aim of this study was to introduce a continuous monitoring of side effects related to sedation-analgesia in the field. A document was completed by physicians on board the ambulances for all prehospital interventions and checked daily by the medical staff. A total of 3605 interventions were evaluated over a 12-month period. Six hundred four patients undertook analgesia and/or sedation: group 1 (spontaneously breathing patients) n = 289 and group 2 (intubated-ventilated patients) n = 315. Sixty-four percent of patients received intravenous opioids in group 1. The anesthetic technique used for intubation was the rapid sequence induction in 70% of patients. Side effects were observed in 5.5% in group 1 (nausea: 2%, hypotension: 1%, hypoxemia: 1%) and 22% of patients in group 2 (hypotension-arrhythmia: 12%, cardiac arrest: 2%, difficult intubation: 5%, hypoxemia: 1%, pulmonary aspiration: 1%, laryngospasm/bronchospasm: 2%). No death was related to these medications. A close monitoring of side effects related to sedation-analgesia must be included in a quality program to improve patient safety in the field.
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Affiliation(s)
- Agnes Ricard-Hibon
- Department of Anesthesiology and Intensive Care, Beaujon University Hospital, 100 bd du Général Leclerc, 92110 , Clichy , France.
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Marvez E, Weiss SJ, Houry DE, Ernst AA. Predicting adverse outcomes in a diagnosis-based protocol system for rapid sequence intubation. Am J Emerg Med 2003; 21:23-9. [PMID: 12563574 DOI: 10.1053/ajem.2003.50002] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Our ED at Louisiana State University developed a unique approach to airway management by having four diagnosis-based protocols for rapid sequence intubation (RSI). This study examines protocol use and outcome from RSI in an academic ED. The study objective was to identify variables that are predictive of adverse outcomes in patients requiring RSI. This was a 4-year prospective, observational, data-gathering study of all intubations in an academic ED setting with >250,000 patient visits per year. Four protocols were established for 1) children <10 years of age, 2) adults with increased intracranial pressure, 3) adults with chronic obstructive pulmonary disease/asthma, and 4) other adults not fitting B or C. A special continuing quality improvement (CQI) committee was established to examine each case of RSI. Prospective data were collected, including age, race, gender, protocol, diagnostic group, intubation indication, and preintubation oxygen saturation. Diagnostic group was categorized as medical, blunt trauma, or penetrating trauma. Adverse outcome was defined as any case with hemodynamic changes, those requiring surgical or bronchoscopic intervention, and those requiring more than three attempts at intubation. Data were analyzed using univariate analysis, logistic regression, and a binomial regression tree analysis with SPSS 9.0 (Chicago, IL) and Answer Tree (SPSS). A total of 1,320 consecutive intubated patients were included. Protocol A was used in 4%, B in 43%, C in 15%, and D in 38%. Significant differences in number of cases with adverse outcome were based on protocol (P =.03) and final diagnosis (P <.03). Protocol C was less likely to be associated with adverse outcome than protocol D (odds ratio [OR] = 0.2, 95% confidence interval [CI] = 0.1-0.7). Penetrating trauma was more likely to be associated with adverse outcome (OR = 1.8, 95%, CI = 1.1-3.2) than blunt trauma. A regression tree analysis yielded the following, all cases using protocol A or C or medical cases using B had an adverse event in 11 of 458 (2.4%), whereas nonmedical cases using protocols B or D and medical cases using D had adverse outcomes in 73 of 862 cases (8.5%). The decision rules lead to a better classification of cases with adverse outcomes (2.4 vs 8.5%, of = 6.1%, 95% CI = 3.7-8.4). Adult trauma patients who fit the protocols B or D or adult medical patients who fit protocol B were at higher risk for adverse outcomes with RSI. This could alert the physician to a population at higher risk for adverse outcomes. Variables available in a diagnosis-based protocol RSI system can be used to predict adverse outcome among patients requiring RSI.
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Affiliation(s)
- Eduardo Marvez
- Louisiana State University/Charity Hospital, New Orleans, LA, USA
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Succinylcholine improves the time of performance of a tracheal intubation in prehospital critical care medicine. Eur J Anaesthesiol 2002. [DOI: 10.1097/00003643-200205000-00008] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Le Tacon S, Wolter P, Rusterholtz T, Harlay M, Gayol S, Sauder P, Jaeger A. [Complications of difficult tracheal intubations in a critical care unit] . ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2000; 19:719-24. [PMID: 11200758 DOI: 10.1016/s0750-7658(00)00316-6] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
OBJECTIVES This study was performed in order to evaluate the frequency of DI, the predictive factors of DI and to list the related complications. STUDY DESIGN Prospective non randomized, open study. PATIENTS AND METHODS All patients intubated in the critical care unit during the five months of the study were included. The previous history and clinical setting of the patients, the conditions and the complications of intubation were collected. DI was defined when the procedure required more than two laryngoscopies. RESULTS The study included 80 patients. The rate of DI was 22.5%. The Mallampati score (p < 0.001) was the only predictive factor. The frequency of complications was 25%. This rate was 55% for DI versus 16% for easy intubations (p < 0.001). CONCLUSION This study confirms the high incidence of DI and associated complications in critical care. We suggest the development of airway management protocols in critical care unit in order to reduce the rate of DI.
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Affiliation(s)
- S Le Tacon
- Service de réanimation médicale, Hôpital Civil, hôpitaux universitaires de Strasbourg, 1, place de l'Hôpital, 67000 Strasbourg, France
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Ricard-Hibon A, Marty J. [Management of severe head-injured patients in the first 24 hours. Resuscitation and initial diagnostic strategy]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2000; 19:286-95. [PMID: 10836116 DOI: 10.1016/s0750-7658(99)00149-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Limitation of secondary insults after severe head injury is a permanent concern during the early phase of head trauma management. The objectives are to maintain mean arterial pressure between 80 and 100 mmHg, to avoid hypoxaemia, and to maintain arterial PCO2 near to 35 mmHg. Volume loading can be necessary to improve arterial pressure, and is carried out with isotonic critalloid (NaCl 9/1000) or colloids, with the exclusion of all hypotonic solutions (Ringer lactate or glucose). The use of catecholamines is reserved for patients with unstable haemodynamics despite an adequate volume loading. The rapid sequence induction is recommended for endotracheal intubation and is followed by continuous analgesia-sedation to keep patient-ventilator dysynchrony, but without compromising haemodynamic objectives. Mannitol is used in case of life-threatening intracranial hypertension. Conversely, specific treatment of intracranial hypertension, especially hypocapnia, is not recommended. Initial diagnostic procedures include cerebral tomodensitometry (TDM). However, TDM may be delayed in case of haemorrhage, which requires a rapid treatment. Intrahospital transport for additional explorations risks secondary insults, and thus requires close monitoring to detect and treat in due time all adverse events. This monitoring includes invasive arterial blood pressure assessment, use of continuous capnography and repeated arterial blood gas measurements. The usefulness of transcranial Doppler for initial management of head-trauma patients needs further evaluation.
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Affiliation(s)
- A Ricard-Hibon
- Service d'anesthésie-réanimation-smur, hôpital Beaujon, Clichy, France
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Adnet F, Hennequin B, Lapandry C. [Rapid sequence anesthetic induction via prehospital tracheal intubation]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 1998; 17:688-98. [PMID: 9750807 DOI: 10.1016/s0750-7658(98)80106-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The choice of sedation for emergency intubation remains controversial. This lack of consensus has led to various sedation protocols used in French prehospital care setting. A review of data from the literature suggests that the association etomidate-suxamethonium is probable the best choice for rapid sequence intubations in the prehospital setting. Its benefits include protection against myocardial and cerebral ischaemia, decreased risk of pulmonary aspiration, and a stable haemodynamic profile. Randomized studies are needed to substantiate the advantages of the association etomidate-suxamethonium for rapid sequences intubation in the prehospital setting.
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Affiliation(s)
- F Adnet
- Samu 93 et département d'anesthésie et de réanimation, CHU Avicenne, université Paris XIII, Bobigny, France
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