An observational survey of emergency department rapid sequence intubation

Airway managed by emergency physicians or anaesthesiologists in trauma patients: A retrospective cohort analysis of outcomes

Objectives:

In some trauma centres, anaesthesiologists have the primary responsibility of managing airway in trauma resuscitation. However, as emergency physicians establish a separate specialty with airway management and endotracheal intubation being one of the core skills, role delineation within trauma members may vary. In this cohort study, we aim to determine the difference in mortality of trauma patients requiring intubation in the emergency department between emergency physicians and anaesthesiologists.

Methods:

We screened all 1588 patients in the hospital trauma registry from 2015 to 2018. We included all patients requiring endotracheal intubation and aged 18 or above but excluded those with pregnancy, presented with cardiac arrest and secondarily transferred from other hospitals. A total of 349 eligible patients were sorted into two cohorts according to the physicians who performed intubations (anaesthesiologists = 205 patients, emergency physicians = 144 patients). Patients’ baseline demographics, 30-day all-cause mortality and other predefined secondary outcomes were compared by statistical tests. Stepwise logistic regression of 30-day all-cause mortality was performed.

Results:

Our study has shown that intubation by emergency physicians was not associated with higher 30-day all-cause mortality after potential confounders were controlled by logistic regression (adjusted odds ratio = 1.253, p = 0.607). Both groups also did not differ in other clinical important secondary outcomes, including proportion of successful intubations, use of surgical airway or rescue manoeuvres, respiratory and airway complications, mortality in intensive care or high-dependency unit, post-intubation cardiac arrest, post-intubation hypotension and post-intubation hypoxia.

Conclusion:

Endotracheal intubation by emergency physicians is not associated with increased 30-day all-cause mortality when compared to anaesthesiologists after accounting for confounders.

Emergency Airway Management: A Look into the Practice, Rate of Success, and Adverse Events of 94 Endotracheal Intubations

CONTEXT

Endotracheal intubation in the critically unwell is a life-saving procedure, frequently performed in the emergency department (ED). The 4^th National Audit Project (NAP4) of the Royal College of Anaesthetists and Difficult Airway Society, however, highlighted the deficiencies that could have led to serious harm. In direct response to NAP4, a 2018 guideline was published on the management of intubations in critically ill adults.

AIMS

This study describes the current practice of endotracheal intubation, in comparison to the published 2018 guideline.

SETTINGS AND DESIGN

A retrospective observational study in an ED of a district general hospital in Greater London.

SUBJECTS AND METHODS

Adult attendances from September 1, 2017, to September 1, 2018 (>18 years old) fulfilling the search criteria were reviewed, producing 1553 case notes. These cases were individually reviewed by the authors.

STATISTICAL ANALYSIS USED

Mann-Whitney U-test.

RESULTS

There were 94 intubations, male to female ratio 1.8:1. The most common indication was for airway protection (n = 35), followed by respiratory failure (n = 23). There were 31 first-pass intubation successes. Intensivists performed most of the intubations (n = 66), followed by anesthetists (n = 13), and ED physicians (n = 10), but with no significant difference between the response rates of ED and external physicians (P = 0.0477). Propofol was the induction drug of choice (n = 37), with rocuronium the paralyzing agent of choice (n = 42). Altogether, there were eight complications reported.

CONCLUSIONS

This study provides an overview of the intubation practices in a single-center ED. Non-ED physicians perform the majority of intubations, with a variety of induction and paralyzing agents being used. It adds to the growing call for better standardization and provision of care to patients with a deteriorating airway and the continued auditing of practice.

Audit on Current Practice of Rapid Sequence Induction and Intubation of Anesthesia in the University of Gondar Hospital, Northwest Ethiopia, 2018

Background

In patients who are liable to the risk of pulmonary aspiration, airway control is the primary and first concern for the anesthetists both in emergency and elective surgical procedures. Rapid sequence induction is universally required in any occasion of emergent endotracheal intubation needed for unfasted patients or patients' fasting status is unknown.

Methods

institutional-based prospective observational study was conducted from December 2017 to January 2018 in all elective and emergency adult or pediatric patients with a risk of pulmonary aspiration who were operated under general anesthesia with rapid sequence induction and intubation during the audit period.

Result

A total of 35 patients were operated during the study period. Of these, 31 (88.57%) patients were adults and 4 (11.43%) patients were pediatrics. Most of the patients were emergency (29 (82.857%)), and the rest were elective (6 (17.142%)).

Conclusion

Most anesthetists were good at preparing all available monitoring and drugs, making sure that IV line is well-functioning, preparing suction with a suction machine, preoxygenation, application of cricoid pressure, and checking the position of the ETT after intubation was performed. Preparing difficult airway equipment during planning of rapid sequence induction and intubation, giving roles and told to proceed their assigned role for the team, attempt to ventilate with a small tidal volume, and routine use of bougie or stylet to increase the chance of success of intubation needed improvement.

Advancing emergency airway management practice and research

Emergency airway management is one of the vital resuscitative procedures undertaken in the emergency department (ED). Despite its clinical and research importance in the care of critically ill and injured patients, earlier studies have documented suboptimal intubation performance and high adverse event rates with a wide variation across the EDs. The optimal emergency airway management strategies remain to be established and their dissemination to the entire nation is a challenging task. This article reviews the current published works on emergency airway management with a focus on the use of airway management algorithms as well as the importance of first‐pass success and systematic use of rescue intubation strategies. Additionally, the review summarizes the current evidence for each of the important airway management processes, such as assessment of the difficult airway, preparation (e.g., positioning and oxygenation), intubation methods (e.g., rapid sequence intubation), medications (e.g., premedications, sedatives, and neuromuscular blockades), devices (e.g., direct and video laryngoscopy and supraglottic devises), and rescue intubation strategies (e.g., airway adjuncts and rescue intubators), as well as the airway management in distinct patient populations (i.e., trauma, cardiac arrest, and pediatric patients). Well‐designed, rigorously conducted, multicenter studies that prospectively and comprehensively characterize emergency airway management should provide clinicians with important opportunities for improving the quality and safety of airway management practice. Such data will not only advance research into the determination of optimal airway management strategies but also facilitate the development of clinical guidelines, which will, in turn, improve the outcomes of critically ill and injured patients in the ED.

Sedative dose and patient variable impacts on postintubation hypotension in emergency airway management

PURPOSE

Postintubation hypotension (PIH) is an adverse event associated with poor outcomes in emergency department (ED) endotracheal intubation. This study aimed to evaluate the association between sedative dose adjustment and PIH during emergency airway management. We also investigated the impact of patient and procedural factors on the incidence of PIH.

MATERIALS AND METHODS

This was a single-center, retrospective study that used a prospectively collected registry of airway management performed at the ED from April 2014 to February 2017. Adult patients who received emergency endotracheal intubation were included. Multivariable logistic regression models were used to evaluate the association of PIH with sedative dose, patient variables, and procedural variables.

RESULTS

Overall, 689 patients were included, and 233 (33.8%) patients developed PIH. In the patients overall, multivariable logistic regression demonstrated that age > 70 years, shock index >0.8, arterial acidosis (pH < 7.2), intubation indication, and use of non-depolarizing neuromuscular blocking agent were significantly related to PIH. In patients overall, the sedative dose was not related to PIH (overdose; OR: 1.09, 95%CI: 0.57-2.06), (reduction; OR: 0.93, 95%CI: 0.61-1.42), (none used; OR: 1.28, 95%CI: 0.64-2.53). In subgroup analysis, ketamine dose was not related to PIH (overdose; OR: 0.81, 95%CI: 0.27-2.38, reduction; OR: 1.41, 95%CI: 0.78-2.54). Reduction of etomidate dose was significantly associated with decreased PIH (reduction; OR: 0.46, 95%CI: 0.22-0.98, overdose; OR: 1.77, 95%CI: 0.79-3.93).

CONCLUSIONS

PIH was mainly related to predisposing patient-related factors. Only adjustment of etomidate dose was associated with the incidence of PIH.

Tips to Improve Success Rate of Intubation: A Standardized Rapid Sequence Intubation Protocol Attached to the Resuscitation Cart

OBJECTIVES

The purpose of this study was to determine whether the implementation of a standardized rapid sequence intubation (RSI) protocol easily accessed on the resuscitation cart increased the success rate of intubation and reduced intubation-related complications in the emergency department (ED).

METHODS

This work was a retrospective study of patients who were intubated in the ED between February 2006 and June 2007. The RSI protocol and a dosage cross-table were attached to the resuscitation cart beginning in January 2007. Intubated patients before and after application of the protocol were sorted into two groups: pre-intervention and post-intervention.

RESULTS

A total of 147 patients were enrolled in the study, including 72 patients in the pre-intervention group and 75 patients in the post-intervention group. After application of the standardized protocol prompted on the resuscitation cart. The adherence rates to pre-treatment agents (69% vs. 90%; p < 0.01) and neuromuscular blocking agents (NMBA) (72% vs. 90%; p < 0.01) significantly improved. The first-attempt success rate was 57 of 72 (79%) in the pre-intervention group versus 70 of 75 (93%) in the post-intervention group (p = 0.016). The time to intubation did not differ signifi cantly, but the preintervention group had a higher percentage of prolonged time to intubation (13% vs. 3%; p = 0.029). The implementation of a standardized RSI protocol did not induce signifi cant adverse effects.

CONCLUSIONS

Our study demonstrated implementation of a standardized RSI protocol, improved clinician adherence to the RSI, increased success of first-attempt ED intubation and led to a decline in the rate of prolonged time to intubation.

Techniques and outcomes of emergency airway management in Japan: An analysis of two multicentre prospective observational studies, 2010-2016

OBJECTIVES

Continuous surveillance of emergency airway management practice is imperative in improving quality of care and patient safety. We aimed to investigate the changes in the practice of emergency airway management and the related outcomes in the emergency departments (EDs) in Japan.

METHODS

We conducted an analysis of the data from two prospective, observational, multicentre registries of emergency airway management-the Japanese Emergency Airway Network (JEAN)-1 and -2 Registries from April 2010 through May 2016.

RESULTS

We recorded 10,927 ED intubations (capture rate, 96%); 10,875 paediatric and adult patients were eligible for our analysis. The rate of rapid sequence intubation (RSI) use as the initial intubation method significantly increased from 28% in 2010 to 53% in 2016 (P_trend=0.03). Likewise, the rate of video laryngoscope (VL) use as the first intubation device increased significantly from 2% in 2010 to 40% in 2016 (P_trend<0.001), with a significant decrease in the rate of direct laryngoscope use from 97% in 2010 to 58% in 2016 (P_trend<0.001). Concurrent with these changes, the overall first-attempt success rate also increased from 68% in 2010 to 74% in 2016 (P_trend=0.02). By contrast, the rate of adverse events did not change significantly over time (P_trend=0.06).

CONCLUSION

By using data from two large, multicentre, prospective registries, we characterised the current emergency airway management practice, and identified their changes in Japan. The data demonstrated significant increases in the rate of RSI and VL use on the first attempt and the first-attempt success rate over the 6-year study period.

Emergency airway management by resident physicians in Japan: an analysis of multicentre prospective observational study

Aim

To examine the success rates of emergency department airway management by resident physicians in Japan.

Methods

We conducted an analysis of a multicentre prospective registry (Japanese Emergency Airway Network Registry) of 13 academic and community emergency departments in Japan. We included all patients who underwent emergency intubation performed by postgraduate year 1 to 5 transitional or emergency medicine residents (resident physicians) between April 2010 and August 2012. Outcome measures were success rates by the first intubator, and by rescue intubator, according to the level of training.

Results

We recorded 4,094 intubations (capture rate, 96%); 2,800 attempts (2,800/4,094; 68%; 95% confidence interval (CI), 67%-70%) were initially performed by resident physicians. Overall success rate on the first attempt was 63% (1,767/2,789; 95%CI, 61%-64%); the rate improved over the first 3 years of training before reaching a plateau (P _trend < 0.001). Success rate by the first intubator was 78% (2,185/2,800; 95%CI, 76%-79%); the rate steadily improved as level of training increased (P _trend < 0.001). Of 597 failed intubation attempts by the first intubator, 41% (247/597; 95%CI, 37%-45%) of rescue attempts were performed by resident physicians. Success rate on the first rescue attempt was 76% (187/247; 95%CI, 70%-81%), and success rate by first rescue intubator was 89% (220/247; 95%CI, 85%-93%). These rates on rescue attempts steadily improved as level of training increased (both P _trend < 0.001). Intubations were ultimately successful in 2,778 encounters (99.6%).

Conclusion

In this multicentre study characterizing emergency airway management across Japan, we observed that emergency department intubations were primarily managed by resident physicians with acceptably high success rates overall.

Prospective observational study of the practice of endotracheal intubation in the emergency department of a tertiary hospital in Sydney, Australia

OBJECTIVE

To describe the practice of endotracheal intubation in the ED of a tertiary hospital in Australia, with particular emphasis on the indication, staff seniority, technique, number of attempts required and the rate of complications.

METHODS

A prospective observational study.

RESULTS

Two hundred and ninety-five intubations occurred in 18 months. Trauma was the indication for intubation in 30.5% (95% CI 25.3-36.0) and medical conditions in 69.5% (95% CI 64.0-74.5). Emergency physicians were team leaders in 69.5% (95% CI 64.0-74.5), whereas ED registrars or senior Resident Medical Officers made the first attempt at intubation in 88.1% (95% CI 83.9-91.3). Difficult laryngoscopy occurred in 24.0% (95% CI 19.5-29.3) of first attempts, whereas first pass success occurred in 83.4% (95% CI 78.7-87.2). A difficult intubation occurred in 3.4% (95% CI 1.9-6.1) and all patients were intubated orally in five or less attempts. A bougie was used in 30.9% (95% CI 25.8-36.5) of first attempts, whereas a stylet in 37.5% (95% CI 32.1-43.3). Complications occurred in 29.0% (95% CI 23.5-34.1) of the patients, with desaturation the commonest in 15.7% (95% CI 11.9-20.5). Cardiac arrest occurred in 2.2% (95% CI 0.9-4.4) after intubation. No surgical airways were undertaken.

CONCLUSION

Although the majority of results are comparable with overseas data, the rates of difficult laryngoscopy and desaturation are higher than previously reported. We feel that this data has highlighted the need for practice improvement within our department and we would encourage all those who undertake emergent airway management to audit their own practice of this high-risk procedure.

Management of the trauma airway

A priority for all trauma patients is rapid assessment and appropriate, prompt and effective management of the airway. Adequate ventilation and tissue oxygenation can prevent hypoxic injury, particularly within the central nervous system. Failure to secure the airway soon enough is a major cause of preventable death following significant injury (Ivatury and Guilford, 2008). Many controversial issues surround the management of the trauma airway including the effect of early tracheal intubation on morbidity and mortality, the variation in failed intubation rates for paramedics compared with physicians, and the use of manual in-line stabilisation and cricoid pressure during tracheal intubation. Studies have attempted to address these and other questions related to airway management in trauma patients. Unfortunately, many variables within the studies make interpretation of the results difficult. This review aims to summarise the key issues in relation to all of these controversies.

A prospective study of tracheal intubation in an academic emergency department in Malaysia

BACKGROUND

Airway management is an important part of the management of the critically ill and injured patients in the Emergency Department (ED). Numerous studies from developed countries have demonstrated the competency of emergency doctors in intubation. To date there have been no published data on intubations performed in EDs in Malaysia.

METHODS

Data on intubations from 7 August 2007 till 28 August 2008 were prospectively collected.

RESULTS

There were 228 intubations included in the study period. Cardiopulmonary arrest was the main indication for intubation (35.5%). The other indications were head injury (18.4%), respiratory failure (15.4%), polytrauma (9.6%) and cerebrovascular accident (7.0%). All of the 228 patients were successfully intubated. Rapid sequence intubation (RSI) was the most frequent method (49.6%) of intubation. A total of 223 (97.8%) intubations were done by ED personnel. In 79.8% of the cases, intubations were successfully performed on the first attempt. Midazolam was the most common induction agent used (97 patients), while suxamethonium was the muscle relaxant of choice (109 patients). There were 34 patients (14.9%) with 38 reported immediate complications. The most common complication was oesophageal intubation.

CONCLUSION

Emergency Department UKMMC personnel have a high competency level in intubation with an acceptable complication rate. RSI was the most common method for intubation.

A national Internet survey on rapid sequence intubation patterns from Turkey

Aim

To determine which specialty was performing rapid sequence intubation (RSI) in the emergency departments and to determine drug preferences of emergency physicians during RSI in Turkey.

Method

All emergency departments were contacted via e-mail, and the chiefs of the departments were requested to answer a survey consisting of six questions. Hospitals within the specified regions were selected with the only inclusion criteria being that the hospital had an emergency medicine department. We determined that there were 32 university and 9 state hospital emergency medicine residency programs.

Results

Thirty-five emergency departments responded. In 31 (73%) departments emergency medicine physicians, in 4 (10%) departments anesthetists, and in 7 (17%) departments physicians of either specialty were routinely performing RSI. The most commonly preferred drugs were fentanyl for premedication, vecuronium for defasciculation, etomidate for induction, and succinylcholine for neuromuscular blocking.

Conclusion

In the majority of the emergency departments in Turkey, emergency medicine physicians perform the RSI; the anesthetists perform it in only a few departments.

Rapid sequence intubations by emergency doctors: we can but are we?

BACKGROUND

Rapid sequence intubation (RSI) is used by emergency doctors routinely in many parts of the world, but it is unclear how many are using this technique in England and Wales.

AIM

To determine, through a telephonic survey, which specialty was performing RSIs.

METHODS

All emergency departments were telephoned, and senior emergency doctors were asked which specialty provided this service, and whether this was done routinely, often, or could be either specialty.

RESULTS

All 207 departments responded. 3 (1%) departments routinely had emergency doctors perform RSIs, and a further 3 (1%) had anaesthetists performing these routinely. In 33 (15.9%) departments, there were equal chances that it could either specialty. Anaesthetists provided the service routinely in 130 (62.8%) and often in 38 (18.4%) departments.

CONCLUSION

Although there are emergency doctors performing RSIs, the majority of RSIs are still being performed by anaesthetists. When this is added to the curriculum for the Fellowship of the College of Emergency Medicine from 2008, many departments, seemingly, will not be in a position to provide experience in this area.

Tracheal intubation in the emergency department: the Scottish district hospital perspective

BACKGROUND

Tracheal intubation is the accepted gold standard for emergency department (ED) airway management. It may be performed by both anaesthetists and emergency physicians (EPs), with or without drugs.

OBJECTIVE

To characterise intubation practice in a busy district general hospital ED in Scotland over 40 months between 2003 and 2006.

SETTING

Crosshouse Hospital, a 450-bed district general hospital serving a mixed urban and rural population; annual ED census 58,000 patients.

METHODS

Prospective observational study using data collection sheets prepared by the Scottish Trauma Audit Group. Proformas were completed at the time of intubation and checked by investigators. Rapid-sequence induction (RSI) was defined as the co-administration of an induction agent and suxamethonium.

RESULTS

234 intubations over 40 months, with a mean of 6 per month. EPs attempted 108 intubations (46%). Six patients in cardiac arrest on arrival were intubated without drugs. 29 patients were intubated after a gas induction or non-RSI drug administration. RSI was performed on 199 patients. Patients with trauma constituted 75 (38%) of the RSI group. 29 RSIs (15%) were immediate (required on arrival at the ED) and 154 (77%) were urgent (required within 30 min of arrival at the ED). EPs attempted RSI in 88 (44%) patients and successfully intubated 85 (97%). Anaesthetists attempted RSI in 111 (56%) patients and successfully intubated 108 (97%). Anaesthetists had a higher proportion of good views at first laryngoscopy and there was a trend to a higher rate of successful intubation at the first attempt for anaesthetists. Complication rates were comparable for the two specialties.

CONCLUSIONS

Tracheal intubations using RSI in the ED are performed by EPs almost as often as by anaesthetists in this district hospital. Overall success and complication rates are comparable for the two specialties. Laryngoscopy training and the need to achieve intubation at the first (optimum) attempt needs to be emphasised in EP airway training.

Rapid sequence intubation in the emergency department: 5 year trends

AIM

Airway management is a core aspect of emergency medicine. The technique of rapid sequence intubation (RSI) creates continuing debate between anaesthetists and emergency physicians in the UK, although similar complication rates for emergency department (ED) RSI have been shown for both specialties. This study examined prospectively collected data on every ED RSI performed in a university hospital in Glasgow over 5 years.

METHODS

Data were prospectively recorded for every attempted RSI in the ED on a dedicated form (as used in previous studies) between January 1999 and December 2003. Immediate complications were specifically sought in the questionnaire, as was the immediate destination on leaving the ED. The chi2 test was used for categorical data.

RESULTS

On average, 51 ED RSI were performed annually (range 42-60). Emergency physician RSI for trauma increased from 32% (7/22) in 1999 to 75% (21/28) in 2003 (chi2 = 9.32, df = 1, p = 0.002) and for non-trauma from 62% (18/29) in 1999 to 79% (23/29) in 2003 (chi2 = 2.08, df = 1, p = 0.15). Complication rates for emergency physician RSI decreased from 43% (3/7) to 14% (3/21) for trauma (chi2 = 2.55, df = 1, p = 0.11) and from 28% (5/18) to 4% (1/23) for non-trauma (chi2 = 4.44, df = 1, p = 0.035). This compares with mean complication rates for anaesthetists for trauma of 17% and for non-trauma of 22%. Incidence of hypotension decreased in all groups; however, oxygen desaturation is now the most common complication. The rate of ED RSI prior to computed tomography (CT) scans increased in both the trauma (79% v 42%; chi2 = 7.42, df = 1, p = 0.0065) and non-trauma (48% v 17%; chi2 = 5.85, df = 1, p = 0.016) groups.

CONCLUSION

Emergency physician performed ED RSI is increasingly common but is not associated with overall higher numbers of RSIs being performed in the ED. Effective pre-oxygenation should be emphasised during training.

Best evidence topic report. Rapid sequence induction in the emergency department by emergency medicine personnel

A short cut review was carried out to establish whether there are significant differences in the performance of emergency physicians and anaesthetists when carrying out rapid sequence intubation (RSI) in the emergency department. A total of 407 papers were found of which 12 presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these best papers are tabulated. The clinical bottom line is that there is little or no difference in the rates of success and complications between emergency department clinicians and anaesthetists performing RSI.

Advanced airway management in the emergency department: what are the training and skills maintenance needs for UK emergency physicians?

This article reviews the evidence for the training of emergency physicians in advanced airway management.

The who, where, and what of rapid sequence intubation: prospective observational study of emergency RSI outside the operating theatre

BACKGROUND

Emergency rapid sequence intubation (RSI) performed outside the operating room on emergency patients is the cornerstone of emergency airway management. Complication rates are unknown for this procedure in the United Kingdom and the factors contributing to immediate complications have not been identified.

AIMS

To quantify the immediate complications of RSI and to assess the contribution made by environmental, patient, and physician factors to overall complication rates.

METHODS

Prospective observational study of 208 consecutive adult and paediatric patients undergoing RSI over a six month period.

RESULTS

Patients were successfully intubated by RSI in all cases. There were no deaths during the procedure and no patient required a surgical airway. Patient diagnostic groups requiring RSI are described. Immediate complications were hypoxaemia 19.2%, hypotension 17.8%, and arrhythmia 3.4%. Hypoxaemia was more common in patients with pre-existing respiratory or cardiovascular conditions than in patients with other diagnoses (p<0.01). Emergency department intubations were associated with a significantly lower complication rate than other locations (16.9%; p = 0.004). This can be explained by the difference in diagnostic case mix. Intubating teams comprised anaesthetists, non-anaesthetists, or both. There were no significant differences in complication rates between these groups.

CONCLUSIONS

RSI has a significant immediate complication rate, although the clinical significance of transient events is unknown. The likelihood of immediate complications depends on the patient's underlying condition, and relevant diagnoses should be emphasised in airway management training. Complication rates are comparable between anaesthetists and non-anaesthetists. The significantly lower complication rates in emergency department RSI can be explained by a larger proportion of patients with comparatively stable cardiorespiratory function.

Emergency airway management--experience of a tertiary hospital in South-East Asia

OBJECTIVE

To study the indications and diagnoses of patients requiring emergency airway management and to evaluate the adequacy of airway management skills of emergency physicians.

METHODS

Prospective observational study of all patients requiring advanced airway management from 1 November 1998 to 31 October 2002.

RESULTS

There were 1068 cases, 710 (66.5%) were men. The median age was 63 years. The most common diagnoses requiring tracheal intubation were cardiopulmonary arrest (37.7%), congestive heart failure (20.8%) and head injury (8.3%). The main indications were apnoea (42.5%), hypoxia (21.3%) and prophylactic airway protection (17.6%). Orotracheal intubation with no medication was most common (51.5%) followed by rapid sequence induction (RSI) (28.4%) and orotracheal intubation with sedation only (19.6%). The overall success rate for orotracheal intubation was 99.6%. The cricothyrotomy rate was 0.2%. Hypotension (4.2%), multiple intubation attempts (1.9%) and oesophageal intubation (1.5%) were the three most common peri-intubation complications. There was no statistical difference in the occurrence of hypotension between the use of midazolam and etomidate for sedation or induction prior to intubation. Six hundred and forty-six (60.5%) patients survived the immediate post-resuscitation period. No patient died from failure to secure the airway.

CONCLUSION

Airway management and rapid sequence induction for intubation can be safely performed by emergency physicians.

Acute airway management in the emergency department by non-anesthesiologists

PURPOSE

The responsibility of acute airway management often falls into the hands of non-anesthesiologists. Emergency physicians now routinely use neuromuscular blockade to facilitate intubation. The literature in support of this practice has almost exclusively been published in emergency medicine (EM) journals. This body of literature is presented and issues of educational support are discussed.

SOURCE

A narrative review of the literature on the practice of airway management by non-anesthesiologists.

PRINCIPAL FINDINGS

A significant proportion of acute airway management occurring outside the operating room is being performed by non-anesthesiologists. Rapid sequence intubation (RSI) is recognized as a core procedure within the domain of EM. RSI is being performed routinely by emergency physicians practicing in larger centres. Anesthesiologist support for the practice of RSI by non-anesthesiologists has been weak. Formal educational support outside of postgraduate training in the form of dedicated programs for advanced airway management are now being offered. The majority of the literature on the use of RSI by non-anesthesiologists represents retrospective case series, observational studies and registry data published in EM journals. The reported success rates for RSI performed by non-anesthesiologists is high. Complication rates are significant, however reporting consistency has been poor.

CONCLUSIONS

The role of non-anesthesiologists in acute airway management is significant. Despite shortcomings in methodology, current evidence and practice supports the use of RSI by trained emergency physicians. Constructive collaborative efforts between anesthesiology and EM need to occur to ensure that educational needs are met and that competent airway management is provided.

Rapid sequence intubation of trauma patients in Scotland

BACKGROUND

Endotracheal intubation remains the gold standard for trauma airway management. Rapid sequence intubation (RSI) has traditionally been performed by anesthesiologists but increasingly, emergency physicians are also undertaking RSI. We aimed to compare success and complication rates for trauma intubations for the two specialties.

METHODS

Two year, prospective multi-center descriptive study of trauma RSI in seven Scottish urban emergency departments.

RESULTS

439 trauma patients were identified, including 233 RSIs. Patients intubated by emergency physicians had a higher median ISS (p < 0.001) and lower median RTS (p < 0.001) compared with anesthesiologists. For RSI, anesthesiologists had more grade I & II views at laryngoscopy (p = 0.051) and more successful first attempt intubations (p = 0.034) but there was no difference in the number of patients suffering complications (emergency physicians 10.0%, anesthesiologists 10.6%).

CONCLUSION

There is no significant difference in complication rates for trauma RSI between emergency physicians and anesthesiologists in Scottish urban centers. A collaborative approach to the critical trauma airway is vital. Emergency physicians should consult with senior anesthesiologists before RSI when intubation is predicted to be difficult.

Trauma airway experience by emergency physicians

The objective of this study was to evaluate the success rates of endotracheal intubation of trauma patients by emergency physicians and to determine if there are areas in which the care of these patients could be improved. This was a retrospective observational study of 142 major trauma patients who required advanced airway management. The median age was 32 years and 74% of the patients were men. Fifty per cent had isolated head injury. The main indications for intubation were a Glasgow Coma Score of less than 9 (40.1%), trauma arrest (24.6%), and prophylactic protection of the airway (10.6%). Emergency physicians successfully intubated 90.8% of the patients. The pretreatment of head-injured patients with lignocaine was performed in only six out of 66 indicated cases (9.1%). The complication rate was 23.2%. Hypotension occurred in 22.9% of cases treated with midazolam, and was more common than in those who were intubated without a sedating agent [odds ratio (OR) 3.108; 95% confidence interval (CI) 1.060, 9.109].

Airway management in the emergency department

Airway management in the emergency department and the role of anaesthetists and emergency physicians is reviewed. The training for emergency physicians in the advanced airway skills of rapid sequence induction and tracheal intubation is discussed.

In patients with head injuries who undergo rapid sequence intubation using succinylcholine, does pretreatment with a competitive neuromuscular blocking agent improve outcome? A literature review

A literature search was undertaken for evidence of the effect of succinylcholine (SCH) on the intracranial pressure (ICP) of patients with acute brain injury and whether pretreatment with a defasciculating dose of competitive neuromuscular blocker is beneficial in this patient group. The authors could find no definitive evidence that SCH caused a rise in ICP in patients with brain injury. However, these studies were often weak and small. For those patients suffering acute traumatic brain injury the authors could find no studies that investigated the issue of pretreatment with defasciculating doses of competitive neuromuscular blockers and their effect on ICP in patients given SCH. There is level 2 evidence that SCH caused an increase in ICP for patients undergoing neurosurgery for brain tumours with elective anaesthesia and that pretreatment with defasciculating doses of neuromuscular blockers reduced such increases. It is unknown if this affects neurological outcome for this patient group.