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

Outcomes and potential for improvement in the prehospital treatment of penetrating chest injuries in a European metropolitan area: A retrospective analysis of 2009 - 2017

BACKGROUND

Trauma is the leading cause of death in patients <45 years living in high-resource settings. However, penetrating chest injuries are still relatively rare in Europe - with an upwards trend. These cases are of particular interest to emergency medical services (EMS) due to available invasive treatment options like chest tube placement or resuscitative thoracotomy. To date, there is no sufficient data from Austria regarding penetrating chest trauma in a metropolitan area, and no reliable source to base decisions regarding further skill proficiency training on.

METHODS

For this retrospective observational study, we screened all trauma emergency responses of the Viennese EMS between 01/2009 and 12/2017 and included all those with a National Advisory Committee for Aeronautics (NACA) score ≥ IV (= potentially life-threatening). Data were derived from EMS mission documentations and hospital files, and for those cases with the injuries leading to cardiopulmonary resuscitation (CPR), we assessed the EMS cardiac arrest registry and consulted a forensic physician.

RESULTS

We included 480 cases of penetrating chest injuries of NACA IV-VII (83% male, 64% > 30 years old, 74% stab wounds, 16% cuts, 8% gunshot wounds, 56% inflicted by another party, 26% self-inflicted, 18% unknown). In the study period, the incidence rose from 1.4/100,000 to 3.5/100,000 capita, and overall, about one case was treated per week. In the cases with especially severe injury patterns (= NACA V-VII, 43% of total), (tension-)pneumothorax was the most common injury (29%). The highest mortality was seen in injuries to pulmonary vessels (100%) or the heart (94%). Fifty-eight patients (12% of total) deceased, whereas in 15 cases, the forensic physician stated survival could theoretically have been possible. However, only five of these CPR patients received at least unilateral thoracostomy. Regarding all penetrating chest injuries, thoracostomy had only been performed in eight patients.

CONCLUSIONS

Severe cases of penetrating chest trauma are rare in Vienna and happened about once a week between 2009 and 2017. Both incidence and case load increased over the years, and potentially life-saving invasive procedures were only reluctantly applied. Therefore, a structured educational and skill retention approach aimed at both paramedics and emergency physicians should be implemented.

TRIAL REGISTRATION

Retrospective analysis without intervention.

Tracheal intubation practices and adverse events in trauma victims on arrival to trauma triage: A single centre prospective observational study

Background and Aims:

Trauma is one of the leading causes of global disease burden. Data on airway management in trauma patients from developing countries, particularly India is sparse. Hence, we planned a prospective observational study to assess the airway management practice patterns and associated complications.

Methods:

The study was conducted in trauma triage of a tertiary care hospital. Data was collected on all tracheal intubations occurring in trauma victims requiring definitive airway control, a detailed proforma including patient details, mode of injury, drugs used, intubation procedure, and complications were filled out for each patient.

Results:

We observed that the airway in trauma patients was primarily managed by non-anaesthesia speciality residents (426 patients); anaesthesia residents were primarily called for deferred or difficult intubations. The first attempt success rate of intubation by anaesthesia residents was significantly higher than speciality residents (P = 0.0001; 95% CI 9.02-24.66). Non-anaesthesia residents used midazolam in varying doses (3-12 mg) for intubation, whereas, rapid sequence intubation was the most common technique used by anaesthesia residents. Airway injuries were the most frequent complication observed in 32.8% of patients intubated by specialty residents compared to 5.9% of patients intubated by anaesthesia residents.

Conclusion:

The trauma triage is a high-volume area for frequent tracheal intubations which are manned by non-anaesthesia speciality teams. A number of factors related to the patient, staff, availability of airway equipment and unfavourable surroundings impact airway management and may explain the high incidence of airway complications, such as airway injuries in these trauma victims.

Critical emergency medicine and the resuscitative care unit

Critical emergency medicine is the medical field concerned with management of critically ill patients in the emergency department (ED). Increased ED stay due to intensive care unit (ICU) overcrowding has a negative impact on patient care and outcome. It has been proposed that implementation of critical care services in the ED can negate this effect. Two main Critical Emergency Medicine models have been proposed, the "resource intensivist" and "ED-ICU" models. The resource intensivist model is based on constant presence of an intensivist in the traditional ED setting, while the ED-ICU model encompasses the notion of a separate ED-based unit, with monitoring and therapeutic capabilities similar to those of an ICU. Critical emergency medicine has the potential to improve patient care and outcome; however, establishment of evidence-based protocols and a multidisciplinary approach in patient management are of major importance.

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.

Spectrum and frequency of critical procedures performed at a Level I adult and pediatric trauma center

OBJECTIVES

The primary objective of this study was to provide physician-level data about the frequency of critical procedures at a combined adult and pediatric Level I trauma center, high-acuity, high-volume academic ED. The inspiration for this study question came from a previous study by Mittiga et al. (2013) describing pediatric critical procedure data at a similar high-acuity, high-volume, pediatric-only academic ED. Our secondary objective is to compare our pediatric level procedural spectrum and frequency with those published by Mittiga et al. (2013).

METHODS

This prospective observational study occurred over eleven consecutive months at an urban, Level I combined adult/pediatric trauma center with 96,000 annual visits (8500 pediatric). We recorded only procedures performed in the resuscitation bays. All data analysis is descriptive.

RESULTS

Over eleven months, data on 3891 resuscitations were collected (3686 adults and 205 children); 38 faculty physicians supervised 1838 total critical procedures, 64 on children. The mean number of critical procedures per physician per month was 4.42 (0.15 on children). Additionally, ultrasound for intravenous access, extended focused assessment with sonography for trauma (e-FAST), or cardiac ultrasound were performed in 3862 resuscitations (178 pediatric).

CONCLUSIONS

Emergency medicine faculty physicians at a combined Level I adult and pediatric trauma center performed and/or supervised 4.4 total (0.15 pediatric) critical procedures per month per faculty which is nearly 6 times more critical procedures monthly than faculty at a similar volume pediatric-only trauma center. However, fewer critical procedures were performed on children at the combined facility.

Skill Proficiency is Predicted by Intubation Frequency of Emergency Medicine Attending Physicians

Introduction

Airway management is a fundamental skill of emergency medicine (EM) practice, and suboptimal management leads to poor outcomes. Endotracheal intubation (ETI) is a procedure that is specifically taught in residency, but little is known how best to maintain proficiency in this skill throughout the practitioner’s career. The goal of this study was to identify how the frequency of intubation correlated with measured performance.

Methods

We assessed 44 emergency physicians for proficiency at ETI by direct laryngoscopy on a simulator. The electronic health record was then queried to obtain their average number of annual ETIs and the time since their last ETI, supervised and individually performed, over a two-year period. We evaluated the strength of correlation between these factors and assessment scores, and then conducted a receiver operator characteristic (ROC) curve analysis to identify factors that predicted proficient performance.

Results

The mean score was 81% (95% confidence interval, 76% – 86%). Scores correlated well with the mean number of ETIs performed annually and with the mean number supervised annually (r = 0.6, p = 0.001 for both). ROC curve analysis identified that physicians would obtain a proficient score if they had performed an average of at least three ETIs annually (sensitivity = 90%, specificity = 64%, AUC = 0.87, p = 0.001) or supervised an average of at least five ETIs annually (sensitivity = 90%, specificity = 59%, AUC = 0.81, p = 0.006) over the previous two years.

Conclusion

Performing at least three or supervising at least five ETIs annually, averaged over a two-year period, predicted proficient performance on a simulation-based skills assessment. We advocate for proactive maintenance and enhancement of skills, particularly for those who infrequently perform this procedure.

Effects of an elevated position on time to tracheal intubation by novice intubators using Macintosh laryngoscopy or videolaryngoscopy: randomized crossover trial

Objective

To investigate the time to tracheal intubation using Glidescope videolaryngoscopy (GVL) compared to that of standard laryngoscopy, by using a Macintosh blade (SLM) in a human patient simulator in supine and elevated (ramped) positions.

Methods

In this randomized crossover design, novice intubators (first-year medical students), using both laryngoscopic techniques, attempted tracheal intubation on a human patient simulator with a “normal airway” anatomy (Cormack-Lehane grade I). The simulator was placed in both supine and ramped positions using a commercial mattress system. The mean time to intubation and complications were compared between GVL and SLM in both positions. The percentage of glottic opening (POGO, GVL only) was estimated during intubation in the ramped and supine positions. The primary outcome was time to intubation, and the secondary outcomes included complication rates such as esophageal intubation and dental trauma.

Results

There was no difference in the mean time to intubation in either position (P=0.33). The SLM intubation was significantly faster than GVL (mean difference, 1.5 minutes; P<0.001). The mean POGO score for GVL improved by 8% in the ramped position compared to that in supine position (P=0.018). The esophageal intubation rate for SLM was 15% to 17% compared to 1.3% for GVL; dental trauma occurred in 53% to 56% of GVL, compared to 2% to 6% for SLM (P<0.001, respectively).

Conclusion

Novices had shorter intubation times using standard laryngoscopy with a SLM compared to GVL in both supine and ramped positions. GVL resulted in fewer esophageal intubations, but more dental trauma than standard laryngoscopy.

Prospective observational study of emergent endotracheal intubation practice in the intensive care unit and emergency department of an Australian regional tertiary hospital

OBJECTIVE

The present study aimed to describe the characteristics and outcomes of intubation occurring in the ICU and ED of an Australian tertiary teaching hospital.

METHODS

This was a prospective observational study of intubation practice across the Geelong Hospital over a 6 month period from 1 August 2012 to 31 January 2013. Data were entered by the intubating team through an online data collection form.

RESULTS

There were 119 patients intubated and 134 attempts at intubation in the ED and ICU over a 6 month period. The first-pass success rate was 104/119 (87.4%), and all but a single patient was intubated by the second attempt. Propofol, fentanyl, midazolam and suxamethonium were the most common drugs used in rapid sequence induction. AEs were reported in 44/134 (32.8%) of intubation attempts, with transient hypoxia and hypotension being the most common. A significant adverse outcome, namely aspiration pneumonitis, occurred in one patient. There were no peri-intubation deaths.

CONCLUSION

The majority of airways are managed by ICU and ED consultants and trainees, with success rates and AE rates comparable with other published studies.

The difficult airway with recommendations for management--part 1--difficult tracheal intubation encountered in an unconscious/induced patient

Background

Previously active in the mid-1990s, the Canadian Airway Focus Group (CAFG) studied the unanticipated difficult airway and made recommendations on management in a 1998 publication. The CAFG has since reconvened to examine more recent scientific literature on airway management. The Focus Group’s mandate for this article was to arrive at updated practice recommendations for management of the unconscious/induced patient in whom difficult or failed tracheal intubation is encountered.

Methods

Nineteen clinicians with backgrounds in anesthesia, emergency medicine, and intensive care joined this iteration of the CAFG. Each member was assigned topics and conducted reviews of Medline, EMBASE, and Cochrane databases. Results were presented and discussed during multiple teleconferences and two face-to-face meetings. When appropriate, evidence- or consensus-based recommendations were made together with assigned levels of evidence modelled after previously published criteria.

Conclusions

The clinician must be aware of the potential for harm to the patient that can occur with multiple attempts at tracheal intubation. This likelihood can be minimized by moving early from an unsuccessful primary intubation technique to an alternative “Plan B” technique if oxygenation by face mask or ventilation using a supraglottic device is non-problematic. Irrespective of the technique(s) used, failure to achieve successful tracheal intubation in a maximum of three attempts defines failed tracheal intubation and signals the need to engage an exit strategy. Failure to oxygenate by face mask or supraglottic device ventilation occurring in conjunction with failed tracheal intubation defines a failed oxygenation, “cannot intubate, cannot oxygenate” situation. Cricothyrotomy must then be undertaken without delay, although if not already tried, an expedited and concurrent attempt can be made to place a supraglottic device.

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.

Training Healthcare Personnel for Mass-Casualty Incidents in a Virtual Emergency Department: VED II

Introduction:

Training emergency personnel on the clinical management of a mass-casualty incident (MCI) with prior chemical, biological, radioactive, nuclear, or explosives (CBRNE)-exposed patients is a component of hospital preparedness procedures.

Objective:

The objective of this research was to determine whether a Virtual Emergency Department (VED), designed after the Stanford University Medical Center's Emergency Department (ED) and populated with 10 virtual patient victims who suffered from a dirty bomb blast (radiological) and 10 who suffered from exposure to a nerve toxin (chemical), is an effective clinical environment for training ED physicians and nurses for such MCIs.

Methods:

Ten physicians with an average of four years of post-training experience, and 12 nurses with an average of 9.5 years of post-graduate experience at Stanford University Medical Center and San Mateo County Medical Center participated in this IRB-approved study. All individuals were provided electronic information about the clinical features of patients exposed to a nerve toxin or radioactive blast before the study date and an orientation to the “game” interface, including an opportunity to practice using it immediately prior to the study. An exit questionnaire was conducted using a Likert Scale test instrument.

Results:

Among these 22 trainees, two-thirds of whom had prior Code Triage (multiple casualty incident) training, and one-half had prior CBRNE training, about two-thirds felt immersed in the virtual world much or all of the time. Prior to the training, only four trainees (18%) were confident about managing CBRNE MCIs. After the training, 19 (86%) felt either “confident” or “very confident”, with 13 (59%) attributing this change to practicing in the virtual ED. Twenty-one (95%) of the trainees reported that the scenarios were useful for improving healthcare team skills training, the primary objective for creating them. Eighteen trainees (82%) believed that the cases also were instructive in learning about clinical skills management of such incidents. Conclusions: These data suggest that training healthcare teams in online, virtual environments with dynamic virtual patients is an effective method of training for management of MCIs, particularly for uncommonly occurring incidents.

Conclusions:

These data suggest that training healthcare teams in online, virtual environments with dynamic virtual patients is an effective method of training for management of MCIs, particularly for uncommonly occurring incidents.

Patient safety in pre-hospital emergency tracheal intubation: a comprehensive meta-analysis of the intubation success rates of EMS providers

Introduction

Pre-hospital airway management is a controversial subject, but there is general agreement that a small number of seriously ill or injured patients require urgent emergency tracheal intubation (ETI) and ventilation. Many European emergency medical services (EMS) systems provide physicians to care for these patients while other systems rely on paramedics (or, rarely, nurses). The ETI success rate is an important measure of provider and EMS system success and a marker of patient safety.

Methods

We conducted a systematic search of Medline and EMBASE to identify all of the published original English-language articles reporting pre-hospital ETI in adult patients. We selected all of the studies that reported ETI success rates and extracted information on the number of attempted and successful ETIs, type of provider, level of ETI training and the availability of drugs on scene. We calculated the overall success rate using meta-analysis and assessed the relationships between the ETI success rate and type of provider and between the ETI success rate and the types of drugs available on the scene.

Results

From 1,070 studies initially retrieved, we identified 58 original studies meeting the selection criteria. Sixty-four per cent of the non-physician-manned services and 54% of the physician-manned services reported ETI success rates but the success rate reporting was incomplete in three studies from non-physician-manned services. Median success rate was 0.905 (0.491, 1.000). In a weighted linear regression analysis, physicians as providers were significantly associated with increased success rates, 0.092 (P = 0.0345). In the non-physician group, the use of drug-assisted intubation significantly increased the success rates. All physicians had access to traditional rapid sequence induction (RSI) and, comparing these to non-physicians using muscle paralytics or a traditional RSI, there still was a significant difference in success rate in favour of physicians, 0.991 and 0.955, respectively (P = 0.047).

Conclusions

This comprehensive meta-analysis suggests that physicians have significantly fewer pre-hospital ETI failures overall than non-physicians. This finding, which remains true when the non-physicians administer muscle paralytics or RSI, raises significant patient safety issues. In the absence of pre-hospital physicians, conducting basic or advanced airway techniques other than ETI should be strongly considered.

Role of anesthesiology curriculum in improving bag-mask ventilation and intubation success rates of emergency medicine residents: a prospective descriptive study

Background

Rapid and safe airway management has always been of paramount importance in successful management of critically ill and injured patients in the emergency department. The purpose of our study was to determine success rates of bag-mask ventilation and tracheal intubation performed by emergency medicine residents before and after completing their anesthesiology curriculum.

Methods

A prospective descriptive study was conducted at Nikoukari Hospital, a teaching hospital located in Tabriz, Iran. In a skills lab, a total number of 18 emergency medicine residents (post graduate year 1) were given traditional intubation and bag-mask ventilation instructions in a 36 hour course combined with mannequin practice. Later the residents were given the opportunity of receiving training on airway management in an operating room for a period of one month which was considered as an additional training program added to their Anesthesiology Curriculum. Residents were asked to ventilate and intubate 18 patients (Mallampati class I and ASA class I and II) in the operating room; both before and after completing this additional training program. Intubation achieved at first attempt within 20 seconds was considered successful. Successful bag-mask ventilation was defined as increase in ETCo₂ to 20 mm Hg and back to baseline with a 3 L/min fresh gas-flow and the adjustable pressure limiting valve at 20 cm H₂O. An attending anesthesiologist who was always present in the operating room during the induction of anesthesia confirmed the endotracheal intubation by direct laryngoscopy and capnography. Success rates were recorded and compared using McNemar, marginal homogeneity and paired t-Test tests in SPSS 15 software.

Results

Before the additional training program in the operating room, the participants had intubation and bag-mask ventilation success rates of 27.7% (CI 0.07-0.49) and 16.6% (CI 0-0.34) respectively. After the additional training program in the operating room the success rates increased to 83.3% (CI 0.66-1) and 88.8% (CI 0.73-1), respectively. The differences in success rates were statistically significant (P = 0.002 and P = 0.0004, respectively).

Conclusions

The success rate of emergency medicine residents in airway management improved significantly after completing anesthesiology rotation. Anesthesiology rotations should be considered as an essential component of emergency medicine training programs. A collateral curriculum of this nature should also focus on the acquisition of skills in airway management.

Rapid sequence induction anaesthesia: a guide for nurses in the emergency department

Emergency rapid sequence induction (RSI) anaesthesia is the cornerstone of emergency airway management performed on patients in the emergency department (ED). The Royal College of Anaesthetists has stated that anaesthesia should not proceed without a skilled, dedicated assistant. It is essential that ED nurses are educated, skilled and competent to assist with RSI in the ED.

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.

Is digital intubation an option for emergency physicians in definitive airway management?

OBJECTIVES

This study was designed to determine whether digital intubation is a valid option for definitive airway control by emergency physicians.

METHODS

Digital intubation was performed by 18 emergency medicine residents and 4 staff emergency medicine physicians on 6 different cadavers. Placement was confirmed by direct laryngoscopy. The total time for all attempts used, as well as the number of attempts, was recorded. Each participant attempted intubation on all 6 cadavers.

RESULTS

For 5 of the 6 cadavers, successful intubation occurred 90.9% of the time (confidence interval [CI], 85.5%-96.3%) for all participants. The average number of attempts for these 5 cadavers was 1.5 (CI, 1.4-1.7), and the average time required for success or failure was 20.8 seconds (CI, 16.9-24.8). The sixth cadaver developed soft tissue damage and a false passage near the vocal cords resulting in multiple failed attempts.

CONCLUSIONS

Although the gold standard for routine endotracheal intubation remains to be direct laryngoscopy, its effectiveness in certain situations may be limited. We believe that digital intubation provides emergency physicians with another option in securing the unprotected airway.