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Ljungqvist H, Pirneskoski J, Saviluoto A, Iirola T, Kirves H, Nurmi J. A standard operating procedure for prehospital anaesthesia and its effect on mortality-An observational study. Acta Anaesthesiol Scand 2024; 68:1068-1075. [PMID: 38798085 DOI: 10.1111/aas.14459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 04/26/2024] [Accepted: 05/13/2024] [Indexed: 05/29/2024]
Abstract
BACKGROUND Prehospital anaesthesia is a complex intervention performed for critically ill patients. To minimise complications, a standard operating procedure (SOP) outlining the process is considered valuable. We investigated the implementation of an SOP for prehospital anaesthesia in helicopter emergency medical services (HEMS). METHODS We performed a retrospective observational study of patients receiving prehospital anaesthesia by Finnish HEMS from January 2012 to August 2019. The intervention studied was the implementation of an SOP at two of the five bases during 2015-2016. Patients were stratified according to whether they were anaesthetised before, during or after implementation and the primary outcomes were 1- and 30-day mortality. Secondary outcomes included anaesthesia quality indicators. Confounding factors was assessed via logistic regression. RESULTS A total of 3902 tracheal intubations were performed without an SOP, 430 during implementation and 1525 after implementation. The SOP had a significant effect on 1-day mortality during implementation with an odds ratio (OR) of 0.56, 95% confidence interval (95% CI) 0.37-0.81 and a further trend towards benefit after implementation (OR 0.84, 95% CI 0.68-1.04), but no difference in 30-day mortality (OR after implementation 1.10, 95% CI 0.92-1.30). Implementation of an SOP improved first-pass success rate from 87.3% to 96.5%, p < 0.001. CONCLUSION Implementation of an SOP for prehospital anaesthesia was associated with a trend towards lower 1-day mortality and an improved first-pass success but did not affect 30-day mortality. Despite this, we advocate prehospital systems to consider implementation of a prehospital anaesthesia SOP as immediate performance markers improved significantly.
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Affiliation(s)
- Harry Ljungqvist
- Emergency Medicine and Services, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Jussi Pirneskoski
- Emergency Medicine and Services, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Anssi Saviluoto
- Emergency Medicine and Services, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Timo Iirola
- Emergency Medical Services, Turku University Hospital, University of Turku, Turku, Finland
| | - Hetti Kirves
- Emergency Medicine and Services, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Jouni Nurmi
- Emergency Medicine and Services, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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2
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Ljungqvist H, Tommila M, Setälä P, Raatiniemi L, Pulkkinen I, Toivonen P, Nurmi J. Front of neck airway in Finnish helicopter emergency medical services. Injury 2024; 55:111689. [PMID: 38924838 DOI: 10.1016/j.injury.2024.111689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Revised: 06/03/2024] [Accepted: 06/17/2024] [Indexed: 06/28/2024]
Abstract
INTRODUCTION An emergent front of neck airway (FONA) is needed when a 'can't intubate, can't oxygenate' crisis occurs. A FONA may also in specific cases be the primary choice of airway management. Two techniques exist for FONA, with literature favouring the surgical technique over the percutaneous. The reported need for a prehospital FONA is fortunately rare as the mortality has been shown to be high. Due to the low incidence, literature on FONA is limited with regards to different settings, techniques and operators. As a foundation for future research and improvement of patient care, we aim to describe the frequency, indications, technique, success, and outcomes of FONA in the Finnish helicopter emergency medical services (HEMS). MATERIALS AND METHODS This retrospective descriptive study reviews FONA performed at the Finnish HEMS during 1.1.2012 to 8.9.2019. The Finnish HEMS consists of six units, staffed mainly by anaesthesiologists. Clinical data was gathered from a national HEMS database and trough chart reviews. Data on mortality was obtained from a population registry. Only descriptive statistics were performed. RESULTS A total of 22 FONA were performed during the study period, 7 were primary and 14 performed after failure to intubate (missing data regarding indication for one attempt). This equals a 0.13 % (14/10,813) need for a rescue FONA and a rate of 0.20 % (22/10,813) FONA out of all advanced airway management. All but one FONA was performed using a surgical approach (20/21, 95 %, missing data = 1) and all were successful (22/22, 100 %). Indications were mainly cardiac arrest (10/22, 45 %) and trauma (6/22, 27 %), and the most common reason for a need for a secondary FONA was obstruction of airway by food or fluids (7/14, 50 %). On-scene mortality was 36 % (8/22) and 30-day mortality 90 % (19/21, missing data = 1). CONCLUSION The need for FONA is scarce in a HEMS system with experienced airway providers. Even though the procedure is successfully performed, the mortality is markedly high.
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Affiliation(s)
- Harry Ljungqvist
- Emergency Medicine and Services, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Miretta Tommila
- Department of Perioperative Services, Intensive Care Medicine and Pain Management, Turku University Hospital and University of Turku, Turku, Finland
| | - Piritta Setälä
- Centre for Prehospital Emergency Care, Tampere University Hospital, Tampere, Finland
| | - Lasse Raatiniemi
- Research Group of Surgery, Anaesthesiology and Intensive Care, Medical Research Centre, University of Oulu, Oulu, Finland and Department of air ambulance, University Hospital of North Norway, Tromsoe, Norway
| | - Ilkka Pulkkinen
- Prehospital Emergency Care, Lapland Hospital District, Rovaniemi, Finland
| | - Pamela Toivonen
- Centre for Prehospital Emergency Care, Kuopio University Hospital, Kuopio, Finland
| | - Jouni Nurmi
- Emergency Medicine and Services, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
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Jenkins L, Johnston T, Armour R, Maria S. Informing Utstein-style reporting guidelines for prehospital thrombolysis: A scoping review. Australas Emerg Care 2024; 27:148-154. [PMID: 38233295 DOI: 10.1016/j.auec.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 11/08/2023] [Accepted: 12/10/2023] [Indexed: 01/19/2024]
Abstract
BACKGROUND Rural Australians with acute myocardial infarction (AMI) face higher mortality rates due to limited access to specialised cardiac services. Paramedic-administered prehospital thrombolysis (PHT) has emerged as an alternative to primary percutaneous intervention (pPCI) for patients facing barriers or delays to cardiac care. There is variability in PHT practices among Australian ambulance services, lacking standardised definitions and outcome measures. The aim of this scoping review was to identify quality indicators and influencing factors associated with outcomes for patients receiving PHT. METHODS A systematic search of literature in SCOPUS and Academic Search Complete, CINAHL and Health Source: Nursing/Academic Edition databases via EBSCO (Health) was conducted following the Joanna Briggs Institute methodology. Peer-reviewed studies from the past decade were screened using search criteria relevant to prehospital thrombolysis and quality indicators. Data extraction was performed and themed using five domains from the Utstein-style template commonly known for standardised prehospital cardiac arrest reporting. RESULTS After removing duplicates, the search yielded 3596 articles with 28 empirical studies meeting inclusion criteria for the review. These were primarily retrospective cohort studies performed in Australia, Canada and the United States. The scoping review identified 24 clinical quality indicators and factors related to Emergency Medical Service (EMS) systems, AMI recognition and ambulance dispatch, patient variables, PHT processes and patient outcomes. These findings correlate to the Donabedian structure-process-outcome quality of care model and have utility to inform future PHT reporting guidelines for jurisdictional ambulance services. CONCLUSIONS Given the variability in prehospital practice across Australian ambulance services, standardised reporting on quality indicators for PHT is needed. The Utstein-style template used to report data on pre-hospital cardiac arrest, trauma and airway management could be used for quality improvement in PHT. This review presents 24 quality indicators representing system, recognition and response, patient, process, and outcomes related to PHT. These results could be used to inform a future Delphi study and Utstein-like reporting guideline for prehospital thrombolysis.
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Affiliation(s)
- Louis Jenkins
- Faculty of Science and Health, School of Nursing, Paramedicine and Healthcare Sciences, Charles Sturt University, Bathurst, New South Wales, Australia
| | - Tania Johnston
- Faculty of Science and Health, School of Nursing, Paramedicine and Healthcare Sciences, Charles Sturt University, Bathurst, New South Wales, Australia; Ambulance Tasmania, Hobart, Tasmania, Australia
| | - Richard Armour
- Faculty of Science and Health, School of Nursing, Paramedicine and Healthcare Sciences, Charles Sturt University, Bathurst, New South Wales, Australia; Department of Paramedicine, School of Primary and Allied Health Care, Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria, Australia
| | - Sonja Maria
- Faculty of Science and Health, School of Nursing, Paramedicine and Healthcare Sciences, Charles Sturt University, Bathurst, New South Wales, Australia.
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4
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Heikkilä E, Setälä P, Jousi M, Nurmi J. Association among blood pressure, end-tidal carbon dioxide, peripheral oxygen saturation and mortality in prehospital post-resuscitation care. Resusc Plus 2024; 17:100577. [PMID: 38375443 PMCID: PMC10875297 DOI: 10.1016/j.resplu.2024.100577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 01/14/2024] [Accepted: 01/31/2024] [Indexed: 02/21/2024] Open
Abstract
Aim Post-resuscitation care is described as the fourth link in a chain of survival in resuscitation guidelines. However, data on prehospital post-resuscitation care is scarce. We aimed to examine the association among systolic blood pressure (SBP), peripheral oxygen saturation (SpO2) and end-tidal carbon dioxide (EtCO2) after prehospital stabilisation and outcome among patients resuscitated from out-of-hospital cardiac arrest (OHCA). Methods In this retrospective study, we evaluated association of the last measured prehospital SBP, SpO2 and EtCO2 before patient handover with 30-day and one-year mortality in 2,611 patients receiving prehospital post-resuscitation care by helicopter emergency medical services in Finland. Statistical analyses were completed through locally estimated scatterplot smoothing (LOESS) and multivariable logistic regression. The regression analyses were adjusted by sex, age, initial rhythm, bystander CPR, and time interval from collapse to the return of spontaneous circulation (ROSC). Results Mortality related to SBP and EtCO2 values were U-shaped and lowest at 135 mmHg and 4.7 kPa, respectively, whereas higher SpO2 shifted towards lower mortality. In adjusted analyses, increased 30-day mortality and one year mortality was observed in patients with SBP < 100 mmHg (OR 1.9 [95% CI 1.4-2.4]) and SBP < 100 (OR 1.8 [1.2-2.6]) or EtCO2 < 4.0 kPa (OR 1.4 [1.1-1.5]), respectively. SpO2 was not significantly associated with either 30-day or one year mortality. Conclusions After prehospital post-resuscitation stabilization, SBP < 100 mmHg and EtCO2 < 4.0 kPa were observed to be independently associated with higher mortality. The optimal targets for prehospital post-resuscitation care need to be established in the prospective studies.
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Affiliation(s)
- Elina Heikkilä
- Faculty of Medicine, University of Helsinki, Helsinki, Finland
- Emergency Medicine and Services, Helsinki University Hospital and University of Helsinki, Finland
| | - Piritta Setälä
- Emergency Medical Services, Centre for Prehospital Emergency Care, Tampere University Hospital, Tampere, Finland
| | - Milla Jousi
- Emergency Medicine and Services, Helsinki University Hospital and University of Helsinki, Finland
| | - Jouni Nurmi
- Emergency Medicine and Services, Helsinki University Hospital and University of Helsinki, Finland
- FinnHEMS Research and Development Unit, Finland 4
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5
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Garner AA. A retrospective analysis of intubation quality metrics in physician-staffed helicopter emergency medical services. Can J Anaesth 2023; 70:1411-1413. [PMID: 37217734 DOI: 10.1007/s12630-023-02489-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 01/19/2023] [Accepted: 01/25/2023] [Indexed: 05/24/2023] Open
Affiliation(s)
- Alan A Garner
- Nepean Clinical School, University of Sydney, Sydney, NSW, Australia.
- CareFlight Australia, Sydney, NSW, Australia.
- Trauma Department, Nepean Hospital, Sydney, NSW, Australia.
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6
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Ångerman S, Kirves H, Nurmi J. Multifaceted implementation and sustainability of a protocol for prehospital anaesthesia: a retrospective analysis of 2115 patients from helicopter emergency medical services. Scand J Trauma Resusc Emerg Med 2023; 31:21. [PMID: 37122004 PMCID: PMC10148755 DOI: 10.1186/s13049-023-01086-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Accepted: 04/18/2023] [Indexed: 05/02/2023] Open
Abstract
BACKGROUND Prehospital emergency anaesthesia (PHEA) is a high-risk procedure. We developed a prehospital anaesthesia protocol for helicopter emergency medical services (HEMS) that standardises the process and involves ambulance crews as active team members to increase efficiency and patient safety. The aim of the current study was to evaluate this change and its sustainability in (i) on-scene time, (ii) intubation first-pass success rate, and (iii) protocol compliance after a multifaceted implementation process. METHODS The protocol was implemented in 2015 in a HEMS unit and collaborating emergency medical service systems. The implementation comprised dissemination of information, lectures, simulations, skill stations, academic detailing, and cognitive aids. The methods were tailored based on implementation science frameworks. Data from missions were gathered from mission databases and patient records. RESULTS During the study period (2012-2020), 2381 adults underwent PHEA. The implementation year was excluded; 656 patients were analysed before and 1459 patients after implementation of the protocol. Baseline characteristics and patient categories were similar. On-scene time was significantly redused after the implementation (median 32 [IQR 25-42] vs. 29 [IQR 21-39] minutes, p < 0.001). First pass success rate increased constantly during the follow-up period from 74.4% (95% CI 70.7-77.8%) to 97.6% (95% CI 96.7-98.3%), p = 0.0001. Use of mechanical ventilation increased from 70.6% (95% CI 67.0-73.9%) to 93.4% (95% CI 92.3-94.8%), p = 0.0001, and use of rocuronium increased from 86.4% (95% CI 83.6-88.9%) to 98.5% (95% CI 97.7-99.0%), respectively. Deterioration in compliance indicators was not observed. CONCLUSIONS We concluded that clinical performance in PHEA can be significantly improved through multifaceted implementation strategies.
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Affiliation(s)
- Susanne Ångerman
- Department of Emergency Medicine and Services, Helsinki University Hospital and University of Helsinki, FinnHEMS 10, Vesikuja 9, 01530 Vantaa, Finland
| | - Hetti Kirves
- Department of Emergency Medicine and Services, Helsinki University Hospital and University of Helsinki, FinnHEMS 10, Vesikuja 9, 01530 Vantaa, Finland
| | - Jouni Nurmi
- Department of Emergency Medicine and Services, Helsinki University Hospital and University of Helsinki, FinnHEMS 10, Vesikuja 9, 01530 Vantaa, Finland
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7
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Meulendyks S, Korpal D, Jin HJ, Mal S, Pace J. Airway registries in primarily adult, emergent endotracheal intubation: a scoping review. Scand J Trauma Resusc Emerg Med 2023; 31:11. [PMID: 36890554 PMCID: PMC9993388 DOI: 10.1186/s13049-023-01075-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 02/28/2023] [Indexed: 03/10/2023] Open
Abstract
BACKGROUND Emergency Department (ED) airway registries are formalized methods to collect and document airway practices and outcomes. Airway registries have become increasingly common in EDs globally; yet there is no consensus of airway registry methodology or intended utility. This review builds on previous literature and aims to provide a thorough description of international ED airway registries and discuss how airway registry data is utilized. METHODS A search of Medline, Embase, Scopus, Cochrane Libraries, Web of Science, and Google Scholar was performed with no date limitations applied. English language full-text publications and grey literature from centres implementing an ongoing airway registry to monitor intubations performed in mainly adult patients in an ED setting were included. Non-English publications and publications describing airway registries to monitor intubation practices in predominantly paediatric patients or settings outside of the ED were excluded. Study screening for eligibility was performed by two team members individually, with any disagreements resolved by a third team member. Data was charted using a standardized data charting tool created for this review. RESULTS Our review identified 124 eligible studies from 22 airway registries with a global distribution. We found that airway registry data is used for quality assurance, quality improvement, and clinical research regarding intubation practices and contextual factors. This review also demonstrates that there is a great deal of heterogeneity in definitions of first-pass success and adverse events in the peri-intubation period. CONCLUSIONS Airway registries are used as a crucial tool to monitor and improve intubation performance and patient care. ED airway registries inform and document the efficacy of quality improvement initiatives to improve intubation performance in EDs globally. Standardized definitions of first-pass success and peri-intubation adverse events, such as hypotension and hypoxia, may allow for airway management performance to be compared on a more equivalent basis and allow for the development of more reliable international benchmarks for first-pass success and rates of adverse events in the future.
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Affiliation(s)
- Sarah Meulendyks
- Schulich School of Medicine and Dentistry, 1151 Richmond St, London, ON, N6A 5C1, Canada.
| | - Daniel Korpal
- Department of Emergency Medicine, London Health Sciences Centre, 800 Commissioners Rd E, London, ON, N6A 5W9, Canada
| | - Helen Jingshu Jin
- Schulich School of Medicine and Dentistry, 1151 Richmond St, London, ON, N6A 5C1, Canada
| | - Sameer Mal
- Department of Emergency Medicine, London Health Sciences Centre, 800 Commissioners Rd E, London, ON, N6A 5W9, Canada
| | - Jacob Pace
- Department of Emergency Medicine, London Health Sciences Centre, 800 Commissioners Rd E, London, ON, N6A 5W9, Canada
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8
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Ferguson IMC, Miller MR, Partyka C, Bliss J, Aneman A, Harris IA. The effect of ketamine and fentanyl on haemodynamics during intubation in pre-hospital and retrieval medicine. Acta Anaesthesiol Scand 2023; 67:364-371. [PMID: 36495319 DOI: 10.1111/aas.14177] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 11/14/2022] [Accepted: 11/26/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Ketamine use for rapid sequence intubation (RSI) is frequent in pre-hospital and retrieval medicine (PHARM) and is associated with potentially deleterious haemodynamic changes, which may be ameliorated by concurrent use of fentanyl. OBJECTIVES To describe the frequency with which fentanyl is used in conjunction with ketamine in a system where its use is discretionary, and to explore any observed changes in haemodynamics with its use. METHODS A retrospective observational study of over 800 patients undergoing RSI with ketamine ± fentanyl in the PHARM setting between 2015 and 2019. The primary outcome was the proportion of patients in each group who had a systolic blood pressure (SBP) outside a pre-specified target range, with adjustment for baseline abnormality, within 10 min of anaesthetic induction. RESULTS Eight hundred and seventy-six patients were anaesthetised with ketamine, of whom 804 were included in the analysis. 669 (83%, 95% CI 80%-86%) received ketamine alone, and 135 (17%, 95% CI 14%-20%) received both fentanyl and ketamine. Median fentanyl dose was 1.1 mcg/kg (IQR 0.75-1.5 mcg/kg). Systolic blood pressure (SBP) at induction was consistently associated with SBP after intubation in multivariable logistic regression, but fentanyl use was not associated with a change in odds of meeting the primary outcome (OR 1.08; 95% CI 0.72-1.60), becoming hypertensive (OR 1.35; 95% CI 0.88-2.07) or hypotensive (OR 0.76; 95% CI 0.47-1.21). CONCLUSIONS The addition of fentanyl to ketamine for RSI was not associated with an alteration of the odds of post-induction haemodynamic stability, although the doses used were low. These findings justify further study into the optimal dosing of fentanyl during RSI in pre-hospital and retrieval medicine.
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Affiliation(s)
- Ian M C Ferguson
- Aeromedical Retrieval Service, New South Wales Ambulance, Rozelle, New South Wales, Australia.,South West Clinical School, University of New South Wales, Sydney, New South Wales, Australia.,Emergency Department, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Matthew R Miller
- Aeromedical Retrieval Service, New South Wales Ambulance, Rozelle, New South Wales, Australia.,St George Clinical School, University of New South Wales, Sydney, New South Wales, Australia.,Department of Anesthesiology, St George Hospital, Sydney, New South Wales, Australia
| | - Christopher Partyka
- Aeromedical Retrieval Service, New South Wales Ambulance, Rozelle, New South Wales, Australia.,South West Clinical School, University of New South Wales, Sydney, New South Wales, Australia.,Emergency Department, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - James Bliss
- Aeromedical Retrieval Service, New South Wales Ambulance, Rozelle, New South Wales, Australia.,South West Clinical School, University of New South Wales, Sydney, New South Wales, Australia.,Emergency Department, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Anders Aneman
- South West Clinical School, University of New South Wales, Sydney, New South Wales, Australia.,Intensive Care Unit, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Ian A Harris
- South West Clinical School, University of New South Wales, Sydney, New South Wales, Australia.,Whitlam Orthopaedic Research Centre, Liverpool, New South Wales, Australia
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Ljungqvist H, Pirneskoski J, Saviluoto A, Setälä P, Tommila M, Nurmi J. Intubation first-pass success in a high performing pre-hospital critical care system is not associated with 30-day mortality: a registry study of 4496 intubation attempts. Scand J Trauma Resusc Emerg Med 2022; 30:61. [PMID: 36411447 PMCID: PMC9677625 DOI: 10.1186/s13049-022-01049-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 11/12/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Lower intubation first-pass success (FPS) rate is associated with physiological deterioration, and FPS is widely used as a quality indicator of the airway management of a critically ill patient. However, data on FPS's association with survival is limited. We aimed to investigate if the FPS rate is associated with 30-day mortality or physiological complications in a pre-hospital setting. Furthermore, we wanted to describe the FPS rate in Finnish helicopter emergency medical services. METHODS This was a retrospective observational study. Data on drug-facilitated intubation attempts by helicopter emergency medical services were gathered from a national database and analysed. Multivariate logistic regression, including known prognostic factors, was performed to assess the association between FPS and 30-day mortality, collected from population registry data. RESULTS Of 4496 intubation attempts, 4082 (91%) succeeded on the first attempt. The mortality rates in FPS and non-FPS patients were 34% and 38% (P = 0.21), respectively. The adjusted odds ratio of FPS for 30-day mortality was 0.88 (95% CI 0.66-1.16). Hypoxia after intubation and at the time of handover was more frequent in the non-FPS group (12% vs. 5%, P < 0.001, and 5% vs. 3%, P = 0.01, respectively), but no significant differences were observed regarding other complications. CONCLUSION FPS is not associated with 30-day mortality in pre-hospital critical care delivered by advanced providers. It should therefore be seen more as a process quality indicator instead of a risk factor of poor outcome, at least considering the current limitations of the parameter.
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Affiliation(s)
- Harry Ljungqvist
- grid.7737.40000 0004 0410 2071University of Helsinki, Helsinki, Finland
| | - Jussi Pirneskoski
- grid.15485.3d0000 0000 9950 5666Department of Emergency Medicine and Services, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Anssi Saviluoto
- grid.15485.3d0000 0000 9950 5666Department of Emergency Medicine and Services, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Piritta Setälä
- grid.412330.70000 0004 0628 2985Centre for Prehospital Emergency Care, Helicopter Emergency Medical Services, Tampere University Hospital, Tampere, Finland
| | - Miretta Tommila
- grid.410552.70000 0004 0628 215XDepartment of Perioperative Services, Intensive Care Medicine and Pain Management, Turku University Hospital and University of Turku, Turku, Finland
| | - Jouni Nurmi
- grid.15485.3d0000 0000 9950 5666Department of Emergency Medicine and Services, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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10
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Saviluoto A, Jäntti H, Kirves H, Setälä P, Nurmi JO. Association between case volume and mortality in pre-hospital anaesthesia management: a retrospective observational cohort. Br J Anaesth 2022; 128:e135-e142. [PMID: 34656323 PMCID: PMC8792835 DOI: 10.1016/j.bja.2021.08.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 08/12/2021] [Accepted: 08/18/2021] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Pre-hospital anaesthesia is a core competency of helicopter emergency medical services (HEMS). Whether physician pre-hospital anaesthesia case volume affects outcomes is unknown in this setting. We aimed to investigate whether physician case volume was associated with differences in mortality or medical management. METHODS We conducted a registry-based cohort study of patients undergoing drug-facilitated intubation by HEMS physician from January 1, 2013 to August 31, 2019. The primary outcome was 30-day mortality, analysed using multivariate logistic regression controlling for patient-dependent variables. Case volume for each patient was determined by the number of pre-hospital anaesthetics the attending physician had managed in the previous 12 months. The explanatory variable was physician case volume grouped by low (0-12), intermediate (13-36), and high (≥37) case volume. Secondary outcomes were characteristics of medical management, including the incidence of hypoxaemia and hypotension. RESULTS In 4818 patients, the physician case volume was 511, 2033, and 2274 patients in low-, intermediate-, and high-case-volume groups, respectively. Higher physician case volume was associated with lower 30-day mortality (odds ratio 0.79 per logarithmic number of cases [95% confidence interval: 0.64-0.98]). High-volume physician providers had shorter on-scene times (median 28 [25th-75th percentile: 22-38], compared with intermediate 32 [23-42] and lowest 32 [23-43] case-volume groups; P<0.001) and a higher first-pass success rate for tracheal intubation (98%, compared with 93% and 90%, respectively; P<0.001). The incidence of hypoxaemia and hypotension was similar between groups. CONCLUSIONS Mortality appears to be lower after pre-hospital anaesthesia when delivered by physician providers with higher case volumes.
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Affiliation(s)
- Anssi Saviluoto
- Research and Development Unit, FinnHEMS, Vantaa, Finland; University of Eastern Finland, Kuopio, Finland
| | - Helena Jäntti
- Centre for Prehospital Emergency Care, Kuopio University Hospital, Kuopio, Finland
| | - Hetti Kirves
- Prehospital Emergency Care, Hyvinkää Hospital Area, Hospital District of Helsinki and Uusimaa, Hyvinkää, Finland
| | - Piritta Setälä
- Centre for Prehospital Emergency Care, Tampere University Hospital, Tampere, Finland
| | - Jouni O Nurmi
- Research and Development Unit, FinnHEMS, Vantaa, Finland; Emergency Medicine and Services, Helsinki University Hospital and University of Helsinki, Helsinki, Finland.
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11
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Vithalani V, Sondheim S, Cornelius A, Gonzales J, Mercer MP, Burton B, Redlener M. Quality Management of Prehospital Airway Programs: An NAEMSP Position Statement and Resource Document. PREHOSP EMERG CARE 2022; 26:14-22. [PMID: 35001828 DOI: 10.1080/10903127.2021.1989530] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Prehospital airway management encompasses a multitude of complex decision-making processes, techniques, and interventions. Quality management (encompassing quality assurance and quality improvement activities) in EMS is dynamic, evidence-based, and most of all, patient-centric. Long a mainstay of the EMS clinician skillset, airway management deserves specific focus and attention and dedicated quality management processes to ensure the delivery of high-quality clinical care.It is the position of NAEMSP that:All EMS agencies should dedicate sufficient resources to patient-centric, comprehensive prehospital airway quality management program. These quality management programs should consist of prospective, concurrent, and retrospective activities. Quality management programs should be developed and operated with the close involvement of the medical director.Quality improvement and quality assurance efforts should operate in an educational, non-disciplinary, non-punitive, evidence-based medicine culture focused on patient safety. The highest quality of care is only achieved when the quality management program rewards those who identify and seek to prevent errors before they occur.Information evaluated in prehospital airway quality management programs should include both subjective and objective data elements with uniform reporting and operational definitions.EMS systems should regularly measure and report process, outcome, and balancing airway management measures.Quality management activities require large-scale bidirectional information sharing between EMS agencies and receiving facilities. Hospital outcome information should be shared with agencies and the involved EMS clinicians.Findings from quality management programs should be used to guide and develop initial education and continued training.Quality improvement programs must continually undergo evaluation and assessment to identify strengths and shortcomings with a focus on continuous improvement.
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Ljungqvist HE, Nurmi JO. Reasons behind failed prehospital intubation attempts while combining C-MAC videolaryngoscope and Frova introducer. Acta Anaesthesiol Scand 2022; 66:132-140. [PMID: 34582041 DOI: 10.1111/aas.13985] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 08/11/2021] [Accepted: 09/04/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND High first-pass success rate is achieved with the routine use of C-MAC videolaryngoscope and Frova introducer. We aim to identify potential reasons and subgroups associated with failed intubation attempts, analyse actions taken after them and study possible complications. METHODS We conducted a retrospective observational study of adult intubated patients at a single helicopter emergency medical service unit in southern Finland between 2016 and 2018. We collected data on patient characteristics, reasons for failed attempts, complications and follow-up measures from a national helicopter emergency medical service database and from prehospital patient records. RESULTS 1011 tracheal intubations were attempted. First attempt was successful in 994 cases (FPS 994/1011, 98.3%), 15 needed a second or third attempt and two a surgical airway (non-FPS 17/1011, 1.7%, 95% CI 1.0-2.7). The failed first attempt group had heterogenous characteristics. The most common cause for a failed first attempt was obstruction of the airway by vomit, food, mucus or blood (10/13, 76%). After the failed first attempt, there were six cases (6/14, 43%) of deviation from the protocol and the most frequent complications were five cases (5/17, 29%) of hypoxia and four cases (4/17, 24%) of hypotension. CONCLUSIONS When a protocol combining the C-MAC videolaryngoscope and Frova introducer is used, the most common reason for a failed first attempt is an airway blocked by gastric content, blood or mucus. These findings highlight the importance of effective airway decontamination methods and questions the appropriateness of anatomically focused pre-intubation assessment tools when such protocol is used.
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Affiliation(s)
| | - Jouni O. Nurmi
- University of Helsinki Helsinki Finland
- Emergency Medicine and Services Helsinki University Hospital Helsinki Finland
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13
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Elonheimo L, Ljungqvist H, Harve‐Rytsälä H, Jäntti H, Nurmi J. Frequency, indications and success of out-of-hospital intubations in Finnish children. Acta Anaesthesiol Scand 2022; 66:125-131. [PMID: 34514584 DOI: 10.1111/aas.13980] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 08/19/2021] [Accepted: 08/23/2021] [Indexed: 01/10/2023]
Abstract
BACKGROUND Earlier studies have shown variable results regarding the success of paediatric emergency endotracheal intubation between different settings and operators. We aimed to describe the paediatric population intubated by physician-staffed helicopter emergency medical service (HEMS) and evaluate the factors associated with overall and first-pass success (FPS). METHODS We conducted a retrospective observational cohort study in Finland including all children less than 16 years old who required endotracheal intubation by a HEMS physician from January 2014 to August 2019. Utilising a national HEMS database, we analysed the incidence, indications, overall and first-pass success rates of endotracheal intubation. RESULTS A total of 2731 children were encountered by HEMS, and intubation was attempted in 245 (9%); of these, 22 were younger than 1 year, 103 were aged 1-5 years and 120 were aged 6-15 years. The most common indications for airway management were cardiac arrest for the youngest age group, neurological reasons (e.g., seizures) for those aged 1-5 years and trauma for those aged 6-15. The HEMS physicians had an overall success rate of 100% (95% CI: 98-100) and an FPS rate of 86% (95% CI: 82-90). The FPS rate was lower in the youngest age group (p = .002) and for patients in cardiac arrest (p < .001). CONCLUSIONS Emergency endotracheal intubation of children is successfully performed by a physician staffed HEMS unit even though these procedures are rare. To improve the care, emphasis should be on airway management of infants and patients in cardiac arrest.
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Affiliation(s)
- Lauri Elonheimo
- Emergency Medicine and Services Helsinki University Hospital Helsinki Finland
| | | | - Heini Harve‐Rytsälä
- Emergency Medicine and Services Helsinki University Hospital Helsinki Finland
- University of Helsinki Helsinki Finland
| | - Helena Jäntti
- Center for Prehospital Emergency Care Kuopio University Hospital Kuopio Finland
| | - Jouni Nurmi
- Emergency Medicine and Services Helsinki University Hospital Helsinki Finland
- University of Helsinki Helsinki Finland
- FinnHEMS Research and Development Unit Vantaa Finland
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Länkimäki S, Spalding M, Saari A, Alahuhta S. Procedural Sedation Intubation in a Paramedic-Staffed Helicopter Emergency Medical System in Northern Finland. Air Med J 2021; 40:385-389. [PMID: 34794775 DOI: 10.1016/j.amj.2021.08.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 07/14/2021] [Accepted: 08/26/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Airway management to ensure sufficient gas exchange is of major importance in emergency care. Prehospital endotracheal intubation (ETI) by paramedics is a widely debated method to ensure a patent airway. ETI is performed with procedural sedation in comatose patients because of the regulation. The use of medications increases the rate of successful airway management compared with nonmedication ETI and may also improve outcomes in patients with traumatic brain injury. In the absence of an operative emergency physician and with long distances, paramedic-induced airway management may increase the survival of patients in selected scenarios. A paramedic-staffed helicopter emergency medical system in Northern Finland operates in a rural area without an emergency physician and paralytic medications and treats critically ill patients using basic or advanced life support ground units. The aim of this study was to evaluate the success rates of ETI performed by a small, appropriately trained, and experienced group of 8 nurse paramedics in an out-of-hospital setting. METHODS The inclusion criterion for the study was an attempted intubation in patients with medical or traumatic indication for airway management by nurse paramedic. RESULTS Fifty-one patients were treated with ETI. The first-pass success rate was 72.5%, the second-pass success rate was 94.1%, and the overall success rate was 100% within 4 attempts. The median on-scene time was 54 minutes, and there were no signs of aspiration during laryngoscopy or after successful ETI. The primary mortality rate was 11.7%. CONCLUSION The use of a rigid standard operating procedure for paramedic rapid sequence induction, paralytics, a video laryngoscope, and a gum elastic bougie might positively affect the ETI first-pass success rate. A follow-up study after these future modifications is needed. This small study suggests that intubation might be 1 option for airway management by an experienced nonanesthesiologist in Lapland.
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Affiliation(s)
- Sami Länkimäki
- Emergency Medical Service, Department of Emergency Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; Department of Anaesthesiology, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland.
| | - Michael Spalding
- Department of Anaesthesiology, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Antti Saari
- Centre for Prehospital Emergency Care, Lapland Hospital District, Rovaniemi, Finland
| | - Seppo Alahuhta
- Department of Anaesthesiology, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
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Árnason B, Hertzberg D, Kornhall D, Günther M, Gellerfors M. Pre-hospital emergency anaesthesia in trauma patients treated by anaesthesiologist and nurse anaesthetist staffed critical care teams. Acta Anaesthesiol Scand 2021; 65:1329-1336. [PMID: 34152597 PMCID: PMC9291089 DOI: 10.1111/aas.13946] [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: 01/25/2021] [Revised: 05/06/2021] [Accepted: 05/08/2021] [Indexed: 12/05/2022]
Abstract
Background Pre‐hospital tracheal intubation in trauma patients has recently been questioned. However, not only the trauma and patient characteristics but also airway provider competence differ between systems making simplified statements difficult. Method The study is a subgroup analysis of trauma patients included in the PHAST study. PHAST was a prospective, observational, multicentre study on pre‐hospital advanced airway management by anaesthesiologist and nurse anaesthetist manned pre‐hospital critical care teams in the Nordic countries May 2015‐November 2016. Endpoints include intubation success rate, complication rate (airway‐related complication according to Utstein Airway Template by Sollid et al), scene time (time from arrival of the critical care team to departure of the patient) and pre‐hospital mortality. Result The critical care teams intubated 385 trauma patients, of which 65 were in shock (SBP <90 mm Hg), during the study. Of the trauma patients, 93% suffered from blunt trauma, the mean GCS was 6 and 75% were intubated by an experienced provider who had performed >2500 tracheal intubations. The pre‐hospital tracheal intubation overall success rate was 98.6% and the complication rate was 13.6%, with no difference between patients with or without shock. The mean scene time was significantly shorter in trauma patients with shock (21.4 min) compared to without shock (21.4 vs 25.1 min). Following pre‐hospital tracheal intubation, 97% of trauma patients without shock and 91% of the patients in shock with measurable blood pressure were alive upon arrival to the ED. Conclusion Pre‐hospital tracheal intubation success and complication rates in trauma patients were comparable with in‐hospital rates in a system with very experienced airway providers. Whether the short scene times contributed to a low pre‐hospital mortality needs further investigation in future studies.
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Affiliation(s)
- Bjarni Árnason
- Department of Perioperative Medicine and Intensive Care Karolinska University Hospital Stockholm Sweden
- Rapid Response CarCapio Stockholm Sweden
| | - Daniel Hertzberg
- Department of Perioperative Medicine and Intensive Care Karolinska University Hospital Stockholm Sweden
- Department of Physiology and PharmacologyKarolinska Institutet Stockholm Sweden
| | - Daniel Kornhall
- Swedish Air Ambulance (SLA) Mora Sweden
- East Anglian Air Ambulance Cambridge UK
| | - Mattias Günther
- Department of Clinical Research and Education Karolinska Institutet Stockholm Sweden
| | - Mikael Gellerfors
- Department of Perioperative Medicine and Intensive Care Karolinska University Hospital Stockholm Sweden
- Rapid Response CarCapio Stockholm Sweden
- Department of Physiology and PharmacologyKarolinska Institutet Stockholm Sweden
- Swedish Air Ambulance (SLA) Mora Sweden
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Pediatric Prehospital Advanced Airway Management by Anesthesiologist and Nurse Anesthetist Staffed Critical Care Teams. Prehosp Disaster Med 2021; 36:547-552. [PMID: 34254579 DOI: 10.1017/s1049023x21000637] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
INTRODUCTION Prehospital pediatric tracheal intubation (TI) is a possible life-saving intervention that requires adequate experience to mitigate associated complications. The pediatric airway and respiratory physiology present challenges in addition to a relatively rare incidence of prehospital pediatric TI. STUDY OBJECTIVE The aim of this study was to describe characteristics and outcomes of prehospital TI in pediatric patients treated by critical care teams. METHODS This is a sub-group analysis of all pediatric (<16 years old) patients from a prospective, observational, multi-center study on prehospital advanced airway management in the Nordic countries from May 2015 through November 2016. The TIs were performed by anesthesiologists and nurse anesthetists staffing six helicopter and six Rapid Response Car (RRC) prehospital critical care teams. RESULTS In the study, 74 children were tracheal intubated, which corresponds to 3.7% (74/2,027) of the total number of patients. The pediatric patients were intubated by very experienced providers, of which 80% had performed ≥2,500 TIs. The overall TI success rate, first pass success rate, and airway complication rate were in all children (<16 years) 98%, 82%, and 12%. The corresponding rates among infants (<2 years) were 94%, 67%, and 11%. The median time on scene was 30 minutes. CONCLUSION This study observed a high overall prehospital TI success rate in children with relatively few associated complications and short time on scene, despite the challenges presented by the pediatric prehospital TI.
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Otto Q, Nolan JP, Chamberlain DA, Cummins RO, Soar J. Utstein Style for emergency care - the first 30 years. Resuscitation 2021; 163:16-25. [PMID: 33823223 DOI: 10.1016/j.resuscitation.2021.03.022] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 03/11/2021] [Accepted: 03/22/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Utstein Abbey near Stavanger in Norway, hosted a meeting in 1990 on guidelines for the uniform reporting of data from out-of-hospital cardiac arrest. In this paper we describe the last 30 years of the Utstein style. METHODS A systematic literature search identified publications from Utstein-style meetings or groups using the Utstein format. RESULTS 30 outputs were found, describing primarily resuscitation structure, process and outcome measures. They originated from all over the world and from multiple medical disciplines. Some were co-published in multiple journals. CONCLUSIONS The meeting at Utstein Abbey in 1990 has had a sustained and far-reaching impact, particularly in resuscitation science, implementation and outcomes. The Utstein format will continue to evolve following the key principles from the original meeting and with the ultimate aim of improving patient care and outcomes.
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Affiliation(s)
| | - Jerry P Nolan
- University of Warwick, Warwick Medical School, Coventry, Consultant in Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, UK
| | | | - Richard O Cummins
- Department of Emergency Medicine, University of Washington, Seattle, USA
| | - Jasmeet Soar
- Consultant in Anaesthetics and Intensive Care Medicine, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
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Saviluoto A, Björkman J, Olkinuora A, Virkkunen I, Kirves H, Setälä P, Pulkkinen I, Laukkanen-Nevala P, Raatiniemi L, Jäntti H, Iirola T, Nurmi J. The first seven years of nationally organized helicopter emergency medical services in Finland - the data from quality registry. Scand J Trauma Resusc Emerg Med 2020; 28:46. [PMID: 32471467 PMCID: PMC7260827 DOI: 10.1186/s13049-020-00739-4] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 05/20/2020] [Indexed: 12/28/2022] Open
Abstract
Background Helicopter Emergency Medical Services (HEMS) play an important role in prehospital care of the critically ill. Differences in funding, crew composition, dispatch criteria and mission profile make comparison between systems challenging. Several systems incorporate databases for quality control, performance evaluation and scientific purposes. FinnHEMS database was incorporated for such purposes following the national organization of HEMS in Finland 2012. The aims of this study are to describe information recorded in the database, data collection, and operational characteristics of Finnish HEMS during 2012–2018. Methods All dispatches of the six Finnish HEMS units recorded in the national database from 2012 to 2018 were included in this observational registry study. Five of the units are physician staffed, and all are on call 24/7. The database follows a template for uniform reporting in physician staffed pre-hospital services, exceeding the recommended variables of relevant guidelines. Results The study included 100,482 dispatches, resulting in 33,844 (34%) patient contacts. Variables were recorded with little or no missing data. A total of 16,045 patients (16%) were escorted by HEMS to hospital, of which 2239 (2%) by helicopter. Of encountered patients 4195 (4%) were declared deceased on scene. The number of denied or cancelled dispatches was 66,638 (66%). The majority of patients were male (21,185, 63%), and the median age was 57.7 years. The median American Society of Anesthesiologists Physical Scale classification was 2 and Eastern Cooperative Oncology Group performance class 0. The most common reason for response was trauma representing 26% (8897) of the patients, followed by out-of-hospital cardiac arrest 20% (6900), acute neurological reason excluding stroke 13% (4366) and intoxication and related psychiatric conditions 10% (3318). Blunt trauma (86%, 7653) predominated in the trauma classification. Conclusions Gathering detailed and comprehensive data nationally on all HEMS missions is feasible. A national database provides valuable insights into where the operation of HEMS could be improved. We observed a high number of cancelled or denied missions and a low percentage of patients transported by helicopter. The medical problem of encountered patients also differs from comparable systems.
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Affiliation(s)
- Anssi Saviluoto
- Research and Development Unit, FinnHEMS, WTC Helsinki Airport, Lentäjäntie 3, FI-01530, Vantaa, Finland. .,University of Eastern Finland, PO Box 1627, FI-70211, Kuopio, Finland.
| | - Johannes Björkman
- Research and Development Unit, FinnHEMS, WTC Helsinki Airport, Lentäjäntie 3, FI-01530, Vantaa, Finland.,University of Helsinki, PO Box 4, FI-00014, Helsinki, Finland
| | - Anna Olkinuora
- Research and Development Unit, FinnHEMS, WTC Helsinki Airport, Lentäjäntie 3, FI-01530, Vantaa, Finland
| | - Ilkka Virkkunen
- Research and Development Unit, FinnHEMS, WTC Helsinki Airport, Lentäjäntie 3, FI-01530, Vantaa, Finland
| | - Hetti Kirves
- Prehospital Emergency Care, Hyvinkää hospital area, Hospital District of Helsinki and Uusimaa, PO Box 585, FI-05850, Hyvinkää, Finland
| | - Piritta Setälä
- Emergency Medical Services, Tampere University Hospital, PO Box 2000, FI-33521, Tampere, Finland
| | - Ilkka Pulkkinen
- Research and Development Unit, FinnHEMS, WTC Helsinki Airport, Lentäjäntie 3, FI-01530, Vantaa, Finland
| | - Päivi Laukkanen-Nevala
- Research and Development Unit, FinnHEMS, WTC Helsinki Airport, Lentäjäntie 3, FI-01530, Vantaa, Finland
| | - Lasse Raatiniemi
- Centre for Prehospital Emergency Care, Oulu University Hospital, PO Box 50, FI-90029, Oulu, Finland
| | - Helena Jäntti
- University of Eastern Finland, PO Box 1627, FI-70211, Kuopio, Finland.,Center for Prehospital Emergency Care, Kuopio University Hospital, PO Box 100, FI-70029, Kuopio, Finland
| | - Timo Iirola
- Emergency Medical Services, Turku University Hospital and University of Turku, PO Box 52, FI-20521, Turku, Finland
| | - Jouni Nurmi
- Research and Development Unit, FinnHEMS, WTC Helsinki Airport, Lentäjäntie 3, FI-01530, Vantaa, Finland.,Emergency Medicine and Services, Helsinki University Hospital and Emergency Medicine, University of Helsinki, PO Box 100, FI-00029, Helsinki, Finland
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Garner AA, Bennett N, Weatherall A, Lee A. Physician-staffed helicopter emergency medical services augment ground ambulance paediatric airway management in urban areas: a retrospective cohort study. Emerg Med J 2019; 36:678-683. [DOI: 10.1136/emermed-2019-208421] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Revised: 08/09/2019] [Accepted: 08/25/2019] [Indexed: 01/07/2023]
Abstract
ObjectivesPaediatric intubation is a high-risk procedure for ground emergency medical services (GEMS). Physician-staffed helicopter EMS (PS-HEMS) may bring additional skills, drugs and equipment to the scene including advanced airway management beyond the scope of GEMS even in urban areas with short transport times. This study aimed to evaluate prehospital paediatric intubation performed by a PS-HEMS when dispatched to assist GEMS in a large urban area and examine how often PS-HEMS provided airway intervention that was not or could not be provided by GEMS.MethodsWe performed a retrospective observational study from July 2011 to December 2016 of a PS-HEMS in a large urban area (Sydney, Australia), which responds in parallel to GEMS. GEMS intubate without adjuvant neuromuscular blockade, whereas the PS-HEMS use neuromuscular blockade and anaesthetic agents. We examined endotracheal intubation success rate, first-look success rate and complications for the PS-HEMS and contrasted this with the advanced airway interventions provided by GEMS prior to PS-HEMS arrival.ResultsOverall intubation success rate was 62/62 (100%) and first-look success was 59/62 (95%) in the PS-HEMS-treated group, whereas the overall success rate was 2/7 (29%) for the GEMS group. Peri-intubation hypoxia was documented in 5/65 (8%) of the PS-HEMS intubation attempts but no other complications were reported. However, 3/7 (43%) of the attempted intubations by GEMS were oesophageal intubations, two of which were unrecognised.ConclusionsPS-HEMS have high success with low complication rates in paediatric prehospital intubation. Even in urban areas with rapid GEMS response, PS-HEMS activated in parallel can provide safe and timely advanced prehospital airway management for seriously ill and injured children beyond the scope of GEMS practice. Review of GEMS airway management protocols and the PS-HEMS case identification and dispatch system in Sydney is warranted.
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Gamberini L, Baldazzi M, Coniglio C, Gordini G, Bardi T. Prehospital Airway Management in Severe Traumatic Brain Injury. Air Med J 2019; 38:366-373. [PMID: 31578976 DOI: 10.1016/j.amj.2019.06.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 05/12/2019] [Accepted: 06/13/2019] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Traumatic brain injury (TBI) is a leading cause of death and disability among trauma patients. The final outcome of TBI results from a complex interaction between primary and secondary mechanisms of injury that begin immediately after the traumatic event. The aim of this review was to evaluate the latest evidence regarding the impact of prehospital airway management and the outcome after traumatic brain injury. METHODS PubMed, Embase, and Cochrane searches were conducted using the MeSH database. Airway management, traumatic brain injury, pneumonia, and the subheadings of these Medical Subject Headings were combined. RESULTS The review is structured into 4 major topics: airway management devices, prehospital pharmacologic management, mortality and neurologic outcomes, and early respiratory infections. The available literature shows a shift toward a more comprehensive view of prehospital airway management, taking into account not only the location where airway management is attempted but also the drugs administered, the airway management devices used, and the skills of the main professional figures attending the scene. CONCLUSIONS Literature about this topic is still inconclusive; however, new evidence taking into consideration more complex aspects of airway management rather than orotracheal intubation per se shows improved outcomes with aggressive prehospital airway management.
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Affiliation(s)
- Lorenzo Gamberini
- Division of Anesthesia, Intensive Care and Prehospital Emergency, Ospedale Maggiore Carlo Alberto Pizzardi, Bologna, Italy.
| | - Marzia Baldazzi
- Division of Anesthesia, Intensive Care and Prehospital Emergency, Ospedale Maggiore Carlo Alberto Pizzardi, Bologna, Italy
| | - Carlo Coniglio
- Division of Anesthesia, Intensive Care and Prehospital Emergency, Ospedale Maggiore Carlo Alberto Pizzardi, Bologna, Italy
| | - Giovanni Gordini
- Division of Anesthesia, Intensive Care and Prehospital Emergency, Ospedale Maggiore Carlo Alberto Pizzardi, Bologna, Italy
| | - Tommaso Bardi
- Division of Anesthesia, Intensive Care and Prehospital Emergency, Ospedale Maggiore Carlo Alberto Pizzardi, Bologna, Italy
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Glasheen J, Holmes P, Rampersad N, Raman S. Endotracheal intubation by a specialised paediatric retrieval team. Emerg Med Australas 2019; 32:75-79. [PMID: 31264388 DOI: 10.1111/1742-6723.13341] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 06/02/2019] [Accepted: 06/04/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Intubation of critically ill children is an infrequent procedure, and is associated with significant risk. We set out to describe intubations carried out by the Children's Health Queensland Retrieval Service (CHQRS), with the intention to identify areas for improvement in the performance of intubation in the retrieval setting. METHODS Paediatric patients undergoing transport while intubated were identified, and cases where intubation occurred after the arrival of the CHQRS team were examined. RESULTS Over the study period of January 2015 to September 2018, 498 intubated retrievals were undertaken; 85 patients were intubated after the arrival of CHQRS; the age range was 1 day to 16.5 years (median 0.5, interquartile range [IQR] 0.11-3 years). The median weight was 6.2 kg (IQR 3.7-16.5 kg). The pathology requiring intubation included respiratory 36 (42.3%), sepsis 21 (24.7%), neurological 11 (12.9%) and trauma 7 (8.2%). A total of 470 of 498 (94.4%) of intubated patients were from regional referral or tertiary hospitals, 28 of 498 (5.6%) were from rural and remote facilities. Of 85 patients, 57 (67.1%) were intubated by CHQRS and 28 (32.9%) were intubated by a doctor from the referring facility. The CHQRS team was more likely to perform the intubation in smaller children (median weight 5.0 vs 9.9 kg, P = 0.03). The mean scene time was 2.8 h. The scene time was shorter if the intubation was performed by CHQRS (mean 2.6 h, median 2.5, IQR 1.8-3.3; median 3, IQR 2.2-3.9; P = 0.048). The scene time was shorter when the intubation was predicted from tasking information (2.6 vs 3.1 h; P = 0.03). CONCLUSION Paediatric endotracheal intubation is an infrequent procedure in our service. An airway registry could improve documentation and gather information to identify specific training requirements and areas for practice improvement.
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Affiliation(s)
- John Glasheen
- Children's Health Queensland Retrieval Service, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Paul Holmes
- Children's Health Queensland Retrieval Service, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Neeta Rampersad
- Children's Health Queensland Retrieval Service, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Sainath Raman
- Children's Health Queensland Retrieval Service, Queensland Children's Hospital, Brisbane, Queensland, Australia
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Oud FRW, Kooij FO, Burns BJ. Long-term Effectiveness of the Airway Registry at Sydney Helicopter Emergency Medical Service. Air Med J 2019; 38:161-164. [PMID: 31122579 DOI: 10.1016/j.amj.2019.01.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Accepted: 01/31/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVE Prehospital rapid sequence intubation (RSI) is prone to suboptimal documentation. The Greater Sydney Area Helicopter Emergency Medical Service (GSA-HEMS) uses a dedicated Airway Registry (AR) to aid documentation. The AR was only evaluated shortly after its introduction. This first evaluation is followed up to assess the long-term effectiveness of the AR. The secondary objective was to compare the AR with templates in the literature. METHODS A retrospective review of electronic records was undertaken to compare completeness of documentation between an immediate postintroduction and a long-term postintroduction cohort. Differences between the two cohorts were tested for significance. RESULTS There was no significant difference in documentation for Cormack-Lehane laryngoscopy grade at the first intubation attempt (P = .552) and confirmation of end-tidal carbon dioxide (P = .258). A significant improvement in the documentation of laryngoscopy grade for the second attempt (P = 0) was found. The documentation of intubator details remained at 100% (165/165). The variables collected by GSA-HEMS corresponded well to the literature, but some definitions differ (eg, desaturation). CONCLUSION There was no significant change in completeness of documentation for most key intubation variables eight years after the introduction of the AR. GSA-HEMS performs well in registering variables as proposed in the literature; however, variable definitions need to be synchronized.
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Affiliation(s)
- Floris R W Oud
- Greater Sydney Area Helicopter Emergency Medical Service, New South Wales Ambulance, Bankstown Airport, New South Wales, Australia; Department of Anesthesiology, Amsterdam University Medical Centres, location AMC, Amsterdam Zuidoost, The Netherlands(3) Sydney Medical School, Sydney University.
| | - Fabian O Kooij
- Department of Anesthesiology, Amsterdam University Medical Centres, location AMC, Amsterdam Zuidoost, The Netherlands(3) Sydney Medical School, Sydney University
| | - Brian J Burns
- Greater Sydney Area Helicopter Emergency Medical Service, New South Wales Ambulance, Bankstown Airport, New South Wales, Australia; Department of Anesthesiology, Amsterdam University Medical Centres, location AMC, Amsterdam Zuidoost, The Netherlands(3) Sydney Medical School, Sydney University
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23
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Gamberini L, Giugni A, Ranieri S, Meconi T, Coniglio C, Gordini G, Bardi T. Early-Onset Ventilator-Associated Pneumonia in Severe Traumatic Brain Injury: is There a Relationship with Prehospital Airway Management? J Emerg Med 2019; 56:657-665. [PMID: 31000428 DOI: 10.1016/j.jemermed.2019.02.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 01/22/2019] [Accepted: 02/02/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND Prehospital airway management in severe traumatic brain injury (TBI) is widely recommended by international guidelines for the management of trauma. Early-onset ventilator-associated pneumonia (EOVAP) is a common occurrence in this population and can worsen mortality and functional outcome. OBJECTIVES In this retrospective observational study, we aimed to evaluate the association between different prehospital airway management variables and the occurrence of EOVAP. Secondarily we evaluated the correlation between EOVAP and mortality and neurological outcome. METHODS The study retrospectively evaluated 223 patients admitted from 2010 to 2017 in our trauma intensive care unit for severe TBI. The population was divided into three groups on the basis of the airway management technique adopted (bag mask ventilation, laryngeal tube, orotracheal intubation). Uni- and multivariate logistic regression analyses were performed using the occurrence of EOVAP as the dependent variable, to investigate potential associations with prehospital airway management. RESULTS A total of 131 episodes (58.7%) of EOVAP were registered in the study population (223 patients). Laryngeal tube and orotracheal intubation were used in patients with significantly lower Glasgow Coma Scale score on scene and a higher Face Abbreviated Injury Scale; advanced airway management significantly increased the total rescue time. The prehospital airway management technique adopted, prehospital type of sedation or use of muscle relaxants, type of transport, and rescue times were not associated with the occurrence of EOVAP. CONCLUSIONS Prehospital airway management does not have a significant impact on the occurrence of EOVAP in severe TBI patients. Similarly, it does not have a significant impact on mortality or long-term neurological outcome despite increasing duration of mechanical ventilation, intensive care unit, and hospital stay.
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Affiliation(s)
- Lorenzo Gamberini
- Division of Anesthesia, Intensive Care, and Prehospital Emergency, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
| | - Aimone Giugni
- Division of Anesthesia, Intensive Care, and Prehospital Emergency, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
| | - Serena Ranieri
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum, University of Bologna and S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Tommaso Meconi
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum, University of Bologna and S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Carlo Coniglio
- Division of Anesthesia, Intensive Care, and Prehospital Emergency, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
| | - Giovanni Gordini
- Division of Anesthesia, Intensive Care, and Prehospital Emergency, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
| | - Tommaso Bardi
- Division of Anesthesia, Intensive Care, and Prehospital Emergency, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
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24
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Glasheen J, Wall B, Keogh S. A BRILL idea? The benefits, risks, insights, learning and limitations of an emergency airway registry in pre-hospital and retrieval medicine. Emerg Med Australas 2019; 31:483-486. [PMID: 30924314 DOI: 10.1111/1742-6723.13283] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 02/04/2019] [Accepted: 02/24/2019] [Indexed: 12/31/2022]
Abstract
Airway management is a cornerstone of emergency care. Development of a robust evidence base to support the practice of pre-hospital emergency anaesthesia is key to the safety and evolution of this common but high-risk procedure. This paper discusses the benefits, risks, insights, learning and limitations of the use of an airway registry in pre-hospital and retrieval medicine, for both research and quality improvement purposes.
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Affiliation(s)
- John Glasheen
- LifeFlight Retrieval Medicine, Brisbane, Queensland, Australia.,Anaesthesia Trauma and Critical Care, Lancashire, UK
| | - Brigid Wall
- Anaesthesia Trauma and Critical Care, Lancashire, UK.,Queensland Ambulance Service, Brisbane, Queensland, Australia
| | - Sean Keogh
- Faculty of Science, Health, Education and Engineering, University of the Sunshine Coast, Sunshine Coast, Queensland, Australia
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25
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Tønsager K, Rehn M, Ringdal KG, Lossius HM, Virkkunen I, Østerås Ø, Røislien J, Krüger AJ. Collecting core data in physician-staffed pre-hospital helicopter emergency medical services using a consensus-based template: international multicentre feasibility study in Finland and Norway. BMC Health Serv Res 2019; 19:151. [PMID: 30849977 PMCID: PMC6408770 DOI: 10.1186/s12913-019-3976-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 02/26/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Comparison of services and identification of factors important for favourable patient outcomes in emergency medical services (EMS) is challenging due to different organization and quality of data. The purpose of the present study was to evaluate the feasibility of physician-staffed EMS (p-EMS) to collect patient and system level data by using a consensus-based template. METHODS The study was an international multicentre observational study. Data were collected according to a template for uniform reporting of data from p-EMS using two different data collection methods; a standard and a focused data collection method. For the standard data collection, data were extracted retrospectively for one year from all FinnHEMS bases and for the focused data collection, data were collected prospectively for six weeks from four selected Norwegian p-EMS bases. Completeness rates for the two data collection methods were then compared and factors affecting completeness rates and template feasibility were evaluated. Standard Chi-Square, Fisher's Exact Test and Mann-Whitney U Test were used for group comparison of categorical and continuous data, respectively, and Kolomogorov-Smirnov test for comparison of distributional properties. RESULTS All missions with patient encounters were included, leaving 4437 Finnish and 128 Norwegian missions eligible for analysis. Variable completeness rates indicated that physiological variables were least documented. Information on pain and respiratory rate were the most frequently missing variables with a standard data collection method and systolic blood pressure was the most missing variable with a focused data collection method. Completeness rates were similar or higher when patients were considered severely ill or injured but were lower for missions with short patient encounter. When a focused data collection method was used, completeness rates were higher compared to a standard data collection method. CONCLUSIONS We found that a focused data collection method increased data capture compared to a standard data collection method. The concept of using a template for documentation of p-EMS data is feasible in physician-staffed services in Finland and Norway. The greatest deficiencies in completeness rates were evident for physiological parameters. Short missions were associated with lower completeness rates whereas severe illness or injury did not result in reduced data capture.
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Affiliation(s)
- Kristin Tønsager
- The Norwegian Air Ambulance Foundation, Oslo, Norway
- Department of Anaesthesiology and Intensive Care, Stavanger University Hospital, Stavanger, Norway
- Department of Health Studies, University of Stavanger, Stavanger, Norway
| | - Marius Rehn
- The Norwegian Air Ambulance Foundation, Oslo, Norway
- Department of Health Studies, University of Stavanger, Stavanger, Norway
- Pre-hospital Division, Air Ambulance Department, Oslo University Hospital, Oslo, Norway
| | - Kjetil G. Ringdal
- Department of Anesthesiology, Vestfold Hospital Trust, Tønsberg, Norway
- Division of Emergencies and Critical Care, Department of Anesthesiology, Oslo University Hospital, Oslo, Norway
- Norwegian Trauma Registry, Oslo University Hospital, Oslo, Norway
| | - Hans Morten Lossius
- The Norwegian Air Ambulance Foundation, Oslo, Norway
- Department of Health Studies, University of Stavanger, Stavanger, Norway
| | | | - Øyvind Østerås
- Department of Anaesthesiology and Intensive Care, Haukeland University Hospital, Bergen, Norway
| | - Jo Røislien
- The Norwegian Air Ambulance Foundation, Oslo, Norway
- Department of Health Studies, University of Stavanger, Stavanger, Norway
| | - Andreas J. Krüger
- The Norwegian Air Ambulance Foundation, Oslo, Norway
- Department of Emergency Medicine and Pre-Hospital Services, St. Olavs Hospital, Trondheim, Norway
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26
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Bernhard M, Bax SN, Hartwig T, Yahiaoui-Doktor M, Petros S, Bercker S, Ramshorn-Zimmer A, Gries A. Airway Management in the Emergency Department (The OcEAN-Study) - a prospective single centre observational cohort study. Scand J Trauma Resusc Emerg Med 2019; 27:20. [PMID: 30764832 PMCID: PMC6376794 DOI: 10.1186/s13049-019-0599-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Accepted: 02/07/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Emergency airway management (AM) is a major key for successful resuscitation of critically ill non-traumatic (CINT) patients. Details of the AM of these patients in German emergency departments (ED) are unknown. This observational study describes epidemiology, airway techniques, success rates and complications of AM in CINT ED patients in the resuscitation room (RR). METHODS Data was collected prospectively on adult CINT patients admitted to the RR of a single German university ED September 2014 to August 2015. Patient characteristics, out-of-hospital and in-hospital RR AM, complications and success rates were recorded using a self-developed airway registry form. RESULTS During the study period 34,303 patients were admitted to the ED, out of those 21,074 patients for non-trauma emergencies. Suffering from severe acute life-threatening problems, 532 CINT patients were admitted to the RR. 150 (28.2%) CINT patients had received out-of-hospital AM. In 16 of these cases (10.7%) the inserted airway needed to be changed after RR admission (unrecognized oesophageal intubation: n = 2, laryngeal tube exchange: n = 14). 136 (25.6%) CINT patients without out-of-hospital AM received RR AM immediately after admission. The first-pass and overall success rate in the RR were 71 and 100%, respectively, and multiple intubation attempts were necessary in 29%. A lower Cormack/Lehane (C/L) grade was associated with less intubation attempts (C/L1/2 vs. 3/4: 1.2 ± 0.5 vs. 1.8 ± 1.2, p = 0.0002). Complication rate was 43%. CONCLUSIONS OcEAN demonstrates the challenges of AM in CINT patients in a German ED RR. We propose a nation-wide ED airway registry to better track outcomes in the future.
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Affiliation(s)
- Michael Bernhard
- Emergency Department, University Hospital of Düsseldorf, Düsseldorf, Germany.,Emergency Department, University Hospital of Leipzig, Leipzig, Germany.,Working group "Trauma and Resuscitation Room Management", Task Force Emergency Medicine, German Society of Anaesthesiology and Intensiv care Medizin, Nürnberg, Germany
| | - Sönke Nils Bax
- Emergency Department, University Hospital of Leipzig, Leipzig, Germany. .,Emergency Department, Paracelsus Hospital of Henstedt-Ulzburg, Wilstedter Straße 134, D-24558, Henstedt-Ulzburg, Germany.
| | - Thomas Hartwig
- Emergency Department, University Hospital of Leipzig, Leipzig, Germany
| | - Maryam Yahiaoui-Doktor
- Institute for Medical Informatics, Statistics and Epidemiology (IMISE), University of Leipzig, Leipzig, Germany
| | - Sirak Petros
- Medical Intensive Care Unit, University Hospital of Leipzig, Leipzig, Germany
| | - Sven Bercker
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Leipzig, Leipzig, Germany
| | | | - André Gries
- Emergency Department, University Hospital of Leipzig, Leipzig, Germany
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27
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Crewdson K, Lockey D, Voelckel W, Temesvari P, Lossius HM. Best practice advice on pre-hospital emergency anaesthesia & advanced airway management. Scand J Trauma Resusc Emerg Med 2019; 27:6. [PMID: 30665441 PMCID: PMC6341545 DOI: 10.1186/s13049-018-0554-6] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 09/25/2018] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Effective and timely airway management is a priority for sick and injured patients. The benefit and conduct of pre-hospital emergency anaesthesia (PHEA) and advanced airway management remains controversial but there are a proportion of critically ill and injured patients who require urgent advanced airway management prior to hospital arrival. This document provides current best practice advice for the provision of PHEA and advanced airway management. METHOD This best practice advice was developed from EHAC Medical Working Group enforced by pre-hospital critical care experts. The group used a nominal group technique to establish the current best practice for the provision of PHEA and advanced airway management. The group met on three separate occasions to discuss and develop the guideline. All members of the working party were able to access and edit the guideline online. RESULTS This EHAC best practice advice covers all areas of PHEA and advanced airway management and provides up to date evidence of current best practice. CONCLUSION PHEA and advanced airway management are complex interventions that should be delivered by appropriately trained personnel using a well-rehearsed approach and standardised equipment. Where advanced airway interventions cannot be delivered, careful attention should be given to applying basic airway interventions and ensuring their effectiveness at all times.
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Affiliation(s)
| | - David Lockey
- Norwegian Air Ambulance Foundation, Drøbak, Norway
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28
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Crewdson K, Rehn M, Lockey D. Airway management in pre-hospital critical care: a review of the evidence for a 'top five' research priority. Scand J Trauma Resusc Emerg Med 2018; 26:89. [PMID: 30342543 PMCID: PMC6196027 DOI: 10.1186/s13049-018-0556-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Accepted: 10/04/2018] [Indexed: 12/21/2022] Open
Abstract
The conduct and benefit of pre-hospital advanced airway management and pre-hospital emergency anaesthesia have been widely debated for many years. In 2011, prehospital advanced airway management was identified as a ‘top five’ in physician-provided pre-hospital critical care. This article summarises the evidence for and against this intervention since 2011 and attempts to address some of the more controversial areas of this topic.
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Affiliation(s)
- K Crewdson
- Department of Anaesthesia, North Bristol NHS Trust, Southmead Hospital, Southmead Way, Bristol, BS10 5NB, UK.
| | - M Rehn
- Department of Research, Norwegian Air Ambulance Foundation, Drøbak, Norway.,Pre-hospital Division, Air Ambulance Department, Oslo University Hospital, Oslo, Norway.,Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
| | - D Lockey
- Department of Anaesthesia, North Bristol NHS Trust, Southmead Hospital, Southmead Way, Bristol, BS10 5NB, UK.,Department of Research, Norwegian Air Ambulance Foundation, Drøbak, Norway.,Bristol University, Bristol, UK
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29
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[Systematic analysis of airway registries in emergency medicine]. Anaesthesist 2018; 67:664-673. [PMID: 30105516 DOI: 10.1007/s00101-018-0476-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2018] [Revised: 07/07/2018] [Accepted: 07/16/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND A myriad of publications have contributed to an evidence-based approach to airway management in emergency services and admissions in recent years; however, it remains unclear which international registries on airway management in emergency medicine currently exist and how they are characterized concerning inclusion criteria, patient characteristics and definition of complications. METHODS A systematic literature research was carried out in PubMed with respect to publications from 2007-2017. All publications from airway registries collecting data on prehospital or emergency department (ED) airway management were included. Publications from pediatric intensive care units (PICU) were also included as long as they were the primary place of pediatric emergency care. RESULTS A total of eleven emergency airway registries (EAR) were identified that were primarily concerned with airway management. Furthermore, reported data on emergency airway management were extracted from different, national resuscitation registries. There was only one multinational EAR which exclusively collects data on pediatric emergency airway management (NEAR4KIDS, National Emergency Airway Registry for Kids). Additionally, all emergency department airway registries identified include data on pediatric emergency airway management to varying degrees (0.2-10.5%). Published observation periods were also highly variable with a minimum of 18 months and a maximum of 156 months. The ANZEDAR (Australia and New Zealand Emergency Airway Registry) is currently the largest EAR with data from 43 participating institutions in 2 different countries, while the NEAR III (National Emergency Airway Registry) includes data on 21,374 emergency intubations over a 10-year period and thus has the largest number of emergency interventions. Reported rapid sequence induction (RSI) rates in the registries are between 27.5% and 100%. First-pass success rates vary between 69% and 89%, while the reported use of video laryngoscopy is 0-73%. CONCLUSION This study identified eleven EARs that sometimes widely differed concerning inclusion periods, inclusion criteria, definition of complications and application of newer methods of emergency airway management. Thus, comparability of the reported results and first-pass success rates is only possible to a limited extent. The authors therefore advocate the initiation of an airway registry in emergency medicine in German-speaking countries.
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30
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Sunde GA, Kottmann A, Heltne JK, Sandberg M, Gellerfors M, Krüger A, Lockey D, Sollid SJM. Standardised data reporting from pre-hospital advanced airway management - a nominal group technique update of the Utstein-style airway template. Scand J Trauma Resusc Emerg Med 2018; 26:46. [PMID: 29866144 PMCID: PMC5987657 DOI: 10.1186/s13049-018-0509-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Accepted: 05/09/2018] [Indexed: 12/31/2022] Open
Abstract
Background Pre-hospital advanced airway management with oxygenation and ventilation may be vital for managing critically ill or injured patients. To improve pre-hospital critical care and develop evidence-based guidelines, research on standardised high-quality data is important. We aimed to identify which airway data were most important to report today and to revise and update a previously reported Utstein-style airway management dataset. Methods We recruited sixteen international experts in pre-hospital airway management from Australia, United States of America, and Europe. We used a five-step modified nominal group technique to revise the dataset, and clinical study results from the original template were used to guide the process. Results The experts agreed on a key dataset of thirty-two operational variables with six additional system variables, organised in time, patient, airway management and system sections. Of the original variables, one remained unchanged, while nineteen were modified in name, category, definition or value. Sixteen new variables were added. The updated dataset covers risk factors for difficult intubation, checklist and standard operating procedure use, pre-oxygenation strategies, the use of drugs in airway management, airway currency training, developments in airway devices, airway management strategies, and patient safety issues not previously described. Conclusions Using a modified nominal group technique with international airway management experts, we have updated the Utstein-style dataset to report standardised data from pre-hospital advanced airway management. The dataset enables future airway management research to produce comparable high-quality data across emergency medical systems. We believe this approach will promote research and improve treatment strategies and outcomes for patients receiving pre-hospital advanced airway management. Trial registration The Regional Committee for Medical and Health Research Ethics in Western Norway exempted this study from ethical review (Reference: REK-Vest/2017/260). Electronic supplementary material The online version of this article (10.1186/s13049-018-0509-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- G A Sunde
- Norwegian Air Ambulance Foundation, Drøbak, Norway. .,Dept. of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway. .,Faculty of Health Sciences, University of Stavanger, Stavanger, Norway.
| | - A Kottmann
- Norwegian Air Ambulance Foundation, Drøbak, Norway.,Faculty of Health Sciences, University of Stavanger, Stavanger, Norway.,Emergency Dept., University Hospital of Lausanne, Lausanne, Switzerland.,Swiss Air Ambulance - Rega, Zürich, Switzerland
| | - J K Heltne
- Dept. of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway.,Dept. of Medical Sciences, University of Bergen, Bergen, Norway
| | - M Sandberg
- Air Ambulance Dept., Oslo University Hospital, Oslo, Norway.,Faculty of Medicine, University of Oslo, Oslo, Norway
| | - M Gellerfors
- Karolinska Institutet, Dept. of Clinical Science and Education, Section of Anaesthesiology and Intensive Care, Stockholm, Sweden.,Swedish Air Ambulance (SLA), Mora, Sweden.,Dept. of Anaesthesiology and Intensive Care, Södersjukhuset, Stockholm, Sweden
| | - A Krüger
- Norwegian Air Ambulance Foundation, Drøbak, Norway.,Dept. of Emergency Medicine and Pre-hospital Services, St. Olavs Hospital, Trondheim, Norway
| | - D Lockey
- Faculty of Health Sciences, University of Stavanger, Stavanger, Norway.,London's Air Ambulance, Bartshealth NHS Trust, London, UK
| | - S J M Sollid
- Norwegian Air Ambulance Foundation, Drøbak, Norway.,Faculty of Health Sciences, University of Stavanger, Stavanger, Norway.,Air Ambulance Dept., Oslo University Hospital, Oslo, Norway
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Pre-hospital advanced airway management by anaesthetist and nurse anaesthetist critical care teams: a prospective observational study of 2028 pre-hospital tracheal intubations. Br J Anaesth 2018; 120:1103-1109. [DOI: 10.1016/j.bja.2017.12.036] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Revised: 12/19/2017] [Accepted: 12/27/2017] [Indexed: 12/12/2022] Open
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Sinclair N, Swinton PA, Donald M, Curatolo L, Lindle P, Jones S, Corfield AR. Clinician tasking in ambulance control improves the identification of major trauma patients and pre-hospital critical care team tasking. Injury 2018; 49:897-902. [PMID: 29622470 DOI: 10.1016/j.injury.2018.03.034] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Revised: 03/09/2018] [Accepted: 03/29/2018] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Trauma remains the fourth leading cause of death in western countries and is the leading cause of death in the first four decades of life. NICE guidance in 2016 advocated the attendance of pre-hospital critical care trauma team (PHCCT) in the pre-hospital stage of the care of patients with major trauma. Previous publications support dispatch by clinicians who are also actively involved in the delivery of the PHCCT service; however there is a lack of objective outcome measures across the current reviewed evidence base. In this study, we aimed to assess the accuracy of PHCCT clinician led dispatch, when measured by Injury Severity Score (ISS). METHODS A retrospective cohort study over a 2 year period pre and post implementation of a PHCCT clinician led dispatch of PHCCT for potential major trauma patients, using national ambulance data combined with national trauma registry data. RESULTS A total of 99,702 trauma related calls were made to SAS including 495 major trauma patients with an ISS >15, and a total of 454 dispatches of a PHCCT. Following the introduction of a PHCCT clinician staffed trauma desk, the sensitivity for major trauma was increased from 11.3% to 25.9%. The difference in sensitivity between the pre and post trauma desk group was significant at 14.6% (95% CI 7.4%-21.4%, p < .001). DISCUSSION The results from the study support the results from other studies recommending that a PHCCT clinician should be located in ambulance control to identify major trauma patients as early as possible and co-ordinate the response.
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Affiliation(s)
- Neil Sinclair
- ScotSTAR, Scottish Ambulance Service, United Kingdom
| | | | - Michael Donald
- ScotSTAR, Scottish Ambulance Service, United Kingdom; Emergency Department, Ninewells Hospital, United Kingdom
| | - Lisa Curatolo
- ScotSTAR, Scottish Ambulance Service, United Kingdom
| | - Peter Lindle
- ScotSTAR, Scottish Ambulance Service, United Kingdom
| | - Steph Jones
- ScotSTAR, Scottish Ambulance Service, United Kingdom
| | - Alasdair R Corfield
- ScotSTAR, Scottish Ambulance Service, United Kingdom; Emergency Department, Royal Alexandra Hospital, United Kingdom.
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Rubenson Wahlin R, Nelson DW, Bellander BM, Svensson M, Helmy A, Thelin EP. Prehospital Intubation and Outcome in Traumatic Brain Injury-Assessing Intervention Efficacy in a Modern Trauma Cohort. Front Neurol 2018; 9:194. [PMID: 29692755 PMCID: PMC5903008 DOI: 10.3389/fneur.2018.00194] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Accepted: 03/13/2018] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Prehospital intubation in traumatic brain injury (TBI) focuses on limiting the effects of secondary insults such as hypoxia, but no indisputable evidence has been presented that it is beneficial for outcome. The aim of this study was to explore the characteristics of patients who undergo prehospital intubation and, in turn, if these parameters affect outcome. MATERIAL AND METHODS Patients ≥15 years admitted to the Department of Neurosurgery, Stockholm, Sweden with TBI from 2008 through 2014 were included. Data were extracted from prehospital and hospital charts, including prospectively collected Glasgow Outcome Score (GOS) after 12 months. Univariate and multivariable logistic regression models were employed to examine parameters independently correlated to prehospital intubation and outcome. RESULTS A total of 458 patients were included (n = 178 unconscious, among them, n = 61 intubated). Multivariable analyses indicated that high energy trauma, prehospital hypotension, pupil unresponsiveness, mode of transportation, and distance to the hospital were independently correlated with intubation, and among them, only pupil responsiveness was independently associated with outcome. Prehospital intubation did not add independent information in a step-up model versus GOS (p = 0.154). Prehospital reports revealed that hypoxia was not the primary cause of prehospital intubation, and that the procedure did not improve oxygen saturation during transport, while an increasing distance from the hospital increased the intubation frequency. CONCLUSION In this modern trauma cohort, prehospital intubation was not independently associated with outcome; however, hypoxia was not a common reason for prehospital intubation. Prospective trials to assess efficacy of prehospital airway intubation will be difficult due to logistical and ethical considerations.
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Affiliation(s)
- Rebecka Rubenson Wahlin
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
- Department of Anesthesia and Intensive Care, Södersjukhuset, Stockholm, Sweden
| | - David W. Nelson
- Section of Anesthesiology and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Bo-Michael Bellander
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurosurgery, Karolinska University Hospital Solna, Stockholm, Sweden
| | - Mikael Svensson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurosurgery, Karolinska University Hospital Solna, Stockholm, Sweden
| | - Adel Helmy
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Eric Peter Thelin
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
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Ångerman S, Kirves H, Nurmi J. A before-and-after observational study of a protocol for use of the C-MAC videolaryngoscope with a Frova introducer in pre-hospital rapid sequence intubation. Anaesthesia 2018; 73:348-355. [PMID: 29315473 DOI: 10.1111/anae.14182] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/13/2017] [Indexed: 01/01/2023]
Abstract
Results using videolaryngoscopy in pre-hospital rapid sequence intubation are mixed. A bougie is not commonly used with videolaryngoscopy. We hypothesised that using videolaryngoscopy and a bougie as core elements of a standardised protocol that includes a drugs and a laryngoscopy algorithm would result in a high first-pass tracheal intubation success rate. We employed videolaryngoscopy (C-MAC) combined with a bougie (Frova intubating introducer) in an anaesthetist-staffed helicopter emergency medical service. Data for adult tracheal intubation were collected prospectively as part of the airway registry of our unit for 22 months after implementation of the protocol (n = 543) and compared with controls (n = 238) treated in the previous year before the implementation. The mean first-pass success rate (95%CI) was 98.2% (96.6-99.0%) in the study group and 85.7% (80.7-89.6%) in the control group, p < 0.0001. Combining C-MAC videolaryngoscopy and bougie with a standardised rapid sequence induction protocol leads to a high first attempt intubation success rate when performed by an anaesthetist-led helicopter emergency medical service team.
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Affiliation(s)
- S Ångerman
- Emergency Medicine and Services, Helsinki University Hospital and Department of Emergency Medicine, University of Helsinki, Finland
| | - H Kirves
- Prehospital Emergency Care, Hyvinkää Hospital Area, Hospital District of Helsinki and Uusimaa, Finland
| | - J Nurmi
- Emergency Medicine and Services, Helsinki University Hospital and Department of Emergency Medicine, University of Helsinki, Finland.,FinnHEMS Research and Development Unit, Finland
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35
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Burns BJ, Watterson JB, Ware S, Regan L, Reid C. Analysis of Out-of-Hospital Pediatric Intubation by an Australian Helicopter Emergency Medical Service. Ann Emerg Med 2017; 70:773-782.e4. [DOI: 10.1016/j.annemergmed.2017.03.020] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 02/10/2017] [Accepted: 03/10/2017] [Indexed: 11/16/2022]
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Fouche PF, Stein C, Simpson P, Carlson JN, Doi SA. Nonphysician Out-of-Hospital Rapid Sequence Intubation Success and Adverse Events: A Systematic Review and Meta-Analysis. Ann Emerg Med 2017; 70:449-459.e20. [DOI: 10.1016/j.annemergmed.2017.03.026] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2016] [Revised: 03/12/2017] [Accepted: 03/16/2017] [Indexed: 12/20/2022]
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Sunde GA, Sandberg M, Lyon R, Fredriksen K, Burns B, Hufthammer KO, Røislien J, Soti A, Jäntti H, Lockey D, Heltne JK, Sollid SJM. Hypoxia and hypotension in patients intubated by physician staffed helicopter emergency medical services - a prospective observational multi-centre study. BMC Emerg Med 2017; 17:22. [PMID: 28693491 PMCID: PMC5504565 DOI: 10.1186/s12873-017-0134-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Accepted: 06/30/2017] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND The effective treatment of airway compromise in trauma and non-trauma patients is important. Hypoxia and hypotension are predictors of negative patient outcomes and increased mortality, and may be important quality indicators of care provided by emergency medical services. Excluding cardiac arrests, critical trauma and non-trauma patients remain the two major groups to which helicopter emergency medical services (HEMS) are dispatched. Several studies describe the impact of pre-hospital hypoxia or hypotension on trauma patients, but few studies compare this in trauma and non-trauma patients. The primary aim was to describe the incidence of pre-hospital hypoxia and hypotension in the two groups receiving pre-hospital tracheal intubation (TI) by physician-staffed HEMS. METHODS Data were collected prospectively over a 12-month period, using a uniform Utstein-style airway template. Twenty-one physician-staffed HEMS in Europe and Australia participated. We compared peripheral oxygen saturation and systolic blood pressure before and after definitive airway management. Data were analysed using Cochran-Mantel-Haenszel methods and mixed-effects models. RESULTS Eight hundred forty three trauma patients and 422 non-trauma patients receiving pre-hospital TI were included. Non-trauma patients had significantly lower predicted mean pre-intervention SpO2 compared to trauma patients. Post-intervention and admission SpO2 for the two groups were comparable. However, 3% in both groups were still hypoxic at admission. For hypotension, the differences between the groups were less prominent. However, 9% of trauma and 10% of non-trauma patients were still hypotensive at admission. There was no difference in short-term survival between trauma (97%) and non-trauma patients (95%). Decreased level of consciousness was the most frequent indication for TI, and was associated with increased survival to hospital (cOR 2.8; 95% CI: 1.4-5.4). CONCLUSIONS Our results showed that non-trauma patients had a higher incidence of hypoxia before TI than trauma patients, but few were hypoxic at admission. The difference for hypotension was less prominent, but one in ten patients were still hypotensive at admission. Further investigations are needed to identify reversible causes that may be corrected to improve haemodynamics in the pre-hospital setting. We found high survival rates to hospital in both groups, suggesting that physician-staffed HEMS provide high-quality emergency airway management in trauma and non-trauma patients. TRIAL REGISTRATION Clinicaltrials.gov Identifier: NCT01502111 . Registered 22 Desember 2011.
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Affiliation(s)
- Geir Arne Sunde
- Norwegian Air Ambulance Foundation, Drøbak, Norway. .,Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway. .,Department of Health Sciences, University of Stavanger, Stavanger, Norway. .,Norwegian Air Ambulance Foundation, Møllendalsveien 34, 5009, Bergen, Norway.
| | - Mårten Sandberg
- Air Ambulance Department, Oslo University Hospital, Oslo, Norway.,Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Richard Lyon
- University of Surrey, Guildford, UK.,Kent, Surrey & Sussex Air Ambulance Trust, Marden, UK
| | - Knut Fredriksen
- UiT - The Arctic University of Norway, Tromsø, Norway.,The University Hospital of North Norway, Tromsø, Norway
| | - Brian Burns
- Sydney HEMS, NSW Ambulance, Sydney, Australia.,Sydney Medical School, University of Sydney, Sydney, Australia
| | | | - Jo Røislien
- Norwegian Air Ambulance Foundation, Drøbak, Norway.,Department of Health Sciences, University of Stavanger, Stavanger, Norway
| | - Akos Soti
- Hungarian Air Ambulance Nonprofit Ltd, Budaors, Hungary
| | - Helena Jäntti
- Centre for Pre-hospital Emergency Care, Kuopio University Hospital, Kuopio, Finland
| | - David Lockey
- Department of Health Sciences, University of Stavanger, Stavanger, Norway.,London's Air Ambulance, Bartshealth NHS Trust, London, UK
| | - Jon-Kenneth Heltne
- Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway.,Department of Medical Sciences, University of Bergen, Bergen, Norway
| | - Stephen J M Sollid
- Norwegian Air Ambulance Foundation, Drøbak, Norway.,Department of Health Sciences, University of Stavanger, Stavanger, Norway.,Air Ambulance Department, Oslo University Hospital, Oslo, Norway
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Lockey DJ, Crewdson K, Davies G, Jenkins B, Klein J, Laird C, Mahoney PF, Nolan J, Pountney A, Shinde S, Tighe S, Russell MQ, Price J, Wright C. AAGBI: Safer pre-hospital anaesthesia 2017: Association of Anaesthetists of Great Britain and Ireland. Anaesthesia 2017; 72:379-390. [PMID: 28045209 PMCID: PMC5324693 DOI: 10.1111/anae.13779] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/11/2016] [Indexed: 12/19/2022]
Abstract
Pre-hospital emergency anaesthesia with oral tracheal intubation is the technique of choice for trauma patients who cannot maintain their airway or achieve adequate ventilation. It should be carried out as soon as safely possible, and performed to the same standards as in-hospital emergency anaesthesia. It should only be conducted within organisations with comprehensive clinical governance arrangements. Techniques should be straightforward, reproducible, as simple as possible and supported by the use of checklists. Monitoring and equipment should meet in-hospital anaesthesia standards. Practitioners need to be competent in the provision of in-hospital emergency anaesthesia and have supervised pre-hospital experience before carrying out pre-hospital emergency anaesthesia. Training programmes allowing the safe delivery of pre-hospital emergency anaesthesia by non-physicians do not currently exist in the UK. Where pre-hospital emergency anaesthesia skills are not available, oxygenation and ventilation should be maintained with the use of second-generation supraglottic airways in patients without airway reflexes, or basic airway manoeuvres and basic airway adjuncts in patients with intact airway reflexes.
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Affiliation(s)
- D. J. Lockey
- North Bristol NHS TrustAAGBI Working PartyBristol UniversityBristolUK
| | - K. Crewdson
- Anaesthetics and Intensive Care MedicineSevern DeaneryUK
| | - G. Davies
- Royal London Hospital/Royal College of Emergency MedicineLondonUK
| | | | - J. Klein
- Derby Hospitals NHS Foundation TrustFaculty of Pre‐hospital CareRoyal College of Surgeons of EdinburghEdinburghUK
| | - C. Laird
- British Association for Immediate CareAuchterarderPerthshireUK
| | - P. F. Mahoney
- Royal Centre for Defence MedicineImperial CollegeLondonUK
| | - J. Nolan
- Royal United Hospital, BathAnaesthesia and Intensive Care Medicine/Resuscitation Medicine at Bristol UniversityRoyal College of AnaesthetistsBristolUK
| | - A. Pountney
- Mid‐Yorkshire NHS TrustBritish Association for Immediate CareIpswichSuffolkUK
| | - S. Shinde
- North Bristol NHS TrustAAGBI BoardBristolUK
| | - S. Tighe
- Countess of Chester HospitalAAGBI BoardChesterUK
| | - M. Q. Russell
- Kent, Surrey, Sussex Air Ambulance TrustRoyal College of General PractitionersTonbridgeUK
| | - J. Price
- Royal United Hospital BathGroup of Anaesthetists in TrainingAAGBIAvonUK
| | - C. Wright
- St Mary's Major Trauma CentreImperial CollegeMilitary Pre‐hospital Emergency MedicineLondonUK
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Crewdson K, Lockey DJ, Røislien J, Lossius HM, Rehn M. The success of pre-hospital tracheal intubation by different pre-hospital providers: a systematic literature review and meta-analysis. Crit Care 2017; 21:31. [PMID: 28196506 PMCID: PMC5309978 DOI: 10.1186/s13054-017-1603-7] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Accepted: 01/04/2017] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Pre-hospital basic airway interventions can be ineffective at providing adequate oxygenation and ventilation in some severely ill or injured patients, and advanced airway interventions are then required. Controversy exists regarding the level of provider required to perform successful pre-hospital intubation. A previous meta-analysis reported pre-hospital intubation success rates of 0.849 for non-physicians versus 0.991 for physicians. The evidence base on the topic has expanded significantly in the last 10 years. This study systematically reviewed recent literature and presents comprehensive data on intubation success rates. METHODS A systematic search of MEDLINE and EMBASE was performed using PRISMA methodology to identify articles on pre-hospital tracheal intubation published between 2006 and 2016. Overall success rates were estimated using random effects meta-analysis. The relationship between intubation success rate and provider type was assessed in weighted linear regression analysis. RESULTS Of the 1838 identified studies, 38 met the study inclusion criteria. Intubation was performed by non-physicians in half of the studies and by physicians in the other half. The crude median (range) reported overall success rate was 0.969 (0.616-1.000). In random effects meta-analysis, the estimated overall intubation success rate was 0.953 (0.938-0.965). The crude median (range) reported intubation success rates for non-physicians were 0.917 (0.616-1.000) and, for physicians, were 0.988 (0.781-1.000) (p = 0.003). DISCUSSION The reported overall success rate of pre-hospital intubation has improved, yet there is still a significant difference between non-physician and physician providers. The finding that less-experienced personnel perform less well is not unexpected, but since there is considerable evidence that poorly performed intubation carries a significant risk of morbidity and mortality careful consideration should be given to the training and experience required to deliver this intervention safely.
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Affiliation(s)
- K. Crewdson
- London Air Ambulance, Royal London Hospital, Whitechapel Road, London, E1 1BB UK
- North Bristol NHS Trust, Southmead Way, Bristol, BS10 5NB UK
| | - D. J. Lockey
- London Air Ambulance, Royal London Hospital, Whitechapel Road, London, E1 1BB UK
- North Bristol NHS Trust, Southmead Way, Bristol, BS10 5NB UK
- The Norwegian Air Ambulance Foundation, Holterveien 24, N-1441 Drøbak, Norway
| | - J. Røislien
- Department of Health Studies, University of Stavanger, Kjell Arholmsgate 41, N-4036 Stavanger, Norway
| | - H. M. Lossius
- The Norwegian Air Ambulance Foundation, Holterveien 24, N-1441 Drøbak, Norway
- Department of Health Studies, University of Stavanger, Kjell Arholmsgate 41, N-4036 Stavanger, Norway
| | - M. Rehn
- London Air Ambulance, Royal London Hospital, Whitechapel Road, London, E1 1BB UK
- The Norwegian Air Ambulance Foundation, Holterveien 24, N-1441 Drøbak, Norway
- Department of Health Studies, University of Stavanger, Kjell Arholmsgate 41, N-4036 Stavanger, Norway
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Burns B, Habig K, Eason H, Ware S. Difficult Intubation Factors in Prehospital Rapid Sequence Intubation by an Australian Helicopter Emergency Medical Service. Air Med J 2017; 35:28-32. [PMID: 26856657 DOI: 10.1016/j.amj.2015.10.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Accepted: 10/17/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Prehospital rapid sequence intubation (RSI) of critically ill trauma patients is a high-risk procedure that may be associated with an increased rate of severe complications such as failed intubation, failure of oxygenation, hypoxia, hypotension, or need for surgical airway. The objective of this study was to describe the factors associated with difficult intubation in prehospital RSI as defined by more than a single look at laryngoscopy to achieve tracheal intubation. METHODS This is an observational study using prospectively collected data. RESULTS Four hundred forty-three RSIs were performed. Paramedics were the initial laryngoscopist in 290 (65.5%). First-look laryngoscopy resulted in successful tracheal intubation (TI) in 372 (84.0%) (95% confidence interval, 80.3%-87.1%). Intubation was achieved on second look at laryngoscopy in 58 (13.1%). "First-pass" TI was achieved in 394 (88.9%). Overall, successful TI was achieved in 438 (98.9%) (95% confidence interval, 97.4%-99.5%). Complications occurred in 116 (26.2%), with desaturation the commonest in 77 (17.4%). CONCLUSION Factors associated with more than 1 look at laryngoscopy before TI included paramedic laryngoscopist and the presence of at least 1 of the following indicators: blood/vomitus in the airway, limited mouth opening, and limited neck movement. Trauma to face/neck, obese body habitus, C-spine precautions, cricoid pressure, midline stabilization, and intubation on the ground did not influence the level of difficulty encountered.
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Affiliation(s)
- Brian Burns
- Greater Sydney Area Helicopter Emergency Medical Service, NSW Ambulance; Discipline of Emergency Medicine, Sydney University.
| | - Karel Habig
- Greater Sydney Area Helicopter Emergency Medical Service, NSW Ambulance; Discipline of Emergency Medicine, Sydney University
| | - Hilary Eason
- Department of Paediatric Anaesthesia, Royal Manchester Children's Hospital, UK
| | - Sandra Ware
- Greater Sydney Area Helicopter Emergency Medical Service, NSW Ambulance; Discipline of Emergency Medicine, Sydney University
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Rehn M, Hyldmo PK, Magnusson V, Kurola J, Kongstad P, Rognås L, Juvet LK, Sandberg M. Scandinavian SSAI clinical practice guideline on pre-hospital airway management. Acta Anaesthesiol Scand 2016; 60:852-64. [PMID: 27255435 PMCID: PMC5089575 DOI: 10.1111/aas.12746] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Revised: 04/13/2016] [Accepted: 04/24/2016] [Indexed: 12/17/2022]
Abstract
Background The Scandinavian society of anaesthesiology and intensive care medicine task force on pre‐hospital airway management was asked to formulate recommendations following standards for trustworthy clinical practice guidelines. Methods The literature was systematically reviewed and the grading of recommendations assessment, development and evaluation (GRADE) system was applied to move from evidence to recommendations. Results We recommend that all emergency medical service (EMS) providers consider to: apply basic airway manoeuvres and airway adjuncts (good practice recommendation); turn unconscious non‐trauma patients into the recovery position when advanced airway management is unavailable (good practice recommendation); turn unconscious trauma patients to the lateral trauma position while maintaining spinal alignment when advanced airway management is unavailable [strong recommendation, low quality of evidence (QoE)]. We suggest that intermediately trained providers use a supraglottic airway device (SAD) or basic airway manoeuvres on patients in cardiac arrest (weak recommendation, low QoE). We recommend that advanced trained providers consider using an SAD in selected indications or as a rescue device after failed endotracheal intubation (ETI) (good practice recommendation). We recommend that ETI should only be performed by advanced trained providers (strong recommendation, low QoE). We suggest that videolaryngoscopy is considered for ETI when direct laryngoscopy fails or is expected to be difficult (weak recommendation, low QoE). We suggest that advanced trained providers apply cricothyroidotomy in ‘cannot intubate, cannot ventilate’ situations (weak recommendation, low QoE). Conclusion This guideline for pre‐hospital airway management includes a combination of techniques applied in a stepwise fashion appropriate to patient clinical status and provider training.
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Affiliation(s)
- M. Rehn
- The Norwegian Air Ambulance Foundation Drøbak Norway
- London's Air Ambulance Barts Health Trust London UK
- Field of Pre‐hospital Critical Care University of Stavanger Stavanger Norway
| | - P. K. Hyldmo
- The Norwegian Air Ambulance Foundation Drøbak Norway
- Department of Anaesthesiology and Intensive Care Sørlandet Hospital Kristiansand Norway
| | - V. Magnusson
- Department of Anaesthesia and Intensive Care Medicine Landspitali University Hospital Reykjavik Iceland
| | - J. Kurola
- Centre for Pre‐hospital Emergency Care Kuopio University Hospital Kuopio Finland
| | - P. Kongstad
- Department of Pre‐hospital Care and Disaster Medicine Region of Skåne Lund Sweden
| | - L. Rognås
- Pre‐hospital Critical Care Service Aarhus University Hospital Aarhus Denmark
- The Danish Air Ambulance Aarhus Denmark
| | - L. K. Juvet
- Norwegian Institute of Public Health Oslo Norway
- University College of Southeast Norway Notodden Norway
| | - M. Sandberg
- Air Ambulance Department Oslo University Hospital Oslo Norway
- University of Oslo Oslo Norway
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Rhode MG, Vandborg MP, Bladt V, Rognås L. Video laryngoscopy in pre-hospital critical care - a quality improvement study. Scand J Trauma Resusc Emerg Med 2016; 24:84. [PMID: 27297563 PMCID: PMC4906985 DOI: 10.1186/s13049-016-0276-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Accepted: 06/09/2016] [Indexed: 11/10/2022] Open
Abstract
Background Pre-hospital endotracheal intubation is challenging and repeated endotracheal intubation is associated with increased morbidity and mortality. We investigated whether the introduction of the McGrath MAC video laryngoscope as the primary device for pre-hospital endotracheal intubation could improve first-pass success rate in our anaesthesiologist-staffed pre-hospital critical care services. We also investigated the incidence of failed pre-hospital endotracheal intubation, the use of airway adjuncts and back-up devices and problems encountered using the McGrath MAC video laryngoscope. Methods Prospective quality improvement study collecting data from all adult pre-hospital endotracheal intubation performed by four anaesthesiologist-staffed pre-hospital critical care teams between December 15th 2013 and December 15th 2014. Results We registered data from 273 consecutive patients. When using the McGrath MAC video laryngoscope the overall pre-hospital endotracheal intubation first-pass success rate was 80.8 %. Following rapid sequence intubation (RSI) it was 88.9 %. This was not significantly different from previously reported first-pass success rates in our system (p = 0.27 and p = 0.41). During the last nine months of the study period the overall first-pass success rate was 80.1 (p = 0.47) but the post-RSI first-pass success rate improved to 94.4 % (0.048). The overall pre-hospital endotracheal intubation success rate with the McGrath MAC video laryngoscope was 98.9 % (p = 0.17). Gastric content, blood or secretion in the airway resulted in reduced vision when using the McGrath MAC video laryngoscope. Conclusion In this study of video laryngoscope implementation in a Scandinavian anaesthesiologist-staffed pre-hospital critical care service, overall pre-hospital endotracheal first pass success rate did not change. The post-RSI first-pass success rate was significantly higher during the last nine months of our 12-month study compared with our results from before introducing McGrath MAC video laryngoscope. The implementation of the Standard Operating Procedure and check list for pre-hospital anaesthesia during the study period may have influenced the first-pass success rate and constitutes a potential confounder. The potential limitations of the McGrath MAC video laryngoscope when there are gastric content, blood and secretions in the airways need to be further investigated before the McGrath MAC video laryngoscope can be recommended as the primary device in all pre-hospital endotracheal intubations. Electronic supplementary material The online version of this article (doi:10.1186/s13049-016-0276-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Marianne Grønnebæk Rhode
- Prehospital Critical Care Service, Aarhus University Hospital, Oluf Palmes Alle 32, 1, Aarhus, N, 8200, Denmark. .,Department of Pre-hospital Critical Care Services, The Central Denmark Region, Oluf Palmes Alle 34, Aarhus, N, 8200, Denmark.
| | - Mads Partridge Vandborg
- Department of Pre-hospital Critical Care Services, The Central Denmark Region, Oluf Palmes Alle 34, Aarhus, N, 8200, Denmark.,Pre-hospital Critical Care Service, Department of Anaesthesia, Viborg Regional Hospital, Heibergs Alle 4, Viborg, 8800, Denmark
| | - Vibeke Bladt
- Department of Pre-hospital Critical Care Services, The Central Denmark Region, Oluf Palmes Alle 34, Aarhus, N, 8200, Denmark.,Pre-hospital Critical Care Service, Department and Anaesthesia, Randers Regional Hospital, Skovlyvej 1, Randers, 8930, Denmark
| | - Leif Rognås
- Prehospital Critical Care Service, Aarhus University Hospital, Oluf Palmes Alle 32, 1, Aarhus, N, 8200, Denmark.,Department of Pre-hospital Critical Care Services, The Central Denmark Region, Oluf Palmes Alle 34, Aarhus, N, 8200, Denmark
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Abstract
The need for timely and appropriate airway management for trauma patients is widely recognised. There are a small number of severely injured patients who cannot be adequately supported with basic airway manoeuvres, and require early advanced airway management. The way in which this care is provided remains highly controversial. Whilst it is clear that effective airway management remains a priority for all patients and poorly performed pre-hospital anaesthesia may be detrimental to patient outcome, debate remains over exactly which patients will benefit from early advanced airway interventions, and how it should be provided. The evidence base is small and inconsistent, with significant heterogeneity in the reported data, making it impossible to draw meaningful conclusions. Current practice is not standardised, and care is delivered by providers of different abilities using a range of equipment and techniques. Standards of care provided during in-hospital practice relating to these issues of provider competence, equipment, and monitoring should be directly translated into delivery of care outside the hospital, but this is not always the case. The aim of this review is to evaluate the current evidence surrounding pre-hospital advanced airway management.
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Affiliation(s)
- Kate Crewdson
- North Bristol NHS Trust, Southmead Hospital, UK
- London’s Air Ambulance, Royal London Hospital, UK
| | - David Lockey
- North Bristol NHS Trust, Southmead Hospital, UK
- London’s Air Ambulance, Royal London Hospital, UK
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Bernhard M, Hossfeld B. Im prähospitalen Atemwegsmanagement nicht „Äpfel mit Birnen“ vergleichen. Med Klin Intensivmed Notfmed 2015; 110:534-5. [DOI: 10.1007/s00063-015-0053-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Tarpgaard M, Hansen TM, Rognås L. Anaesthetist-provided pre-hospital advanced airway management in children: a descriptive study. Scand J Trauma Resusc Emerg Med 2015; 23:61. [PMID: 26307040 PMCID: PMC4549899 DOI: 10.1186/s13049-015-0140-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Accepted: 08/15/2015] [Indexed: 11/20/2022] Open
Abstract
Background Pre-hospital advanced airway management has been named one of the top-five research priorities in physician-provided pre-hospital critical care. Few studies have been made on paediatric pre-hospital advanced airway management. The aim of this study was to investigate pre-hospital endotracheal intubation success rate in children, first-pass success rates and complications related to pre-hospital advanced airway management in patients younger than 16 years of age treated by pre-hospital critical care teams in the Central Denmark Region (1.3 million inhabitants). Methods A prospective descriptive study based on data collected from eight anaesthetist-staffed pre-hospital critical care teams between February 1st 2011 and November 1st 2012. Primary endpoints were 1) pre-hospital endotracheal intubation success rate in children 2) pre-hospital endotracheal intubation first-pass success rate in children and 3) complications related to prehospital advanced airway management in children. Results The pre-hospital critical care anaesthetists attempted endotracheal intubation in 25 children, 13 of which were less than 2 years old. In one patient, a neonate (600 g birth weight), endotracheal intubation failed. The patient was managed by uneventful bag-mask ventilation. All other 24 children had their tracheas successfully intubated by the pre-hospital critical care anaesthetists resulting in a pre-hospital endotracheal intubation success rate of 96 %. Overall first pass success-rate was 75 %. In the group of patients younger than 2 years old, first pass success-rate was 54 %. The total rate of airway management related complications such as vomiting, aspiration, accidental intubation of the oesophagus or right main stem bronchus, hypoxia (oxygen saturation < 90 %) or bradycardia (according to age) was 20 % in children younger than 16 years of age and 38 % in children younger than 2 years of age. No deaths, cardiac arrests or severe bradycardia (heart rate <60) occurred in relation to pre-hospital advanced airway management. Conclusion Compared with the total population of patients receiving pre-hospital advanced airway management in our system, the overall success rate following pre-hospital endotracheal intubations in children is acceptable but the first-pass success rate is low. The complication rates in the paediatric population are higher than in our pre-hospital advanced airway management patient population as a whole. This illustrates that young children may represent a substantial pre-hospital airway management challenge even for experienced pre-hospital critical care anaesthetists. This may influence future training and quality insurance initiatives in paediatric pre-hospital advanced airway management.
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Affiliation(s)
- Mona Tarpgaard
- Pre-hospital Critical Care Team, Aarhus University Hospital, Oluf Palmes Alle 32, Aarhus N, 8200, Denmark. .,Department of Pre-hospital Medical Services, Central Denmark Region, Oluf Palmes Alle 34, Aarhus N, 8200, Denmark.
| | - Troels Martin Hansen
- Pre-hospital Critical Care Team, Aarhus University Hospital, Oluf Palmes Alle 32, Aarhus N, 8200, Denmark. .,Department of Pre-hospital Medical Services, Central Denmark Region, Oluf Palmes Alle 34, Aarhus N, 8200, Denmark.
| | - Leif Rognås
- Pre-hospital Critical Care Team, Aarhus University Hospital, Oluf Palmes Alle 32, Aarhus N, 8200, Denmark. .,Department of Pre-hospital Medical Services, Central Denmark Region, Oluf Palmes Alle 34, Aarhus N, 8200, Denmark.
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Sunde GA, Heltne JK, Lockey D, Burns B, Sandberg M, Fredriksen K, Hufthammer KO, Soti A, Lyon R, Jäntti H, Kämäräinen A, Reid BO, Silfvast T, Harm F, Sollid SJM. Airway management by physician-staffed Helicopter Emergency Medical Services - a prospective, multicentre, observational study of 2,327 patients. Scand J Trauma Resusc Emerg Med 2015; 23:57. [PMID: 26250700 PMCID: PMC4528299 DOI: 10.1186/s13049-015-0136-9] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2015] [Accepted: 07/14/2015] [Indexed: 11/22/2022] Open
Abstract
Background Despite numerous studies on prehospital airway management, results are difficult to compare due to inconsistent or heterogeneous data. The objective of this study was to assess advanced airway management from international physician-staffed helicopter emergency medical services. Methods We collected airway data from 21 helicopter emergency medical services in Australia, England, Finland, Hungary, Norway and Switzerland over a 12-month period. A uniform Utstein-style airway template was used for collecting data. Results The participating services attended 14,703 patients on primary missions during the study period, and 2,327 (16 %) required advanced prehospital airway interventions. Of these, tracheal intubation was attempted in 92 % of the cases. The rest were managed with supraglottic airway devices (5 %), bag-valve-mask ventilation (2 %) or continuous positive airway pressure (0.2 %). Intubation failure rates were 14.5 % (first-attempt) and 1.2 % (overall). Cardiac arrest patients showed significantly higher first-attempt intubation failure rates (odds ratio: 2.0; 95 % CI: 1.5-2.6; p < 0.001) compared to non-cardiac arrest patients. Complications were recorded in 13 %, with recognised oesophageal intubation being the most frequent (25 % of all patients with complications). For non-cardiac arrest patients, important risk predictors for first-attempt failure were patient age (a non-linear association) and administration of sedatives (reduced failure risk). The patient’s sex, provider’s intubation experience, trauma type (patient category), indication for airway intervention and use of neuromuscular blocking agents were not risk factors for first-attempt intubation failure. Conclusions Advanced airway management in physician-staffed prehospital services was performed frequently, with high intubation success rates and low complication rates overall. However, cardiac arrest patients showed significantly higher first-attempt failure rates compared to non-cardiac arrest patients. All failed intubations were handled successfully with a rescue device or surgical airway. Trial registration Study registration: www.clinicaltrials.govNCT01502111. Registered 22 December 2011.
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Affiliation(s)
- Geir Arne Sunde
- Norwegian Air Ambulance Foundation, Drøbak, Norway. .,Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway. .,Department of Health Sciences, University of Stavanger, Stavanger, Norway.
| | - Jon-Kenneth Heltne
- Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway. .,Department of Medical Sciences, University of Bergen, Bergen, Norway.
| | - David Lockey
- Department of Health Sciences, University of Stavanger, Stavanger, Norway. .,Institute of Prehospital Care, London's Air Ambulance, Bartshealth NHS Trust, London, UK.
| | - Brian Burns
- Sydney HEMS, Ambulance Service of NSW, Sydney, Australia. .,Sydney Medical School, University of Sydney, Sydney, Australia.
| | - Mårten Sandberg
- Air Ambulance Department, Oslo University Hospital, Oslo, Norway. .,Faculty of Medicine, University of Oslo, Oslo, Norway.
| | - Knut Fredriksen
- UiT - The Arctic University of Norway, Tromsø, Norway. .,The University Hospital of North Norway, Tromsø, Norway.
| | - Karl Ove Hufthammer
- Centre for Clinical Research, Haukeland University Hospital, Bergen, Norway.
| | - Akos Soti
- Hungarian Air Ambulance Nonprofit Ltd., Budaors, Hungary.
| | - Richard Lyon
- Emergency Medicine Research Group, Edinburgh, UK. .,Kent, Surrey & Sussex Air Ambulance Trust, Marden, UK.
| | - Helena Jäntti
- Centre for Prehospital Emergency Care, Kuopio University Hospital, Kuopio, Finland.
| | - Antti Kämäräinen
- Emergency Medical Services, Tampere University Hospital, Tampere, Finland.
| | - Bjørn Ole Reid
- Department of Emergency Medicine and Prehospital Services, St. Olavs Hospital, Trondheim, Norway.
| | - Tom Silfvast
- Emergency Medical Services, Helsinki University Hospital, Helsinki, Finland. .,University of Helsinki, Helsinki, Finland.
| | - Falko Harm
- Department for Anaesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland.
| | - Stephen J M Sollid
- Norwegian Air Ambulance Foundation, Drøbak, Norway. .,Department of Health Sciences, University of Stavanger, Stavanger, Norway. .,Air Ambulance Department, Oslo University Hospital, Oslo, Norway.
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47
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Anaesthesiologist-provided prehospital airway management in patients with traumatic brain injury: an observational study. Eur J Emerg Med 2015; 21:418-23. [PMID: 24368407 PMCID: PMC4212878 DOI: 10.1097/mej.0000000000000103] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Background Guidelines recommend that patients with brain trauma with a Glasgow Coma Scale (GCS) score of less than 9 should have an airway established. Hypoxia, hypotension and hypertension as well as hypoventilation and hyperventilation may worsen outcome in these patients. Objectives The objectives were to investigate guideline adherence, reasons for nonadherence and the incidences of complications related to prehospital advanced airway management in patients with traumatic brain injury. Materials and methods We prospectively collected data from eight anaesthesiologist-staffed prehospital critical care teams in the Central Denmark Region according to the Utstein-style template. Results Among 1081 consecutive prehospital advanced airway management patients, we identified 54 with a traumatic brain injury and an initial GCS score of less than 9. Guideline adherence in terms of airway management was 92.6%. The reasons for nonadherence were the patient’s condition, anticipated difficult airway management and short distance to the emergency department. Following rapid sequence intubation (RSI), 11.4% developed oxygen saturation below 90%, 9.1% had a first post-RSI systolic blood pressure below 90 mmHg and 48.9% had a first post-RSI systolic blood pressure below 120 mmHg. The incidence of hypertension following prehospital RSI was 4.5%. The incidence of postendotracheal intubation hyperventilation was as high as 71.1%. Conclusion The guideline adherence was high. The incidences of post-RSI hypoxia and systolic blood pressure below 90 compare with the results reported from other physician-staffed prehospital services. The incidence of systolic blood pressure below 120 as well as that of hyperventilation following prehospital endotracheal intubation in patients with traumatic brain injury call for a change in our current practice.
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Länkimäki S, Alahuhta S, Silfvast T, Kurola J. Feasibility of LMA Supreme for airway management in unconscious patients by ALS paramedics. Scand J Trauma Resusc Emerg Med 2015; 23:24. [PMID: 25888519 PMCID: PMC4345009 DOI: 10.1186/s13049-015-0105-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Accepted: 02/16/2015] [Indexed: 11/29/2022] Open
Abstract
Background Airway management to ensure sufficient gas exchange is of major importance in emergency care. The accepted basic technique is to maintain an open airway and perform artificial ventilation in emergency situations is bag-valve mask (BVM) ventilation with manual airway management without airway adjuncts or with an oropharyngeal tube (OPA) only. Endotracheal intubation (ETI) is often referred to as the golden standard of airway management, but is associated with low success rates and significant insertion-related complications when performed by non-anaesthetists. Supraglottic devices (SADs) are one alternative to ETI in these situations, but there is limited evidence regarding the use of SAD in non-cardiac arrest situations. LMA Supreme (LMA-S) is a new SAD which theoretically has an advantage concerning the risk of aspiration due to an oesophageal inlet gastric tube port. Methods Forty paramedics were recruited to participate in the study. Adult (>18 years) patients, unconscious due to medical or traumatic cause with a GCS score corresponding to 3–5 and needed airway management were included in the study. Our aim was to study the feasibility of LMA-S as a primary airway method in unconscious patients by advanced life support (ALS) trained paramedics in prehospital care. Results Three regional Emergency Medical Service (EMS) services participated and 21 patients were treated during the survey. The LMA-S was placed correctly on the first attempt in all instances 21/21 (100%), with a median time to first ventilation of 9.8 s. Paramedics evaluated the insertion to be easy in every case 21/21 (100%). Because of air leak later in the patient care, the LMA-S was exchanged to an LT-D in two cases and to ETI in three cases (23.81%) by the paramedics. Regurgitation occurred after insertion two times out of 21 (9.52%) and in one of these cases (4.76%), paramedics reported regurgitation inside the LMA-S. Conclusion We conclude that the LMA-S seems to be relatively easy and quick to insert in unconscious patients by paramedics. However, we found out that there were ventilation related problems with the LMA-S. Further studies are warranted.
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Affiliation(s)
- Sami Länkimäki
- Helsinki Area Helicopter Emergency Medical Service, Helsinki University Central Hospital, FI-00029 HUS, Helsinki, Finland. .,Centre for Prehospital Emergency Care, Länsi-Pohja Healthcare District, Kauppakatu 25, FI-94100, Kemi, Finland.
| | - Seppo Alahuhta
- Department of Anaesthesiology, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland.
| | - Tom Silfvast
- Helsinki Area Helicopter Emergency Medical Service, Helsinki University Central Hospital, FI-00029 HUS, Helsinki, Finland.
| | - Jouni Kurola
- Centre for Prehospital Emergency Care, Kuopio University Hospital, PO Box 1777, FI-70210, Kuopio, Finland.
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Rognås L, Hansen TM, Kirkegaard H, Tønnesen E. Pre-hospital critical care anaesthesiologists and traumatic brain injury-guideline adherence. Scand J Trauma Resusc Emerg Med 2014. [PMCID: PMC4123186 DOI: 10.1186/1757-7241-22-s1-p7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
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Weatherall A, Garner A, Lovell N, Redmond S, Lee A, Skowno J, Egan J. Study protocol for the PHANTOM study: prehospital assessment of noninvasive tissue oximetry monitoring. Scand J Trauma Resusc Emerg Med 2014; 22:57. [PMID: 25280485 PMCID: PMC4189732 DOI: 10.1186/s13049-014-0057-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Accepted: 09/11/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Traumatic brain injury is a major cause of mortality and morbidity worldwide. It can be worsened by secondary injury particularly with hypoxia or hypotension. Current prehospital guidelines emphasise regular measurement of peripheral oxygen saturation and blood pressure but there is no monitor in use to provide direct information relating to blood flow or oxygen delivery to the brain tissue. This prospective cohort study will assess the utility of near-infrared spectroscopy monitoring in prehospital medicine in demonstrating injury, pathophysiology and associations with long-term functional outcomes. METHODS/DESIGN A prospective cohort study will be conducted in prehospital services where physician/paramedic teams respond rapidly to patients suffering significant traumatic injuries. A study observer accompanying the clinical team will apply non-invasive near-infrared spectroscopy tissue oximetry using a Nonin EQUANOX 7610 Regional Oximetry monitor (TM Nonin Medical, Inc.). This will be applied to patients with traumatic injuries less than 30 minutes old requiring transport. Measurements will be taken at two sites on the forehead and one on the forearm. Clinical teams will be blinded to all monitoring values. Near-infrared spectroscopy tissue oximetry parameters of oxyhaemoglobin%, deoxyhaemoglobin%, total tissue haemoglobin index and regional oxygen saturation will be recorded. Separate statistical analysis relating to time spent with cerebral regional oxygen saturation values < 45% and time series analysis will be performed to demonstrate associations with acute phase outcomes including injuries seen on cerebral imaging, and long-term functional outcomes measured by Glasgow Outcome Score and Extended Glasgow Outcome Score will then be undertaken. DISCUSSION This prospective cohort study will demonstrate associations evident from the earliest stages of prehospital treatment between near-infrared spectroscopy tissue oximetry values and both acute and long-term outcomes of patients suffering traumatic injuries. This may provide the basis for future interventional studies utilising near-infrared spectroscopy tissue oximetry to guide prehospital trauma care. TRIAL REGISTRATION This trial is registered with the Australian and New Zealand Clinical Trials Registry. The registration number is ACTRN12611001124921 .
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Affiliation(s)
- Andrew Weatherall
- CareFlight, Westmead, NSW, Australia.
- The Children's Hospital at Westmead, Westmead, NSW, 2145, Australia.
- The University of Sydney, Westmead, NSW, 2145, Australia.
| | - Alan Garner
- CareFlight, Westmead, NSW, Australia.
- The University of Sydney, Westmead, NSW, 2145, Australia.
| | - Nigel Lovell
- The University of New South Wales, Randwick, NSW, 2031, Australia.
| | - Stephen Redmond
- The University of New South Wales, Randwick, NSW, 2031, Australia.
| | - Anna Lee
- The Chinese University of Hong Kong, Shatin, NT, Hong Kong.
| | - Justin Skowno
- The Children's Hospital at Westmead, Westmead, NSW, 2145, Australia.
- The University of Sydney, Westmead, NSW, 2145, Australia.
| | - Jonathan Egan
- The Children's Hospital at Westmead, Westmead, NSW, 2145, Australia.
- The University of Sydney, Westmead, NSW, 2145, Australia.
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