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Botha JC, Lourens A, Stassen W. Rapid sequence intubation: a survey of current practice in the South African pre-hospital setting. Int J Emerg Med 2021; 14:45. [PMID: 34404352 PMCID: PMC8369626 DOI: 10.1186/s12245-021-00368-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 07/27/2021] [Indexed: 11/24/2022] Open
Abstract
Background Rapid sequence intubation (RSI) is an advanced airway skill commonly performed in the pre-hospital setting globally. In South Africa, pre-hospital RSI was first approved for non-physician providers by the Health Professions Council of South Africa in 2009 and introduced as part of the scope of practice of degree qualified Emergency Care Practitioners (ECPs) only. The research study aimed to investigate and describe, based on the components of the minimum standards of pre-hospital RSI in South Africa, specific areas of interest related to current pre-hospital RSI practice. Methods An online descriptive cross-sectional survey was conducted amongst operational ECPs in the pre-hospital setting of South Africa, using convenience and snowball sampling strategies. Results A total of 87 participants agreed to partake. Eleven (12.6%) incomplete survey responses were excluded while 76 (87.4%) were included in the data analysis. The survey response rate could not be calculated. Most participants were operational in Gauteng (n = 27, 35.5%) and the Western Cape (n = 25, 32.9%). Overall participants reported that their education and training were perceived as being of good quality. The majority of participants (n = 69, 90.8%) did not participate in an internship programme before commencing duties as an independent practitioner. Most RSI and post-intubation equipment were reported to be available; however, our results found that introducer stylets and/or bougies and end-tidal carbon dioxide devices are not available to some participants. Only 50 (65.8%) participants reported the existence of a clinical governance system within their organisation. Furthermore, our results indicate a lack of clinical feedback, deficiency of an RSI database, infrequent clinical review meetings and a shortage of formal consultation frameworks. Conclusion The practice of safe and effective pre-hospital RSI, performed by non-physician providers or ECPs, relies on comprehensive implementation and adherence to all the components of the minimum standards. Although there is largely an apparent alignment with the minimum standards, recurrent revision of practice needs to occur to ensure alignment with recommendations. Additionally, some areas may benefit from further research to improve current practice. Supplementary Information The online version contains supplementary material available at 10.1186/s12245-021-00368-3.
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Affiliation(s)
- Johanna Catharina Botha
- Division of Emergency Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
| | - Andrit Lourens
- Division of Emergency Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.,School of Nursing, Midwifery and Health, Faculty of Health and Life Sciences, Coventry University, Coventry, UK
| | - Willem Stassen
- Division of Emergency Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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Knapp J, Eberle B, Bernhard M, Theiler L, Pietsch U, Albrecht R. Analysis of tracheal intubation in out-of-hospital helicopter emergency medicine recorded by video laryngoscopy. Scand J Trauma Resusc Emerg Med 2021; 29:49. [PMID: 33731197 PMCID: PMC7968290 DOI: 10.1186/s13049-021-00863-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 03/04/2021] [Indexed: 11/13/2022] Open
Abstract
Background Tracheal intubation remains the gold standard of airway management in emergency medicine and maximizing safety, intubation success, and especially first-pass intubation success (FPS) in these situations is imperative. Methods We conducted a prospective observational study on all 12 helicopter emergency medical service (HEMS) bases of the Swiss Air Rescue, between February 15, 2018, and February 14, 2019. All 428 patients on whom out-of-hospital advanced airway management was performed by the HEMS crew were included. The C-MAC video laryngoscope was used as the primary device for tracheal intubation. Intubation procedures were recorded by the video laryngoscope and precise time points were recorded to verify the time necessary for each attempt and the overall procedure time until successful intubation. The videos were further analysed for problems and complications during airway management by an independent reviewer. Additionally, a questionnaire about the intubation procedure, basic characteristics of the patient, circumstances, environmental factors, and the provider’s level of experience in airway management was filled out. Main outcome measures were FPS of tracheal intubation, overall success rate, overall intubation time, problems and complications of video laryngoscopy. Results FPS rate was 87.6% and overall success rate 98.6%. Success rates, overall time to intubation, and subjective difficulty were not associated to the providers’ expertise in airway management. In patients undergoing CPR FPS was 84.8%, in trauma patients 86.4% and in non-trauma patients 93.3%. FPS in patients with difficult airway characteristics, facial trauma/burns or obesity ranges between 87 and 89%. Performing airway management indoors or inside an ambulance resulted in a significantly higher FPS of 91.1% compared to outdoor locations (p < 0.001). Direct solar irradiation on the screen, fogging of the lens, and blood on the camera significantly impaired FPS. Several issues for further improvements in the use of video laryngoscopy in the out-of-hospital setting and for quality control in airway management were identified. Conclusion Airway management using the C-MAC video laryngoscope with Macintosh blade in a group of operators with mixed experience showed high FPS and overall rates of intubation success. Video recording emergency intubations may improve education and quality control.
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Affiliation(s)
- Jürgen Knapp
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, 3010, Bern, Switzerland.
| | - Bettina Eberle
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, 3010, Bern, Switzerland.,Department of Anaesthesiology, Cantonal Hospital of Graubünden, Chur, Switzerland
| | - Michael Bernhard
- Emergency Department, Heinrich-Heine-University, University Hospital of Düsseldorf, Düsseldorf, Germany
| | - Lorenz Theiler
- Department of Anaesthesiology, Cantonal Hospital of Aargau, Aarau, Switzerland.,Swiss Air Rescue, Rega, Zurich, Switzerland
| | - Urs Pietsch
- Swiss Air Rescue, Rega, Zurich, Switzerland.,Department of Anaesthesiology and Intensive Care Medicine, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Roland Albrecht
- Swiss Air Rescue, Rega, Zurich, Switzerland.,Department of Anaesthesiology and Intensive Care Medicine, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
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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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4
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Orozco JA, Rojas JL, Medina-Vera AJ. Haemodynamic response and effectiveness of tracheal intubation with Airtraq® versus Macintosh laryngoscope in paediatric patient undergoing elective surgery: Prospective, randomised and blind clinical trial. ACTA ACUST UNITED AC 2017; 65:24-30. [PMID: 28965646 DOI: 10.1016/j.redar.2017.07.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Revised: 07/08/2017] [Accepted: 07/10/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To compare the haemodynamic response and effectiveness of tracheal intubation with Airtraq® device and Macintosh laryngoscope, for airway management of patients between 2 and 8 years undergoing elective surgery. METHODS A prospective, comparative, randomised and blind clinical trial where the effectiveness of tracheal intubation in 80 paediatric patients undergoing elective surgery was determined. Patients were divided into 2 groups of 40 subjects each: group A, intubated with Airtraq® optical laryngoscope; and group M, intubated with Macintosh laryngoscope. Haemodynamic changes, time and number of attempts at intubation and its complications were evaluated in both. RESULTS Heart rate was higher in group M from minute 1 to 5 with statistically significant difference (p: .001). The mean, systolic and diastolic blood pressure and EtCO2 values were higher in group M. There were no statistically significant differences in SO2. There was a statistically significant difference in time (group A: 18 ± 4seconds, group M: 27 ± 7seconds) and the number of attempts for intubation were lower for group A (p: .001). Seven patients in group M had post-intubation complications while only one subject had in group A. CONCLUSION Intubation with Airtraq® device is more effective than Macintosh laryngoscope in terms of reduction of haemodynamic changes, SO2, EtCO2, time and number of attempts for intubation and complications in paediatric patients undergoing elective surgery.
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Affiliation(s)
- J A Orozco
- Servicio de Anestesiología, Hospital General del Este «Dr. Domingo Luciani», Caracas, Venezuela
| | - J L Rojas
- Servicio de Anestesiología, Hospital General del Este «Dr. Domingo Luciani», Caracas, Venezuela
| | - A J Medina-Vera
- Servicio de Anestesiología, Hospital General del Este «Dr. Domingo Luciani», Caracas, Venezuela.
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5
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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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6
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Wajekar AS, Kotak N, Patel R, Moharir R. Successful Airtraq ® use for emergency off-centre glottic intubation in a patient with post-dialysis neck haematoma. Indian J Anaesth 2016; 60:872-873. [PMID: 27942071 PMCID: PMC5125201 DOI: 10.4103/0019-5049.193709] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Anjana S Wajekar
- Department of Anaesthesia, KEM Hospital, Mumbai, Maharashtra, India
| | - Nirav Kotak
- Department of Anaesthesia, KEM Hospital, Mumbai, Maharashtra, India
| | - Rajendra Patel
- Department of Anaesthesia, KEM Hospital, Mumbai, Maharashtra, India
| | - Rohit Moharir
- Department of Anaesthesia, KEM Hospital, Mumbai, Maharashtra, India
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Kim YY, Kang GH, Kim WH, Choi HY, Jang YS, Lee YJ, Kim JG, Kim H, Kim GY. Comparison of blind intubation through supraglottic devices and direct laryngoscopy by novices: a simulation manikin study. Clin Exp Emerg Med 2016; 3:75-80. [PMID: 27752621 PMCID: PMC5051610 DOI: 10.15441/ceem.15.069] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 03/27/2016] [Accepted: 03/31/2016] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE This study aimed to compare intubation performance between blind intubation through supraglottic airway devices and direct laryngoscopy by novices under manikin simulation. We hypothesized that the intubation time by novices using supraglottic airway devices was superior to that with the Macintosh laryngoscope (MCL). METHODS A prospective, randomized crossover study was conducted with 95 participants, to evaluate i-gel, air-Q, LMA Fastrach, and MCL devices. Primary outcomes were the intubation time and the success rate for intubation. RESULTS The i-gel showed the shortest insertion and tube passing time among the four devices; the i-gel and air-Q also showed the shortest total intubation time (all P<0.0083; i-gel vs. air-Q, P=0.03). The i-gel and MCL showed the highest cumulative success rate (all P<0.0083; i-gel vs. MCL, P=0.12). CONCLUSION Blind intubation through the i-gel showed almost equal intubation performance compared to direct laryngoscopy.
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Affiliation(s)
- Young Yong Kim
- Department of Emergency Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Gu Hyun Kang
- Department of Emergency Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Won Hee Kim
- Department of Emergency Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Hyun Young Choi
- Department of Emergency Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Yong Soo Jang
- Department of Emergency Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Young Jae Lee
- Department of Emergency Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Jae Guk Kim
- Department of Emergency Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Hyeongtae Kim
- Department of Emergency Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
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Ertürk T, Deniz S, Şimşek F, Purtuloğlu T, Kurt E. Comparison of the Macintosh and Airtraq Laryngoscopes in Endotracheal Intubation Success. Turk J Anaesthesiol Reanim 2016; 43:181-7. [PMID: 27366492 DOI: 10.5152/tjar.2015.38278] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2014] [Accepted: 09/29/2014] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE Endotracheal intubation of patients is an effective method for controlling airway and breathing. However, laryngoscopy and endotracheal intubation is not easy in every case. There is a recent abundance of equipment used for controlling ventilation and intubation. Airtraq is one of those equipments. In this study, our main objective is to compare the success rates of the Airtraq and Macintosh (direct and classic) laryngoscopes in endotracheal intubation. METHODS In this single-center, prospective, randomized, clinical study was performed on 80 patients who were operated under general anesthesia, ASA I-II, 18-65 years old. Patients were intubated using two different endotracheal intubation tools. Group A was intubated using the Macintosh (direct and classic) laryngoscope, meanwhile Group B was intubated using the Airtraq laryngoscope. Patients' snoring complaints, modified Mallampati scores, sternomental distances, thyromental distances, interincisor distance measurements and Cormack-Lehane (C-L) laryngoscopic classification, upper lip bite test results, intubation time, number of intubation attempts, maneuvers and techniques used for facilitating intubation and complications arising from intubation were recorded. RESULTS There was a statistically significant difference between the groups in terms of C-L scores (p=0.041). In all, 8 patients in the Macintosh group, and 2 patients in the Airtraq group were C-L grade III. In intubation of the Airtraq group, only 3 patients required facilitating techniques, meanwhile in intubation of the Macintosh group 15 patients we had to use one or more facilitating maneuver. The rate of Mallampati scoring "difficult" was 4/6 in the Macintosh and 2/11 in Airtraq laryngoscopy groups (p=0.553). CONCLUSION In cases with seemingly difficult intubations, we believe the Airtraq laryngoscope has an advantage over the Macintosh laryngoscope, owing to its better view of the oropharyngeal and glottic areas in addition to facilitating intubation in patients with limited head extension.
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Affiliation(s)
- Tuna Ertürk
- Department of Anaesthesiology and Reanimation, Gülhane Military Medical Academy, Ankara, Turkey
| | - Süleyman Deniz
- Department of Anaesthesiology and Reanimation, Gülhane Military Medical Academy Haydarpaşa Training Hospital, İstanbul, Turkey
| | - Fatih Şimşek
- Department of Anaesthesiology and Reanimation, Ardahan Military Hospital, Ardahan, Turkey
| | - Tarık Purtuloğlu
- Department of Anaesthesiology and Reanimation, Gülhane Military Medical Academy, Ankara, Turkey
| | - Ercan Kurt
- Department of Anaesthesiology and Reanimation, Gülhane Military Medical Academy, Ankara, Turkey
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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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10
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A Randomized Comparison Simulating Face to Face Endotracheal Intubation of Pentax Airway Scope, C-MAC Video Laryngoscope, Glidescope Video Laryngoscope, and Macintosh Laryngoscope. BIOMED RESEARCH INTERNATIONAL 2015; 2015:961782. [PMID: 26161424 PMCID: PMC4486761 DOI: 10.1155/2015/961782] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Accepted: 01/25/2015] [Indexed: 11/18/2022]
Abstract
OBJECTIVES Early airway management is very important for severely ill patients. This study aimed to investigate the efficacy of face to face intubation in four different types of laryngoscopes (Macintosh laryngoscope, Pentax airway scope (AWS), Glidescope video laryngoscope (GVL), and C-MAC video laryngoscope (C-MAC)). METHOD Ninety-five nurses and emergency medical technicians were trained to use the AWS, C-MAC, GVL and Macintosh laryngoscope with standard airway trainer manikin and face to face intubation. We compared VCET (vocal cord exposure time), tube pass time, 1st ventilation time, VCET to tube pass time, tube pass time to 1st ventilation time, and POGO (percentage of glottis opening) score. In addition, we compared success rate according to the number of attempts and complications. RESULT VCET was similar among all laryngoscopes and POGO score was higher in AWS. AWS and Macintosh blade were faster than GVL and C-MAC in total intubation time. Face to face intubation success rate was lower in GVL than other laryngoscopes. CONCLUSION AWS and Macintosh were favorable laryngoscopes in face to face intubation. GVL had disadvantage performing face to face intubation.
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11
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Lockey DJ, Crewdson K, Lossius HM. Pre-hospital anaesthesia: the same but different. Br J Anaesth 2014; 113:211-9. [PMID: 25038153 DOI: 10.1093/bja/aeu205] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Advanced airway management is one of the most controversial areas of pre-hospital trauma care and is carried out by different providers using different techniques in different Emergency Medical Services systems. Pre-hospital anaesthesia is the standard of care for trauma patients arriving in the emergency department with airway compromise. A small proportion of severely injured patients who cannot be managed with basic airway management require pre-hospital anaesthesia to avoid death or hypoxic brain injury. The evidence base for advanced airway management is inconsistent, contradictory and rarely reports all key data. There is evidence that poorly performed advanced airway management is harmful and that less-experienced providers have higher intubation failure rates and complication rates. International guidelines carry many common messages about the system requirements for the practice of advanced airway management. Pre-hospital rapid sequence induction (RSI) should be practiced to the same standard as emergency department RSI. Many in-hospital standards such as monitoring, equipment, and provider competence can be achieved. Pre-hospital and emergency in-hospital RSI has been modified from standard RSI techniques to improve patient safety, physiological disturbance, and practicality. Examples include the use of opioids and long-acting neuromuscular blocking agents, ventilation before intubation, and the early release of cricoid pressure to improve laryngoscopic view. Pre-hospital RSI is indicated in a small proportion of trauma patients. Where pre-hospital anaesthesia cannot be carried out to a high standard by competent providers, excellent quality basic airway management should be the mainstay of management.
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Affiliation(s)
- D J Lockey
- North Bristol NHS Trust, Bristol BS16 1LE, UK London's Air Ambulance, Barts Health NHS Trust, London E1 1BB, UK
| | - K Crewdson
- London's Air Ambulance, Barts Health NHS Trust, London E1 1BB, UK
| | - H M Lossius
- Department of Research and Development, The Norwegian Air Ambulance Foundation, Holterveien 24, PO Box 94, N-1441 Drøbak, Norway Field of Pre-hospital Critical Care, Network for Medical Sciences, University of Stavanger, Kjell Arholmsgate 41, Stavanger 4036, Norway
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