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Hayashi K, Kikuchi J, Hishinuma H, Noguchi T, Zaitsu M, Wake K. Impact of the Coronavirus Pandemic on Patients Requiring Tracheal Intubation by Helicopter Emergency Medical Services: A Retrospective, Single-Center, Observational Study. J Clin Med 2024; 13:3694. [PMID: 38999261 PMCID: PMC11242781 DOI: 10.3390/jcm13133694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2024] [Revised: 06/16/2024] [Accepted: 06/21/2024] [Indexed: 07/14/2024] Open
Abstract
Background/Objectives: The impacts of the coronavirus disease 2019 (COVID-19) pandemic on patients using helicopter emergency medical services (HEMS) regarding tracheal intubation and patient management remain unclear. Thus, we aimed to investigate this matter in Japan. Methods: In this retrospective, observational study, we analyzed 2277 patients who utilized HEMS in Tochigi Prefecture during 2018-2022. We included only patients who required tracheal intubation. We categorized patients from February 2020 to January 2022 in the pandemic group and those from February 2018 to January 2020 in the control group. We compared the interval from arrival at the scene to leaving the scene (on-scene time) and secondary variables between the two groups. Results: A total of 278 eligible patients were divided into the pandemic group (n = 127) and the control group (n = 151). The on-scene time was lower during the pandemic than that before (25.64 ± 9.19 vs. 27.83 ± 8.74 min, p = 0.043). The percentage of patients using midazolam was lower (11.8% vs. 22.5%, p = 0.02) and that of patients using rocuronium bromide was higher (29.1% vs. 6.0%, p < 0.001) during the pandemic. In contrast, the type of intervention other than tracheal intubation and the type of transportation to the hospital did not differ between the groups. Conclusions: The COVID-19 pandemic was associated with changes in the mission time of and the frequency of certain drugs administered by the HEMS. However, the type of intervention and the type of transportation did not differ. Further research is needed on changes in patient prognosis and condition due to the effects of the COVID-19 pandemic.
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Affiliation(s)
- Kentaro Hayashi
- Department of Emergency and Critical Care Medicine, Dokkyo Medical University, Tochigi 321-0293, Japan
- Data Science Center, Jichi Medical University, Tochigi 329-0498, Japan
| | - Jin Kikuchi
- Department of Emergency and Critical Care Medicine, Dokkyo Medical University, Tochigi 321-0293, Japan
| | - Hidekazu Hishinuma
- Department of Public Health, School of Medicine, Dokkyo Medical University, Tochigi 321-0293, Japan
| | - Takafumi Noguchi
- Department of Adult Nursing, School of Nursing, Dokkyo Medical University, Tochigi 321-0293, Japan
| | - Masayoshi Zaitsu
- Center for Research of the Aging Workforce, University of Occupational and Environmental Health, Fukuoka 807-8555, Japan
| | - Koji Wake
- Department of Emergency and Critical Care Medicine, Dokkyo Medical University, Tochigi 321-0293, Japan
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Borgström AM, Bäckström D. Swedish consensus regarding difficult pre-hospital airway management: a Delphi study. BMC Emerg Med 2024; 24:88. [PMID: 38802737 PMCID: PMC11129497 DOI: 10.1186/s12873-024-01013-x] [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: 11/18/2023] [Accepted: 05/23/2024] [Indexed: 05/29/2024] Open
Abstract
BACKGROUND The aim of this study was to establish a consensus among experts in prehospital work regarding the management of difficult airways in prehospital care in Sweden. The results were subsequently used to develop an algorithm for handling difficult airway in prehospital care, as there was none available in Sweden prior to this study. METHODS This two-round Delphi study was conducted by forming an expert panel comprising anesthesiologists and anesthesia nurses working in prehospital setting in Sweden. The expert panel responded digital forms with questions and statements related to airway management. The study continued until consensus was reached, defined as more than 70% agreement. The study took place from December 4, 2021, to May 15, 2022. RESULTS In the first round, 74 participants took part, while the second round involved 37 participants. Consensus was reached in 16 out of 17 statements. 92% of the participants agreed that an airway algorithm adapted for prehospital use is necessary. CONCLUSIONS The capacity to adapt the approach to airway management based on specific pre-hospital circumstances is crucial. It holds significance to establish a uniform framework that is applicable across various airway management scenarios. Consequently, the airway management algorithm that has been devised should be regarded as a recommendation, allowing for flexibility rather than being interpreted as a rigid course of action. This represents the inaugural nationwide algorithm for airway management designed exclusively for pre-hospital operations in Sweden. The algorithm is the result of a consensus reached by experts in pre-hospital care.
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Affiliation(s)
- Anton Modée Borgström
- Department of Anaesthesiology and Intensive Care, Capio St. Göran's Hospital, Stockholm, 112 19, Sweden
| | - Denise Bäckström
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, 581 83, Sweden.
- Capio Akutläkarbilar, Stockholm, Sweden.
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Feth M, Fritz S, Grübl T, Gliwitzky B, Düsterwald S, Bathe J, Bernhard M, Hossfeld B. [Airwaymangement in Emergencies]. Dtsch Med Wochenschr 2024; 149:458-469. [PMID: 38565120 DOI: 10.1055/a-2220-1411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
Emergency airway management is a rare but essential emergency medical intervention directly impacting morbidity and mortality of emergency patients. The success of airway management depends on various factors such as patient anatomy, environmental aspects and the provider performing the procedure. Therefore, the use of a clearly structured algorithm for anticipating the difficult airway in emergency situations is strongly recommended. Our article explains different ways of securing the airway as part of a structured algorithm as well as pitfalls and helpful tips.
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Lapidus O, Rubenson Wahlin R, Bäckström D. Trauma patient transport to hospital using helicopter emergency medical services or road ambulance in Sweden: a comparison of survival and prehospital time intervals. Scand J Trauma Resusc Emerg Med 2023; 31:101. [PMID: 38104083 PMCID: PMC10725597 DOI: 10.1186/s13049-023-01168-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 12/08/2023] [Indexed: 12/19/2023] Open
Abstract
BACKGROUND The benefits of helicopter emergency medical services (HEMS) transport of adults following major trauma have been examined with mixed results, with some studies reporting a survival benefit compared to regular emergency medical services (EMS). The benefit of HEMS in the context of the Swedish trauma system remains unclear. AIM To investigate differences in survival and prehospital time intervals for trauma patients in Sweden transported by HEMS compared to road ambulance EMS. METHODS A total of 74,032 trauma patients treated during 2012-2022 were identified through the Swedish Trauma Registry (SweTrau). The primary outcome was 30-day mortality and Glasgow Outcome Score at discharge from hospital (to home or rehab); secondary outcomes were the proportion of severely injured patients who triggered a trauma team activation (TTA) on arrival to hospital and the proportion of severely injured patients with GCS ≤ 8 who were subject to prehospital endotracheal intubation. RESULTS 4529 out of 74,032 patients were transported by HEMS during the study period. HEMS patients had significantly lower mortality compared to patients transported by EMS at 1.9% vs 4.3% (ISS 9-15), 5.4% vs 9.4% (ISS 16-24) and 31% vs 42% (ISS ≥ 25) (p < 0.001). Transport by HEMS was also associated with worse neurological outcome at discharge from hospital, as well as a higher rate of in-hospital TTA for severely injured patients and higher rate of prehospital intubation for severely injured patients with GCS ≤ 8. Prehospital time intervals were significantly longer for HEMS patients compared to EMS across all injury severity groups. CONCLUSION Trauma patients transported to hospital by HEMS had significantly lower mortality compared to those transported by EMS, despite longer prehospital time intervals and greater injury severity. However, this survival benefit may have been at the expense of a higher degree of adverse neurological outcome. Increasing the availability of HEMS to include all regions should be considered as it may be the preferrable option for transport of severely injured trauma patients in Sweden.
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Affiliation(s)
- Oscar Lapidus
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden.
| | - Rebecka Rubenson Wahlin
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Huddinge, Sweden
- Ambulance Medical Service in Stockholm (AISAB), Stockholm, Sweden
| | - Denise Bäckström
- Division of Surgery, Orthopedics and Oncology, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
- VO Ambulans Och Akut, Region Gävleborg, Sweden
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Renberg M, Dahlberg M, Gellerfors M, Rostami E, Günther M. Prehospital and emergency department airway management of severe penetrating trauma in Sweden during the past decade. Scand J Trauma Resusc Emerg Med 2023; 31:85. [PMID: 38001526 PMCID: PMC10675952 DOI: 10.1186/s13049-023-01151-4] [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: 08/25/2023] [Accepted: 11/11/2023] [Indexed: 11/26/2023] Open
Abstract
BACKGROUND Prehospital tracheal intubation (TI) is associated with increased mortality in patients with penetrating trauma, and the utility of prehospital advanced airway management is debated. The increased incidence of deadly violence in Sweden warrants a comprehensive evaluation of current airway management for patients with penetrating trauma in the Swedish prehospital environment and on arrival in the emergency department (ED). METHODS This was an observational, multicenter study of all patients with penetrating trauma and injury severity scores (ISSs) ≥ 15 included in the Swedish national trauma register (SweTrau) between 2011 and 2019. We investigated the frequency and characteristics of prehospital and ED TI, including 30-day mortality and patient characteristics associated with TI. RESULT Of 816 included patients, 118 (14.5%) were intubated prehospitally, and 248 (30.4%) were intubated in the ED. Patients who were intubated prehospitally had a higher ISS, 33 (interquartile range [IQR] 25, 75), than those intubated in the ED, 25 (IQR 18, 34). Prehospital TI was associated with a higher associated mortality, OR 4.26 (CI 2.57, 7.27, p < 0.001) than TI in the ED, even when adjusted for ISS (OR 2.88 [CI 1.64, 5.14, p < 0.001]). Hemodynamic collapse (≤ 40 mmHg) and low GCS score (≤ 8) were the characteristics most associated with prehospital TI. Traumatic cardiac arrests (TCAs) occurred in 154 (18.9%) patients, of whom 77 (50%) were intubated prehospitally and 56 (36.4%) were intubated in the ED. A subgroup analysis excluding TCA showed that patients with prehospital TI did not have a higher mortality rate than those with ED TI, OR 2.07 (CI 0.93, 4.51, p = 0.068), with OR 1.39 (0.56, 3.26, p = 0.5) when adjusted for ISS. CONCLUSION Prehospital TI was associated with a higher mortality rate than those with ED TI, which was specifically related to TCA; intubation did not affect mortality in patients without cardiac arrest. Mortality was high when airway management was needed, regardless of cardiac arrest, thereby emphasizing the challenges posed when anesthesia is needed. Several interventions, including whole blood transfusions, the implementation of second-tier EMS units and measures to shorten scene times, have been initiated in Sweden to counteract these challenges.
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Affiliation(s)
- Mattias Renberg
- Department of Anesthesiology and Intensive Care, Södersjukhuset, Sjukhusbacken, 10, S1 SE-118 83, Stockholm, Sweden.
| | - Martin Dahlberg
- Department of Surgery, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Mikael Gellerfors
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
- Rapid Response Car, Capio, Stockholm, Sweden
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
- Swedish Air Ambulance (SLA), Mora, Sweden
| | - Elham Rostami
- Experimental Traumatology Unit, Department of Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Medical Sciences, Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Mattias Günther
- Department of Anesthesiology and Intensive Care, Södersjukhuset, Sjukhusbacken, 10, S1 SE-118 83, Stockholm, Sweden
- Experimental Traumatology Unit, Department of Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
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Thompson G, Miller B, Lenz TJ. Comparing Intubation Success Between Flight Nurses and Flight Paramedics in Helicopter Emergency Medical Services. Air Med J 2023; 42:436-439. [PMID: 37996178 DOI: 10.1016/j.amj.2023.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 07/05/2023] [Accepted: 07/12/2023] [Indexed: 11/25/2023]
Abstract
OBJECTIVE Intubation is a vital skill performed by flight nurses and paramedics. Before flight training, nurses do not routinely intubate and must be trained in proper techniques. Flight paramedics universally train in intubation before flight training and are the primary managers of in-flight airways. The aim of this study was to determine if a difference exists in intubation attempts and success rates between flight nurses and flight paramedics. METHODS A 5-year retrospective chart review was performed from a regional helicopter emergency medical service. Intubation attempts and the success of flight nurses compared with flight paramedics were the primary outcomes. RESULTS Three hundred three of 322 cases in which intubation was attempted were successful. Three hundred forty-four total intubation attempts were made. Two hundred seventy-one (88.9%) patients were intubated by paramedics, and 32 (10.5%) were intubated by nurses. Of the 19 unsuccessfully intubated patients, 14 (73.7%) were attempted by a paramedic and 5 (26.3%) by a nurse. Two hundred seventy-seven intubations were successful on the first attempt, 250 (90.3%) of which were performed by a paramedic and 27 (9.7%) by a nurse. CONCLUSION Flight paramedics performed more intubations with greater success than flight nurses.
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Affiliation(s)
- Gregory Thompson
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Blake Miller
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Timothy J Lenz
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI.
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Strandqvist E, Olheden S, Bäckman A, Jörnvall H, Bäckström D. Physician-staffed prehospital units: a retrospective follow-up from an urban area in Scandinavia. Int J Emerg Med 2023; 16:43. [PMID: 37452288 PMCID: PMC10349430 DOI: 10.1186/s12245-023-00519-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 07/10/2023] [Indexed: 07/18/2023] Open
Abstract
BACKGROUND The aim of this study was to determine when and how rapid response vehicles (RRVs) make a difference in prehospital care by investigating the number and kinds of RRV assignment dispatches and the prehospital characteristics and interventions involved. METHODS This retrospective cohort study was based on data from a quality assurance system where all assignments are registered. RRV staff register every assignment directly at the site, using a smartphone, tablet, or computer. There is no mandatory information requirement or time limit for registration. The study includes data for all RRVs operating in Region Stockholm, three during daytime hours and one at night - from January 1, 2021 to December 31, 2021. RESULTS In 2021, RRVs in Stockholm were dispatched on 11,283 occasions, of which 3,571 (31.6%) resulted in stand-downs. In general, stand-downs were less common for older patients. The most common dispatch category was blunt trauma (1,584 or 14.0%), which accounted for the highest frequency of stand-downs (676 or 6.0%). The second most common category was cardiac arrest (1,086 or 9.6%), followed by shortness of breath (691 or 6.1%), medical not specified (N/S) (596 or 5.3%), and seizures (572 or 5.1%). CONCLUSION The study findings confirm that RRVs provide valuable assistance to the ambulance service in Stockholm, especially for cardiac arrest and trauma patients. In particular, RRV personnel have more advanced medical knowledge and can administer medications and perform interventions that the regular ambulance service cannot provide.
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Affiliation(s)
| | - Staffan Olheden
- Capio Akutläkarbilar, Stockholm, Sweden
- Function Perioperative Medicine and Intensive Care, Department of Perioperative Care, Solna Karolinska University Hospital, Stockholm, Sweden
| | - Anders Bäckman
- Capio Akutläkarbilar, Stockholm, Sweden
- Center for Resuscitation Science, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden
| | - Henrik Jörnvall
- Capio Akutläkarbilar, Stockholm, Sweden
- Function Perioperative Medicine and Intensive Care, Department of Perioperative Care, Solna Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology, Section for Anesthesia and Intensive Care Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Denise Bäckström
- Capio Akutläkarbilar, Stockholm, Sweden
- Department of Biomedical and Clinical Sciences, Linköping University, 581 83 Linköping, Sweden
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Finke SR, Schroeder DC, Ecker H, Böttiger BW, Herff H, Wetsch WA. Comparing suction rates of novel DuCanto catheter against Yankauer and standard suction catheter using liquids of different viscosity—a technical simulation. BMC Anesthesiol 2022; 22:285. [PMID: 36088303 PMCID: PMC9463842 DOI: 10.1186/s12871-022-01830-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 09/06/2022] [Indexed: 11/10/2022] Open
Abstract
Purpose Aspiration is a feared complication that may occur during airway management, and can significantly contribute to morbidity and mortality. Availability of a suctioning device with a suction catheter capable of clearing the airway is mandatory for airway management. However, suction performance may be significantly different amongst different suction catheters. The aim of this study was to compare suction rates of a standard 14 Ch suction catheter (SC), a Yankauer catheter (Y) and a DuCanto catheter (DC) using 4 fluids with different viscosity. Methods In this simulation trial, 4 preparations with standardized viscosity were prepared using a Xanthane-based medical fluid thickener. Lowest viscosity was achieved using tap water without thickener, syrup-like viscosity was achieved by adding 10 g per liter tap water, honey-like viscosity was achieved by adding 20 g per liter, and a pudding-like viscosity was achieved by adding 30 g of thickening powder per liter tap water. Each preparation was suctioned for 15 s with the three different suctioning devices. Measurements were repeated four times. The amount of removed preparation by suctioning was measured using a tared scale. Results Suction rates for water were 580 ± 34 mg for SC, 888 ± 5 mg for Y and 1087 ± 15 for DC; for syrup-like viscosity it was 383 ± 34(SC) vs. 661 ± 64(Y) vs. 935 ± 42(DC); for honey-like viscosity it was 191 ± 21(SC) vs. 426 ± 34(Y) vs. 590 ± 68(DC); and for pudding-like viscosity 74 ± 13(SC) vs. 164 ± 6(Y) vs. 211 ± 8(DC). Conclusion Suctioning liquids of different viscosity, the new DuCanto catheter was more effective than the Yankauer catheter that was more effective than a standard suctioning catheter. The relative superiority of the DuCanto was highest in fluids with high viscosity.
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A retrospective descriptive analysis of non-physician-performed prehospital endotracheal intubation practices and performance in South Africa. BMC Emerg Med 2022; 22:129. [PMID: 35842578 PMCID: PMC9287876 DOI: 10.1186/s12873-022-00688-4] [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: 12/29/2021] [Accepted: 07/04/2022] [Indexed: 11/25/2022] Open
Abstract
Introduction Prehospital advanced airway management, including endotracheal intubation (ETI), is one of the most commonly performed advanced life support skills. In South Africa, prehospital ETI is performed by non-physician prehospital providers. This practice has recently come under scrutiny due to lower first pass (FPS) and overall success rates, a high incidence of adverse events (AEs), and limited evidence regarding the impact of ETI on mortality. The aim of this study was to describe non-physician ETI in a South African national sample in terms of patient demographics, indications for intubation, means of intubation and success rates. A secondary aim was to determine what factors were predictive of first pass success. Methods This study was a retrospective chart review of prehospital ETIs performed by non-physician prehospital providers, between 01 January 2017 and 31 December 2017. Two national private Emergency Medical Services (EMS) and one provincial public EMS were sampled. Data were analysed descriptively and summarised. Logistic regression was performed to evaluate factors that affect the likelihood of FPS. Results A total of 926 cases were included. The majority of cases were adults (n = 781, 84.3%) and male (n = 553, 57.6%). The most common pathologies requiring emergency treatment were head injury, including traumatic brain injury (n = 328, 35.4%), followed by cardiac arrest (n = 204, 22.0%). The mean time on scene was 46 minutes (SD = 28.3). The most cited indication for intubation was decreased level of consciousness (n = 515, 55.6%), followed by cardiac arrest (n = 242, 26.9%) and ineffective ventilation (n = 96, 10.4%). Rapid sequence intubation (RSI, n = 344, 37.2%) was the most common approach. The FPS rate was 75.3%, with an overall success rate of 95.7%. Intubation failed in 33 (3.6%) patients. The need for ventilation was inversely associated with FPS (OR = 0.42, 95% CI: 0.20–0.88, p = 0.02); while deep sedation (OR = 0.56, 95% CI: 0.36–0.88, p = 0.13) and no drugs (OR = 0.47, 95% CI: 0.25–0.90, p = 0.02) compared to RSI was less likely to result in FPS. Increased scene time (OR = 0.99, 95% CI: 0.985–0.997, p < 0.01) was inversely associated FPS. Conclusion This is one of the first and largest studies evaluating prehospital ETI in Africa. In this sample of ground-based EMS non-physician ETI, we found success rates similar to those reported in the literature. More research is needed to determine AE rates and the impact of ETI on patient outcome. There is an urgent need to standardise prehospital ETI reporting in South Africa to facilitate future research. Supplementary Information The online version contains supplementary material available at 10.1186/s12873-022-00688-4.
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Intubation success in prehospital emergency anaesthesia: a retrospective observational analysis of the Inter-Changeable Operator Model (ICOM). Scand J Trauma Resusc Emerg Med 2022; 30:44. [PMID: 35804435 PMCID: PMC9264686 DOI: 10.1186/s13049-022-01032-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 06/22/2022] [Indexed: 01/30/2023] Open
Abstract
Background Pre hospital emergency anaesthesia (PHEA) is a complex procedure with significant risks. First-pass intubation success (FPS) is recommended as a quality indicator in pre hospital advanced airway management. Previous data demonstrating significantly lower FPS by non-physicians does not distinguish between non-physicians operating in isolation or within physician teams. In several UK HEMS, the role of the intubating provider is interchangeable between the physician and critical care paramedic—termed the Inter-Changeable Operator Model (ICOM). The objectives of this study were to compare first-pass intubation success rate between physicians and critical care paramedics (CCP) in a large regional, multi-organisational dataset of trauma PHEA patients, and to report the application of the ICOM. Methods A retrospective observational study of consecutive trauma patients ≥ 16 years old who underwent PHEA at two different ICOM Helicopter Emergency Medical Services in the East of England, 2015–2020. Data are presented as number (percentage) and median [inter-quartile range]. Fisher’s exact test was used to compare proportions, reported as odds ratio (OR (95% confidence interval, 95% CI)), p value. The study design complied with the STROBE (Strengthening The Reporting of Observational studies in Epidemiology) reporting guidelines. Results In the study period, 13,654 patients were attended. 674 (4.9%) trauma patients ≥ 16 years old who underwent PHEA were included in the final analysis: the median age was 44 [28–63] years old, and 502 (74.5%) were male. There was no significant difference in the FPS rate between physicians and CCPs—90.2% and 87.4% respectively, OR 1.3 (95% CI 0.7–2.5), p = 0.38. The cumulative first, second, third, and fourth-pass intubation success rates were 89.6%, 98.7%, 99.7%, and 100%. Patients who had a physician-operated initial intubation attempt weighed more and had a higher heart rate, compared to those who had a CCP-operated initial attempt. Conclusion In an ICOM setting, we demonstrated 100% intubation success in adult trauma patients undergoing PHEA. There was no significant difference in first-pass intubation success between physicians and CCPs.
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Ventilator Associated Pneumonia and Intubation Location in Adults with Traumatic Injuries: Systematic Review and Meta-analysis. J Trauma Acute Care Surg 2022; 93:e130-e138. [PMID: 35789149 DOI: 10.1097/ta.0000000000003737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Ventilator associated pneumonia (VAP) is an important cause of morbidity and mortality among critically ill patients, particularly those who present with traumatic injuries. This review aims to determine whether patients with traumatic injuries who are intubated in the prehospital setting are at higher risk of developing VAP compared to those intubated in the hospital. METHODS A systematic review of Medline, Scopus and Cochrane electronic databases was conducted from inception through January 2021. Inclusion criteria were patients with traumatic injuries who were intubated in the prehospital or hospital settings with VAP as an outcome. Using a random effects model, the risk of VAP across study arms was compared by calculating a summary relative risk (RR) with 95% confidence intervals (CI). The results of individual studies were also summarized qualitatively. RESULTS The search identified 754 articles of which 6 studies (N = 2990) met inclusion criteria. All studies were good quality based on assessment with the Newcastle Ottawa scale. Prehospital intubation demonstrated an increased risk of VAP development in 2 of the 6 studies. Among the 6 studies, the overall quality weighted risk ratio was 1.09 (95% CI 0.90-1.31). CONCLUSIONS Traumatically injured patients who are intubated in the prehospital setting have a similar risk of developing VAP compared to those that are intubated in the hospital setting. LEVEL OF EVIDENCE Level IV systematic review and meta-analysis.
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Harris CT, Taghavi S, Bird E, Duchesne J, Jacome T, Tatum D. Prehospital Simple Thoracostomy Does Not Improve Patient Outcomes Compared to Needle Thoracostomy in Severely Injured Trauma Patients. Am Surg 2022:31348221075746. [PMID: 35142224 DOI: 10.1177/00031348221075746] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND ATLS suggests simple thoracostomy (ST) after failure of needle thoracostomy (NT) in thoracic trauma. Some EMS agencies have adopted ST into their practice. We sought to describe our experience implementing ST in the prehospital setting, hypothesizing that prehospital ST would reduce failure rates and improve outcomes compared to NT. METHODS This was a retrospective review of adult trauma patients who received prehospital ST or NT from 2017 to 2020. RESULTS There were 48 patients with 64 procedures included. 83.7% were male and 65.8% injured by penetrating mechanism and of median (IQR) age of 31 (25-46) years. 28 (43.8%) procedures were NT and 36 (56.3%) were ST. Rates of improved patient response (P = .15), noted return of blood/air (P = .19), and return of spontaneous circulation (P = .62) did not differ. On-scene times were higher for ST (16.8 vs 11.5 minutes; P < .02). Overall mortality did not differ between ST and NT (68.2% vs 46.4%, respectively; P = .125). For patients that survived beyond the ED, procedure-related complication rates were 2 of 21 patients (9.5%) in ST and 1 of 12 (8.3%) in NT. In penetrating trauma, simple thoracostomy had longer on-scene time and total prehospital time. DISCUSSION ST did not improve success rates of ROSC and was associated with prolonged prehospital times, especially in penetrating trauma patients. Given the benefit of "scoop and run" in urban penetrating trauma, consideration should be given to direct transport in lieu of ST. Use of ST in blunt trauma should be evaluated prospectively.
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Affiliation(s)
- Charles T Harris
- Section of Trauma and Critical Care, Department of Surgery, 12256Tulane University, New Orleans, LA, USA
| | - Sharven Taghavi
- Section of Trauma and Critical Care, Department of Surgery, 12256Tulane University, New Orleans, LA, USA
| | - Emily Bird
- Trauma Services, 23087Our Lady of the Lake Regional Medical Center, Baton Rouge, LA, USA
| | - Juan Duchesne
- Section of Trauma and Critical Care, Department of Surgery, 12256Tulane University, New Orleans, LA, USA
| | - Tomas Jacome
- Trauma Services, 23087Our Lady of the Lake Regional Medical Center, Baton Rouge, LA, USA
| | - Danielle Tatum
- Section of Trauma and Critical Care, Department of Surgery, 12256Tulane University, New Orleans, LA, USA
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13
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Pietsch U, Müllner R, Theiler L, Wenzel V, Meuli L, Knapp J, Sollid SJM, Albrecht R. Airway management in a Helicopter Emergency Medical Service (HEMS): a retrospective observational study of 365 out-of-hospital intubations. BMC Emerg Med 2022; 22:23. [PMID: 35135493 PMCID: PMC8822827 DOI: 10.1186/s12873-022-00579-8] [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: 08/03/2021] [Accepted: 01/31/2022] [Indexed: 11/29/2022] Open
Abstract
Background Airway management is a key skill in any helicopter emergency medical service (HEMS). Intubation is successful less often than in the hospital, and alternative forms of airway management are more often needed. Methods Retrospective observational cohort study in an anaesthesiologist-staffed HEMS in Switzerland. Patient charts were analysed for all calls to the scene (n = 9,035) taking place between June 2016 and May 2017 (12 months). The primary outcome parameter was intubation success rate. Secondary parameters included the number of alternative techniques that eventually secured the airway, and comparison of patients with and without difficulties in airway management. Results A total of 365 patients receiving invasive ventilatory support were identified. Difficulties in airway management occurred in 26 patients (7.1%). Severe traumatic brain injury was the most common indication for out-of-hospital Intubation (n = 130, 36%). Airway management was performed by 129 different Rega physicians and 47 different Rega paramedics. Paramedics were involved in out-of-hospital airway manoeuvres significantly more often than physicians: median 7 (IQR 4 to 9) versus 2 (IQR 1 to 4), p < 0.001. Conclusion Despite high overall success rates for endotracheal intubation in the physician-staffed service, individual physicians get only limited real-life experience with advanced airway management in the field. This highlights the importance of solid basic competence in a discipline such as anaesthesiology.
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Affiliation(s)
- Urs Pietsch
- Department of Anaesthesiology and Intensive Care Medicine, Cantonal Hospital St, Gallen, St. Gallen, Switzerland. .,Swiss Air-Ambulance, Rega (Rettungsflugwacht/Guarde Aérienne), Zürich, Switzerland. .,Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, 3010, Bern, Switzerland.
| | - Raphael Müllner
- Department of Anaesthesiology, Cantonal Hospital Luzern, Luzern, Switzerland
| | - Lorenz Theiler
- Department of Anaesthesiology, Kantonsspital Aarau, Aarau, Switzerland
| | - Volker Wenzel
- Department of Anaesthesiology and Intensive Care Medicine, Friedrichshafen Regional Hospital, Friedrichshafen, Germany
| | - Lorenz Meuli
- Department of Vascular Surgery, University Hospital Zürich, Zürich, Switzerland
| | - Jürgen Knapp
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Stephen J M Sollid
- Norwegian Air Ambulance Foundation, PB 414 Sentrum, 0103, Oslo, Norway.,Faculty of Health Sciences, University of Stavanger, PB 8600, 4036, Stavanger, Norway
| | - Roland Albrecht
- Department of Anaesthesiology and Intensive Care Medicine, Cantonal Hospital St, Gallen, St. Gallen, Switzerland.,Swiss Air-Ambulance, Rega (Rettungsflugwacht/Guarde Aérienne), Zürich, Switzerland.,Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, 3010, Bern, Switzerland
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14
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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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15
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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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16
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Hunter K, McHenry AS, Curtis L, Avest ET, Mitchinson S, Griggs JE, Lyon RM. Feasibility of Prehospital Emergency Anesthesia in the Cabin of an AW169 Helicopter Wearing Personal Protective Equipment During Coronavirus Disease 2019. Air Med J 2021; 40:395-398. [PMID: 34794777 PMCID: PMC8382585 DOI: 10.1016/j.amj.2021.08.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 08/20/2021] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Prehospital emergency anesthesia in the form of rapid sequence intubation (RSI) is a critical intervention delivered by advanced prehospital critical care teams. Our previous simulation study determined the feasibility of in-aircraft RSI. We now examine whether this feasibility is preserved in a simulated setting when clinicians wear personal protective equipment (PPE) for aerosol-generating procedures (AGPs) for in-aircraft, on-the-ground RSI. METHODS Air Ambulance Kent Surrey Sussex is a helicopter emergency medical service that uses an AW169 cabin simulator. Wearing full AGP PPE (eye protection, FFP3 mask, gown, and gloves), 10 doctor-paramedic teams performed RSI in a standard "can intubate, can ventilate" scenario and a "can't intubate, can't oxygenate" (CICO) scenario. Prespecified timings were reported, and participant feedback was sought by questionnaire. RESULTS RSI was most commonly performed by direct laryngoscopy and was successfully achieved in all scenarios. The time to completed endotracheal intubation (ETI) was fastest (287 seconds) in the standard scenario and slower (370 seconds, P = .01) in the CICO scenario. The time to ETI was not significantly delayed by wearing PPE in the standard (P = .19) or CICO variant (P = .97). Communication challenges, equipment complications, and PPE difficulties were reported, but ways to mitigate these were also reported. CONCLUSION In-aircraft RSI (aircraft on the ground) while wearing PPE for AGPs had no significant impact on the time to successful completion of ETI in a simulated setting. Patient safety is paramount in civilian helicopter emergency medical services, but the adoption of in-aircraft RSI could confer significant patient benefit in terms of prehospital time savings, and further research is warranted.
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Affiliation(s)
- Kat Hunter
- Air Ambulance Kent Surrey Sussex, Redhill, Surrey, United Kingdom
| | - Allan S McHenry
- Air Ambulance Kent Surrey Sussex, Redhill, Surrey, United Kingdom
| | - Leigh Curtis
- Air Ambulance Kent Surrey Sussex, Redhill, Surrey, United Kingdom
| | - Ewoud Ter Avest
- Air Ambulance Kent Surrey Sussex, Redhill, Surrey, United Kingdom; Department of Emergency Medicine, University Medical Center Groningen, Groningen, The Netherlands
| | | | - Joanne E Griggs
- Air Ambulance Kent Surrey Sussex, Redhill, Surrey, United Kingdom; University of Surrey, Guildford, United Kingdom.
| | - Richard M Lyon
- Air Ambulance Kent Surrey Sussex, Redhill, Surrey, United Kingdom; University of Surrey, Guildford, United Kingdom
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17
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First pass success of tracheal intubation using the C-MAC PM videolaryngoscope as first-line device in prehospital cardiac arrest compared with other emergencies: An observational study. Eur J Anaesthesiol 2021; 38:806-812. [PMID: 32833853 DOI: 10.1097/eja.0000000000001286] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Successful airway management is a priority in the resuscitation of critically ill or traumatised patients. Several studies have demonstrated the importance of achieving maximum first pass success, particularly in prehospital advanced airway management. OBJECTIVE To compare success rates of emergency intubations between patients requiring cardiopulmonary resuscitation (CPR) for cardiac arrest (CPR group) and other emergencies (non-CPR group) using the C-MAC PM videolaryngoscope. DESIGN Ongoing analysis of prospective collected prehospital advanced airway management core variables. SETTING Single helicopter emergency medical service (HEMS) 'Christoph 22', Ulm Military Hospital, Germany, May 2009 to July 2018. PATIENTS We included all 1006 HEMS patients on whom prehospital advanced airway management was performed by board-certified anaesthesiologists on call at HEMS 'Christoph 22'. INTERVENTIONS The C-MAC PM was used as the first-line device. The initial direct laryngoscopy was carried out using the C-MAC PM without the monitor in sight. After scoring the direct laryngoscopic view according to the Cormack and Lehane grade, the monitor was folded within the sight of the physician and tracheal intubation was performed using the videolaryngoscopic view without removing the blade. MAIN OUTCOME MEASURES The primary outcome was successful airway management. Secondary outcomes were the patient's position during airway management, necessity for suction, direct and videolaryngoscopic view according to Cormack and Lehane grading, as well as number of attempts needed for successful intubation. RESULTS A patent airway was achieved in all patients including rescue techniques. There was a lower first pass success rate in the CPR group compared with the non-CPR group (84.4 vs. 91.4%, P = 0.01). In the CPR group, direct laryngoscopy resulted more often in a clinically unfavourable (Cormack and Lehane grade 3 or 4) glottic view (CPR vs. non-CPR-group 37.2 vs. 26.7%, P = 0.0071). Using videolaryngoscopy reduced the clinically unfavourable grading to Cormack and Lehane 1 or 2 (P < 0.0001). The odds of achieving first pass success were approximately 12-fold higher with a favourable glottic view than with an unfavourable glottic view (OR 12.6, CI, 6.70 to 23.65). CONCLUSION Airway management in an anaesthesiologist-staffed HEMS is associated with a high first pass success rate but even with skilled providers using the C-MAC PM videolaryngoscope routinely, patients who require CPR offer more difficulties for successful prehospital advanced airway management at the first attempt. TRIAL REGISTRATION German Clinical trials register (drks.de) DRKS00020484.
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18
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Steel A, Haldane C, Cody D. Impact of videolaryngoscopy introduction into prehospital emergency medicine practice: a quality improvement project. Emerg Med J 2021; 38:549-555. [PMID: 33589515 DOI: 10.1136/emermed-2020-209944] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 01/10/2021] [Accepted: 01/12/2021] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Advanced airway management is necessary in the prehospital environment and difficult airways occur more commonly in this setting. Failed intubation is closely associated with the most devastating complications of airway management. In an attempt to improve the safety and success of tracheal intubation, we implemented videolaryngoscopy (VL) as our first-line device for tracheal intubation within a UK prehospital emergency medicine (PHEM) setting. METHODS An East of England physician-paramedic PHEM team adopted VL as first line for undertaking all prehospital advanced airway management. The study period was 2016-2020. Statistical process control charts were used to assess whether use of VL altered first-pass intubation success, frequency of intubation-related hypoxia and laryngeal inlet views. A survey was used to collect the team's views of VL introduction. RESULTS 919 patients underwent advanced airway management during the study period. The introduction of VL did not improve first-pass intubation success, view of laryngeal inlet or intubation-associated hypoxia. VL improved situational awareness and opportunities for training but performed poorly in some environments. CONCLUSION Despite the lack of objective improvement in care, subjective improvements meant that overall PHEM clinicians wanted to retain VL within their practice.
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Affiliation(s)
- Alistair Steel
- Magpas Air Ambulance, Huntingdon, Cambridgeshire, UK .,Department of Anaesthesia, Queen Elizabeth Hospital NHS Foundation Trust, King's Lynn, UK
| | - Charlotte Haldane
- Magpas Air Ambulance, Huntingdon, Cambridgeshire, UK.,North West Air Ambulance, Knowsley, UK
| | - Dan Cody
- Magpas Air Ambulance, Huntingdon, Cambridgeshire, UK.,South East Coast Ambulance Service NHS Foundation Trust, Crawley, UK
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19
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Latimer AJ, Harrington B, Counts CR, Ruark K, Maynard C, Watase T, Sayre MR. Routine Use of a Bougie Improves First-Attempt Intubation Success in the Out-of-Hospital Setting. Ann Emerg Med 2020; 77:296-304. [PMID: 33342596 DOI: 10.1016/j.annemergmed.2020.10.016] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 09/28/2020] [Accepted: 10/05/2020] [Indexed: 11/25/2022]
Abstract
STUDY OBJECTIVE The bougie is typically treated as a rescue device for difficult airways. We evaluate whether first-attempt success rate during paramedic intubation in the out-of-hospital setting changed with routine use of a bougie. METHODS A prospective, observational, pre-post study design was used to compare first-attempt success rate during out-of-hospital intubation with direct laryngoscopy for patients intubated 18 months before and 18 months after a protocol change that directed the use of the bougie on the first intubation attempt. We included all patients with a paramedic-performed intubation attempt. Logistic regression was used to examine the association between routine bougie use and first-attempt success rate. RESULTS Paramedics attempted intubation in 823 patients during the control period and 771 during the bougie period. The first-attempt success rate increased from 70% to 77% (difference 7.0% [95% confidence interval 3% to 11%]). Higher first-attempt success rate was observed during the bougie period across Cormack-Lehane grades, with rates of 91%, 60%, 27%, and 6% for Cormack-Lehane grade 1, 2, 3, and 4 views, respectively, during the control period and 96%, 85%, 50%, and 14%, respectively, during the bougie period. Intubation during the bougie period was independently associated with higher first-attempt success rate (adjusted odds ratio 2.82 [95% confidence interval 1.96 to 4.01]). CONCLUSION Routine out-of-hospital use of the bougie during direct laryngoscopy was associated with increased first-attempt intubation success rate.
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Affiliation(s)
- Andrew J Latimer
- Department of Emergency Medicine, University of Washington, Seattle, WA; Seattle Fire Department, Seattle, WA.
| | - Brenna Harrington
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Catherine R Counts
- Department of Emergency Medicine, University of Washington, Seattle, WA; Seattle Fire Department, Seattle, WA
| | - Katelyn Ruark
- University of North Dakota College of Medicine, Grand Forks, ND
| | - Charles Maynard
- Department of Health Services, University of Washington, Seattle, WA
| | - Taketo Watase
- Department of Emergency Medicine, University of Washington, Seattle, WA
| | - Michael R Sayre
- Department of Emergency Medicine, University of Washington, Seattle, WA; Seattle Fire Department, Seattle, WA
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20
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Gandhi A, Sokhi J, Lockie C, Ward PA. Emergency Tracheal Intubation in Patients with COVID-19: Experience from a UK Centre. Anesthesiol Res Pract 2020; 2020:8816729. [PMID: 33376486 PMCID: PMC7729388 DOI: 10.1155/2020/8816729] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 11/06/2020] [Accepted: 11/23/2020] [Indexed: 12/15/2022] Open
Abstract
This retrospective observational case series describes a single centre's preparations and experience of 53 emergency tracheal intubations in patients with COVID-19 respiratory failure. The findings of a contemporaneous online survey exploring technical and nontechnical aspects of airway management, completed by intubation team members, are also presented. Preparations included developing a COVID-19 intubation standard operating procedure and checklist, dedicated airway trolleys, a consultant-led mobile intubation team, and an airway education programme. Tracheal intubation was successful in all patients. Intubation first-pass success rate was 85%, first-line videolaryngoscopy use 79%, oxygen desaturation 49%, and hypotension 21%. Performance was consistent across all clinical areas. The main factor impeding first-pass success was larger diameter tracheal tubes. The majority of intubations was performed by consultant anaesthetists. Nonconsultant intubations demonstrated higher oxygen desaturation rates (75% vs. 45%, p=0.610) and lower first-pass success (0% vs. 92%, p < 0.001). Survey respondents (n = 29) reported increased anxiety at the start of the pandemic, with statistically significant reduction as the pandemic progressed (median: 4/5 very high vs. 2/5 low anxiety, p < 0.001). Reported procedural/environmental challenges included performing tasks in personal protective equipment (62%), remote-site working (48%), and modification of normal practices (41%)-specifically, the use of larger diameter tracheal tubes (21%). Hypoxaemia was identified by 90% of respondents as the most challenging patient-related factor during intubations. Our findings demonstrate that a consultant-led mobile intubation team can safely perform tracheal intubation in critically ill COVID-19 patients across all clinical areas, aided by thorough preparation and training, despite heightened anxiety levels.
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Affiliation(s)
- Ajay Gandhi
- Chelsea and Westminster Hospital, London, UK
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21
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McHenry AS, Curtis L, Ter Avest E, Russell MQ, Halls AV, Mitchinson S, Griggs JE, Lyon RM. Feasibility of Prehospital Rapid Sequence Intubation in the Cabin of an AW169 Helicopter. Air Med J 2020; 39:468-472. [PMID: 33228896 DOI: 10.1016/j.amj.2020.08.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 08/14/2020] [Accepted: 08/20/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Prehospital rapid sequence intubation (RSI) is an important aspect of prehospital care for helicopter emergency medical services (HEMS). This study examines the feasibility of in-aircraft (aircraft on the ground) RSI in different simulated settings. METHODS Using an AW169 aircraft cabin simulator at Air Ambulance Kent Surrey Sussex, 3 clinical scenarios were devised. All required RSI in a "can intubate, can ventilate" (easy variant) and a "can't intubate, can't ventilate" scenario (difficult variant). Doctor-paramedic HEMS teams were video recorded, and elapsed times for prespecified end points were analyzed. RESULTS Endotracheal intubation (ETI) was achieved fastest outside the simulator for the easy variant (median = 231 seconds, interquartile range = 28 seconds). Time to ETI was not significantly longer for in-aircraft RSI compared with RSI outside the aircraft, both in the easy (p = .14) and difficult variant (p = .50). Wearing helmets with noise distraction did not impact the time to intubation when compared with standard in-aircraft RSI, both in the easy (p = .28) and difficult variant (p = .24). CONCLUSION In-aircraft, on-the-ground RSI had no significant impact on the time to successful completion of ETI. Future studies should prospectively examine in-cabin RSI and explore the possibilities of in-flight RSI in civilian HEMS services.
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Affiliation(s)
| | - Leigh Curtis
- Air Ambulance Kent Surrey Sussex, Redhill, Surrey, UK
| | - E Ter Avest
- Air Ambulance Kent Surrey Sussex, Redhill, Surrey, UK; Department of Emergency Medicine, University Medical Center Groningen, Groningen, The Netherlands
| | | | - Amy V Halls
- University of Southampton, Chilworth, Southampton, UK
| | | | | | - Richard M Lyon
- Air Ambulance Kent Surrey Sussex, Redhill, Surrey, UK; University of Surrey, Guildford, UK
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22
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Park CY, Kim OH, Chang SW, Choi KK, Lee KH, Kim SY, Kim M, Lee GJ. Part 3. Clinical Practice Guideline for Airway Management and Emergency Thoracotomy for Trauma Patients from the Korean Society of Traumatology. JOURNAL OF TRAUMA AND INJURY 2020. [DOI: 10.20408/jti.2020.0050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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23
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Maeyama H, Naito H, Guyette FX, Yorifuji T, Banshotani Y, Matsui D, Yumoto T, Nakao A, Kobayashi M. Intubation during a medevac flight: safety and effect on total prehospital time in the helicopter emergency medical service system. Scand J Trauma Resusc Emerg Med 2020; 28:89. [PMID: 32894186 PMCID: PMC7487559 DOI: 10.1186/s13049-020-00784-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 09/01/2020] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION The Helicopter Emergency Medical Service (HEMS) commonly intubates patients who require advanced airway support prior to takeoff. In-flight intubation (IFI) is avoided because it is considered difficult due to limited space, difficulty communicating, and vibration in flight. However, IFI may shorten the total prehospital time. We tested whether IFI can be performed safely by the HEMS. METHODS We conducted a retrospective cohort study in adult patients transported from 2010 to 2017 who received prehospital, non-emergent intubation from a single HEMS. We divided the cohort in two groups, patients intubated during flight (flight group, FG) and patients intubated before takeoff (ground group, GG). The primary outcome was the proportion of successful intubations. Secondary outcomes included total prehospital time and the incidence of complications. RESULTS We analyzed 376 patients transported during the study period, 192 patients in the FG and 184 patients in the GG. The intubation success rate did not differ between the two groups (FG 189/192 [98.4%] vs. GG 179/184 [97.3%], p = 0.50). There were also no differences in hypoxia (FG 4/117 [3.4%] vs. GG 4/95 [4.2%], p = 1.00) or hypotension (FG 6/117 [5.1%] vs. GG 5/95 [5.3%], p = 1.00) between the two groups. Scene time and total prehospital time were shorter in the FG (scene time 7 min vs. 14 min, p < 0.001; total prehospital time 33.5 min vs. 40.0 min, p < 0.001). CONCLUSIONS IFI was safely performed with high success rates, similar to intubation on the ground, without increasing the risk of hypoxia or hypotension. IFI by experienced providers shortened transportation time, which may improve patient outcomes.
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Affiliation(s)
- Hiroki Maeyama
- Department of Emergency, Critical Care, and Disaster Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata, Okayama, 700-8558, Japan.,Department of Emergency and Critical Care Medicine, Tsuyama Chuo Hospital, Tsuyama, Japan
| | - Hiromichi Naito
- Department of Emergency, Critical Care, and Disaster Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata, Okayama, 700-8558, Japan.
| | - Francis X Guyette
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Takashi Yorifuji
- Department of Epidemiology, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Yuki Banshotani
- Tajima Emergency and Critical Care Medical Center, Toyooka Public Hospital, Toyooka, Japan
| | - Daisaku Matsui
- Tajima Emergency and Critical Care Medical Center, Toyooka Public Hospital, Toyooka, Japan
| | - Tetsuya Yumoto
- Department of Emergency, Critical Care, and Disaster Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata, Okayama, 700-8558, Japan
| | - Atsunori Nakao
- Department of Emergency, Critical Care, and Disaster Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata, Okayama, 700-8558, Japan
| | - Makoto Kobayashi
- Tajima Emergency and Critical Care Medical Center, Toyooka Public Hospital, Toyooka, Japan
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Yi IK, Kwak HJ, Lee KC, Lee JH, Min SK, Kim JY. Comparison of McGrath, Pentax, and Macintosh laryngoscope in normal and cervical immobilized manikin by novices: a randomized crossover trial. Eur J Med Res 2020; 25:35. [PMID: 32819444 PMCID: PMC7441605 DOI: 10.1186/s40001-020-00435-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 08/12/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The aim of this study was to compare tracheal intubation performance regarding the time to intubation, glottic view, difficulty, and dental click, by novices using McGrath videolaryngoscope (VL), Pentax Airway Scope (AWS) and Macintosh laryngoscope in normal and cervical immobilized manikin models. METHODS Thirty-five anesthesia nurses without previous intubation experience were recruited. Participants performed endotracheal intubation in a manikin model at two simulated neck positions (normal and fixed neck via cervical immobilization), using three different devices three times each. Performance parameters included intubation time, success rate of intubation, Cormack Lehane laryngoscope grading, dental click, and subjective difficulty score. RESULTS Intubation time and success rate during first attempt were not significantly different between the 3 groups in normal airway manikin. In the cervical immobilized manikin, the intubation time was shorter (p = 0.012), and the success rate with the first attempt was significantly higher (p < 0.001) when using McGrath VL and Pentax AWS compared with Macintosh laryngoscope. Both VLs showed less difficulty score (p < 0.001) and more Cormack Lehane grade I (p < 0.001) in both scenarios. The incidence of dental clicks was higher with Macintosh laryngoscope compared with McGrath VL in cervical immobilized airway (p < 0.001). CONCLUSIONS McGrath VL and Pentax AWS did not show clinically significant decrease in intubation time, however, they achieved higher first attempt success rate, easier intubation and better glottis view compared with Macintosh laryngoscope by novices in a cervical immobilized manikin model. McGrath VL may reduce the risk of dental injury compared with Macintosh laryngoscope in cervical immobilized scenario. TRIAL REGISTRATION ClinicalTrials.gov (NCT03161730), May 22, 2017 https://clinicaltrials.gov/ct2/hom.
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Affiliation(s)
- In Kyong Yi
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, 164, World cup-ro, Yeongtong-gu, Suwon, 16499, Korea
| | - Hyun Jeong Kwak
- Department of Anesthesiology and Pain Medicine, Gachon University, Gil Medical Center, 24, Namdong-Daero 774beon-gil, Namdong-gu, Incheon, 21565, Korea
| | - Kyung Cheon Lee
- Department of Anesthesiology and Pain Medicine, Gachon University, Gil Medical Center, 24, Namdong-Daero 774beon-gil, Namdong-gu, Incheon, 21565, Korea
| | - Ji Hyea Lee
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, 164, World cup-ro, Yeongtong-gu, Suwon, 16499, Korea
| | - Sang Kee Min
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, 164, World cup-ro, Yeongtong-gu, Suwon, 16499, Korea
| | - Jong Yeop Kim
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, 164, World cup-ro, Yeongtong-gu, Suwon, 16499, Korea.
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Moritz A, Leonhardt V, Prottengeier J, Birkholz T, Schmidt J, Irouschek A. Comparison of Glidescope® Go™, King Vision™, Dahlhausen VL, I‑View™ and Macintosh laryngoscope use during difficult airway management simulation by experienced and inexperienced emergency medical staff: A randomized crossover manikin study. PLoS One 2020; 15:e0236474. [PMID: 32730283 PMCID: PMC7392330 DOI: 10.1371/journal.pone.0236474] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 06/29/2020] [Indexed: 11/18/2022] Open
Abstract
Background In pre-hospital emergency care, video laryngoscopes (VLs) with disposable blades are preferably used due to hygienic reasons. However, there is limited existing data on the use of VLs with disposable blades by emergency medical staff. Therefore, the aim of this study was to compare the efficacy of four different VLs with disposable blades and the conventional standard Macintosh laryngoscope, when used by anesthetists with extensive previous experience and paramedics with little previous experience in endotracheal intubation (ETI) in a simulated difficult airway. Methods Fifty-eight anesthetists and fifty-four paramedics participated in our randomized crossover manikin trial. Each performed ETI with the new Glidescope® Go™, the Dahlhausen VL, the King Vision™, the I-View™ and the Macintosh laryngoscope. “Time to intubate” was the primary endpoint. Secondary endpoints were “time to vocal cords”, “time to ventilate”, overall success rate, number of intubation attempts and optimization maneuvers, Cormack-Lehane score, severity of dental compression and subjective impressions. Results The Glidescope® Go™, the Dahlhausen VL and the King Vision™ provided superior intubation conditions in both groups without affecting the number of intubation attempts or the time required for successful intubation. When used by anesthetists with extensive experience in ETI, the use of VLs did not affect the overall success rate. In the hands of paramedics with little previous experience in ETI, the failure rate with the Macintosh laryngoscope (14.8%) decreased to 3.7% using the Glidescope® Go™ and the Dahlhausen VL. Despite the advantages of hyperangulated video laryngoscopes, the I-View™ performed worst. Conclusions VLs with hyperangulated blades facilitated ETI in both groups and decreased the failure rate by an absolute 11.1% when used by paramedics with little previous experience in ETI. Our results therefore suggest that hyperangulated VLs could be beneficial and might be the method of choice in comparable settings, especially for emergency medical staff with less experience in ETI.
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Affiliation(s)
- Andreas Moritz
- Department of Anesthesiology, University Hospital Erlangen, Faculty of Medicine, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany
- * E-mail:
| | - Veronika Leonhardt
- Department of Anesthesiology, University Hospital Erlangen, Faculty of Medicine, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Johannes Prottengeier
- Department of Anesthesiology, University Hospital Erlangen, Faculty of Medicine, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Torsten Birkholz
- Department of Anesthesiology, University Hospital Erlangen, Faculty of Medicine, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Joachim Schmidt
- Department of Anesthesiology, University Hospital Erlangen, Faculty of Medicine, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Andrea Irouschek
- Department of Anesthesiology, University Hospital Erlangen, Faculty of Medicine, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany
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Hudson IL, Blackburn MB, Staudt AM, Ryan KL, Mann-Salinas EA. Analysis of Casualties That Underwent Airway Management Before Reaching Role 2 Facilities in the Afghanistan Conflict 2008-2014. Mil Med 2020; 185:10-18. [PMID: 32074383 DOI: 10.1093/milmed/usz383] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION Airway compromise is the second leading cause of potentially survivable death on the battlefield. The purpose of this study was to better understand wartime prehospital airway patients. MATERIALS AND METHODS The Role 2 Database (R2D) was retrospectively reviewed for adult patients injured in Afghanistan between February 2008 and September 2014. Of primary interest were prehospital airway interventions and mortality. Prehospital combat mortality index (CMI-PH), hemodynamic interventions, injury mechanism, and demographic data were also included in various statistical analyses. RESULTS A total of 12,780 trauma patients were recorded in the R2D of whom 890 (7.0%) received prehospital airway intervention. Airway intervention was more common in patients who ultimately died (25.3% vs. 5.6%); however, no statistical association was found in a multivariable logistic regression model (OR 1.28, 95% CI 0.98-1.68). Compared with U.S. military personnel, other military patients were more likely to receive airway intervention after adjusting for CMI-PH (OR 1.33, 95% CI 1.07-1.64). CONCLUSIONS In the R2D, airway intervention was associated with increased odds of mortality, although this was not statistically significant. Other patients had higher odds of undergoing an airway intervention than U.S. military. Awareness of these findings will facilitate training and equipment for future management of prehospital/prolonged field care airway interventions.
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Affiliation(s)
- Ian L Hudson
- US Army Institute of Surgical Research is United States of America (USA), 3698 Chambers Pass, San Antonio TX 78234, USA
| | - Megan B Blackburn
- US Army Institute of Surgical Research is United States of America (USA), 3698 Chambers Pass, San Antonio TX 78234, USA
| | - Amanda M Staudt
- US Army Institute of Surgical Research is United States of America (USA), 3698 Chambers Pass, San Antonio TX 78234, USA
| | - Kathy L Ryan
- US Army Institute of Surgical Research is United States of America (USA), 3698 Chambers Pass, San Antonio TX 78234, USA
| | - Elizabeth A Mann-Salinas
- US Army Institute of Surgical Research is United States of America (USA), 3698 Chambers Pass, San Antonio TX 78234, USA
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Yamauchi S, Tagore A, Ariyaprakai N, Geranio JV, Merlin MA. Out-of-Hospital Intubation and Bronchoscopy Using a New Disposable Device: The Initial Case. PREHOSP EMERG CARE 2019; 24:857-861. [PMID: 31825700 DOI: 10.1080/10903127.2019.1701156] [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] [Indexed: 10/25/2022]
Abstract
Airway management is one of the critically important skills in practicing emergency medicine. However, intubation in the prehospital setting is quite different from those done in controlled environment and still poses significant risks for serious complications. Although checking for clinical findings and end-tidal carbon dioxide detection system (ETCO2) are well-established and widely adopted way to verify ETT placement in the prehospital setting, there are certain situations that the use of these methods could be unreliable. The use of advanced flexible bronchoscopy technology allows us to directly visualize the tube placement and can also assist difficult intubation. Studies have shown that the verification of tube placement utilizing bronchoscopy is an easy and highly reliable methods and this is especially beneficial in the prehospital settings. Although the use of bronchoscopy in prehospital setting currently is somehow limited, this new, rapidly advancing technology and technique is believed to be a game changer in our prehospital intubation/post-intubation practice in the near future.
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Impact of Suction-Assisted Laryngoscopy and Airway Decontamination Technique on Intubation Quality Metrics in a Helicopter Emergency Medical Service: An Educational Intervention. Air Med J 2019; 39:107-110. [PMID: 32197686 DOI: 10.1016/j.amj.2019.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 10/14/2019] [Accepted: 10/16/2019] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Suction-assisted laryngoscopy and airway decontamination (SALAD) was created to assist with the decontamination of a massively soiled airway. This study aims to investigate the usefulness of SALAD training to prehospital emergency providers to improve their ability to intubate a massively contaminated airway. METHODS This was a prospective study conducted as a before and after teaching intervention. Participants were made up of prehospital providers who were present at regularly scheduled training sessions and were asked to intubate a high-fidelity mannequin simulating large-volume emesis before and after SALAD instruction. They were subsequently tested on 3-month skill retention. Twenty subjects participated in all stages of the study and were included in the analysis. RESULTS The median time to successful intubation for all study participants before instruction was 60.5 seconds (interquartile range [IQR] = 44.0-84.0); post-training was 43.0 seconds (IQR = 38.0-57.5); and at the 3-month follow-up, it was 29.5 seconds (IQR = 24.5-39.0). The greatest improvement was seen on subgroup analysis of the slowest 50th percentile where the median time before instruction was 84.0 seconds (IQR = 68.0-96.0); post-instruction was 41.5 seconds (IQR = 36.0-65.0); and at the 3-month follow-up, it was 29.5 seconds (IQR = 25.0-39.0). CONCLUSION The implementation of the SALAD technique through a structured educational intervention improved time to intubation and the total number of attempts.
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Powell EK, Hinckley WR, Stolz U, Golden AJ, Ventura A, McMullan JT. Predictors of Definitive Airway Sans Hypoxia/Hypotension on First Attempt (DASH-1A) Success in Traumatically Injured Patients Undergoing Prehospital Intubation. PREHOSP EMERG CARE 2019; 24:470-477. [DOI: 10.1080/10903127.2019.1670299] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Elizabeth K. Powell
- Received October 7, 2018 from Department of Anesthesiology, University of Cincinnati, Cincinnati, Ohio (EKP); Department of Emergency Medicine, University of Cincinnati, Cincinnati,Ohio (WRH, US, AJG, AV, JTM). Revision received September 9, 2019; accepted for publication September 17, 2019
| | - William R. Hinckley
- Received October 7, 2018 from Department of Anesthesiology, University of Cincinnati, Cincinnati, Ohio (EKP); Department of Emergency Medicine, University of Cincinnati, Cincinnati,Ohio (WRH, US, AJG, AV, JTM). Revision received September 9, 2019; accepted for publication September 17, 2019
| | - Uwe Stolz
- Received October 7, 2018 from Department of Anesthesiology, University of Cincinnati, Cincinnati, Ohio (EKP); Department of Emergency Medicine, University of Cincinnati, Cincinnati,Ohio (WRH, US, AJG, AV, JTM). Revision received September 9, 2019; accepted for publication September 17, 2019
| | - Andrew J. Golden
- Received October 7, 2018 from Department of Anesthesiology, University of Cincinnati, Cincinnati, Ohio (EKP); Department of Emergency Medicine, University of Cincinnati, Cincinnati,Ohio (WRH, US, AJG, AV, JTM). Revision received September 9, 2019; accepted for publication September 17, 2019
| | - Amanda Ventura
- Received October 7, 2018 from Department of Anesthesiology, University of Cincinnati, Cincinnati, Ohio (EKP); Department of Emergency Medicine, University of Cincinnati, Cincinnati,Ohio (WRH, US, AJG, AV, JTM). Revision received September 9, 2019; accepted for publication September 17, 2019
| | - Jason T. McMullan
- Received October 7, 2018 from Department of Anesthesiology, University of Cincinnati, Cincinnati, Ohio (EKP); Department of Emergency Medicine, University of Cincinnati, Cincinnati,Ohio (WRH, US, AJG, AV, JTM). Revision received September 9, 2019; accepted for publication September 17, 2019
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Maignan M, Viglino D, Collomb Muret R, Vejux N, Wiel E, Jacquin L, Laribi S, N-Gueye P, Joly LM, Dumas F, Beaune S. Intensity of care delivered by prehospital emergency medical service physicians to patients with deliberate self-poisoning: results from a 2-day cross-sectional study in France. Intern Emerg Med 2019; 14:981-988. [PMID: 31104303 DOI: 10.1007/s11739-019-02108-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 05/08/2019] [Indexed: 10/26/2022]
Abstract
Emergency management of deliberate self-poisoning (DSP) by drug overdose is common in emergency medicine. There is a paucity of data about the prehospital care of these patients. The principal aim was to describe the intensity of care received by patients with DSP who were managed by prehospital emergency medical service (EMS) physicians. A 48-h cross-sectional study was conducted in 319 EMS and emergency units in France. Patient and poisoning characteristics and treatments administered were recorded. Complications of poisoning, hospitalization, intensive care unit admission and death were recorded until day 30. The primary endpoint was the probability of receiving prehospital intensive care, including fluid resuscitation, vasopressor therapy, invasive ventilation, or antidotal treatments, depending whether prehospital treatment was carried out by an EMS physician or not. Data from 703 patients (median age was 43 [30-52] years, 288 (40%) men) were analyzed. One hundred and fifteen (16%) patients were attended by an EMS physician. Patients attended by EMS physicians were more likely to receive intensive treatment in the prehospital setting [odds ratio (OR) 7.4, 95% confidence interval 4.3-12.9]. These patients had more severe poisoning as suggested mainly by a lower Glasgow Coma Score (13 [8-15] vs. 15 [15-15]; p < 0.001) and a higher rate of admission to an intensive care unit [29 (25%) vs. 15 (2%), p < 0.001]. Patients with DSP attended by prehospital EMS physicians frequently received intensive care. The level of care seemed appropriate for the severity of the poisoning.
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Affiliation(s)
- Maxime Maignan
- Emergency Department, CHU Grenoble Alpes University Hospital, HP2 INSERM U1042, CS 10217, 38043, Grenoble cedex 9, France.
| | - Damien Viglino
- Emergency Department, CHU Grenoble Alpes University Hospital, HP2 INSERM U1042, CS 10217, 38043, Grenoble cedex 9, France
| | - Roselyne Collomb Muret
- Emergency Department, CHU Grenoble Alpes University Hospital, HP2 INSERM U1042, CS 10217, 38043, Grenoble cedex 9, France
| | - Nathan Vejux
- Emergency Department, CHU Grenoble Alpes University Hospital, HP2 INSERM U1042, CS 10217, 38043, Grenoble cedex 9, France
| | - Eric Wiel
- Emergency Department and SAMU 59, Lille University Hospital, Inserm UMR1011 and UDSL, Institut Pasteur de Lille, EGID, Lille, France
| | - Laurent Jacquin
- Emergency Department, Hospices Civiles de Lyon, Lyon, France
| | - Said Laribi
- Emergency Department, Tours University Hospital, 37044, Tours, France
- INSERM, U942, BIOmarkers in CArdioNeuroVAScular Diseases, Paris, France
| | - Papa N-Gueye
- Emergency Department, APHP Hôpital Lariboisière, Paris, France
| | - Luc-Marie Joly
- Emergency Department, Charles Nicolle Hospital, Rouen, France
| | - Florence Dumas
- Emergency Department, APHP Hôpital Cochin, Sudden Death Expertise Center, Paris Cardiovascular Research Center, INSERM Unit 970, Paris, France
| | - Sebastien Beaune
- Department of Emergency Medicine, Ambroise Paré Hospital, APHP, University Paris Diderot, INSERM UMR-S 1144, Paris, France
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Cavus E, Janssen S, Reifferscheid F, Caliebe A, Callies A, von der Heyden M, Knacke PG, Doerges V. Videolaryngoscopy for Physician-Based, Prehospital Emergency Intubation: A Prospective, Randomized, Multicenter Comparison of Different Blade Types Using A.P. Advance, C-MAC System, and KingVision. Anesth Analg 2019; 126:1565-1574. [PMID: 29239965 DOI: 10.1213/ane.0000000000002735] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Videolaryngoscopy is a valuable technique for endotracheal intubation. When used in the perioperative period, different videolaryngoscopes vary both in terms of technical use and intubation success rates. However, in the prehospital environment, the relative performance of different videolaryngoscopic systems is less well studied. METHODS We conducted this prospective, randomized, multicenter study at 4 German prehospital emergency medicine centers. One hundred sixty-eight adult patients requiring prehospital emergency intubation were treated by an emergency physician and randomized to 1 of 3 portable videolaryngoscopes (A.P. Advance, C-MAC PM, and channeled blade KingVision) with different blade types. The primary outcome variable was overall intubation success and secondary outcomes included first-attempt intubation success, glottis visualization, and difficulty with handling the devices. P values for pairwise comparisons are corrected by the Bonferroni method for 3 tests (P[BF]). All presented P values are adjusted for center. RESULTS Glottis visualization was comparable with all 3 devices. Overall intubation success for A.P. Advance, C-MAC, and KingVision was 96%, 97%, and 61%, respectively (overall: P < .001, A.P. Advance versus C-MAC: odds ratio [OR], 0.97, 95% confidence interval [CI], 0.13-7.42, P[BF] > 0.99; A.P. Advance versus KingVision: OR, 0.043, 95% CI, 0.0088-0.21, P[BF] < 0.001; C-MAC versus KingVision: OR, 0.043, 95% CI, 0.0088-0.21, P[BF] < 0.001). Intubation success on the first attempt with A.P. Advance, C-MAC, and KingVision was 86%, 85%, and 48%, respectively (overall: P < .001, A.P. Advance versus C-MAC: OR, 0.89, 95% CI, 0.31-2.53, P[BF] > 0.99; A.P. Advance versus KingVision: OR, 0.24, 95% CI, 0.055-0.38, P[BF] = 0.0054; C-MAC versus KingVision: OR, 0.21, 95% CI, 0.043-.34, P[BF] < 0.003). Direct laryngoscopy for successful intubation with the videolaryngoscopic device was necessary with the A.P. Advance in 5 patients, and with the C-MAC in 4 patients. In the KingVision group, 21 patients were intubated with an alternative device. CONCLUSIONS During prehospital emergency endotracheal intubation performed by emergency physicians, success rates of 3 commercially available videolaryngoscopes A.P. Advance, C-MAC PM, and KingVision varied markedly. We also found that although any of the videolaryngoscopes provided an adequate view, actual intubation was more difficult with the channeled blade KingVision.
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Affiliation(s)
- Erol Cavus
- From the Faculty of Medicine, Christian-Albrechts-University, Kiel, Germany.,Department of Anesthesiology, Anästhesie-Partner Holstein, MARE Clinics Kiel, Kiel, Germany
| | - Sebastian Janssen
- From the Faculty of Medicine, Christian-Albrechts-University, Kiel, Germany
| | - Florian Reifferscheid
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Amke Caliebe
- Institute of Medical Informatics and Statistics, Kiel University and University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Andreas Callies
- Department of Anesthesiology, Intensive Care Medicine and Emergency Medicine, Hospital Links der Weser, Bremen, Germany
| | - Martin von der Heyden
- Department of Anesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Medicine, Greifswald University Hospital, Greifswald, Germany
| | - Peer G Knacke
- Department of Anesthesiology, Emergency Medicine, Sana Clinics Ostholstein, Hospital Eutin, Eutin, Germany
| | - Volker Doerges
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
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Wylie C, Welzel T, Hodkinson P. Waveform capnography in a South African prehospital service: Knowledge assessment of paramedics. Afr J Emerg Med 2019; 9:96-100. [PMID: 31193774 PMCID: PMC6543069 DOI: 10.1016/j.afjem.2019.01.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 01/14/2019] [Indexed: 11/24/2022] Open
Abstract
Background Waveform capnography has proven to be of great value in the provision of safe patient care especially in the intubated patient. Although seldom available, or used in African contexts, capnography has become standard practice in well-resourced out-of-hospital services for confirmation of intubation, and optimization of resuscitation and ventilation. To date there has been little research into the knowledge of out-of-hospital staff, both local and internationally, utilising capnography. This study describes the knowledge of paramedics who use waveform capnography in the out-of-hospital environment. Methods A cohort of advanced life support qualified paramedics in a private ambulance service in South Africa undertook a web-based survey around their background, training and use of capnography. Participants’ knowledge was assessed by exploring their interpretation of waveform capnography and establishing attitudes pertaining to training and constraints of availability of capnography. Results Seventy eight paramedics responded, and most (91%) indicated they were likely to use capnography when the tool was available. The majority of training in capnography had been during their primary qualification (85%). Most participants indicated that they would like further training (91%). Use of capnography for confirmation of endotracheal tube placement and quality of compressions during cardiopulmonary resuscitation was well understood (correct in 94% and 84% respectively), while more complicated knowledge such as waveform changes during ventilation (66%) and the effect of hypovolaemia (48%) on capnography were lacking. Conclusion Paramedics report using waveform capnography extensively when it is available in the South African out-of-hospital environment. Although the knowledge around capnography and its usage was found to be good in most areas, more complicated scenarios exposed flaws in the knowledge of many paramedics and suggest the need for improved and ongoing training, as well as incorporation into curricula as the field develops across the continent.
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Crewdson K, Fragoso‐Iniguez M, Lockey DJ. Requirement for urgent tracheal intubation after traumatic injury: a retrospective analysis of 11,010 patients in the Trauma Audit Research Network database. Anaesthesia 2019; 74:1158-1164. [DOI: 10.1111/anae.14692] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/04/2019] [Indexed: 11/27/2022]
Affiliation(s)
| | | | - D. J. Lockey
- North Bristol NHS Trust BristolUK
- Blizard Institute for Trauma and Neurosciences Queen Mary University London UK
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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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35
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Root Causes of Preventable Prehospital Deaths in Road Traffic Injuries: A Systematic Review. Trauma Mon 2019. [DOI: 10.5812/traumamon.88412] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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What is the impact of physicians in prehospital treatment for patients in need of acute critical care? - An overview of reviews. Int J Technol Assess Health Care 2019; 35:27-35. [PMID: 30722802 DOI: 10.1017/s0266462318003616] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVES The aim of this overview was to systematically identify and synthesize existing evidence from systematic reviews on the impact of prehospital physician involvement. METHODS The Medline, Embase, and Cochrane library were searched from 1 January 2000 to 17 November 2017. We included systematic reviews comparing physician-based with non-physician-based prehospital treatment in patients with one of five critical conditions requiring a rapid response. RESULTS Ten reviews published from 2009 to 2017 were included. Physician treatment was associated with increased survival in patients with out-of-hospital cardiac arrest and patients with severe trauma; in the latter group, the result was based on more limited evidence. The success rate of prehospital endotracheal intubation (ETI) has improved over the years, but ETI by physicians is still associated with higher success rates than intubation by paramedics. In patients with severe traumatic brain injury, intubation by paramedics who were not well skilled to do so markedly increased mortality. CONCLUSIONS Current evidence is hinting at a benefit of physicians in selected aspects of prehospital emergency services, including treatment of patients with out-of-hospital cardiac arrest and critically ill or injured patients in need of prehospital intubation. Evidence is, however, limited by confounding and bias, and comparison is hampered by differences in case mix and the organization of emergency medical services. Future research should strive to design studies that enable appropriate control of baseline confounding and obtain follow-up data for the proportion of patients who die in the prehospital setting.
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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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Impact of Paralytic Agent on Postintubation Sedation. Air Med J 2018; 38:39-44. [PMID: 30711084 DOI: 10.1016/j.amj.2018.09.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 08/02/2018] [Accepted: 09/22/2018] [Indexed: 12/20/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the difference in the time to postintubation sedation between patients receiving etomidate and either succinylcholine or rocuronium in the prehospital setting. SETTING Patients who received rapid sequence intubation medications from transport service personnel and were subsequently intubated were included. The critical care transport agency operates 8 helicopter- and 3 ground-based emergency medical service units. METHODS This retrospective cohort study compared the time to the first sedative in patients intubated with etomidate and succinylcholine versus etomidate and rocuronium. Enrollment of 64 patients per arm was needed to achieve 80% power with a 2-tailed alpha of 0.05. RESULTS Sixty-four and 38 patients received succinylcholine or rocuronium, respectively. The median time to postetomidate sedation was 10 (range, 5.0-16.0) and 13.5 (range, 7.0-20.8) minutes for succinylcholine and rocuronium patients, respectively (P = .13). Given the average duration of effect of etomidate, succinylcholine, and rocuronium, 0 (0%) succinylcholine versus 33 (86.8%) rocuronium patients were found to be at risk of wakeful paralysis. CONCLUSIONS This study suggests rocuronium's long duration of effect puts patients at risk for wakeful paralysis once the short effects of etomidate have subsided.
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Sørskår LIK, Abrahamsen EB, Olsen E, Sollid SJM, Abrahamsen HB. Psychometric properties of the Norwegian version of the hospital survey on patient safety culture in a prehospital environment. BMC Health Serv Res 2018; 18:784. [PMID: 30333021 PMCID: PMC6192077 DOI: 10.1186/s12913-018-3576-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Accepted: 09/27/2018] [Indexed: 11/10/2022] Open
Abstract
Background To develop a culture of patient safety in a regime that strongly focuses on saving patients from emergencies may seem counter-intuitive and challenging. Little research exists on patient safety culture in the context of Emergency Medical Services (EMS), and the use of survey tools represents an appropriate approach to improve patient safety. Research indicates that safety climate studies may predict safety behavior and safety-related outcomes. In this study we apply the Norwegian versions of Hospital Survey on Patient Safety Culture (HSOPSC) and assess the psychometric properties when tested on a national sample from the EMS. Methods This study adopted a web based survey design. The Norwegian HSOPSC has 13 dimensions, consisting of 46 items, in addition to two single-item outcome variables. SPSS (version 21) was used for descriptive data analysis, estimating internal consistency, and performing exploratory factor analysis. Confirmatory factor analysis (CFA) was applied to test the dimensional structure of the instruments using Amos (version 21). Results N = 1387 (27%) EMS employees participated in the survey. Overall, acceptable psychometric properties were observed, i.e. acceptable internal consistencies and construct validity. The patient safety climate dimensions with highest scores (number of positive answers) were “teamwork within units” and “manager expectations & actions promoting patient safety”. The dimension “hospital management support for patient safety” had the lowest score. Conclusions The results provided a validated instrument, the Prehospital Survey on Patient Safety Culture (PreHSOPSC), for measuring patient safety climate in an EMS setting. In addition, the explanatory power was strong for several of the outcome dimensions; i.e., several of the safety climate dimensions have a strong predictive effect on outcome variables related to employees’ perceptions on patient safety and safety-related attitude. Electronic supplementary material The online version of this article (10.1186/s12913-018-3576-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Leif Inge K Sørskår
- Institute for Safety, Economics and Planning, University of Stavanger, Kjølv Egelands hus, Kristine Bonnevies vei 22, 4021, Stavanger, Norway.
| | - Eirik B Abrahamsen
- Institute for Safety, Economics and Planning, University of Stavanger, Kjølv Egelands hus, Kristine Bonnevies vei 22, 4021, Stavanger, Norway
| | - Espen Olsen
- Centre for Resilience in Healthcare, Faculty of Health Sciences, University of Stavanger, Kjell Arholms hus, Kjell Arholms gate 39, 4021, Stavanger, Norway
| | - Stephen J M Sollid
- Faculty of Health Sciences, University of Stavanger, Norway & Prehospital Clinic, Stavanger University Hospital, Stavanger, Norway
| | - Håkon B Abrahamsen
- Institute for Safety, Economics and Planning, University of Stavanger, Kjølv Egelands hus, Kristine Bonnevies vei 22, 4021, Stavanger, Norway.,Department of Anesthesiology and Intensive Care, Stavanger University Hospital, Stavanger, Norway
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Louka A, Stevenson C, Jones G, Ferguson J. Intubation Success after Introduction of a Quality Assurance Program Using Video Laryngoscopy. Air Med J 2018; 37:303-305. [PMID: 30322632 DOI: 10.1016/j.amj.2018.05.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 05/07/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE The deployment of video laryngoscopy devices that include recording capability presents a new and unique opportunity for medical directors to review prehospital patient encounters. We sought to evaluate the effect of introducing a video laryngoscope and video quality assurance program to an air medical program on measures of intubation success including overall success, first-pass success, success within 2 attempts, and the total number of attempts. METHODS This was a retrospective review of data collected on intubations by nurses and paramedics of the Virginia State Police Med-Flight 1 air medical program. RESULTS After introduction of the video laryngoscope and quality assurance program, the overall intubation success improved to 100% but did not reach statistical significance (95% confidence interval [CI], -4.40 to 12.57; P = .25). First-pass success improved from 76.19% to 92.86% (CI, 1.14-33.14; P = .02), whereas the average attempts declined from 1.31 to 1.09 per patient encounter (CI, -.41 to -.03; P = .02). Success within 2 attempts was 92.86% before the intervention and 98.21% after (CI, 4.25-17.82; P = .19). CONCLUSION Video laryngoscopy and a robust means for medical director oversight are important components of a high-performance airway management program and demonstrably improve intubation first-pass success.
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Affiliation(s)
- Amir Louka
- VCU Health, Department of Emergency Medicine, Richmond, VA.
| | | | - Gregory Jones
- VCU Health, Department of Emergency Medicine, Richmond, VA
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Fukuda T, Ohashi-Fukuda N, Kondo Y, Hayashida K, Kukita I. Association of Prehospital Advanced Life Support by Physician With Survival After Out-of-Hospital Cardiac Arrest With Blunt Trauma Following Traffic Collisions: Japanese Registry-Based Study. JAMA Surg 2018; 153:e180674. [PMID: 29710068 DOI: 10.1001/jamasurg.2018.0674] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Importance Controversy remains as to whether advanced life support (ALS) or basic life support (BLS) is superior for critically ill and injured patients, including out-of-hospital cardiac arrest (OHCA) and major trauma, in the prehospital setting. Objective To assess whether prehospital ALS should be provided for traumatic OHCA and who should perform it. Design, Setting, and Participants Japanese government-managed nationwide population-based registry data of patients with OHCA transported to an emergency hospital were analyzed. Patients who experienced traumatic OHCA following a traffic collision from 2013 to 2014 were included. Patients provided prehospital ALS by a physician were compared with both patients provided ALS by emergency medical service (EMS) personnel and patients with only BLS. The data were analyzed on May 1, 2017. Exposures Advanced life support by physician, ALS by EMS personnel, or BLS only. Main Outcomes and Measures The primary outcome was 1-month survival. The secondary outcomes were prehospital return of spontaneous circulation and favorable neurologic outcomes with the Glasgow-Pittsburgh cerebral performance category score of 1 or 2. Results A total of 4382 patients were included (mean [SD] age, 57.5 [22.2] years; 67.9% male); 828 (18.9%) received prehospital ALS by physician, 1591 (36.3%) received prehospital ALS by EMS personnel, and 1963 (44.8%) received BLS only. Among these patients, 96 (2.2%) survived 1 month after OHCA, including 26 of 828 (3.1%) for ALS by physician, 25 of 1591 (1.6%) for ALS by EMS personnel, and 45 of 1963 (2.3%) for BLS. After adjusting for potential confounders using multivariable logistic regression, ALS by physician was significantly associated with higher odds for 1-month survival compared with both ALS by EMS personnel and BLS (adjusted OR, 2.13; 95% CI, 1.20-3.78; and adjusted OR, 1.94; 95% CI, 1.14-3.25; respectively), whereas there was no significant difference between ALS by EMS personnel and BLS (adjusted OR, 0.91; 95% CI, 0.54-1.51). A propensity score-matched analysis in the ALS cohort showed that ALS by physician was associated with increased chance of 1-month survival compared with ALS by EMS personnel (risk ratio, 2.00; 95% CI, 1.01-3.97; P = .04). This association was consistent across a variety of sensitivity analyses. Conclusions and Relevance In traumatic OHCA, ALS by physician was associated with increased chance of 1-month survival compared with both ALS by EMS personnel and BLS.
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Affiliation(s)
- Tatsuma Fukuda
- Department of Emergency and Critical Care Medicine, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan.,Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Naoko Ohashi-Fukuda
- Department of Emergency and Critical Care Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yutaka Kondo
- Department of Emergency and Critical Care Medicine, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan.,Division of Acute Care Surgery, Trauma, and Surgical Critical Care, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Kei Hayashida
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo, Japan.,Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ichiro Kukita
- Department of Emergency and Critical Care Medicine, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
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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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Lockey DJ, Crewdson K. Pre-hospital anaesthesia: no longer the 'poor relative' of high quality in-hospital emergency airway management. Br J Anaesth 2018; 120:898-901. [PMID: 29661406 DOI: 10.1016/j.bja.2018.01.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Accepted: 01/29/2018] [Indexed: 02/06/2023] Open
Affiliation(s)
- D J Lockey
- London's Air Ambulance, Bartshealth NHS Trust, London, UK; North Bristol NHS Trust, Bristol, UK.
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Alter SM, Haim ED, Sullivan AH, Clayton LM. Intubation of prehospital patients with curved laryngoscope blade is more successful than with straight blade. Am J Emerg Med 2018; 36:1807-1809. [PMID: 29463438 DOI: 10.1016/j.ajem.2018.01.100] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2017] [Revised: 01/30/2018] [Accepted: 01/30/2018] [Indexed: 10/18/2022] Open
Abstract
OBJECTIVE Direct laryngoscopy can be performed using curved or straight blades, and providers usually choose the blade they are most comfortable with. However, curved blades are anecdotally thought of as easier to use than straight blades. We seek to compare intubation success rates of paramedics using curved versus straight blades. METHODS Design: retrospective chart review. SETTING hospital-based suburban ALS service with 20,000 annual calls. SUBJECTS prehospital patients with any direct laryngoscopy intubation attempt over almost 9years. First attempt and overall success rates were calculated for attempts with curved and straight blades. Differences between the groups were calculated. RESULTS 2299 patients were intubated by direct laryngoscopy. 1865 had attempts with a curved blade, 367 had attempts with a straight blade, and 67 had attempts with both. Baseline characteristics were similar between groups. First attempt success was 86% with a curved blade and 73% with a straight blade: a difference of 13% (95% CI: 9-17). Overall success was 96% with a curved blade and 81% with a straight blade: a difference of 15% (95% CI: 12-18). There was an average of 1.11 intubation attempts per patient with a curved blade and 1.13 attempts per patient with a straight blade (2% difference, 95% CI: -3-7). CONCLUSIONS Our study found a significant difference in intubation success rates between laryngoscope blade types. Curved blades had higher first attempt and overall success rates when compared to straight blades. Paramedics should consider selecting a curved blade as their tool of choice to potentially improve intubation success.
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Affiliation(s)
- Scott M Alter
- Division of Emergency Medicine, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, USA.
| | - Eithan D Haim
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, USA
| | - Alex H Sullivan
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, USA
| | - Lisa M Clayton
- Division of Emergency Medicine, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, USA
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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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Walker RG, White LJ, Whitmore GN, Esibov A, Levy MK, Cover GC, Edminster JD, Nania JM. Evaluation of Physiologic Alterations during Prehospital Paramedic-Performed Rapid Sequence Intubation. PREHOSP EMERG CARE 2018; 22:300-311. [PMID: 29297718 DOI: 10.1080/10903127.2017.1380095] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Physiologic alterations during rapid sequence intubation (RSI) have been studied in several emergency airway management settings, but few data exist to describe physiologic alterations during prehospital RSI performed by ground-based paramedics. To address this evidence gap and provide guidance for future quality improvement initiatives in our EMS system, we collected electronic monitoring data to evaluate peri-intubation vital signs changes occurring during prehospital RSI. METHODS Electronic patient monitor data files from cases in which paramedic RSI was attempted were prospectively collected over a 15-month study period to supplement the standard EMS patient care documentation. Cases were analyzed to identify peri-intubation changes in oxygen saturation, heart rate, and blood pressure. RESULTS Data from 134 RSI cases were available for analysis. Paramedic-assigned prehospital diagnostic impression categories included neurologic (42%), respiratory (26%), toxicologic (22%), trauma (9%), and cardiac (1%). The overall intubation success rate (95%) and first-attempt success rate (82%) did not differ across diagnostic impression categories. Peri-intubation desaturation (SpO2 decrease to below 90%) occurred in 43% of cases, and 70% of desaturation episodes occurred on first-attempt success. The incidence of desaturation varied among patient categories, with a respiratory diagnostic impression associated with more frequent, more severe, and more prolonged desaturations, as well as a higher incidence of accompanying cardiovascular instability. Bradycardia (HR decrease to below 60 bpm) occurred in 13% of cases, and 60% of bradycardia episodes occurred on first-attempt success. Hypotension (systolic blood pressure decrease to below 90 mmHg) occurred in 7% of cases, and 63% of hypotension episodes occurred on first-attempt success. Peri-intubation cardiac arrest occurred in 2 cases, one of which was on first-attempt success. Only 11% of desaturations and no instances of bradycardia were reflected in the standard EMS patient care documentation. CONCLUSIONS In this study, the majority of peri-intubation physiologic alterations occurred on first-attempt success, highlighting that first-attempt success is an incomplete and potentially deceptive measure of intubation quality. Supplementing the standard patient care documentation with electronic monitoring data can identify unrecognized physiologic instability during prehospital RSI and provide valuable guidance for quality improvement interventions.
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Policy, Practice, and Research Agenda for Emergency Medical Services Oversight: A Systematic Review and Environmental Scan. Prehosp Disaster Med 2018; 33:89-97. [PMID: 29293077 DOI: 10.1017/s1049023x17007129] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Introduction In a 2015 report, the Institute of Medicine (IOM; Washington, DC USA), now the National Academy of Medicine (NAM; Washington, DC USA), stated that the field of Emergency Medical Services (EMS) exhibits signs of fragmentation; an absence of system-wide coordination and planning; and a lack of federal, state, and local accountability. The NAM recommended clarifying what roles the federal government, state governments, and local communities play in the oversight and evaluation of EMS system performance, and how they may better work together to improve care. OBJECTIVE This systematic literature review and environmental scan addresses NAM's recommendations by answering two research questions: (1) what aspects of EMS systems are most measured in the peer-reviewed and grey literatures, and (2) what do these measures and studies suggest for high-quality EMS oversight? METHODS To answer these questions, a systematic literature review was conducted in the PubMed (National Center for Biotechnology Information, National Institutes of Health; Bethesda, Maryland USA), Web of Science (Thomson Reuters; New York, New York USA), SCOPUS (Elsevier; Amsterdam, Netherlands), and EMBASE (Elsevier; Amsterdam, Netherlands) databases for peer-reviewed literature and for grey literature; targeted web searches of 10 EMS-related government agencies and professional organizations were performed. Inclusion criteria required peer-reviewed literature to be published between 1966-2016 and grey literature to be published between 1996-2016. A total of 1,476 peer-reviewed titles were reviewed, 76 were retrieved for full-text review, and 58 were retained and coded in the qualitative software Dedoose (Manhattan Beach, California USA) using a codebook of themes. Categorizations of measure type and level of application were assigned to the extracted data. Targeted websites were systematically reviewed and 115 relevant grey literature documents were retrieved. RESULTS A total of 58 peer-reviewed articles met inclusion criteria; 46 included process, 36 outcomes, and 18 structural measures. Most studies applied quality measures at the personnel level (40), followed by the agency (28) and system of care (28), and few at the oversight level (5). Numerous grey literature articles provided principles for high-quality EMS oversight. CONCLUSIONS Limited quality measurement at the oversight level is an important gap in the peer-reviewed literature. The grey literature is ahead in this realm and can guide the policy and research agenda for EMS oversight quality measurement. Taymour RK , Abir M , Chamberlin M , Dunne RB , Lowell M , Wahl K , Scott J . Policy, practice, and research agenda for Emergency Medical Services oversight: a systematic review and environmental scan. Prehosp Disaster Med. 2018;33(1):89-97.
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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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Jiang J, Ma D, Li B, Yue Y, Xue F. Video laryngoscopy does not improve the intubation outcomes in emergency and critical patients - a systematic review and meta-analysis of randomized controlled trials. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:288. [PMID: 29178953 PMCID: PMC5702235 DOI: 10.1186/s13054-017-1885-9] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Accepted: 11/06/2017] [Indexed: 01/12/2023]
Abstract
Background There is significant controversy regarding the influence of video laryngoscopy on the intubation outcomes in emergency and critical patients. This systematic review and meta-analysis was designed to determine whether video laryngoscopy could improve the intubation outcomes in emergency and critical patients. Methods We searched the Cochrane Central Register of Controlled Trials, PubMed, Embase, and Scopus databases from database inception until 15 February 2017. Only randomized controlled trials comparing video and direct laryngoscopy for tracheal intubation in emergency department, intensive care unit, and prehospital settings were selected. The primary outcome was the first-attempt success rate. Review Manager 5.3 software was used to perform the pooled analysis and assess the risk of bias for each eligible study. The GRADE (Grading of Recommendations Assessment, Development and Evaluation) system was used to assess the quality of evidence for all outcomes. Results Twelve studies (2583 patients) were included in the review for data extraction. Pooled analysis did not show an improved first-attempt success rate using video laryngoscopy (relative risk [RR], 0.93; P = 0.28; low-quality evidence). There was significant heterogeneity among studies (I2 = 91%). Subgroup analyses showed that, in the prehospital setting, video laryngoscopy decreased the first-attempt success rate (RR, 0.57; P < 0.01; high-quality evidence) and overall success rate (RR, 0.58; 95% CI, 0.48–0.69; moderate-quality evidence) by experienced operators, whereas in the in-hospital setting, no significant difference between two devices was identified for the first-attempt success rate (RR, 1.06; P = 0.14; moderate-quality evidence), regardless of the experience of the operators or the types of video laryngoscopes used (P > 0.05), although a slightly higher overall success rate was shown (RR, 1.11; P = 0.03; moderate-quality evidence). There were no differences between devices for other outcomes (P > 0.05), except for a lower rate of esophageal intubation (P = 0.01) and a higher rate of Cormack and Lehane grade 1 (P < 0.01) when using video laryngoscopy. Conclusions On the basis of the results of this study, we conclude that, compared with direct laryngoscopy, video laryngoscopy does not improve intubation outcomes in emergency and critical patients. Prehospital intubation is even worsened by use of video laryngoscopy when performed by experienced operators. Electronic supplementary material The online version of this article (doi:10.1186/s13054-017-1885-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jia Jiang
- Department of Anesthesiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, 100020, China
| | - Danxu Ma
- Department of Anesthesiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, 100020, China
| | - Bo Li
- Beijing Hospital of Traditional Chinese Medicine, affiliated with Capital Medical University, Beijing Institute of Traditional Chinese Medicine, Beijing, 100010, China
| | - Yun Yue
- Department of Anesthesiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, 100020, China.
| | - Fushan Xue
- Department of Anesthesiology, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100144, China.
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