Endotracheal intubation to reduce aspiration events in acutely comatose patients: a systematic review

Airway Management in Austere Settings: Intubation Is Not Always the Best Option

Management of the airway in austere environments can differ substantially from standard in-hospital airway management. Devices such as nasopharyngeal airways, oropharyngeal airways, endotracheal tubes, extraglottic airways, ventilators, and sedative and paralytic medications may not be available. Weather, scene hazards, difficulties of extrication, transport times, skill sets of rescuers, and availability of advanced equipment are highly variable. Standard decision-making processes and guidelines, such as intubation for Glasgow Coma Scale score ≤ 8, are not always optimal in austere settings. Airway management in austere settings involves many variables leading to complex decision-making. We present 2 cases in which airway management likely would have been similar in hospital settings but differed in austere environments based on the available resources. We discuss current concepts and methods for airway management in austere environments with a review of the pertinent literature.

Effects of a scoring aid on glasgow coma score assessment and physicians' comprehension: a simulator-based randomized clinical trial

PURPOSE

Examining the impact of scoring aids on the accuracy of assessing the Glasgow Coma Score (GCS) in a standardized trauma scenario (primary outcome). Evaluating physicians' understanding of the GCS assessment and clinical application (secondary outcome).

MATERIALS AND METHODS

This randomized trial was performed at the simulator center of a Swiss tertiary academic medical hospital. Participants included intensivists, emergency physicians, internists, and neurologists. The setting involved a trauma patient portraying a GCS of 8 (eyes 1, verbal 2, motor 5). Participants were randomized to receiving or not receiving a scoring aid. Video/audio recordings of the assessments and questionnaires were analyzed by two investigators.

RESULTS

Among 109 participants, 55 received a scoring aid. Overall, 52% scored correctly (score interquartile range 7-8); 43% scored too low and 90% scored within a range of ± 1. A scoring aid increased accuracy (62% vs. 43%, p = 0.045) and participants' confidence, whilst decreasing assessment duration. Clinical experience further improved reliability. 89% found assessing a GCS of 8 most challenging, particularly with motor response evaluation (64%). 26% indicated tracheal intubation to be mandatory with a score of GCS ≤ 8.

CONCLUSIONS

GCS assessment is improved by professional experience and a scoring aid, the use of which needs to be promoted in daily clinical practice. Frequent inaccuracy and misunderstanding regarding clinical applications may alter patient management and misguide treatment and prognosis.

TRIAL REGISTRATION

ISRCTN registry (IDISRCTN12257237) https://www.isrctn.com/ISRCTN12257237 Retrospectively registered (last amendment 08/22/2023).

Mapping Glasgow Coma scale to AVPU scores among adults in the prehospital setting

OBJECTIVE

To develop a translation between the Glasgow Come Scale and the Alert-Verbal-Pain-Unresponsive (AVPU) scale among adults with out-of-hospital emergencies.

METHODS

We performed a retrospective analysis of adults (≥18 years) from the 2022 National Emergency Medical Services (EMS) Information System with a ground scene encounter with a concurrently documented GCS and AVPU assessment. Using a training partition of 2.5 million encounters, we performed a grid search to identify all combinations of mutually exclusive cutpoints which divided the GCS into four segments. We identified the combination with the highest Kappa statistic and reported metrics of performance in this sample in the test partition.

RESULTS

We identified 16,321,299 encounters with a concurrent AVPU and GCS. Using the AVPU scale, 93.3 % were classified as Alert; 2.9 % as Verbal; 1.5 % as Pain; and 2.3 % as Unresponsive. Using a grid-based search, optimal cutpoints were identified when using a GCS of 14-15 for Alert, 10-13 for Verbal, 7-9 for Pain, and 3-6 for Unresponsive. Cohen's Kappa was 0.63 in the test partition, indicating substantial agreement. Intraclass F1 score varied across different alertness levels and were 0.97 for "Alert", 0.43 for "Verbal", 0.49 for "Pain", and 0.83 for "Unresponsive". Findings were similar in analyses performed by age group and by the presence or absence of trauma.

CONCLUSION

We report an optimal crosswalk between the AVPU and GCS scales. Performance in the Verbal and Pain categories was lower than the Alert and Unresponsive categories. These findings may facilitate clinician handovers between EMS and non-EMS clinicians.

Development and Validation of a Bayesian Network Predicting Intubation Following Hospital Arrival Among Injured Children

BACKGROUND

Inadequate airway management can contribute to preventable trauma deaths. Current machine learning tools for predicting intubation in trauma are limited to adult populations and include predictors not readily available at the time of patient arrival. We developed a Bayesian network to predict intubation in injured children and adolescents using observable data available upon or immediately after patient arrival.

METHODS

We obtained patient demographic, injury, resuscitation, and transportation characteristics from trauma registries from four American College of Surgeons-verified level 1 pediatric trauma centers from January 2010 through December 2021. We trained and validated a Bayesian network to predict emergent intubation after pediatric injury. We evaluated model performance using the area under the receiver operating and calibration curves.

RESULTS

The final model, TITAN (Timing of Intubation in Trauma Analysis Network), incorporated five factors: Glasgow Coma Scale, mechanism of injury, injury type (e.g., penetrating, blunt), systolic blood pressure, and age. The model achieved an area under the receiver operating characteristic curve of 0.83 (95% CI 0.80, 0.85) and had a calibration curve slope of 0.98 (95% CI 0.67, 1.29). TITAN had high specificity (98%), negative predictive value (97%), and accuracy (96%) at a binary probability threshold of 22.6%.

CONCLUSION

The TITAN Bayesian network predicts the risk of intubation in pediatric trauma patients using five factors that are observable early in trauma resuscitation. Prospective validation of the model performance with patient outcomes is needed to assess real-life application benefits and risks.

LEVEL OF EVIDENCE

Prognostic and Epidemiological, Level III.

Comparing AVPU and Glasgow Coma Scales Among Children Seen by Emergency Medical Services

OBJECTIVES

Consciousness assessment is an important component in the prehospital care of ill or injured children. Both the Glasgow Coma Scale (GCS) and the Alert, Verbal, Pain, Unresponsive (AVPU) scale are used for this purpose. We sought to identify cut points for the GCS to correspond to the AVPU scale for pediatric emergency medical services (EMS) encounters.

METHODS

We conducted a retrospective cross-sectional analysis using the 2019-2022 National EMS Information System data set, including children (<18 years) with a GCS and AVPU score. We evaluated several approaches to develop cut points for the GCS within the AVPU scale and reported measures of performance.

RESULTS

Of 6 186 663 pediatric encounters, 4 311 598 with both GCS and AVPU documentation were included (median age was 10 years [interquartile range 3-15]; 50.9% boys). Lower AVPU scores correlated with life-sustaining procedures, including those for airway management, seizure, and cardiac arrest. Optimal GCS cut points obtained via a grid-based search were 14 to 15 for alert, 11 to 13 for verbal, 7 to 10 for pain, and 3 to 6 for unresponsive. Overall accuracy was 0.95, with kappa of 0.61. Intraclass F1 statistics were lower for verbal (0.37) and pain (0.50) categories compared with alert (0.98) and unresponsive (0.78).

CONCLUSIONS

We developed a cross-walking between the AVPU and GCS scales. Overall performance was high, though performance within the verbal and pain categories was lower. These findings can be useful to enhance clinician handovers and to aid in the development of EMS-based prediction models.

Critical Care: What You May Have Missed in 2023

Critical care medicine is a specialty that brings together a truly wide spectrum of patient populations, disease states, and treatment methods. This article highlights 10 important pieces of research from 2023 (and 1 from 2022) in critical care. The literature was screened for new evidence relevant to internal medicine physicians and hospitalists whose focus of practice is not critical care but who may be taking care of seriously ill patients. The articles highlight the diverse spectrum of pathology and interplay of various specialties that go into critical care. Topics include transfusion medicine, fluid resuscitation, safe intubation practices and respiratory failure, and the management of acute ischemic stroke. Several trials are groundbreaking, forcing clinicians to reconsider preexisting dogma and likely adopt new treatment strategies.

Paramedics' Success and Complications in Prehospital Pediatric Intubation: A Meta-Analysis

BACKGROUND

Prehospital pediatric intubation is a potentially life-saving procedure in which paramedics are relied upon. However, due to the anatomical nature of pediatrics and associated adverse events, it is more challenging compared to adult intubation. In this study, the knowledge and attitude of paramedics was assessed by measuring their overall success rate and associated complications.

METHODS

An online search using PubMed, Scopus, Web of Science, and Cochrane CENTRAL was conducted using relevant keywords to include studies that assess success rates and associated complications. Studies for eligibility were screened. Data were extracted from eligible studies and pooled as risk ratio (RR) with a 95% confidence interval (CI).

RESULTS

Thirty-eight studies involving 14,207 pediatrics undergoing intubation by paramedics were included in this study. The prevalence of success rate was 82.5% (95% CI, 0.745-0.832) for overall trials and 77.2% (95% CI, 0.713-0.832) success rate after the first attempt. By subgrouping the patients according to using muscle relaxants during intubation, the group that used muscle relaxants showed a high overall successful rate of 92.5% (95% CI, 0.877-0.973) and 79.9% (95% CI, 0.715-0.994) success rate after the first attempt, more than the group without muscle relaxant which represent 78.9% (95% CI, 0.745-0.832) overall success rate and 73.3% (95% CI, 0.616-0.950) success rate after first attempt.

CONCLUSION

Paramedics have a good overall successful rate of pediatric intubation with a lower complication rate, especially when using muscle relaxants.

Effect of Noninvasive Airway Management of Comatose Patients With Acute Poisoning: A Randomized Clinical Trial

Importance

Tracheal intubation is recommended for coma patients and those with severe brain injury, but its use in patients with decreased levels of consciousness from acute poisoning is uncertain.

Objective

To determine the effect of intubation withholding vs routine practice on clinical outcomes of comatose patients with acute poisoning and a Glasgow Coma Scale score less than 9.

Design, Setting, and Participants

This was a multicenter, randomized trial conducted in 20 emergency departments and 1 intensive care unit (ICU) that included comatose patients with suspected acute poisoning and a Glasgow Coma Scale score less than 9 in France between May 16, 2021, and April 12, 2023, and followed up until May 12, 2023.

Intervention

Patients were randomized to undergo conservative airway strategy of intubation withholding vs routine practice.

Main Outcomes and Measures

The primary outcome was a hierarchical composite end point of in-hospital death, length of ICU stay, and length of hospital stay. Key secondary outcomes included adverse events resulting from intubation as well as pneumonia within 48 hours.

Results

Among the 225 included patients (mean age, 33 years; 38% female), 116 were in the intervention group and 109 in the control group, with respective proportions of intubations of 16% and 58%. No patients died during the in-hospital stay. There was a significant clinical benefit for the primary end point in the intervention group, with a win ratio of 1.85 (95% CI, 1.33 to 2.58). In the intervention group, there was a lower proportion with any adverse event (6% vs 14.7%; absolute risk difference, 8.6% [95% CI, -16.6% to -0.7%]) compared with the control group, and pneumonia occurred in 8 (6.9%) and 16 (14.7%) patients, respectively (absolute risk difference, -7.8% [95% CI, -15.9% to 0.3%]).

Conclusions and Relevance

Among comatose patients with suspected acute poisoning, a conservative strategy of withholding intubation was associated with a greater clinical benefit for the composite end point of in-hospital death, length of ICU stay, and length of hospital stay.

Trial Registration

ClinicalTrials.gov Identifier: NCT04653597.

Evaluation of Donor Lungs for Transplantation: The Efficacy of Screening Bronchoscopy for Detecting Donor Aspiration and Its Relationship to the Resulting Allograft Function in Corresponding Recipients

BACKGROUND

Potential organ donors often have suffered anoxic and/or traumatic brain injury during which they may have experienced aspiration of gastric material (AGM). Evaluation of such donors typically includes a screening bronchoscopic examination during which determinations of aspiration are made. The efficacy of this visual screening and its relationship to post-transplant allograft function are unknown.

METHODS

Before procurement, bronchoscopy was performed on donors in which both bronchoalveolar lavage fluid (BALF) was collected and a visual inspection made. As a marker of AGM, BALF specimens were analyzed for the presence of bile salts. Data collected on the corresponding recipients included primary graft dysfunction (PGD) score, post-transplant spirometry, acute rejection scores (ARS), and overall survival.

RESULTS

Of 31 donors evaluated, bronchoscopies revealed only 2 with visual evidence of AGM, whereas BALF analysis for bile salts indicated AGM in 14. As such, screening bronchoscopy had a sensitivity of only 7.1%. Visual detection of AGM via bronchoscopy was not associated with any resulting grade of PGD (χ2 = 2.96, P = .23); however, AGM defined by detection of bile salts was associated (χ2 = 7.56, P = .02). Over the first post-transplant year, the corresponding recipients experienced a similar improvement in allograft function (χ2 = 1.63, P = .69), ARS (P = .69), and survival (P = .24).

CONCLUSION

Visual inspection during a single bronchoscopic examination of lung donors underestimates the prevalence of AGM. The detection of bile salts in donor BALF is associated with early allograft dysfunction in the corresponding recipients but not with later allograft proficiency, acute rejection responses, or 1-year post-transplant survival.

Rapid Sequence Intubation Using the SEADUC Manual Suction Unit in a Contaminated Airway

The case presented here highlights the utility/feasibility of the SEADUC (EM Innovations, Galloway, OH) manual suction unit in clearing a contaminated airway during rapid sequence intubation. The case also highlights the importance of intubation in a patient with declining mental status in the prehospital environment. A 75-year-old woman suffered a head injury, and a helicopter emergency medical service team staffed with a physician and nurse was tasked with retrieval and transfer back to the tertiary care center. As the flight team rendezvoused with ground emergency medical services and the patient, a decision to intubate was made because of the patient's declining mental status and inability to protect her own airway. While in preparation for intubation, it was noted that the ambulance's electrical suction system was not working, and the flight crew had to resort to a SEADUC manual suction unit to clear the patient's airway of contaminants. The patient's airway was cleared, and she was successfully intubated and transported to a tertiary care center where the patient underwent an emergent neurosurgery procedure/decompression and was discharged home a few weeks later.

Incidence and Predictors of Aspiration Pneumonia Among Stroke Patients in Western Amhara Region, North-West Ethiopia: A Retrospective Follow Up Study

Background

Aspiration pneumonia is one of the major complications among hospitalized stroke patients, with global incidence ranging from 5-83% and hospital mortality rate of up to 70%. This study aimed to assess the incidence and identify predictors of aspiration pneumonia among stroke patients in Western Amhara region, North-West Ethiopia.

Methods

An institution-based retrospective follow-up study was conducted on a simple random sample of 568 stroke patients in Western Amhara region admitted at Felege Hiwot Referral Hospital. Log binomial regression model, a generalized linear model with log link, was applied to identify significant predictors of aspiration pneumonia.

Results

Cumulative incidence of aspiration pneumonia among the 568 sampled patients was 23.06%. Males were 1.71 times more at risk to acquire aspiration pneumonia than females (ARR = 1.71, 95% CI 1.07-2.74). Patients with vomiting and dysphagia were at more risk of acquiring aspiration pneumonia as compared with patients without vomiting and dysphagia (ARR = 1.81, 95% CI 1.04-3.14 and ARR = 1.95, 95% CI 1.10-3.48, respectively). Patients who received antibiotic prophylaxis and patients with Glasgow Coma Scale greater than 12 had less risk of acquiring aspiration pneumonia as compared with those who did not receive antibiotic prophylaxis and patients with Glasgow Coma Scale less than 8 (ARR = 0.10, 95% CI 0.04-0.28 and ARR = 0.45, 95% CI 0.22-0.94, respectively).

Conclusion

The cumulative incidence of aspiration pneumonia among sampled patients was 23.06%. Vomiting, dysphagia, antibiotic treatment and Glasgow Coma Scale showed significant correlation with the acquiring of aspiration pneumonia. Therefore, we recommend health-care providers should give special attention for patients with these risk factors to prevent aspiration pneumonia.

Risks in the Management of Polytrauma Patients: Clinical Insights

Polytrauma, a patient's condition with multiple injuries that involve multiple organs or systems, is the leading cause of mortality in young adults. Trauma-related injuries are a major public health concern due to their associated morbidity, high disability, associated death, and socioeconomic consequences. Management of polytrauma patients has evolved over the last few decades due to the development of trauma systems, improved pre-hospital assessment, transport and in-hospital care supported by complementary investigations. Recognising the mortality patterns in trauma has led to significant changes in the approach to managing these patients. A structured approach with application of advanced trauma life support (ATLS) algorithms and optimisation of care based on clinical and physiological parameters has led to the development of early appropriate care (EAC) guidelines to treat these patients, with subsequent improved outcomes in such patients. The journey of a polytrauma patient through the stages of pre-hospital care, emergency resuscitation, in-hospital stabilization and rehabilitation pathway can be associated with risks at any of these phases. We describe the various risks that can be anticipated during the management of polytrauma patients at different stages and provide clinical insights into early recognition and effective treatment of these to improve clinical outcomes.

Utility of neuromuscular blockade reversal in the evaluation of acute neurosurgical patients: A retrospective case-series

OBJECTIVE

Sugammadex reversal of neuromuscular blocking agents (NMBAs) is usually performed postoperatively. A scarcity of literature exists exploring sugammadex use for timely neurological examination of neurosurgical patients. NMBAs, like rocuronium, are used in the Emergency Department during intubation and their unpredictable duration of action often impedes timely and accurate assessment of patient neurological status. We aim to explore the role of sugammadex in evaluating patients in need of acute neurosurgical care.

METHODS

Retrospective assessment of patients presenting with traumatic brain injury or intracranial hemorrhage was conducted at our level 1 trauma center. Patients of interest were those for whom sugammadex reversal of rocuronium neuromuscular blockade, from intubating doses, was pursued to ensure timely neurologic assessment. Nine patients were identified for whom GCS pre-/post-sugammadex, rocuronium dosing, elapsed time between rocuronium administration and reversal, and clinical course data were retrieved.

RESULTS

Arrival GCS was 5.2 ± 3.2, with intubation accomplished within 10 ± 2.5 min of presentation. Rocuronium dosing was consistent between patients, average single dose of 1.2 ± 0.3 mg/kg. Lingering neuromuscular blockade ranged from 28 to 132 min (87.3 ± 34.3 min). All patients exhibited a GCS of 3 T upon initial neurosurgical evaluation, prior to reversal. Post-reversal GCS rose to 6.0 T ± 2.2. Sugammadex facilitated more accurate clinical decision making in 8 of 9 patients, including prevention of unnecessary invasive procedures. Two of 9 patients were eventually discharged home or to a rehabilitation facility.

CONCLUSIONS

Rocuronium neuromuscular blockade can linger beyond pharmacokinetic predictions, thus delaying timely and precise neurologic assessment. Our data suggests sugammadex may be a useful addition to the clinician's armamentarium for acute neurologic assessment in the neurosurgical population. Sugammadex may impact clinical decision-making in certain patients and allow for more informed decision-making by families and physicians alike. Prospective studies are needed to definitively assess the impact of sugammadex on outcomes in acute neurosurgical settings.

Early mechanical ventilation for grade IV hepatic encephalopathy is associated with increased mortality among patients with cirrhosis: an exploratory study

BACKGROUND

Unresponsive patients with toxic-metabolic encephalopathies often undergo endotracheal intubation for the primary purpose of preventing aspiration events. However, among patients with pre-existing systemic comorbidities, mechanical ventilation itself may be associated with numerous risks such as hypotension, aspiration, delirium, and infection. Our primary aim was to determine whether early mechanical ventilation for airway protection was associated with increased mortality in patients with cirrhosis and grade IV hepatic encephalopathy.

METHODS

The National Inpatient Sample was queried for hospital stays due to grade IV hepatic encephalopathy among patients with cirrhosis between 2016 and 2019. After applying our exclusion criteria, including cardiopulmonary failure, data from 1,975 inpatient stays were analyzed. Patients who received mechanical ventilation within 2 days of admission were compared to those who did not. Univariable and multivariable logistic regression analyses were performed to identify clinical factors associated with in-hospital mortality.

RESULTS

Of 162 patients who received endotracheal intubation during the first 2 hospital days, 64 (40%) died during their hospitalization, in comparison to 336 (19%) of 1,813 patients in the comparator group. In multivariable logistic regression analysis, mechanical ventilation was the strongest predictor of in-hospital mortality in our primary analysis (adjusted odds ratio, 3.00; 95% confidence interval, 2.14-4.20; P<0.001) and in all sensitivity analyses.

CONCLUSIONS

Mechanical ventilation for the sole purpose of airway protection among patients with cirrhosis and grade IV hepatic encephalopathy may be associated with increased in-hospital mortality. Future studies are necessary to confirm and further characterize our findings.

The Glasgow Coma Scale: a tool to decide the need for tracheal intubation in acutely intoxicated patients?

The Glasgow Coma Scale aids decision making with regards to advanced airway management of acutely intoxicated patients. There is some evidence for lower levels of gastric aspiration when using a Glasgow Coma Scale score of eight or less to decide upon tracheal intubation, but this is not substantiated in the literature.

Aspiration risk in relation to Glasgow Coma Scale score and clinical parameters in patients with severe acute alcohol intoxication: a single-centre, retrospective study

OBJECTIVES

In alcohol intoxicated patients, the decision for or against airway protection can be challenging and is often based on the Glasgow Coma Scale (GCS). Primary aim of this study was to analyse the aspiration risk in relation to the GCS score and clinical parameters in patients with severe acute alcohol monointoxication. Secondary aim was the association between the blood alcohol level and the GCS score.

SETTING

Single-centre, retrospective study of alcoholised patients admitted to a German intensive care unit between 2006 and 2020.

PARTICIPANTS

A total of n=411 admissions were eligible for our analysis.

CLINICAL MEASURES AND ANALYSIS

The following data were extracted: age, gender, admission time, blood alcohol level, blood glucose level, initial GCS score, GCS score at admission, vital signs, clinical signs of aspiration and airway management measures. The empirical distribution of continuous and categorical data was calculated. Binary multivariable logistic regression analysis was used to identify possible risk factors for aspiration.

RESULTS

The mean age was 35 years. 72% (n=294) of the admissions were male. The blood alcohol level (mean 2.7 g/L±1.0, maximum 5.9 g/L) did not correlate with the GCS score but with the age of the patient. In univariate analysis, the aspiration risk correlated with blood alcohol level, age, GCS score, oxygen saturation, respiratory rate and blood glucose level and was significantly higher in male patients, on vomiting, and in patients requiring airway measures. Aspiration rate was 45% (n=10) in patients without vs 6% (n=3) in patients with preserved protective reflexes (p=0.0001). In the multivariate analysis, only age and GCS score were significantly associated with the risk of aspiration.

CONCLUSION

Although in this single-centre, retrospective study the aspiration rate in severe acute alcohol monointoxicated patients correlates with GCS and protective reflexes, the decision for endotracheal intubation might rather be based on the presence of different risk factors for aspiration.