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Tannheimer M, Reinke M, Lechner R. Comparison of Laryngeal Mask Airway Seal Between Anesthesiologists and Individuals Without Previous Airway Experience. J Emerg Med 2024; 66:e470-e476. [PMID: 38461134 DOI: 10.1016/j.jemermed.2023.11.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 11/19/2023] [Accepted: 11/23/2023] [Indexed: 03/11/2024]
Abstract
BACKGROUND Tracheal intubation is the gold standard for airway management in emergency medicine, but more difficult to apply for inexperienced individuals than laryngeal mask airway (LMA). OBJECTIVE The aim of our study was to investigate if inexperienced individuals are able to secure the airway with the help of LMA after a short introduction. A second aim was to evaluate Thiel-fixed specimens against unfixed ones. METHODS In a body donor model, LMA application was evaluated between medical students without previous airway experience and anesthesiologists by comparing the sealing of the larynx using a water column applied to the esophagus. RESULTS LMAs were successfully applied in 46 out of 55 (83.6%) attempts by medical students and in 30 out of 39 (76.9%) attempts by anesthesiologists. Among medical students, 14.1% of all LMA applications were primarily leaky, compared with 18.8% in anesthesiologists. Esophageal sealing was better in Thiel-fixed specimens (leakage 10.9%) compared with unfixed specimens (leakage 22.9%). Our data showed no significant difference between anesthesiologists and medical students in terms of sealing of LMA. Therefore, we conclude that medical students without previous airway experience can quickly learn to apply LMA sufficiently and thus, achieve aspiration protection similar to anesthesiologists. CONCLUSION Medical students without previous airway experience can successfully insert LMAs after a short introduction. Thiel-fixed specimens are suitable for studies as well as for training in LMA application.
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Affiliation(s)
- Markus Tannheimer
- Department of Sport and Rehabilitation Medicine, University of Ulm, Ulm, Germany; Department of General and Visceral Surgery, Krankenhaus Blaubeuren, Blaubeuren, Germany
| | - Martin Reinke
- Institute of Anatomy and Cell Biology, University of Ulm, Ulm, Germany; Department of Pediatric Surgery, Children's Hospital of Eastern Switzerland, St. Gallen, Switzerland
| | - Raimund Lechner
- Department of Anesthesiology, Intensive Care, Emergency Medicine and Pain Therapy, Bundeswehr Hospital Ulm, Ulm, Germany; Medical Service, Police Baden-Württemberg, Stuttgart, Germany
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Waghmare UM, Singh A. Prehospital Cervical Spine (C-spine) Stabilization and Airway Management in a Trauma Patient: A Review. Cureus 2024; 16:e54815. [PMID: 38529441 PMCID: PMC10961654 DOI: 10.7759/cureus.54815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 02/24/2024] [Indexed: 03/27/2024] Open
Abstract
Severe traumatic damage to the brain-to-body signaling bundle that results in bruising and a partial or total tear of the spinal cord is known as a spinal cord injury (SCI). SCI may develop at the time of an event or after. It can also develop while handling the patient and can worsen during the transportation of the patient. So prehospital care is crucial to prevent or minimize SCI. Prehospital care involves examining the patient, immobilizing the cervical spine (C-spine), providing cardiovascular support (keeping the mean arterial blood pressure over 85 mmHg), and carefully managing the airway (possibly intubating the patient using manual in-line stabilization (MILS)). Methylprednisolone (MPS) and other pharmacological treatments have not been shown to offer clinically meaningful and essential benefits for people with SCI. The therapeutic use of MPS in patients with SCI in the prehospital context is no longer supported. Additionally, whether or not pharmaceutical drugs will be effective in therapeutic hypothermia is unknown. When performing endotracheal intubation on these patients, the potential for C-spine damage is always considered. During intubation, the MILS approach significantly reduces C-spine movement. The MILS method, however, can potentially restrict mouth opening and result in subpar laryngoscopic vision. These issues can be handled using the recently developed video laryngoscope, such as Airtraq laryngoscope and AirWay Scope (AWS). Compared to a direct laryngoscope, the AWS and Airtraq laryngoscope reduced the improvement of intubation conditions and the acceleration of tracheal intubation through the occiput-C1 and C2-C4 levels of the C-spine extension movement.
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Affiliation(s)
- Utkarsh M Waghmare
- Accident and Trauma Care Technology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Akhilesh Singh
- Emergency Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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3
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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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4
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Solan T, Cudini D, Humar M, Forsyth N, Meadley B, St Clair T, Hodge D, Smith K, Babl FE, Long E. Characteristics of paediatric pre-hospital intubation by Intensive Care Paramedics. Emerg Med Australas 2023; 35:754-758. [PMID: 37019689 DOI: 10.1111/1742-6723.14207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 03/01/2023] [Accepted: 03/22/2023] [Indexed: 04/07/2023]
Abstract
OBJECTIVES Emergency intubation in children is an infrequent procedure both in the pre-hospital and hospital setting. The anatomical, physiological and situational challenges together with limited clinician exposure can make this a difficult procedure with high risk of adverse events. The aim of this collaborative study between a state-wide ambulance service and a tertiary children's hospital was to describe the characteristics of pre-hospital paediatric intubations by Intensive Care Paramedics. METHODS We conducted a retrospective review of state-wide ambulance service electronic patient care records (ePCRs) in Victoria, Australia, population: 6.5 million. Children aged 0-18 years who were attended by paramedics over a 12-month period that required advanced airway management were analysed for demographics and first-pass success rate. RESULTS Paramedics attended 2674 cases aged 0-18 years over the 12-month study period who received basic or advanced airway management. A total of 78 cases required advanced airway management. The median age of patients was 12 years (interquartile range 3-16) and most were male (60.2%). Sixty-eight patients (87.5%) were intubated successfully on the first attempt, first-pass success was lowest in children <1 year of age. The most common indications for pre-hospital intubation were closed head injury and cardiac arrest. It was not possible to report complication rates because of incomplete documentation. CONCLUSION Pre-hospital intubation in children is performed infrequently in an extremely unwell patient group. Continued high-level paramedic training is required to prevent adverse events and ensure patient safety.
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Affiliation(s)
- Tom Solan
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
- Paediatric Research in Emergency Departments International Collaborative (PREDICT), Melbourne, Victoria, Australia
- Emergency Department, The Royal Children's Hospital, Melbourne, Victoria, Australia
- Departments of Paediatrics and Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
| | - Daniel Cudini
- Ambulance Victoria, Melbourne, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Paramedicine, Monash University, Melbourne, Victoria, Australia
| | - Matthew Humar
- Ambulance Victoria, Melbourne, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Paramedicine, Monash University, Melbourne, Victoria, Australia
| | - Nathan Forsyth
- Emergency Department, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Ben Meadley
- Ambulance Victoria, Melbourne, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Paramedicine, Monash University, Melbourne, Victoria, Australia
| | - Toby St Clair
- Ambulance Victoria, Melbourne, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Paramedicine, Monash University, Melbourne, Victoria, Australia
| | - Darren Hodge
- Ambulance Victoria, Melbourne, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Paramedicine, Monash University, Melbourne, Victoria, Australia
| | - Karen Smith
- Ambulance Victoria, Melbourne, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Paramedicine, Monash University, Melbourne, Victoria, Australia
| | - Franz E Babl
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
- Paediatric Research in Emergency Departments International Collaborative (PREDICT), Melbourne, Victoria, Australia
- Emergency Department, The Royal Children's Hospital, Melbourne, Victoria, Australia
- Departments of Paediatrics and Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
| | - Elliot Long
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
- Paediatric Research in Emergency Departments International Collaborative (PREDICT), Melbourne, Victoria, Australia
- Emergency Department, The Royal Children's Hospital, Melbourne, Victoria, Australia
- Departments of Paediatrics and Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
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5
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Thomas MB, Urban S, Carmichael H, Banker J, Shah A, Schaid T, Wright A, Velopulos CG, Cripps M. Tick-tock: Prehospital intubation is associated with longer field time without any survival benefit. Surgery 2023; 174:1034-1040. [PMID: 37500409 DOI: 10.1016/j.surg.2023.06.021] [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: 02/28/2023] [Revised: 05/16/2023] [Accepted: 06/18/2023] [Indexed: 07/29/2023]
Abstract
BACKGROUND Prehospital endotracheal intubation is a debated topic, and few studies have found it beneficial after trauma. A growing body of evidence suggests that prehospital endotracheal intubation is associated with increased morbidity and mortality. Our study was designed to compare patients with attempted prehospital endotracheal intubation to those intubated promptly upon emergency department arrival. METHODS A retrospective review of a single-center trauma research data repository was utilized. Inclusion criteria included age ≥15 years, transport from the scene by ground ambulance, and undergoing prehospital endotracheal intubation attempts or intubation within 10 minutes of emergency department arrival without prior prehospital endotracheal intubation attempt. Propensity score matching was used to minimize differences in baseline characteristics between groups. Standard mean differences are also presented for pre- and post-matching datasets to evaluate for covariate balance. RESULTS In total, 208 patients met the inclusion criteria. Of these, 95 patients (46%) underwent prehospital endotracheal intubation, which was successful in 47% of cases. A control group of 113 patients (54%) were intubated within 10 minutes of emergency department arrival. We performed propensity score matching between cohorts based on observed differences after univariate analysis and used standard mean differences to estimate covariate balance. After propensity score matching, patients who underwent prehospital endotracheal intubation experienced a longer time on scene as compared with those intubated in the emergency department (9 minutes [interquartile range 6-12] vs 6 minutes [interquartile range 5-9], P < .01) without difference in overall mortality (67% vs 65%, P = 1.00). Rapid sequence intubation was not used in the field; however, it was used for 58% of patients intubated within 10 minutes of emergency department arrival. After matched analysis, patients with a failed prehospital intubation attempt were equally likely to receive rapid sequence intubation during re-intubation in the emergency department as compared with those undergoing a first attempt (n = 13/28, 46% vs n = 28/63, 44%, P = 1.00, standard mean differences 0.04). Among patients with prehospital arrest (n = 98), prehospital endotracheal intubation was associated with shorter time to death (8 minutes [interquartile range 3-17] vs 14 minutes [interquartile range 8-45], P = .008) and longer total transport time (23 minutes [interquartile range 19-31] vs 19 minutes [interquartile range 16-24], P = .006), but there was no difference in observed mortality (n = 29/31, 94% vs n = 30/31, 97%, P = 1.00, standard mean differences = 0.15) after propensity score matching. CONCLUSION Prehospital providers should prioritize expeditious transport over attempting prehospital endotracheal intubation, as prehospital endotracheal intubation is inconsistently successful, may delay definitive care, and appears to have no survival benefit.
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Affiliation(s)
- Madeline B Thomas
- Department of Surgery, University of Colorado, School of Medicine, Anschutz Medical Campus, Aurora, CO.
| | - Shane Urban
- Department of Surgery, University of Colorado, School of Medicine, Anschutz Medical Campus, Aurora, CO
| | - Heather Carmichael
- Department of Surgery, University of Colorado, School of Medicine, Anschutz Medical Campus, Aurora, CO. https://twitter.com/hcarmichaelmd
| | - Jordan Banker
- Department of Surgery, University of Colorado, School of Medicine, Anschutz Medical Campus, Aurora, CO
| | - Ananya Shah
- Department of Surgery, University of Colorado, School of Medicine, Anschutz Medical Campus, Aurora, CO
| | - Terry Schaid
- Department of Surgery, University of Colorado, School of Medicine, Anschutz Medical Campus, Aurora, CO
| | - Angela Wright
- Department of Emergency Medicine, University of Colorado, School of Medicine, Anschutz Medical Campus, Aurora, CO
| | - Catherine G Velopulos
- Department of Surgery, University of Colorado, School of Medicine, Anschutz Medical Campus, Aurora, CO. https://twitter.com/CVelopulos
| | - Michael Cripps
- Department of Surgery, University of Colorado, School of Medicine, Anschutz Medical Campus, Aurora, CO. https://twitter.com/MichaelCrippsMD
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Manning JE, Morrison JJ, Pepe PE. Prehospital Resuscitation: What Should It Be? Adv Surg 2023; 57:233-256. [PMID: 37536856 DOI: 10.1016/j.yasu.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
Prehospital resuscitation is a dynamic field now being energized by new technologies and a shift in thinking regarding intravascular resuscitation. Growing evidence discourages use of intravenous (IV) crystalloid and colloid solutions in trauma, whereas blood products, particularly whole blood, are becoming preferred. Although randomized clinical trials validating definitive resuscitative protocols are still lacking, most preclinical and clinical indicators support this approach. In addition, emerging technologies such as external and endovascular hemorrhage control devices and extracorporeal perfusion are now being used routinely, even in the prehospital setting in many countries, generating new lines of emerging investigations for trauma specialists.
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Affiliation(s)
- James E Manning
- Department of Emergency Medicine, University of North Carolina at Chapel Hill, 170 Manning Drive, CB# 7594, Chapel Hill, NC 27599-7594, USA.
| | - Jonathan J Morrison
- Division of Vascular and Endovascular Surgery, Mayo Clinic, 200 First Street, Rochester, MN 55905, USA
| | - Paul E Pepe
- University of Miami, Miller School of Medicine, Miami, FL, USA; Dallas County Public Safety, Emergency Medical Services, Dallas, TX, USA; Global Emergency Medical Services, Suite 307 Point of Americas One, 2100 South Ocean Lane, Fort Lauderdale, FL 33316-3823, USA
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7
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Kent ME, Sciavolino BM, Blickley ZJ, Pasichow SH. Video Laryngoscopy versus Direct Laryngoscopy for Orotracheal Intubation in the Out-of-Hospital Environment: A Systematic Review and Meta-Analysis. PREHOSP EMERG CARE 2023; 28:221-230. [PMID: 37256300 DOI: 10.1080/10903127.2023.2219727] [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: 03/08/2023] [Accepted: 05/26/2023] [Indexed: 06/01/2023]
Abstract
OBJECTIVE To determine the effect of video and direct laryngoscopy on first-pass success rates for out-of-hospital orotracheal intubation. METHODS MEDLINE, Embase, and Cochrane databases were searched from inception to January 2023. Out-of-hospital studies comparing video and direct laryngoscopy on either first-pass or overall intubation success were included. A random effects meta-analysis was performed with a primary outcome of first-pass success stratified by clinician type and laryngoscope blade geometry. The secondary outcomes were overall intubation success stratified by clinician type, and intubation time. All hypotheses and subgroup analyses were determined a priori. RESULTS Twenty-five studies involving 35,489 intubations met inclusion criteria. Substantial heterogeneity (>75%) precluded reporting point estimates for nearly all analyses. For our primary outcome, video laryngoscopy was associated with improved first-pass success in 3/5 physician studies, 4/6 critical care paramedic/registered nurse studies, and 7/10 paramedic studies. Video laryngoscope devices with Macintosh blade geometry were associated with improved first-pass success in 7/10 studies, while devices with hyperangulated geometry were associated with improved first-pass success in 3/7 studies. Overall intubation success was greater with video laryngoscopy in 2/6 studies in the physician subgroup and 9/10 studies in the paramedic subgroup. Video laryngoscopy was not associated with overall intubation success among critical care paramedics/nurses (OR = 1.89, 0.96 to 3.72, I2 = 34%). Lastly, 4/5 studies found video laryngoscopy to be associated with longer intubation times. CONCLUSIONS We found substantial heterogeneity among out-of-hospital studies comparing video laryngoscopy to direct laryngoscopy on first-pass success, overall success, or intubation time. This heterogeneity was not explained with stratification by study design, clinician type, video laryngoscope blade geometry, or leave-one-out meta-analysis. A majority of studies showed that video laryngoscopy was associated with improved first pass success in all subgroups, but only for paramedics and not physicians when looking at overall success. This improvement was more common in studies that used Macintosh blades than those that used hyperangulated blades. Future research should explore the heterogeneity identified in our analysis with an emphasis on differences in training, clinical milieu, and specific video laryngoscope devices.
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Affiliation(s)
- Matthew E Kent
- Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| | | | | | - Scott H Pasichow
- Division of Emergency Medical Services, Department of Emergency Medicine, Southern Illinois University School of Medicine, Springfield, Illinois, USA
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Karlsson T, Gellerfors M, Gustavsson J, Günther M. Permissive hypoventilation equally effective to maintain oxygenation as positive pressure ventilation after porcine class III hemorrhage and whole blood resuscitation. Transfusion 2023; 63 Suppl 3:S213-S221. [PMID: 37070353 DOI: 10.1111/trf.17344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 03/08/2023] [Accepted: 03/12/2023] [Indexed: 04/19/2023]
Abstract
BACKGROUND Prehospital anesthesia may lead to circulatory collapse after severe hemorrhage. It is possible that permissive hypoventilation, refraining from tracheal intubation and accepting spontaneous ventilation, decreases this risk, but it is not known if oxygen delivery can be maintained. We investigated the feasibility of permissive hypoventilation after class III hemorrhage and whole blood resuscitation in three prehospital phases: 15 min on-scene, 30 min whole blood resuscitation, and 45 min after. STUDY DESIGN AND METHODS 19 crossbred swine, mean weight 58.5 kg, were anesthetized with ketamine/midazolam and hemorrhaged to a mean (SD) 1298 (220) mL (33%) and randomized to permissive hypoventilation (n = 9) or positive pressure ventilation with FiO2 21% (n = 10). RESULTS In permissive hypoventilation versus positive pressure ventilation, indexed oxygen delivery (DO2 I) decreased to mean (SD) 4.73 (1.06) versus 3.70 (1.13) mL min-1 kg-1 after hemorrhage and increased to 8.62 (2.09) versus 6.70 (1.56) mL min-1 kg-1 at completion of resuscitation. DO2 I, indexed oxygen consumption (VO2 I), and arterial saturation (SaO2 ) did not differ. Permissive hypoventilation increased the respiratory rate and increased pCO2 . Positive pressure ventilation did not deteriorate circulation. Cardiac index (CI), systolic arterial pressure (SAP), hemoglobin (Hb), and heart rate did not differ. DISCUSSION Permissive hypoventilation and positive pressure ventilation were equally effective to maintain oxygen delivery in all phases. A respiratory rate of 40 was feasible, showing no signs of respiratory fatigue for 90 min, indicating that whole blood resuscitation may be prioritized in select patients with severe hemorrhage and spontaneous breathing.
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Affiliation(s)
- Tomas Karlsson
- Department of Clinical Science and Education, Section of Anesthesiology and Intensive care, Karolinska Institutet, Stockholm, Sweden
| | - Mikael Gellerfors
- Department of Physiology and Pharmacology, Section of Anesthesiology and Intensive care, Karolinska Institutet, Stockholm, Sweden
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
- Swedish Air Ambulance (SLA), Mora, Sweden
- Rapid Response Cars, Stockholm, Sweden
| | - Jenny Gustavsson
- Department of Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Mattias Günther
- Department of Clinical Science and Education, Section of Anesthesiology and Intensive care, Karolinska Institutet, Stockholm, Sweden
- Department of Neuroscience, Karolinska Institutet, Stockholm, Sweden
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9
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Amagasa S, Utsumi S, Moriwaki T, Yasuda H, Kashiura M, Uematsu S, Kubota M. Advanced airway management for pediatric out-of-hospital cardiac arrest: A systematic review and network meta-analysis. Am J Emerg Med 2023; 68:161-169. [PMID: 37027937 DOI: 10.1016/j.ajem.2023.03.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 03/19/2023] [Accepted: 03/23/2023] [Indexed: 03/31/2023] Open
Abstract
OBJECTIVES Although airway management is important in pediatric resuscitation, the effectiveness of bag-mask ventilation (BMV) and advanced airway management (AAM), such as endotracheal intubation (ETI) and supraglottic airway (SGA) devices, for prehospital resuscitation of pediatric out-of-hospital cardiac arrest (OHCA) remains unclear. We aimed to determine the efficacy of AAM during prehospital resuscitation of pediatric OHCA cases. METHODS We searched four databases from their inception to November 2022 and included randomized controlled trials and observational studies with appropriate adjustments for confounders that evaluated prehospital AAM for OHCA in children aged <18 years in quantitative synthesis. We compared three interventions (BMV, ETI, and SGA) via network meta-analysis using the GRADE Working Group approach. The outcome measures were survival and favorable neurological outcomes at hospital discharge or 1 month after cardiac arrest. RESULTS Five studies (including one clinical trial and four cohort studies with rigorous confounding adjustment) involving 4852 patients were analyzed in our quantitative synthesis. Compared with ETI, BMV was associated with survival (relative risk [RR] 0.44 [95% confidence intervals (CI) 0.25-0.77]) (very low certainty). There were no significant association with survival in the other comparisons (SGA vs. BMV: RR 0.62 [95% CI 0.33-1.15] [low certainty], ETI vs. SGA: RR 0.71 [95% CI 0.39-1.32] [very low certainty]). There was no significant association with favorable neurological outcomes in any comparison (ETI vs. BMV: RR 0.33 [95% CI 0.11-1.02]; SGA vs. BMV: RR 0.50 [95% CI 0.14-1.80]; ETI vs. SGA: RR 0.66 [95% CI 0.18-2.46]) (all very low certainty). In the ranking analysis, the hierarches for efficacy for survival and favorable neurological outcome were BMV > SGA > ETI. CONCLUSION Although the available evidence is from observational studies and its certainty is low to very low, prehospital AAM for pediatric OHCA did not improve outcomes.
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10
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Spoelder EJ, Slagt C, Scheffer GJ, van Geffen GJ. Transport of the patient with trauma: a narrative review. Anaesthesia 2022; 77:1281-1287. [PMID: 36089885 PMCID: PMC9826434 DOI: 10.1111/anae.15812] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/22/2022] [Indexed: 01/11/2023]
Abstract
Trauma and injury place a significant burden on healthcare systems. In most high-income countries, well-developed acute pre-hospital and trauma care systems have been established. In Europe, mobile physician-staffed medical teams are available for the most severely injured patients and apply a wide variety of lifesaving interventions at the same time as ensuring patient comfort. In trauma systems providing pre-hospital care, medical interventions are performed earlier in the patient journey and do not affect time to definite care. The mode of transport from the accident scene depends on the organisation of the healthcare system and the level of hospital care to which the patient is transported. This varies from 'scoop and run' to a basic community care setting, to advanced helicopter emergency medical service transport to a level 4 trauma centre. Secondary transport of trauma patients to a higher level of care should be avoided and may lead to a delay in definitive care. Critically injured patients must be accompanied by at least two healthcare professionals, one of whom must be skilled in cardiopulmonary resuscitation and advanced airway management techniques. Ideally, the standard of care provided during transport, including the level of monitoring, should mirror hospital care. Pre-hospital care focuses on the critical care patient, but the majority of injured patients need only close observation and pain management during transport. Providing comfort and preventing additional injury is the responsibility of the whole transport team.
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Affiliation(s)
- E. J. Spoelder
- Department of Anesthesiology, Pain and Palliative MedicineRadboud University Medical CenterNijmegenthe Netherlands,Helicopter Mobile Medical TeamRadboud University Medical CenterNijmegenthe Netherlands
| | - C. Slagt
- Department of Anesthesiology, Pain and Palliative MedicineRadboud University Medical CenterNijmegenthe Netherlands,Helicopter Mobile Medical TeamRadboud University Medical CenterNijmegenthe Netherlands
| | - G. J. Scheffer
- Department of Anesthesiology, Pain and Palliative MedicineRadboud University Medical CenterNijmegenthe Netherlands
| | - G. J. van Geffen
- Department of Anesthesiology, Pain and Palliative MedicineRadboud University Medical CenterNijmegenthe Netherlands,Helicopter Mobile Medical TeamRadboud University Medical CenterNijmegenthe Netherlands
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11
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Tracheal Intubation during Advanced Life Support Using Direct Laryngoscopy versus Glidescope ® Videolaryngoscopy by Clinicians with Limited Intubation Experience: A Systematic Review and Meta-Analysis. J Clin Med 2022; 11:jcm11216291. [PMID: 36362519 PMCID: PMC9655434 DOI: 10.3390/jcm11216291] [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: 08/17/2022] [Revised: 10/19/2022] [Accepted: 10/22/2022] [Indexed: 11/16/2022] Open
Abstract
The use of the Glidescope® videolaryngoscope might improve tracheal intubation performance in clinicians with limited intubation experience, especially during cardiopulmonary resuscitation (CPR). The objective of this systematic review and meta-analysis is to compare direct laryngoscopy to Glidescope® videolaryngoscopy by these clinicians. PubMed/Medline and Embase were searched from their inception to 7 July 2020 for randomized controlled trials, including simulation studies. Studies on adult patients or adult-sized manikins were included when direct laryngoscopy was compared to Glidescope® videolaryngoscopy by clinicians with limited experience in tracheal intubation (<10 intubations per year). The primary outcome was the intubation first-pass success rate. Secondary outcomes were time to successful intubation and chest compression interruption duration during intubation. The risk of bias was assessed with the Cochrane risk of bias tool. Certainty of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE). We included 4 clinical trials with 525 patients and 20 manikin trials with 2547 intubations. Meta-analyses favored Glidescope® videolaryngoscopy over direct laryngoscopy regarding first-pass success (clinical trials: risk ratio [RR] = 1.61; 95% confidence interval [CI]: 1.16−2.23; manikin trials: RR = 1.17; 95% CI: 1.09−1.25). Clinical trials showed a shorter time to achieve successful intubation when using the Glidescope® (mean difference = 17.04 s; 95% CI: 8.51−25.57 s). Chest compression interruption duration was decreased when using the Glidescope® videolaryngoscope. The certainty of evidence ranged from very low to moderate. When clinicians with limited intubation experience have to perform tracheal intubation during advanced life support, the use of the Glidescope® videolaryngoscope improves intubation and CPR performance compared to direct laryngoscopy.
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12
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Carney N, Totten AM, Cheney T, Jungbauer R, Neth MR, Weeks C, Davis-O'Reilly C, Fu R, Yu Y, Chou R, Daya M. Prehospital Airway Management: A Systematic Review. PREHOSP EMERG CARE 2022; 26:716-727. [PMID: 34115570 DOI: 10.1080/10903127.2021.1940400] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 05/31/2021] [Accepted: 06/04/2021] [Indexed: 10/21/2022]
Abstract
Objective: To assess comparative benefits and harms across three airway management approaches (bag valve mask [BVM], supraglottic airway [SGA], and endotracheal intubation [ETI]) used by prehospital emergency medical services (EMS) to treat patients with trauma, cardiac arrest, or medical emergencies, and how they differ based on techniques and devices, EMS personnel and patient characteristics. Data sources: We searched electronic citation databases (Ovid® MEDLINE®, CINAHL®, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, and Scopus®) from 1990 to September 2020. Review methods: We followed Agency for Healthcare Research and Quality Effective Health Care Program Methods guidance. Outcomes included mortality, neurological function, return of spontaneous circulation (ROSC), and successful advanced airway insertion. Meta-analyses using profile-likelihood random effects models were conducted, with analyses stratified by study design, emergency type, and age. Results: We included 99 studies involving 630,397 patients. We found few differences in primary outcomes across airway management approaches. For survival, there was no difference for BVM versus ETI or SGA in adult and pediatric patients with cardiac arrest or trauma. For neurological function, there was no difference for BVM versus ETI and SGA versus ETI in pediatric patients with cardiac arrest. There was no difference in BVM versus ETI in adults with cardiac arrest, but improved neurological function with BVM or ETI versus SGA. There was no difference in ROSC for patients with cardiac arrest for BVM versus ETI or SGA in adults and pediatrics, or SGA versus ETI in pediatrics. There was higher frequency of ROSC in adults with SGA versus ETI. For successful advanced airway insertion, there was higher first-pass success with SGA versus ETI for all patients except adult medical patients (no difference), and no difference in overall success using SGA versus ETI in adults. Conclusions: The currently available evidence does not indicate benefits of more invasive airway approaches based on survival, neurological function, ROSC, or successful airway insertion. Strength of evidence was low or moderate; most included studies were observational. This supports the need for high-quality randomized controlled trials to advance clinical practice and EMS education and policy, and improve patient-centered outcomes.
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13
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Radhakrishnan A, McCahill C, Atwal RS, Lahiri S. A systematic review of the timing of intubation in patients with traumatic brain injury: pre-hospital versus in-hospital intubation. Eur J Trauma Emerg Surg 2022; 49:1199-1215. [PMID: 35962218 DOI: 10.1007/s00068-022-02048-0] [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: 01/07/2022] [Accepted: 06/30/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE The objective of this systematic review was to examine current evidence on the risks versus benefit of pre-hospital intubation when compared with in-hospital intubation in adult patients with traumatic brain injuries. METHODS We conducted electronic searches of PubMed, Medline, Embase, CIANHL and the Cochrane library up to March 2021. Data extracted compared mortality, length of hospital and intensive care stay, pneumonia and functional outcomes in traumatic brain injured patients undergoing pre-hospital intubation versus in-hospital intubation. The risk of bias was assessed using the Grading of Recommendations Assessment, Development and Evaluation. RESULTS Ten studies including 25,766 patients were analysed. Seven were retrospective studies, two prospective cohort studies and one randomised control study. The mean mortality rate in patients who underwent pre-hospital intubation was 44.5% and 31.98% for in-hospital intubation. The odds ratio for an effect of pre-hospital intubation on mortality ranged from 0.31 (favouring in-hospital intubation) to 3.99 (favouring pre-hospital). The overall quality of evidence is low; however, the only randomised control study showed an improved functional outcome for pre-hospital intubation at 6 months. CONCLUSIONS The existing evidence does not support widespread pre-hospital intubation in all traumatic brain injured patients. This does not, however, contradict the need for the intervention when there is severe airway compromise; instead, it must be assessed by experienced personnel if a time critical transfer to hospital is more advantageous. Favourable neurological outcomes highlighted by the randomised control trial favours pre-hospital intubation, but further research is required in this field.
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Affiliation(s)
| | - Claire McCahill
- Anaesthetic Department, Great Ormond Street Hospital, London, WC1N 3JH, UK
| | | | - Sumitra Lahiri
- Anaesthetic Department, The Royal London Hospital, London, E1 1FR, UK
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14
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Medication-Facilitated Advanced Airway Management with First-Line Use of a Supraglottic Device - A One-Year Quality Assurance Review. Prehosp Disaster Med 2022; 37:561-565. [PMID: 35587719 PMCID: PMC9280059 DOI: 10.1017/s1049023x22000802] [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] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Airway management is a controversial topic in modern Emergency Medical Services (EMS) systems. Among many concerns regarding endotracheal intubation (ETI), unrecognized esophageal intubation and observations of unfavorable neurologic outcomes in some studies raise the question of whether alternative airway techniques should be first-line in EMS airway management protocols. Supraglottic airway devices (SADs) are simpler to use, provide reliable oxygenation and ventilation, and may thus be an alternative first-line airway device for paramedics. In 2019, Alachua County Fire Rescue (ACFR; Alachua, Florida USA) introduced a novel protocol for advanced airway management emphasizing first-line use of a second-generation SAD (i-gel) for patients requiring medication-facilitated airway management (referred to as "rapid sequence airway" [RSA] protocol). STUDY OBJECTIVE This was a one-year quality assurance review of care provided under the RSA protocol looking at compliance and first-pass success rate of first-line SAD use. METHODS Records were obtained from the agency's electronic medical record (EMR), searching for the use of the RSA protocol, advanced airway devices, or either ketamine or rocuronium. If available, hospital follow-up data regarding patient condition and emergency department (ED) airway exchange were obtained. RESULTS During the first year, 33 advanced airway attempts were made under the protocol by 23 paramedics. Overall, compliance with the airway device sequence as specified in the protocol was 72.7%. When ETI was non-compliantly used as first-line airway device, the first-pass success rate was 44.4% compared to 87.5% with adherence to first-line SAD use. All prehospital SADs were exchanged in the ED in a delayed fashion and almost exclusively per physician preference alone. In no case was the SAD exchanged for suspected dislodgement evidenced by lack of capnography. CONCLUSION First-line use of a SAD was associated with a high first-pass attempt success rate in a real-life cohort of prehospital advanced airway encounters. No SAD required emergent exchange upon hospital arrival.
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15
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Braithwaite S, Stephens C, Remick K, Barrett W, Guyette FX, Levy M, Colwell C. Prehospital Trauma Airway Management: An NAEMSP Position Statement and Resource Document. PREHOSP EMERG CARE 2022; 26:64-71. [PMID: 35001817 DOI: 10.1080/10903127.2021.1994069] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Definitive management of trauma is not possible in the out-of-hospital environment. Rapid treatment and transport of trauma casualties to a trauma center are vital to improve survival and outcomes. Prioritization and management of airway, oxygenation, ventilation, protection from gross aspiration, and physiologic optimization must be balanced against timely patient delivery to definitive care. The optimal prehospital airway management strategy for trauma has not been clearly defined; the best choice should be patient-specific. NAEMSP recommends:The approach to airway management and the choice of airway interventions in a trauma patient requires an iterative, individualized assessment that considers patient, clinician, and environmental factors.Optimal trauma airway management should focus on meeting the goals of adequate oxygenation and ventilation rather than on specific interventions. Emergency medical services (EMS) clinicians should perform frequent reassessments to determine if there is a need to escalate from basic to advanced airway interventions.Management of immediately life-threatening injuries should take priority over advanced airway insertion.Drug-assisted airway management should be considered within a comprehensive algorithm incorporating failed airway options and balanced management of pain, agitation, and delirium.EMS medical directors must be highly engaged in assuring clinician competence in trauma airway assessment, management, and interventions.
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16
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Andrei S, Isac S, Carstea M, Martac C, Mihalcea L, Buzatu C, Ionescu D, Georgescu DE, Droc G. Isolated liver trauma: A clinical perspective in a non-emergency center for liver surgery. Exp Ther Med 2021; 23:39. [PMID: 34849154 PMCID: PMC8613533 DOI: 10.3892/etm.2021.10961] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 09/21/2021] [Indexed: 12/16/2022] Open
Abstract
The management of liver trauma is, currently, still heterogeneous ranging from conservative to major invasive liver resections. When appropriate, these cases should be referred to a regional care center. The objective of this study was to analyze the expertise of a non-emergency center for liver surgery from Romania after initial stabilization in county hospitals. This study is a monocentric, retrospective, observational study, including 12 patients with hepatic trauma after a car accident, admitted between 2015 and 2019. We analyzed various clinical and biochemical data as independent variables, and the main outcome was considered the intensive care unit (ICU) length of stay. Our results revealed that intubation status at admission, norepinephrine infusion during surgery, hyperfibrinogenemia and duration of mechanical ventilation in patients with isolated liver trauma were correlated with prolonged ICU length of stay. Further prospective, more comprehensive studies are needed in order to evaluate the exact prognostic factors in terms of short- and long-term mortality.
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Affiliation(s)
- Stefan Andrei
- Department of Anesthesiology and Intensive Care I, 'Fundeni' Clinical Institute, 022328 Bucharest, Romania.,Department of Anesthesiology and Intensive Care, Faculty of Medicine, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Sebastian Isac
- Department of Anesthesiology and Intensive Care I, 'Fundeni' Clinical Institute, 022328 Bucharest, Romania.,Department of Physiology II and Neurosciences, Faculty of Medicine, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Maricica Carstea
- Department of Anesthesiology and Intensive Care I, 'Fundeni' Clinical Institute, 022328 Bucharest, Romania
| | - Cristina Martac
- Department of Anesthesiology and Intensive Care I, 'Fundeni' Clinical Institute, 022328 Bucharest, Romania
| | - Lucian Mihalcea
- Department of Anesthesiology and Intensive Care I, 'Fundeni' Clinical Institute, 022328 Bucharest, Romania
| | - Cristina Buzatu
- Department of Anesthesiology and Intensive Care I, 'Fundeni' Clinical Institute, 022328 Bucharest, Romania
| | - Dorin Ionescu
- Repartment of Medical Semiology, Discipline of Internal Medicine I and Nephrology, Faculty of Medicine, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania.,Department of Nephrology, Bucharest Emergency University Hospital, 050098 Bucharest, Romania
| | - Dragos Eugen Georgescu
- Department of Surgery, Faculty of Medicine, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Gabriela Droc
- Department of Anesthesiology and Intensive Care I, 'Fundeni' Clinical Institute, 022328 Bucharest, Romania.,Department of Anesthesiology and Intensive Care, Faculty of Medicine, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania
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17
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Alenazi A, Alotaibi B, Saleh N, Alshibani A, Alharbi M, Aljerian N, Alharthy N, Alsomali S. Perception and success rate of using advanced airway management by hospital-based paramedics in the Kingdom of Saudi Arabia. Br Paramed J 2021; 6:24-30. [PMID: 34970079 DOI: 10.29045/14784726.2021.12.6.3.24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Objective The study aimed to measure the success rate of pre-hospital tracheal intubation (TI) and supraglottic airway devices (SADs) performed by paramedics for adult patients and to assess the perception of paramedics of advanced airway management. Method The study consisted of two phases: phase 1 was a retrospective analysis to assess the TI and SADs' success rates when applied by paramedics for adult patients aged >14 years from 2012 to 2017, and phase 2 was a distributed questionnaire to assess paramedics' perception of advanced airway management. Result In phase 1, 24 patients met our inclusion criteria. Sixteen (67%) patients had TI, of whom five had failed TI but then were successfully managed using SADs. The TI success rate was 69% from the first two attempts compared to SADs (100% from first attempt). In phase 2, 63/90 (70%) paramedics responded to the questionnaire, of whom 60 (95%) completed it. Forty-eight (80%) paramedics classified themselves to be moderately or very competent with advanced airway management. However, most of them (80%) performed only 1-5 TIs or SADs a year. Conclusion Hospital-based paramedics (i.e. paramedics who are working at hospitals and not in the ambulance service, and who mostly respond to small restricted areas in Saudi Arabia) handled few patients requiring advanced airway management and had a higher competency level with SADs than with TI. The study findings could be impacted by the low sample size. Future research is needed on the success rate and impact on outcomes of using pre-hospital advanced airway management, and on the challenges of mechanical ventilation use during interfacility transfer.
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Affiliation(s)
- Amani Alenazi
- King Saud bin Abdulaziz University for Health Sciences (KSAU-HS)
| | | | | | | | - Meshal Alharbi
- King Saud bin Abdulaziz University for Health Sciences (KSAU-HS)
| | | | - Nesrin Alharthy
- King Saud bin Abdulaziz University for Health Sciences (KSAU-HS)
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18
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Kottmann A, Krüger AJ, Sunde GA, Røislien J, Heltne JK, Carron PN, Lockey D, Sollid SJM. Establishing quality indicators for prehospital advanced airway management: a modified nominal group technique consensus process. Br J Anaesth 2021; 128:e143-e150. [PMID: 34674835 PMCID: PMC8792832 DOI: 10.1016/j.bja.2021.08.031] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 08/05/2021] [Accepted: 08/20/2021] [Indexed: 12/20/2022] Open
Abstract
Background Pre-hospital advanced airway management is a complex intervention composed of numerous steps, interactions, and variables that can be delivered to a high standard in the pre-hospital setting. Standard research methods have struggled to evaluate this complex intervention because of considerable heterogeneity in patients, providers, and techniques. In this study, we aimed to develop a set of quality indicators to evaluate pre-hospital advanced airway management. Methods We used a modified nominal group technique consensus process comprising three email rounds and a consensus meeting among a group of 16 international experts. The final set of quality indicators was assessed for usability according to the National Quality Forum Measure Evaluation Criteria. Results Seventy-seven possible quality indicators were identified through a narrative literature review with a further 49 proposed by panel experts. A final set of 17 final quality indicators composed of three structure-, nine process-, and five outcome-related indicators, was identified through the consensus process. The quality indicators cover all steps of pre-hospital advanced airway management from preoxygenation and use of rapid sequence induction to the ventilatory state of the patient at hospital delivery, prior intubation experience of provider, success rates and complications. Conclusions We identified a set of quality indicators for pre-hospital advanced airway management that represent a practical tool to measure, report, analyse, and monitor quality and performance of this complex intervention.
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Affiliation(s)
- Alexandre Kottmann
- Norwegian Air Ambulance Foundation, Research and Development Department, Oslo, Norway; Lausanne University Hospital, Emergency Department, Lausanne, Switzerland; University of Stavanger, Faculty of Health Sciences, Department of Quality and Health Technology, Stavanger, Norway; Rega - Swiss Air Ambulance, Zürich, Switzerland.
| | - Andreas J Krüger
- Norwegian Air Ambulance Foundation, Research and Development Department, Oslo, Norway; St. Olav University Hospital, Department of Emergency Medicine and Pre-Hospital Services, Trondheim, Norway; Norwegian University of Science and Technology, Institute of Circulation and Medical Imaging, Trondheim, Norway
| | - Geir A Sunde
- Norwegian Air Ambulance Foundation, Research and Development Department, Oslo, Norway; Haukeland University Hospital, Department of Anaesthesia and Intensive Care, Bergen, Norway; Helicopter Emergency Service, Bergen, Norway
| | - Jo Røislien
- Norwegian Air Ambulance Foundation, Research and Development Department, Oslo, Norway; University of Stavanger, Faculty of Health Sciences, Department of Quality and Health Technology, Stavanger, Norway
| | - John-Kenneth Heltne
- Haukeland University Hospital, Department of Anaesthesia and Intensive Care, Bergen, Norway; Helicopter Emergency Service, Bergen, Norway; University of Bergen, Department of Clinical Medicine, Bergen, Norway
| | | | - David Lockey
- Emergency Medical Retrieval and Transfer Service, Dafen, UK; Royal College of Surgeons of Edinburgh, Faculty of Pre-hospital Care, Edinburgh, UK
| | - Stephen J M Sollid
- Norwegian Air Ambulance Foundation, Research and Development Department, Oslo, Norway; University of Stavanger, Faculty of Health Sciences, Department of Quality and Health Technology, Stavanger, Norway
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19
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Lim C, Ko HS, Cho S, Ohu I, Wang HE, Griffin R, Kerrey B, Carlson JN. Development of a Hand Motion-based Assessment System for Endotracheal Intubation Training. J Med Syst 2021; 45:81. [PMID: 34259931 DOI: 10.1007/s10916-021-01755-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 07/08/2021] [Indexed: 10/20/2022]
Abstract
Endotracheal intubation (ETI) is a procedure to manage and secure an unconscious patient's airway. It is one of the most critical skills in emergency or intensive care. Regular training and practice are required for medical providers to maintain proficiency. Currently, ETI training is assessed by human supervisors who may make inconsistent assessments. This study aims at developing an automated assessment system that analyzes ETI skills and classifies a trainee into an experienced or a novice immediately after training. To make the system more available and affordable, we investigate the feasibility of utilizing only hand motion features as determining factors of ETI proficiency. To this end, we extract 18 features from hand motion in time and frequency domains, and also 12 force features for comparison. Subsequently, feature selection algorithms are applied to identify an ideal feature set for developing classification models. Experimental results show that an artificial neural network (ANN) classifier with five hand motion features selected by a correlation-based algorithm achieves the highest accuracy of 91.17% while an ANN with five force features has only 80.06%. This study corroborates that a simple assessment system based on a small number of hand motion features can be effective in assisting ETI training.
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Affiliation(s)
- Chiho Lim
- Department of Industrial Engineering, Southern Illinois University, Edwardsville, IL, 62026, USA
| | - Hoo Sang Ko
- Department of Industrial Engineering, Southern Illinois University, Edwardsville, IL, 62026, USA.
| | - Sohyung Cho
- Department of Industrial Engineering, Southern Illinois University, Edwardsville, IL, 62026, USA
| | - Ikechukwu Ohu
- Industrial Engineering, Gannon University, Erie, PA, 16541, USA
| | - Henry E Wang
- Department of Emergency Medicine, University of Texas Health Science Center At Houston, Houston, TX, 77030, USA
| | | | - Benjamin Kerrey
- Division of Emergency Medicine, Cincinnati Children's Hospital, Cincinnati, OH, 45229, USA
| | - Jestin N Carlson
- Department of Emergency Medicine, Saint Vincent Health System, Erie, PA, 16544, USA.,Patient Simulation Center, Gannon University, Erie, PA, 16541, USA
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20
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Abstract
Introduction Endobronchial intubation is a known complication of endotracheal intubation with significant associated morbidity and a reported incidence of up to 15%. In the out-of-hospital setting, paramedics must rely on bedside techniques to confirm appropriate endotracheal tube (ETT) depth. The present real-world practices of paramedics have not been described in this regard. Methods A multi-point survey was distributed to paramedics within the state of Pennsylvania. Participants were scored on the basis of their use of techniques to confirm ETT depth with the highest sensitivity to exclude endobronchial intubation. Results Four-hundred nine (409) responses from 111 emergency medical services (EMS) agencies were recorded. Participants were found to evaluate endotracheal tube depth via auscultation of bilateral breath sounds (91.7% of participants), visualization of the endotracheal tube as it advances 1-2 cm beyond the vocal cords (82.9%), observation of symmetrical chest rise (80.0%), and by securing the ETT at 21 and 23 cm at the incisors for women and men (18.6%). Experienced paramedics were more likely to use the 21/23 cm rule (p=0.039). Participants did not employ the cumulative use of these techniques (p < 0.001) as per a method that has been previously described to exclude endobronchial intubation with 100% sensitivity. Conclusion These data suggest that paramedics are not presently employing the most sensitive techniques to exclude endobronchial intubation. An educational initiative and protocol update may be beneficial.
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Affiliation(s)
- Jeffrey S Lubin
- Department of Emergency Medicine, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
| | - Evan Fox
- Department of Emergency Medicine, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
| | - Scott Leroux
- Prehospital Care, Tower Health Reading Hospital, Reading, USA
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21
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Orso D, Vetrugno L, Federici N, D'Andrea N, Bove T. Endotracheal intubation to reduce aspiration events in acutely comatose patients: a systematic review. Scand J Trauma Resusc Emerg Med 2020; 28:116. [PMID: 33303004 PMCID: PMC7726605 DOI: 10.1186/s13049-020-00814-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Accepted: 11/24/2020] [Indexed: 01/08/2023] Open
Abstract
Background It is customary to believe that a patient with a Glasgow Coma Scale (GCS) score less than or equal to 8 should be intubated to avoid aspiration. We conducted a systematic review to establish if patients with GCS ≤ 8 for trauma or non-traumatic emergencies and treated in the acute care setting (e.g., Emergency Department or Pre-hospital environment) should be intubated to avoid aspiration or aspiration pneumonia/pneumonitis, and consequently, reduce mortality. Methods We searched six databases, Pubmed, Embase, Scopus, SpringerLink, Cochrane Library, and Ovid Emcare, from April 15th to October 14th, 2020, for studies involving low GCS score patients of whom the risk of aspiration and related complications was assessed. Results Thirteen studies were included in the final analysis (7 on non-traumatic population, 4 on trauma population, 1 pediatric and 1 adult mixed case studies). For the non-traumatic cases, two prospective studies and one retrospective study found no difference in aspiration risk between intubated and non-intubated patients. Two retrospective studies reported a reduction in the risk of aspiration in the intubated patient group. For traumatic cases, the study that considered the risk of aspiration did not show any differences between the two groups. A study on adult mixed cases found no difference in the incidence of aspiration among intubated and non-intubated patients. A study on pediatric patients found increased mortality for intubated versus non-intubated non-traumatic patients with a low GCS score. Conclusion Whether intubation results in a reduction in the incidence of aspiration events and whether these are more frequent in patients with low GCS scores are not yet established. The paucity of evidence on this topic makes clinical trials justifiable and necessary. Trial registration Prospero registration number: CRD42020136987. Supplementary Information The online version contains supplementary material available at 10.1186/s13049-020-00814-w.
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Affiliation(s)
- Daniele Orso
- Department of Medicine, University of Udine, P.le S. Maria della Misericordia 15, 33100, Udine, Italy
| | - Luigi Vetrugno
- Department of Medicine, University of Udine, P.le S. Maria della Misericordia 15, 33100, Udine, Italy. .,Department of Anesthesia and Intensive Care Medicine, ASUFC University Hospital "Santa Maria della Misericordia" of Udine, Udine, Italy.
| | - Nicola Federici
- Department of Medicine, University of Udine, P.le S. Maria della Misericordia 15, 33100, Udine, Italy
| | - Natascia D'Andrea
- Department of Medicine, University of Udine, P.le S. Maria della Misericordia 15, 33100, Udine, Italy
| | - Tiziana Bove
- Department of Medicine, University of Udine, P.le S. Maria della Misericordia 15, 33100, Udine, Italy.,Department of Anesthesia and Intensive Care Medicine, ASUFC University Hospital "Santa Maria della Misericordia" of Udine, Udine, Italy
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22
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Abstract
Objectives To construct a highly detailed yet practical, attainable roadmap for enhancing the likelihood of neurologically intact survival following sudden cardiac arrest. Design Setting and Patients Population-based outcomes following out-of-hospital cardiac arrest were collated for 10 U.S. counties in Alaska, California, Florida, Ohio, Minnesota, Utah, and Washington. The 10 identified emergency medical services systems were those that had recently reported significant improvements in neurologically intact survival after introducing a more comprehensive approach involving citizens, hospitals, and evolving strategies for incorporating technology-based, highly choreographed care and training. Detailed inventories of in-common elements were collated from the ten 9-1-1 agencies and assimilated. For reference, combined averaged outcomes for out-of-hospital cardiac arrest occurring January 1, 2017, to February 28, 2018, were compared with concurrent U.S. outcomes reported by the well-established Cardiac Arrest Registry to Enhance Survival. Interventions Most commonly, interventions and components from the ten 9-1-1 systems consistently included extensive public cardiopulmonary resuscitation training, 9-1-1 system-connected smart phone applications, expedited dispatcher procedures, cardiopulmonary resuscitation quality monitoring, mechanical cardiopulmonary resuscitation, devices for enhancing negative intrathoracic pressure regulation, extracorporeal membrane oxygenation protocols, body temperature management procedures, rapid cardiac angiography, and intensive involvement of medical directors, operational and quality assurance officers, and training staff. Measurements and Main Results Compared with Cardiac Arrest Registry to Enhance Survival (n = 78,704), the cohorts from the 10 emergency medical services agencies examined (n = 2,911) demonstrated significantly increased likelihoods of return of spontaneous circulation (mean 37.4% vs 31.5%; p < 0.001) and neurologically favorable hospital discharge, particularly after witnessed collapses involving bystander cardiopulmonary resuscitation and shockable cardiac rhythms (mean 10.7% vs 8.4%; p < 0.001; and 41.6% vs 29.2%; p < 0.001, respectively). Conclusions The likelihood of neurologically favorable survival following out-of-hospital cardiac arrest can improve substantially in communities that conscientiously and meticulously introduce a well-sequenced, highly choreographed, system-wide portfolio of both traditional and nonconventional approaches to training, technologies, and physiologic management. The commonalities found in the analyzed systems create a compelling case that other communities can also improve out-of-hospital cardiac arrest outcomes significantly by conscientiously exploring and adopting similar bundles of system organization and care.
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Effect of noninvasive ventilation on intubation risk in prehospital patients with acute cardiogenic pulmonary edema: a retrospective study. Eur J Emerg Med 2020; 27:54-58. [PMID: 31295150 PMCID: PMC6946102 DOI: 10.1097/mej.0000000000000616] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim of this study was to assess the effect of prehospital noninvasive ventilation for acute cardiogenic pulmonary edema on endotracheal intubation rate and on ICU admission rate. METHODS We carried out a retrospective study on patients' prehospital files between 2007 and 2010 (control period), and between 2013 and 2016 (intervention period). Adult patients were included if a diagnosis of acute cardiogenic pulmonary edema was made by the prehospital physician. Exclusion criteria were a Glasgow coma scale score less than 9 or any other respiratory diagnosis. We analyzed the association between noninvasive ventilation implementation and endotracheal intubation or ICU admission with univariable and multivariable regression models. The primary outcome was prehospital endotracheal intubation rate. Secondary outcomes were admission to an ICU, prehospital intervention length, and 30-day mortality. RESULTS A total of 1491 patients were included. Noninvasive ventilation availability was associated with a significant decrease in endotracheal intubation rate (2.6% in the control versus 0.7% in the intervention period), with an adjusted odds ratio (OR) of 0.3 [95% confidence interval (CI), 0.1-0.7]. There was a decrease in ICU admissions (18.6% in the control versus 13.0% in the intervention period) with an adjusted OR of 0.6 (95% CI, 0.5-0.9). There was no significant change in 30-day mortality (11.2% in the control versus 11.0% in the intervention period, P = 0.901). CONCLUSION In our physician-staffed prehospital system, use of noninvasive ventilation for acute cardiogenic pulmonary edema decreased both endotracheal intubation and ICU admission rates.
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Schweizer MA, Wampler D, Lu K, Oh AS, Rahm SJ, Studer NM, Cunningham CW. Prehospital Battlefield Casualty Intervention Decision Cognitive Study. Mil Med 2020; 185:274-278. [PMID: 32074373 DOI: 10.1093/milmed/usz226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Airway compromise is the third most common cause of preventable battlefield death. Surgical cricothyroidotomy (SC) is recommended by Tactical Combat Casualty Care (TCCC) guidelines when basic airway maneuvers fail. This is a descriptive analysis of the decision-making process of prehospital emergency providers to perform certain airway interventions. METHODS We conducted a scenario-based survey using two sequential video clips of an explosive injury event. The answers were used to conduct descriptive analyses and multivariable logistic regression models to estimate the association between the choice of intervention and training factors. RESULTS There were 254 respondents in the survey, 176 (69%) of them were civilians and 78 (31%) were military personnel. Military providers were more likely to complete TCCC certification (odds ratio [OR]: 13.1; confidence interval [CI]: 6.4-26.6; P-value < 0.001). The SC was the most frequently chosen intervention after each clip (29.92% and 22.10%, respectively). TCCC-certified providers were more likely to choose SC after viewing the two clips (OR: 1.9; CI: 1.2-3.2; P-value: 0.009), even after controlling for relevant factors (OR: 2.3; CI: 1.1-4.8; P-value: 0.033). CONCLUSIONS Military providers had a greater propensity to be certified in TCCC, which was found to increase their likelihood to choose the SC in early prehospital emergency airway management.
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Affiliation(s)
- Marc A Schweizer
- Department of Defense Joint Trauma System, 3698 Chambers Pass Bldg. 3611, Joint Base San Antonio Fort Sam Houston, TX 78234-6315
| | - David Wampler
- Department of Emergency Health Sciences, University of Texas Health San Antonio, 4201 Medical Dr. Suite 120, San Antonio, TX 78229
| | - Kevin Lu
- Emergency Department, Medical College of Georgia at Augusta University, 1465 Laney Walker Blvd., Augusta, GA 30912
| | - Andrew S Oh
- 1st Battalion, 1st Special Forces Group (Airborne), Okinawa, Japan
| | - Stephen J Rahm
- Centre for Emergency Health Sciences, 353 Rodeo Dr., Spring Branch, TX 78070
| | - Nicholas M Studer
- Department of Emergency Medicine, Brooke Army Medical Center, MCHE-ZSE-R, Joint Base San Antonio Fort Sam Houston, 3551 Roger Brooke Dr., San Antonio, TX 78234-4551
| | - Cord W Cunningham
- Department of Defense Joint Trauma System, 3698 Chambers Pass Bldg. 3611, Joint Base San Antonio Fort Sam Houston, TX 78234-6315
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Girrbach F, Bercker S, Hinkelbein J. Alternative Hilfsmittel zum Atemwegsmanagement in der Notfallmedizin: Pro und Kontra. Notf Rett Med 2019. [DOI: 10.1007/s10049-019-00658-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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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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Jarvis JL, Wampler D, Wang HE. Association of patient age with first pass success in out-of-hospital advanced airway management. Resuscitation 2019; 141:136-143. [DOI: 10.1016/j.resuscitation.2019.06.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Revised: 05/28/2019] [Accepted: 06/03/2019] [Indexed: 12/16/2022]
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Early On-Scene Management of Pediatric Out-of-Hospital Cardiac Arrest Can Result in Improved Likelihood for Neurologically-Intact Survival. Resuscitation 2018; 135:162-167. [PMID: 30412719 DOI: 10.1016/j.resuscitation.2018.11.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Revised: 10/08/2018] [Accepted: 11/02/2018] [Indexed: 11/22/2022]
Abstract
AIM To evaluate the frequency of neurologically-intact survival (SURV) following pediatric out-of-hospital cardiac arrest (POHCA) when comparing traditional early evacuation strategies to those emphasizing resuscitation efforts being performed immediately on-scene. METHODS Before 2014, emergency medical services (EMS) crews in a county-wide EMS agency provided limited treatment for POHCA on-scene and rapidly transported patients to appropriate hospitals. After 2014, training strongly concentrated upon EMS provider comfort levels with on-scene resuscitation efforts including methods to expedite protocols on-site and control positive-pressure ventilation. Frequency of SURV (hospital discharge) was compared for the two years prior to initiating the immediate on-scene care strategy to the ensuing two years following implementation. RESULTS Between 01/01/2012 and 12/31/2015, 94 children experienced POHCA. There were no significant differences before and after the on-scene focus in terms of age, sex, etiology, presenting electrocardiograph, drug infusions or bystander-performed cardiopulmonary resuscitation and total scene times actually remained similar (14.3 vs. 17.67 minutes). SURV increased significantly upon implementation of the immediate on-scene management strategy and was sustained over the next two years (0.0% to 23%; p = 0.0013). Though statistically-indeterminate in this analysis, the improvement was associated with a shorter mean time to epinephrine administration among resuscitated patients (16.6 vs. 7.65 minutes). CONCLUSION Facilitating immediate on-scene management of POHCA can result in improvements in life-saving. Although a historically-controlled evaluation, the compelling appearance of neurologically-intact survivors was immediate and sustained. Targeted training, more efficient, physiologically-driven procedures, and trusted encouragement from supervisors, likely played the most significant roles and not necessarily extended scene times.
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Abstract
AbstractIntroductionRoutine advanced airway usage by Emergency Medical Services (EMS) has had conflicting reports of being the secure airway of choice in pediatric patients.Hypothesis/ProblemThe primary objective was to describe a pediatric cohort requiring airway management upon their arrival directly from the scene to two pediatric emergency departments (PEDs). A secondary objective included assessing for associations in EMS airway management and patient outcomes.MethodsRetrospective data from the health record were reviewed, including EMS reports, for all arrivals less than 18 years old to two PEDs who required airway support between May 2015 and July 2016. The EMS management was classified as basic (oxygen, continuous positive airway pressure [CPAP], or bag-valve-mask [BVM]) or advanced (supraglottic or endotracheal intubation [ETI]) based on EMS documentation. Outcomes included oxygenation as documented by receiving PED and hospital mortality.ResultsIn total, 104 patients with an average age 5.9 (SD=5.1) years and median EMS Glasgow Coma Scale (GCS) of nine (IQR 3-14) were enrolled. Basic management was utilized in 70% of patients (passive: n=49; CPAP: n=2; BVM: n=22). Advanced management was utilized in 30% of patients (supraglottic: n=4; ETI: n=27). Proper ETI placement was achieved in 48% of attempted patients, with 41% of patients undergoing multiple attempts. Inadequate oxygenation occurred in 18% of patients, including four percent of ETI attempts, nine percent of BVM patients, and 32% of passively managed patients. Adjusted for EMS GCS, medical patients undergoing advanced airway management experienced higher risk of mortality (risk-ratio [RR] 2.98; 95% CI, 1.18-7.56; P=.021).ConclusionWith exception to instances where ETI is clearly indicated, BVM management is effective in pediatric patients who required airway support, with ETI providing no definitive protective factors. Most of the patients who exhibited inadequate oxygenation upon arrival to the PED received only passive oxygenation by EMS.TweedJ,GeorgeT,GreenwellC,VinsonL.Prehospital airway management examined at two pediatric emergency centers.Prehosp Disaster Med.2018;33(5):532–538.
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Crewdson K, Rehn M, Lockey D. Airway management in pre-hospital critical care: a review of the evidence for a 'top five' research priority. Scand J Trauma Resusc Emerg Med 2018; 26:89. [PMID: 30342543 PMCID: PMC6196027 DOI: 10.1186/s13049-018-0556-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Accepted: 10/04/2018] [Indexed: 12/21/2022] Open
Abstract
The conduct and benefit of pre-hospital advanced airway management and pre-hospital emergency anaesthesia have been widely debated for many years. In 2011, prehospital advanced airway management was identified as a ‘top five’ in physician-provided pre-hospital critical care. This article summarises the evidence for and against this intervention since 2011 and attempts to address some of the more controversial areas of this topic.
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Affiliation(s)
- K Crewdson
- Department of Anaesthesia, North Bristol NHS Trust, Southmead Hospital, Southmead Way, Bristol, BS10 5NB, UK.
| | - M Rehn
- Department of Research, Norwegian Air Ambulance Foundation, Drøbak, Norway.,Pre-hospital Division, Air Ambulance Department, Oslo University Hospital, Oslo, Norway.,Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
| | - D Lockey
- Department of Anaesthesia, North Bristol NHS Trust, Southmead Hospital, Southmead Way, Bristol, BS10 5NB, UK.,Department of Research, Norwegian Air Ambulance Foundation, Drøbak, Norway.,Bristol University, Bristol, UK
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EBM vs. EBM: combining evidence-based and experienced-based medicine in resuscitation research. Curr Opin Crit Care 2018; 23:199-203. [PMID: 28398910 DOI: 10.1097/mcc.0000000000000413] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW To discuss the clear rationale for evidence-based medicine (EvBM) in the challenging realms of resuscitation research, yet also provide case examples in which even the well designed, multicentered randomized clinical trial may have had unrecognized limitations, and thus misleading results. This is where experienced-based medicine (ExBM) helps to resolve the issue. RECENT FINDINGS Recent publications have brought to task the conclusions drawn from various clinical trials of resuscitative interventions. These articles have indicated that some major clinical trials that later determined the universal guidelines for resuscitative protocols may have been affected by unrecognized confounding variables, effect modifiers and other problems such as delayed timing. Many interventions, deemed to be ineffective because of these study factors, may actually have lifesaving effects that would have been confirmed had the proper circumstances been in place. With the right mindset, the clinician-researcher can often identify and address those situations. SUMMARY When clinical trials indicate ineffectiveness of an intervention that worked very well in other circumstances, both preclinical and clinical, clinician-investigators should continue to re-search the issues and not always take conclusions at face value.
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Supportive technology in the resuscitation of out-of-hospital cardiac arrest patients. Curr Opin Crit Care 2018; 23:209-214. [PMID: 28383297 DOI: 10.1097/mcc.0000000000000409] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
PURPOSE OF REVIEW To discuss the increasing value of technological tools to assess and augment the quality of cardiopulmonary resuscitation (CPR) and, in turn, improve chances of surviving out-of-hospital cardiac arrest (OHCA). RECENT FINDINGS After decades of disappointing survival rates, various emergency medical services systems worldwide are now seeing a steady rise in OHCA survival rates guided by newly identified 'sweet spots' for chest compression rate and chest compression depth, aided by monitoring for unnecessary pauses in chest compressions as well as methods to better ensure full-chest recoil after compressions. Quality-assurance programs facilitated by new technologies that monitor chest compression rate, chest compression depth, and/or frequent pauses have been shown to improve the quality of CPR. Further aided by other technologies that enhance flow or better identify the best location for hand placement, the future outlook for better survival is even more promising, particularly with the potential use of another technology - extracorporeal membrane oxygenation for OHCA. SUMMARY After 5 decades of focus on manual chest compressions for CPR, new technologies for monitoring, guiding, and enhancing CPR performance may enhance outcomes from OHCA significantly in the coming years.
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Fevang E, Haaland K, Røislien J, Bjørshol CA. Semiprone position is superior to supine position for paediatric endotracheal intubation during massive regurgitation, a randomized crossover simulation trial. BMC Anesthesiol 2018; 18:10. [PMID: 29347980 PMCID: PMC5774096 DOI: 10.1186/s12871-018-0474-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 01/12/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Endotracheal intubation of patients with massive regurgitation represents a challenge in emergency airway management. Gastric contents tend to block suction catheters, and few treatment alternatives exist. Based on a technique that was successfully applied in our district, we wanted to examine if endotracheal intubation would be easier and quicker to perform when the patient is turned over to a semiprone position, as compared to the supine position. METHODS In a randomized crossover simulation trial, a child manikin with on-going regurgitation was intubated both in the supine and semiprone positions. Endpoints were experienced difficulty with the procedure and time to intubation, as well as visually confirmed intubation and first-pass success rate. RESULTS Intubation in the semiprone position was significantly easier and faster compared to the supine position; the median experienced difficulty on a visual analogue scale was 27 and 65, respectively (p = 0.004), and the median time to intubation was 26 and 45 s, respectively (p = 0.001). There were no significant differences in frequency of visually confirmed intubation (16 and 18, p = 0.490) of first-pass success rate (17 and 18, p = 1.000). CONCLUSION In this experiment, endotracheal intubation during massive regurgitation with the patient in the semiprone position was significantly easier and quicker to perform than in the supine position. Endotracheal intubation in the semiprone position can provide a quick rescue method in situations where airway management is hindered by massive regurgitation, and it represents a possible supplement to current airway management training.
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Affiliation(s)
- Espen Fevang
- Department of Research and Development, Norwegian Air Ambulance Foundation, Drøbak, Norway. .,Department of Anesthesiology and Intensive Care, Stavanger University Hospital, Stavanger, Norway.
| | - Karin Haaland
- Department of Health Studies, University of Stavanger, Stavanger, Norway
| | - Jo Røislien
- Department of Health Studies, University of Stavanger, Stavanger, Norway
| | - Conrad Arnfinn Bjørshol
- Department of Anesthesiology and Intensive Care, Stavanger University Hospital, Stavanger, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
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Geeraerts T, Velly L, Abdennour L, Asehnoune K, Audibert G, Bouzat P, Bruder N, Carrillon R, Cottenceau V, Cotton F, Courtil-Teyssedre S, Dahyot-Fizelier C, Dailler F, David JS, Engrand N, Fletcher D, Francony G, Gergelé L, Ichai C, Javouhey É, Leblanc PE, Lieutaud T, Meyer P, Mirek S, Orliaguet G, Proust F, Quintard H, Ract C, Srairi M, Tazarourte K, Vigué B, Payen JF. Management of severe traumatic brain injury (first 24hours). Anaesth Crit Care Pain Med 2017; 37:171-186. [PMID: 29288841 DOI: 10.1016/j.accpm.2017.12.001] [Citation(s) in RCA: 99] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The latest French Guidelines for the management in the first 24hours of patients with severe traumatic brain injury (TBI) were published in 1998. Due to recent changes (intracerebral monitoring, cerebral perfusion pressure management, treatment of raised intracranial pressure), an update was required. Our objective has been to specify the significant developments since 1998. These guidelines were conducted by a group of experts for the French Society of Anesthesia and Intensive Care Medicine (Société francaise d'anesthésie et de réanimation [SFAR]) in partnership with the Association de neuro-anesthésie-réanimation de langue française (ANARLF), The French Society of Emergency Medicine (Société française de médecine d'urgence (SFMU), the Société française de neurochirurgie (SFN), the Groupe francophone de réanimation et d'urgences pédiatriques (GFRUP) and the Association des anesthésistes-réanimateurs pédiatriques d'expression française (ADARPEF). The method used to elaborate these guidelines was the Grade® method. After two Delphi rounds, 32 recommendations were formally developed by the experts focusing on the evaluation the initial severity of traumatic brain injury, the modalities of prehospital management, imaging strategies, indications for neurosurgical interventions, sedation and analgesia, indications and modalities of cerebral monitoring, medical management of raised intracranial pressure, management of multiple trauma with severe traumatic brain injury, detection and prevention of post-traumatic epilepsia, biological homeostasis (osmolarity, glycaemia, adrenal axis) and paediatric specificities.
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Affiliation(s)
- Thomas Geeraerts
- Pôle anesthésie-réanimation, Inserm, UMR 1214, Toulouse neuroimaging center, ToNIC, université Toulouse 3-Paul Sabatier, CHU de Toulouse, 31059 Toulouse, France.
| | - Lionel Velly
- Service d'anesthésie-réanimation, Aix-Marseille université, CHU Timone, Assistance publique-Hôpitaux de Marseille, 13005 Marseille, France
| | - Lamine Abdennour
- Département d'anesthésie-réanimation, groupe hospitalier Pitié-Salpêtrière, AP-HP, 75013 Paris, France
| | - Karim Asehnoune
- Service d'anesthésie et de réanimation chirurgicale, Hôtel-Dieu, CHU de Nantes, 44093 Nantes cedex 1, France
| | - Gérard Audibert
- Département d'anesthésie-réanimation, hôpital Central, CHU de Nancy, 54000 Nancy, France
| | - Pierre Bouzat
- Pôle anesthésie-réanimation, CHU Grenoble-Alpes, 38043 Grenoble cedex 9, France
| | - Nicolas Bruder
- Service d'anesthésie-réanimation, Aix-Marseille université, CHU Timone, Assistance publique-Hôpitaux de Marseille, 13005 Marseille, France
| | - Romain Carrillon
- Service d'anesthésie-réanimation, hôpital neurologique Pierre-Wertheimer, groupement hospitalier Est, hospices civils de Lyon, 69677 Bron, France
| | - Vincent Cottenceau
- Service de réanimation chirurgicale et traumatologique, SAR 1, hôpital Pellegrin, CHU de Bordeaux, Bordeaux, France
| | - François Cotton
- Service d'imagerie, centre hospitalier Lyon Sud, hospices civils de Lyon, 69495 Pierre-Bénite cedex, France
| | - Sonia Courtil-Teyssedre
- Service de réanimation pédiatrique, hôpital Femme-Mère-Enfant, hospices civils de Lyon, 69677 Bron, France
| | | | - Frédéric Dailler
- Service d'anesthésie-réanimation, hôpital neurologique Pierre-Wertheimer, groupement hospitalier Est, hospices civils de Lyon, 69677 Bron, France
| | - Jean-Stéphane David
- Service d'anesthésie réanimation, centre hospitalier Lyon Sud, hospices civils de Lyon, 69495 Pierre-Bénite, France
| | - Nicolas Engrand
- Service d'anesthésie-réanimation, Fondation ophtalmologique Adolphe de Rothschild, 75940 Paris cedex 19, France
| | - Dominique Fletcher
- Service d'anesthésie réanimation chirurgicale, hôpital Raymond-Poincaré, université de Versailles Saint-Quentin, AP-HP, Garches, France
| | - Gilles Francony
- Pôle anesthésie-réanimation, CHU Grenoble-Alpes, 38043 Grenoble cedex 9, France
| | - Laurent Gergelé
- Département d'anesthésie-réanimation, CHU de Saint-Étienne, 42055 Saint-Étienne, France
| | - Carole Ichai
- Service de réanimation médicochirurgicale, UMR 7275, CNRS, Sophia Antipolis, hôpital Pasteur, CHU de Nice, 06000 Nice, France
| | - Étienne Javouhey
- Service de réanimation pédiatrique, hôpital Femme-Mère-Enfant, hospices civils de Lyon, 69677 Bron, France
| | - Pierre-Etienne Leblanc
- Département d'anesthésie-réanimation, hôpital de Bicêtre, hôpitaux universitaires Paris-Sud, AP-HP, Le Kremlin-Bicêtre, France; Équipe TIGER, CNRS 1072-Inserm 5288, service d'anesthésie, centre hospitalier de Bourg en Bresse, centre de recherche en neurosciences, Lyon, France
| | - Thomas Lieutaud
- UMRESTTE, UMR-T9405, IFSTTAR, université Claude-Bernard de Lyon, Lyon, France; Service d'anesthésie-réanimation, hôpital universitaire Necker-Enfants-Malades, université Paris Descartes, AP-HP, Paris, France
| | - Philippe Meyer
- EA 08 Paris-Descartes, service de pharmacologie et évaluation des thérapeutiques chez l'enfant et la femme enceinte, 75743 Paris cedex 15, France
| | - Sébastien Mirek
- Service d'anesthésie-réanimation, CHU de Dijon, Dijon, France
| | - Gilles Orliaguet
- EA 08 Paris-Descartes, service de pharmacologie et évaluation des thérapeutiques chez l'enfant et la femme enceinte, 75743 Paris cedex 15, France
| | - François Proust
- Service de neurochirurgie, hôpital Hautepierre, CHU de Strasbourg, 67098 Strasbourg, France
| | - Hervé Quintard
- Service de réanimation médicochirurgicale, UMR 7275, CNRS, Sophia Antipolis, hôpital Pasteur, CHU de Nice, 06000 Nice, France
| | - Catherine Ract
- Département d'anesthésie-réanimation, hôpital de Bicêtre, hôpitaux universitaires Paris-Sud, AP-HP, Le Kremlin-Bicêtre, France; Équipe TIGER, CNRS 1072-Inserm 5288, service d'anesthésie, centre hospitalier de Bourg en Bresse, centre de recherche en neurosciences, Lyon, France
| | - Mohamed Srairi
- Pôle anesthésie-réanimation, Inserm, UMR 1214, Toulouse neuroimaging center, ToNIC, université Toulouse 3-Paul Sabatier, CHU de Toulouse, 31059 Toulouse, France
| | - Karim Tazarourte
- SAMU/SMUR, service des urgences, hospices civils de Lyon, hôpital Édouard-Herriot, 69437 Lyon cedex 03, France
| | - Bernard Vigué
- Département d'anesthésie-réanimation, hôpital de Bicêtre, hôpitaux universitaires Paris-Sud, AP-HP, Le Kremlin-Bicêtre, France; Équipe TIGER, CNRS 1072-Inserm 5288, service d'anesthésie, centre hospitalier de Bourg en Bresse, centre de recherche en neurosciences, Lyon, France
| | - Jean-François Payen
- Pôle anesthésie-réanimation, CHU Grenoble-Alpes, 38043 Grenoble cedex 9, France
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Fevang E, Perkins Z, Lockey D, Jeppesen E, Lossius HM. A systematic review and meta-analysis comparing mortality in pre-hospital tracheal intubation to emergency department intubation in trauma patients. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:192. [PMID: 28756778 PMCID: PMC5535283 DOI: 10.1186/s13054-017-1787-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Accepted: 07/05/2017] [Indexed: 11/17/2022]
Abstract
Background Pre-hospital endotracheal intubation is frequently used for trauma patients in many emergency medical systems. Despite a wide range of publications in the field, it is debated whether the intervention is associated with a favourable outcome, when compared to more conservative airway measures. Methods A systematic literature search was conducted to identify interventional and observational studies where the mortality rates of adult trauma patients undergoing pre-hospital endotracheal intubation were compared to those undergoing emergency department intubation. Results Twenty-one studies examining 35,838 patients were included. The median mortality rate in patients undergoing pre-hospital intubation was 48% (range 8–94%), compared to 29% (range 6–67%) in patients undergoing intubation in the emergency department. Odds ratios were in favour of emergency department intubation both in crude and adjusted mortality, with 2.56 (95% CI: 2.06, 3.18) and 2.59 (95% CI: 1.97, 3.39), respectively. The overall quality of evidence is very low. Twelve of the twenty-one studies found a significantly higher mortality rate after pre-hospital intubation, seven found no significant differences, one found a positive effect, and for one study an analysis of the mortality rate was beyond the scope of the article. Conclusions The rationale for wide and unspecific indications for pre-hospital intubation seems to lack support in the literature, despite several publications involving a relatively large number of patients. Pre-hospital intubation is a complex intervention where guidelines and research findings should be approached cautiously. The association between pre-hospital intubation and a higher mortality rate does not necessarily contradict the importance of the intervention, but it does call for a thorough investigation by clinicians and researchers into possible causes for this finding. Electronic supplementary material The online version of this article (doi:10.1186/s13054-017-1787-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Espen Fevang
- Department of Research and Development, Norwegian Air Ambulance Foundation, Drøbak, Norway. .,Department of Anaesthesiology and Intensive Care, Stavanger University Hospital, Stavanger, Norway.
| | - Zane Perkins
- Blizard Institute, Centre for Trauma Sciences, Queen Mary University, London, UK.,London's Air Ambulance, The Royal London Hospital, London, UK
| | - David Lockey
- Blizard Institute, Centre for Trauma Sciences, Queen Mary University, London, UK.,London's Air Ambulance, The Royal London Hospital, London, UK.,Department of Health Sciences, University of Stavanger, Stavanger, Norway
| | - Elisabeth Jeppesen
- Department of Research and Development, Norwegian Air Ambulance Foundation, Drøbak, Norway.,Department of Health Sciences, University of Stavanger, Stavanger, Norway
| | - Hans Morten Lossius
- Department of Research and Development, Norwegian Air Ambulance Foundation, Drøbak, Norway.,Department of Health Sciences, University of Stavanger, Stavanger, Norway
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Vithalani VD, Vlk S, Davis SQ, Richmond NJ. Unrecognized failed airway management using a supraglottic airway device. Resuscitation 2017; 119:1-4. [PMID: 28750882 DOI: 10.1016/j.resuscitation.2017.07.019] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Revised: 06/29/2017] [Accepted: 07/21/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND 911 Emergency Medical Services (EMS) systems utilize supraglottic devices for either primary advanced airway management, or for airway rescue following failed attempts at direct laryngoscopy endotracheal intubation. There is, however, limited data on objective confirmation of supraglottic airway placement in the prehospital environment. Furthermore, the ability of EMS field providers to recognize a misplaced airway is unknown. METHODS Retrospective review of patients who underwent airway management using the King LTS-D supraglottic airway in a large urban EMS system, between 3/1/15-9/30/2015. Subjective success was defined as documentation of successful airway placement by the EMS provider. Objective success was confirmed by review of waveform capnography, with the presence of a 4-phase waveform greater than 5mmHg. Sensitivity and specificity of the field provider's assessment of success were then calculated. RESULTS A total of 344 supraglottic airway attempts were reviewed. No patients met obvious death criteria. 269 attempts (85.1%) met criteria for both subjective and objective success. 19 attempts (5.6%) were recognized failures by the EMS provider. 47 (13.8%) airways were misplaced but unrecognized by the EMS provider. 4 attempts (1.2%) were correctly placed but misidentified as failures, leading to the unnecessary removal and replacement of the airway. Sensitivity of the provider's assessment was 98.5%; specificity was 28.7%. CONCLUSION The use of supraglottic airway devices results in unrecognized failed placement. Appropriate utilization and review of waveform capnography may remedy a potential blind-spot in patient safety, and systemic monitoring/feedback processes may therefore be used to prevent unrecognized misplaced airways.
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Affiliation(s)
- Veer D Vithalani
- Office of the Medical Director, Emergency Physicians Advisory Board, MedStar Mobile Healthcare, Area Metropolitan EMS Authority, 2900 Alta Mere Drive, Fort Worth, TX 76116, United States.
| | - Sabrina Vlk
- Office of the Medical Director, Emergency Physicians Advisory Board, MedStar Mobile Healthcare, Area Metropolitan EMS Authority, 2900 Alta Mere Drive, Fort Worth, TX 76116, United States.
| | - Steven Q Davis
- Office of the Medical Director, Emergency Physicians Advisory Board, MedStar Mobile Healthcare, Area Metropolitan EMS Authority, 2900 Alta Mere Drive, Fort Worth, TX 76116, United States.
| | - Neal J Richmond
- Office of the Medical Director, Emergency Physicians Advisory Board, MedStar Mobile Healthcare, Area Metropolitan EMS Authority, 2900 Alta Mere Drive, Fort Worth, TX 76116, United States.
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I-gel O 2 resus pack, a rescue device in case of severe facial injury and difficult intubation. Am J Emerg Med 2017; 35:931-932. [DOI: 10.1016/j.ajem.2017.01.057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2017] [Revised: 01/25/2017] [Accepted: 01/26/2017] [Indexed: 11/22/2022] Open
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Dyson K, Bray JE, Smith K, Bernard S, Straney L, Nair R, Finn J. Paramedic Intubation Experience Is Associated With Successful Tube Placement but Not Cardiac Arrest Survival. Ann Emerg Med 2017; 70:382-390.e1. [PMID: 28347556 DOI: 10.1016/j.annemergmed.2017.02.002] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 01/02/2017] [Accepted: 01/31/2017] [Indexed: 10/19/2022]
Abstract
STUDY OBJECTIVE Paramedic experience with intubation may be an important factor in skill performance and patient outcomes. Our objective is to examine the association between previous intubation experience and successful intubation. In a subcohort of out-of-hospital cardiac arrest cases, we also measure the association between patient survival and previous paramedic intubation experience. METHODS We analyzed data from Ambulance Victoria electronic patient care records and the Victorian Ambulance Cardiac Arrest Registry for January 1, 2008, to September 26, 2014. For each patient case, we defined intubation experience as the number of intubations attempted by each paramedic in the previous 3 years. Using logistic regression, we estimated the association between intubation experience and (1) successful intubation and (2) first-pass success. In the out-of-hospital cardiac arrest cohort, we determined the association between previous intubation experience and patient survival. RESULTS During the 6.7-year study period, 769 paramedics attempted intubation in 14,857 patients. Paramedics typically performed 3 intubations per year (interquartile range 1 to 6). Most intubations were successful (95%), including 80% on the first attempt. Previous intubation experience was associated with intubation success (odds ratio 1.04; 95% confidence interval 1.03 to 1.05) and intubation first-pass success (odds ratio 1.02; 95% confidence interval 1.01 to 1.03). In the out-of-hospital cardiac arrest subcohort (n=9,751), paramedic intubation experience was not associated with patient survival. CONCLUSION Paramedics in this Australian cohort performed few intubations. Previous experience was associated with successful intubation. Among out-of-hospital cardiac arrest patients for whom intubation was attempted, previous paramedic intubation experience was not associated with patient survival.
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Affiliation(s)
- Kylie Dyson
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Ambulance Victoria, Victoria, Australia.
| | - Janet E Bray
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Alfred Hospital, Melbourne, Victoria, Australia; School of Nursing, Midwifery and Paramedicine, Curtin University, Perth, Western Australia, Australia
| | - Karen Smith
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Ambulance Victoria, Victoria, Australia; Discipline of Emergency Medicine, University of Western Australia, Perth, Australia
| | - Stephen Bernard
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Ambulance Victoria, Victoria, Australia; Alfred Hospital, Melbourne, Victoria, Australia
| | - Lahn Straney
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | | | - Judith Finn
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Discipline of Emergency Medicine, University of Western Australia, Perth, Australia; School of Nursing, Midwifery and Paramedicine, Curtin University, Perth, Western Australia, Australia
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Ono Y, Shinohara K, Goto A, Yano T, Sato L, Miyazaki H, Shimada J, Tase C. Are prehospital airway management resources compatible with difficult airway algorithms? A nationwide cross-sectional study of helicopter emergency medical services in Japan. J Anesth 2015; 30:205-14. [PMID: 26715428 PMCID: PMC4819484 DOI: 10.1007/s00540-015-2124-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Accepted: 12/13/2015] [Indexed: 11/29/2022]
Abstract
Purpose
Immediate access to the equipment required for difficult airway management (DAM) is vital. However, in Japan, data are scarce regarding the availability of DAM resources in prehospital settings. The purpose of this study was to determine whether Japanese helicopter emergency medical services (HEMS) are adequately equipped to comply with the DAM algorithms of Japanese and American professional anesthesiology societies. Methods This nationwide cross-sectional study was conducted in May 2015. Base hospitals of HEMS were mailed a questionnaire about their airway management equipment and back-up personnel. Outcome measures were (1) call for help, (2) supraglottic airway device (SGA) insertion, (3) verification of tube placement using capnometry, and (4) the establishment of surgical airways, all of which have been endorsed in various airway management guidelines. The criteria defining feasibility were the availability of (1) more than one physician, (2) SGA, (3) capnometry, and (4) a surgical airway device in the prehospital setting. Results Of the 45 HEMS base hospitals questioned, 42 (93.3 %) returned completed questionnaires. A surgical airway was practicable by all HEMS. However, in the prehospital setting, back-up assistance was available in 14.3 %, SGA in 16.7 %, and capnometry in 66.7 %. No HEMS was capable of all four steps. Conclusion In Japan, compliance with standard airway management algorithms in prehospital settings remains difficult because of the limited availability of alternative ventilation equipment and back-up personnel. Prehospital health care providers need to consider the risks and benefits of performing endotracheal intubation in environments not conducive to the success of this procedure. Electronic supplementary material The online version of this article (doi:10.1007/s00540-015-2124-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Yuko Ono
- Emergency and Critical Care Medical Center, Fukushima Medical University Hospital, 1 Hikarigaoka, Fukushima, 960-1295, Japan. .,Department of Anesthesiology, Ohta General Hospital Foundation, Ohta Nishinouchi Hospital, Koriyama, Japan.
| | - Kazuaki Shinohara
- Department of Anesthesiology, Ohta General Hospital Foundation, Ohta Nishinouchi Hospital, Koriyama, Japan
| | - Aya Goto
- Department of Public Health, School of Medicine, Fukushima Medical University, Fukushima, Japan
| | - Tetsuhiro Yano
- Emergency and Critical Care Medical Center, Fukushima Medical University Hospital, 1 Hikarigaoka, Fukushima, 960-1295, Japan
| | - Lubna Sato
- Emergency and Critical Care Medical Center, Fukushima Medical University Hospital, 1 Hikarigaoka, Fukushima, 960-1295, Japan
| | - Hiroyuki Miyazaki
- Emergency and Critical Care Medical Center, Fukushima Medical University Hospital, 1 Hikarigaoka, Fukushima, 960-1295, Japan
| | - Jiro Shimada
- Emergency and Critical Care Medical Center, Fukushima Medical University Hospital, 1 Hikarigaoka, Fukushima, 960-1295, Japan
| | - Choichiro Tase
- Emergency and Critical Care Medical Center, Fukushima Medical University Hospital, 1 Hikarigaoka, Fukushima, 960-1295, Japan
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