Emergency department airway management in the UK

Characteristics, physiology and mortality of intubated patients in an emergency care population in sub-Saharan Africa: a prospective cohort study from Kigali, Rwanda

BACKGROUND

Formalised emergency departments (ED) are in early development in sub-Saharan Africa and there are limited data on emergency airway management in those settings. This study evaluates characteristics and outcomes of ED endotracheal intubation, as well as risk factors for mortality, at a teaching hospital in Rwanda.

METHODS

This was a prospective observational study of consecutive patients requiring endotracheal intubation at the University Teaching Hospital of Kigali ED conducted between 1 January and 31 December 2017. A standardised data collection tool was used to record patient demographics, preintubation clinical presentation, indication for intubation, vital signs. medications and equipment used, and periintubation complications. The primary outcome was in-hospital mortality. Univariate associations were determined for risks of mortality.

RESULTS

Of 198 intubations were analysed, 72.7% were male and the median age was 35 years (IQR 23-51). Airway protection was the most common indication for intubation (73.7%). Rapid sequence intubation was performed in 74.2% of cases; sedative-only facilitated intubation in 20.6% and non-drug assisted in 5.2%. The most common agents used were Ketamine for sedation (85.4%) and vecuronium for paralysis (65.7%). All patients were successfully intubated within three attempts, 85.4% on the first attempt. During intubation, 23.1% of patients experienced hypoxia, 6.7% aspiration and 3.6% cardiac arrest. Median ED length of stay was 2 days. Outcome data were available for 164 patients of whom 67.7% died. Bonferroni-corrected univariate analysis demonstrated that mortality was associated with higher postintubation shock index (p=0.0007) and lower postintubation systolic blood pressure (SBP) (p=0.0006).

CONCLUSION

The first-attempt and overall success rates for intubation in this ED in Rwanda were comparable to those in high-income countries (HIC). Mortality postintubation is associated with lower postintubation SBP and higher postintubation shock index. The high complication and mortality rates suggest the need for better resources and training to address differences in compared with HIC.

Trauma airway management in emergency departments: a multicentre, prospective, observational study in Japan

OBJECTIVES

Although successful airway management is essential for emergency trauma care, comprehensive studies are limited. We sought to characterise current trauma care practice of airway management in the emergency departments (EDs) in Japan.

DESIGN

Analysis of data from a prospective, observational, multicentre registry-the Japanese Emergency Airway Network (JEAN) registry.

SETTING

13 academic and community EDs from different geographic regions across Japan.

PARTICIPANTS

723 trauma patients who underwent emergency intubation from March 2010 through August 2012.

OUTCOME MEASURES

ED characteristics, patient and operator demographics, methods of airway management, intubation success or failure at each attempt and adverse events.

RESULTS

A total of 723 trauma patients who underwent emergency intubation were eligible for the analysis. Traumatic cardiac arrest comprised 32.6% (95% CI 29.3% to 36.1%) of patients. Rapid sequence intubation (RSI) was the initial method chosen in 23.9% (95% CI 21.0% to 27.2%) of all trauma patients and in 35.5% (95% CI 31.4% to 39.9%) of patients without cardiac arrest. Overall, intubation was successful in ≤3 attempts in 96% of patients (95% CI 94.3% to 97.2%). There was a wide variation in the initial methods of intubation; RSI as the initial method was performed in 0-50.9% of all trauma patients among 12 EDs. Similarly, there was a wide variation in success rates and adverse event rates across the EDs. Success rates varied between 35.5% and 90.5% at the first attempt, and 85.1% and 100% within three attempts across the 12 EDs.

CONCLUSIONS

In this multicentre prospective study in Japan, we observed a high overall success rate in airway management during trauma care. However, the methods of intubation and success rates were highly variable among hospitals.

Prospective observational study of the practice of endotracheal intubation in the emergency department of a tertiary hospital in Sydney, Australia

OBJECTIVE

To describe the practice of endotracheal intubation in the ED of a tertiary hospital in Australia, with particular emphasis on the indication, staff seniority, technique, number of attempts required and the rate of complications.

METHODS

A prospective observational study.

RESULTS

Two hundred and ninety-five intubations occurred in 18 months. Trauma was the indication for intubation in 30.5% (95% CI 25.3-36.0) and medical conditions in 69.5% (95% CI 64.0-74.5). Emergency physicians were team leaders in 69.5% (95% CI 64.0-74.5), whereas ED registrars or senior Resident Medical Officers made the first attempt at intubation in 88.1% (95% CI 83.9-91.3). Difficult laryngoscopy occurred in 24.0% (95% CI 19.5-29.3) of first attempts, whereas first pass success occurred in 83.4% (95% CI 78.7-87.2). A difficult intubation occurred in 3.4% (95% CI 1.9-6.1) and all patients were intubated orally in five or less attempts. A bougie was used in 30.9% (95% CI 25.8-36.5) of first attempts, whereas a stylet in 37.5% (95% CI 32.1-43.3). Complications occurred in 29.0% (95% CI 23.5-34.1) of the patients, with desaturation the commonest in 15.7% (95% CI 11.9-20.5). Cardiac arrest occurred in 2.2% (95% CI 0.9-4.4) after intubation. No surgical airways were undertaken.

CONCLUSION

Although the majority of results are comparable with overseas data, the rates of difficult laryngoscopy and desaturation are higher than previously reported. We feel that this data has highlighted the need for practice improvement within our department and we would encourage all those who undertake emergent airway management to audit their own practice of this high-risk procedure.

Emergency airway management: training and experience of chief residents in otolaryngology and anesthesiology

BACKGROUND

Resident training in emergency airway management is not well described. We quantified training and exposure to airway emergencies among graduating Otolaryngology-Head and Neck Surgery and Anesthesiology residents.

METHODS

The methods used for this study were a national web-based survey of chief residents.

RESULTS

The response rate was 52% (otolaryngology) and 60% (anesthesiology). More otolaryngology residents rotated on anesthesiology than anesthesia residents on otolaryngology (33% vs 8%). More anesthesiology chiefs never performed an emergency surgical airway than otolaryngology (92% vs 18%). The most common self-rating of competency was "9," with 82% overall self-rating "8" or higher (10 = "totally competent").

CONCLUSION

Otolaryngology and anesthesiology emergency airway management experience/training is heterogeneous and nonstandardized. Many chief residents graduate with little exposure to airway emergencies, especially surgical airways. Resident confidence levels are high despite minimal experience. This high confidence-low experience dichotomy may reflect novice overconfidence and suggests the need for improved training methods.

Tracheal intubation in the emergency department: the Scottish district hospital perspective

BACKGROUND

Tracheal intubation is the accepted gold standard for emergency department (ED) airway management. It may be performed by both anaesthetists and emergency physicians (EPs), with or without drugs.

OBJECTIVE

To characterise intubation practice in a busy district general hospital ED in Scotland over 40 months between 2003 and 2006.

SETTING

Crosshouse Hospital, a 450-bed district general hospital serving a mixed urban and rural population; annual ED census 58,000 patients.

METHODS

Prospective observational study using data collection sheets prepared by the Scottish Trauma Audit Group. Proformas were completed at the time of intubation and checked by investigators. Rapid-sequence induction (RSI) was defined as the co-administration of an induction agent and suxamethonium.

RESULTS

234 intubations over 40 months, with a mean of 6 per month. EPs attempted 108 intubations (46%). Six patients in cardiac arrest on arrival were intubated without drugs. 29 patients were intubated after a gas induction or non-RSI drug administration. RSI was performed on 199 patients. Patients with trauma constituted 75 (38%) of the RSI group. 29 RSIs (15%) were immediate (required on arrival at the ED) and 154 (77%) were urgent (required within 30 min of arrival at the ED). EPs attempted RSI in 88 (44%) patients and successfully intubated 85 (97%). Anaesthetists attempted RSI in 111 (56%) patients and successfully intubated 108 (97%). Anaesthetists had a higher proportion of good views at first laryngoscopy and there was a trend to a higher rate of successful intubation at the first attempt for anaesthetists. Complication rates were comparable for the two specialties.

CONCLUSIONS

Tracheal intubations using RSI in the ED are performed by EPs almost as often as by anaesthetists in this district hospital. Overall success and complication rates are comparable for the two specialties. Laryngoscopy training and the need to achieve intubation at the first (optimum) attempt needs to be emphasised in EP airway training.