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Mathews AC, McLeod K, Lacy AJ, High K, Brywczynski J, McKinney JJ, Wrenn JO, Jones ID, Stubblefield WB. Characteristics and outcomes of prehospital and emergency department surgical airways. J Am Coll Emerg Physicians Open 2024; 5:e13136. [PMID: 38524352 PMCID: PMC10958099 DOI: 10.1002/emp2.13136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 02/12/2024] [Accepted: 02/19/2024] [Indexed: 03/26/2024] Open
Abstract
Objectives The surgical airway is a high acuity, low occurrence procedure. Data on the complications and outcomes of surgical airways are limited. Our primary objective was to describe immediate complications, late complications, and clinical outcomes of patients who underwent a surgical airway procedure in the prehospital or emergency department (ED) setting. Methods We conducted a retrospective chart review of patients ≥14 years at an academic medical center who underwent a surgical airway procedure in the ED, the prehospital setting, or at a referring ED prior to interfacility transfer. We identified cases from keyword searches of prehospital text pages and hospital electronic medical records from June 1, 2008 to July 1, 2022. Manual chart review was used to confirm inclusion and determine patient and procedure characteristics. Outcomes included immediate complications, delayed in-hospital complications, and neurologic disability as defined by Modified Rankin Score (mRS) at discharge. Results We identified 63 patients (34 prehospital, 11 ED, and 18 referring ED). Immediate complications included mainstem intubation (46.0%) and bleeding that required direct pressure (23.4%). Overall, 29 patients (46%) died after arrival to the hospital. Of the patients surviving to hospital admission, 25 (48%) had an airway-related complication. Nine complications were deemed directly related to technical components of the procedure. Of the patients who survived to discharge, 18 (52.9%) had poor neurologic function (mRS 4-5). Conclusion Procedural complications, mortality, and poor neurologic function were common following a surgical airway procedure in the prehospital or ED setting. Most patients surviving to discharge had a moderate to severe neurologic disability.
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Affiliation(s)
- Amanda C. Mathews
- Department of Emergency MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Kaitlin McLeod
- Department of Emergency MedicineVanderbilt University School of MedicineNashvilleTennesseeUSA
| | - Aaron J. Lacy
- Department of Emergency MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Kevin High
- Department of Emergency MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Jeremy Brywczynski
- Department of Emergency MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Jared J. McKinney
- Department of Emergency MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Jesse O. Wrenn
- Department of Emergency MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Ian D. Jones
- Department of Emergency MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
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Londoño M, Nahmias J, Dolich M, Lekawa M, Kong A, Schubl S, Inaba K, Grigorian A. Development of a novel scoring tool to predict the need for early cricothyroidotomy in trauma patients. Surg Open Sci 2023; 16:58-63. [PMID: 37808420 PMCID: PMC10550758 DOI: 10.1016/j.sopen.2023.09.017] [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: 06/01/2023] [Revised: 08/08/2023] [Accepted: 09/17/2023] [Indexed: 10/10/2023] Open
Abstract
Background The lack of a widely-used tool for predicting early cricothyroidotomy in trauma patients prompted us to develop the Cricothyroidotomy After Trauma (CAT) score. We aimed to predict the need for cricothyroidotomy within one hour of trauma patient arrival. Methods Derivation and validation datasets were obtained from the Trauma Quality Improvement Program (TQIP) database. Logistic modeling identified predictors, and weighted averages were used to create the CAT score. The score's performance was assessed using AUROC. Results Among 1,373,823 derivation patients, <1 % (n = 339) underwent cricothyroidotomy within one hour. The CAT score, comprising nine predictors, achieved an AUROC of 0.88. Severe neck injury and gunshot wound were the strongest predictors. Cricothyroidotomy rates increased from 0.4 % to 9.3 % at scores of 5 and 8, respectively. In the validation set, the CAT tool yielded an AUROC of 0.9. Conclusion The CAT score is a validated tool for predicting the need for early cricothyroidotomy in trauma patients. Further research is necessary to enhance its utility and assess its value in trauma care.
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Affiliation(s)
- Mary Londoño
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, Orange, CA, USA
| | - Jeffry Nahmias
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, Orange, CA, USA
| | - Matthew Dolich
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, Orange, CA, USA
| | - Michael Lekawa
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, Orange, CA, USA
| | - Allen Kong
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, Orange, CA, USA
| | - Sebastian Schubl
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, Orange, CA, USA
| | - Kenji Inaba
- University of Southern California, Department of Surgery, Los Angeles, CA, USA
| | - Areg Grigorian
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, Orange, CA, USA
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Risavi BL, Carlson J, Reese EM, Raleigh A, Wallis J. Prehospital Surgical Airway Management Skills in a Rural Emergency Medical Service System. Cureus 2023; 15:e41864. [PMID: 37581144 PMCID: PMC10423438 DOI: 10.7759/cureus.41864] [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: 06/14/2023] [Accepted: 07/14/2023] [Indexed: 08/16/2023] Open
Abstract
BACKGROUND The objective of this study is to describe the education, training, and use of prehospital surgical airways in a rural Emergency Medical Service (EMS) system. MATERIALS AND METHODS We conducted an internet-based survey instrument of all advanced life support (ALS) EMS agencies in a seven-county rural EMS system in Pennsylvania. ALS agencies were queried regarding basic demographic information as well as the number of surgical airways performed in the previous 10 years as well as the education and training of EMS providers in surgical airways. RESULTS The survey was completed by 11 of 20 ALS EMS agencies in our region (55% rate of return). The content and frequency of training varied considerably among EMS agencies. Only four prehospital surgical airways were performed during the study period. One patient survived to hospital discharge to home. CONCLUSION Surgical airways are an infrequently performed procedure in the rural prehospital setting. There is no universally accepted standard for teaching or evaluating the competency of this potentially life-saving procedure. Further efforts to establish a core educational curriculum appear warranted.
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Affiliation(s)
- Brian L Risavi
- Emergency Medicine, Lake Erie College of Osteopathic Medicine, Erie, USA
| | | | - Erin M Reese
- Emergency Medicine, UPMC (University of Pittsburgh Medical Center) Hamot, Erie, USA
| | - Aaron Raleigh
- Emergency Medicine, Lake Erie College of Osteopathic Medicine, Erie, USA
| | - Jordan Wallis
- Emergency Medicine, Lake Erie College of Osteopathic Medicine, Erie, USA
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van Schuppen H, Boomars R, Kooij FO, den Tex P, Koster RW, Hollmann MW. Optimizing airway management and ventilation during prehospital advanced life support in out-of-hospital cardiac arrest: A narrative review. Best Pract Res Clin Anaesthesiol 2020; 35:67-82. [PMID: 33742579 DOI: 10.1016/j.bpa.2020.11.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 11/03/2020] [Accepted: 11/06/2020] [Indexed: 12/20/2022]
Abstract
Airway management and ventilation are essential components of cardiopulmonary resuscitation to achieve oxygen delivery in order to prevent hypoxic injury and increase the chance of survival. Weighing the relative benefits and downsides, the best approach is a staged strategy; start with a focus on high-quality chest compressions and defibrillation, then optimize mask ventilation while preparing for advanced airway management with a supraglottic airway device. Endotracheal intubation can still be indicated, but has the largest downsides of all advanced airway techniques. Whichever stage of airway management, ventilation and chest compression quality should be closely monitored. Capnography has many advantages and should be used routinely. Optimizing ventilation strategies, harmonizing ventilation with mechanical chest compression devices, and implementation in complex and stressful environments are challenges we need to face through collaborative innovation, research, and implementation.
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Affiliation(s)
- Hans van Schuppen
- Amsterdam UMC, University of Amsterdam, Department of Anesthesiology, Meibergdreef 9, Amsterdam, the Netherlands.
| | - René Boomars
- Regional Ambulance Service Utrecht (RAVU), Jan van Eijcklaan 6, Bilthoven, the Netherlands
| | - Fabian O Kooij
- Amsterdam UMC, University of Amsterdam, Department of Anesthesiology, Meibergdreef 9, Amsterdam, the Netherlands; Amsterdam UMC, Vrije Universiteit Amsterdam, Helicopter Mobile Medical Team (MMT), De Boelelaan 1117, Amsterdam, the Netherlands
| | - Paul den Tex
- University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
| | - Rudolph W Koster
- Amsterdam UMC, University of Amsterdam, Amsterdam Resuscitation Studies (ARREST), Meibergdreef 9, Amsterdam, the Netherlands
| | - Markus W Hollmann
- Amsterdam UMC, University of Amsterdam, Department of Anesthesiology, Meibergdreef 9, Amsterdam, the Netherlands
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Shaw MR, Hughes KE. High Risk, Low Volume: Evaluation of a Reusable Cricothyrotomy Model in a Paramedic Difficult Airway Training Course. Air Med J 2020; 39:380-382. [PMID: 33012476 DOI: 10.1016/j.amj.2020.05.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2020] [Revised: 04/20/2020] [Accepted: 05/25/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Cricothyrotomy is rarely performed by prehospital providers. Developing this low-frequency, high-acuity skill and maintaining competence is difficult; thus, using a realistic training model is paramount to successful training. The aim of this study was to evaluate a 3-dimensional-printed bleeding cricothyrotomy trainer in increasing paramedic comfort level and procedural competence as defined by completing the procedure unassisted without error. METHODS Model implementation took place during mandatory biannual difficult airway training courses for all paramedics employed by a hospital-based ambulance agency. Participating paramedics performed 3 surgical cricothyrotomies using the bleeding trainer and subsequently completed an anonymous written survey that evaluated the comfort level of providers in performing a surgical cricothyrotomy both before and after training using a 10-point visual analog scale. RESULTS Forty-four paramedics participated in the difficult airway training course. All (44/44) completed the postsurvey. Participants noted that their procedural skill comfort level improved after the training took place (average improvement of 3 ± 1.93). Participants also indicated that the high-fidelity trainer played a significant role in their increased comfort after skills training. CONCLUSION The bleeding cricothyrotomy model evaluated provides a high-fidelity, cost-effective means of teaching and maintaining a rare, lifesaving skill that is rarely performed in the field.
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Affiliation(s)
| | - Kate E Hughes
- Department of Emergency Medicine, University of Arizona, Tucson, AZ
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Luckey-Smith K, High K, Cole E. Effectiveness of Surgical Airway Training Laboratory and Assessment of Skill and Knowledge Fade in Surgical Airway Establishment Among Prehospital Providers. Air Med J 2020; 39:369-373. [PMID: 33012474 DOI: 10.1016/j.amj.2020.05.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 05/06/2020] [Accepted: 05/25/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE This study aimed to evaluate the effectiveness of surgical airway education composed of training using cadavers. The secondary aim was to evaluate the presence and degree of knowledge and skill fade 3 months after training. METHODS Thirteen participants were recruited from a helicopter emergency medical services program. Participants were assessed at multiple points during training using a multiple-choice examination and a timed evaluation of the ability to establish a surgical airway. RESULTS Training was effective at increasing knowledge and skill, with a mean increase in multiple-choice examination scores of 14.6 percentage points after training (P < .01) and a mean decrease in time to airway establishment of 26 seconds (P < .01). The training was not associated with the ability to establish a surgical airway in less than 40 seconds, with only 46% of participants able to do so. There was no evidence of knowledge or skill fade at 3 months after training. CONCLUSION Surgical airway training that includes both didactic and clinical learning using human cadavers is effective at increasing both knowledge and skill. Additional training is needed to establish competency in consistently performing surgical airways in less than 40 seconds. No knowledge or skill fade was present at 3 months after training.
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Affiliation(s)
| | - Kevin High
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Elaine Cole
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
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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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Nwanne T, Jarvis J, Barton D, Donnelly JP, Wang HE. Advanced airway management success rates in a national cohort of emergency medical services agencies. Resuscitation 2019; 146:43-49. [PMID: 31756361 DOI: 10.1016/j.resuscitation.2019.11.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 11/06/2019] [Accepted: 11/11/2019] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Despite its important role in care of the critically ill, there have been few large-scale descriptions of the epidemiology of Emergency Medical Services (EMS) advanced airway management (AAM) and the variations in care with different patient subsets. We sought to characterize AAM performance in a national cohort of EMS agencies. METHODS We used data from ESO Solutions, Inc., a national EMS electronic health record system. We analyzed EMS emergency patient encounters during 2011-2015 with attempted AAM. We categorized AAM techniques as conventional endotracheal intubation (cETI), neuromuscular blockade assisted intubation (NMBA-ETI), supraglottic airway (SGA), and cricothyroidotomy (needle and open). Determination of successful AAM was based on EMS provider report. We analyzed the data using descriptive statistics, determining the incidence and clinical characteristics of AAM cases. We determined success rates for each AAM technique, stratifying by the subsets cardiac arrest, medical non-arrest, trauma, and pediatrics (age ≤12 years). RESULTS AAM occurred in 57,209 patients. Overall AAM success was 89.1% (95% CI: 88.8-89.3%) across all patients and techniques. Intubation success rates varied by technique; cETI (n = 38,004; 76.9%, 95% CI: 76.5-77.3%), NMBA-ETI (n = 6768; 89.7%, 88.9-90.4%). SGAs were used both for initial (n = 9461, 90.1% success, 95% CI: 89.5-90.7%) and rescue (n = 5994, 87.3% success, 95% CI: 86.4-88.1%) AAM. Cricothyroidotomy success rates were low: initial cricothyroidotomy (n = 202, 17.3% success, 95% CI: 12.4-23.3%), rescue cricothyroidotomy (n = 85, 52.9% success, 95% CI: 41.8-88%). AAM success rates varied by patient subset: cardiac arrest (n = 35,782; 91.7%, 95% CI: 91.4-92.0), medical non-arrest (n = 17,086; 84.7%, 84.2-85.2%); trauma (n = 4341; 84.3%, 83.1-85.3%); pediatric (n = 1223; 73.7%, 71.2-76.2%). CONCLUSION AAM success rates varied by airway technique and patient subset. In this national cohort, these results offer perspectives of EMS AAM practices.
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Affiliation(s)
- Tracy Nwanne
- McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Jeffrey Jarvis
- Williamson County Emergency Medical Services, Georgetown, TX, United States; Texas A&M Health Science Center, Temple, TX, United States
| | | | - John P Donnelly
- Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI, United States; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, United States
| | - Henry E Wang
- Department of Emergency Medicine, The University of Texas Health Science Center at Houston, Houston, TX, United States.
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