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Bennett S, Alkhouri H, Badge H, Long E, Chan T, Vassiliadis J, Fogg T. Bed tilt and ramp positions are associated with increased first-pass success of adult endotracheal intubation in the emergency department: A registry study. Emerg Med Australas 2023; 35:983-990. [PMID: 37429648 DOI: 10.1111/1742-6723.14276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 06/01/2023] [Accepted: 06/19/2023] [Indexed: 07/12/2023]
Abstract
OBJECTIVE Successful endotracheal intubation in the ED requires optimum body positioning. In patients with obesity, the ramp position was suggested to achieve better intubating conditions. However, limited data are available on the airway management practices for patients with obesity in Australasian EDs. The aim of this study was to identify current patient positioning practices during endotracheal intubation and its association with first-pass success (FPS) at intubation and adverse event (AE) rates in obese and non-obese populations. METHODS Prospectively collected data from the Australia and New Zealand ED Airway Registry (ANZEDAR) between 2012 and 2019 were analysed. Patients were categorised into two groups according to their weight: <100 kg (non-obese) or ≥100 kg (obese). Four position categories were investigated; supine, pillow or occipital pad, bed tilt and ramp or head-up with relation to FPS and complication rate using logistic regression modelling. RESULTS A total of 3708 intubations from 43 EDs were included. Overall, the non-obese cohort had a greater FPS rate (85.9%) compared to the obese group (77.0%). The bed tilt position had the highest FPS rate (87.2%), whereas the supine position had the lowest (83.0%). AE rates were highest in the ramp position (31.2%) compared to all other positions (23.8%). Regression analysis showed ramp, or bed tilt positions and a consultant-level intubator were associated with higher FPS. Obesity, in addition to other factors, was independently associated with lower FPS. CONCLUSION Obesity was associated with lower FPS, which could be improved through performing a bed tilt or ramp positioning.
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Affiliation(s)
- Samantha Bennett
- Faculty of Medicine, The University of Notre Dame Australia, Sydney, New South Wales, Australia
- Sydney Children's Hospital, Sydney, New South Wales, Australia
| | - Hatem Alkhouri
- Emergency Care Institute, Agency for Clinical Innovation, Sydney, New South Wales, Australia
- Faculty of Medicine, The University of New South Wales, Sydney, New South Wales, Australia
| | - Helen Badge
- School of Allied Health, Faculty of Health Science, Australian Catholic University, Sydney, New South Wales, Australia
| | - Elliot Long
- The Royal Children's Hospital, Murdoch Children's Research Institute, The University of Melbourne, Melbourne, Victoria, Australia
| | - Trevor Chan
- Emergency Care Institute, Agency for Clinical Innovation, Sydney, New South Wales, Australia
- Emergency Department, St George Hospital, Sydney, New South Wales, Australia
| | - John Vassiliadis
- Emergency Department, Royal North Shore Hospital, Sydney, New South Wales, Australia
- Discipline of Emergency Medicine, Northern Clinical School, The University of Sydney Medical School, Sydney, New South Wales, Australia
| | - Toby Fogg
- Emergency Department, Royal North Shore Hospital, Sydney, New South Wales, Australia
- CareFlight, Sydney, New South Wales, Australia
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Alkhouri H, Richards C, Miers J, Fogg T, McCarthy S. Case series and review of emergency front-of-neck surgical airways from The Australian and New Zealand Emergency Department Airway Registry. Emerg Med Australas 2021; 33:499-507. [PMID: 33179449 DOI: 10.1111/1742-6723.13678] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 10/12/2020] [Accepted: 10/16/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND An emergency front-of-neck access (eFONA), also called can't intubate, can't oxygenate (CICO) rescue, is a rare event. Little is known about the performance of surgical or percutaneous airways in EDs across Australia and New Zealand. OBJECTIVE To describe the management of cases resulting in an eFONA, and recorded in The Australian and New Zealand Emergency Department Airway Registry (ANZEDAR). METHODS A retrospective case series and review of ED patients undergoing surgical or percutaneous airways. Data were collected prospectively over 60 months between 2010 and 2015 from 44 participating EDs. RESULTS An eFONA/CICO rescue airway was performed on 15 adult patients: 14 cricothyroidotomies (0.3% of registry intubations) and one tracheostomy. The indication for intubation was 60% trauma and 40% medical aetiologies. The intubator specialty was emergency medicine in eight (53.3%) episodes. Thirteen (86.7%) cricothyroidotomies and the sole tracheostomy (6.7%) were performed at major referral hospitals with 12 (80%) surgical airways out of hours. In four (26.7%) cases, cricothyroidotomy was performed as the primary intubation method. Pre-oxygenation techniques were used in 14 (93.3%) episodes; apnoeic oxygenation in four (26.7%). CONCLUSIONS Most cases demonstrated deviations from standard difficult airway practice, which may have increased the likelihood of performance of a surgical airway, and its increased likelihood out of hours. Our findings may inform training strategies to improve care for ED patients requiring this critical intervention. We recommend further discussion of proposed standard terminology for emergency surgical or percutaneous airways, to facilitate clear crisis communication.
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Affiliation(s)
- Hatem Alkhouri
- Emergency Care Institute, Agency for Clinical Innovation, Sydney, New South Wales, Australia
- Faculty of Medicine, The University of New South Wales, Sydney, New South Wales, Australia
- The Simpson Centre for Health Services Research (SWS Clinical School), The University of New South Wales, Ingham Institute of Applied Medical Research, Sydney, New South Wales, Australia
| | - Clare Richards
- Emergency Care Institute, Agency for Clinical Innovation, Sydney, New South Wales, Australia
- Emergency Department, Gosford Hospital, Gosford, New South Wales, Australia
| | - James Miers
- Emergency Care Institute, Agency for Clinical Innovation, Sydney, New South Wales, Australia
- Emergency Department, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Toby Fogg
- Emergency Department, Royal North Shore Hospital, Sydney, New South Wales, Australia
- CareFlight, Sydney, New South Wales, Australia
| | - Sally McCarthy
- Emergency Care Institute, Agency for Clinical Innovation, Sydney, New South Wales, Australia
- Faculty of Medicine, The University of New South Wales, Sydney, New South Wales, Australia
- Emergency Department, Prince of Wales Hospital, Sydney, New South Wales, Australia
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Arnold I, Alkhouri H, Badge H, Fogg T, McCarthy S, Vassiliadis J. Current airway management practices after a failed intubation attempt in Australian and New Zealand emergency departments. Emerg Med Australas 2021; 33:808-816. [PMID: 33543598 DOI: 10.1111/1742-6723.13729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 01/05/2021] [Accepted: 01/10/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The aims of the present study were to describe current airway management practices after a failed intubation attempt in Australian and New Zealand EDs and to explore factors associated with second attempt success. METHODS Data were collected from a multicentre airway registry (The Australian and New Zealand Emergency Department Airway Registry). All intubation episodes that required a second attempt between March 2010 and November 2015 were analysed. Analysis for association with success at the second attempt was undertaken for patient factors including predicted difficulty of laryngoscopy, as well as for changes in laryngoscope type, adjunct devices, intubator and intubating manoeuvres. RESULTS Of the 762 patients with a failed first intubation attempt, 603 (79.1%) were intubated successfully at the second attempt. The majority of second attempts were undertaken by emergency consultants (36.8%) and emergency registrars (34.2%). A change in intubator occurred in 56.5% of intubation episodes and was associated with higher second attempt success (unadjusted odds ratio [OR] 1.85; 95% confidence interval [CI] 1.29-2.65). In 69.7% of second attempts at intubation, there was no change in laryngoscope type. Changes in laryngoscope type, adjunct devices and intubation manoeuvres were not significantly associated with success at the second attempt. In adjusted analyses, second attempt success was higher for a change from a non-consultant intubator to a consultant intubator from any specialty (adjusted OR 2.31; 95% CI 1.35-3.95) and where laryngoscopy was not predicted to be difficult (adjusted OR 2.58; 95% CI 1.58-4.21). CONCLUSIONS The majority of second intubation attempts were undertaken by emergency consultants and registrars. A change from a non-consultant intubator to a consultant intubator of any specialty for the second attempt and intubation episodes where laryngoscopy was predicted to be non-difficult were associated with a higher success rate at intubation. Participation in routine collection and monitoring of airway management practices via a Registry may enable the introduction of appropriate improvements in airway procedures and reduce complication rates.
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Affiliation(s)
- Isaac Arnold
- Faculty of Medicine, The University of New South Wales, Sydney, New South Wales, Australia
| | - Hatem Alkhouri
- Faculty of Medicine, The University of New South Wales, Sydney, New South Wales, Australia.,Emergency Care Institute, Agency for Clinical Innovation, Sydney, New South Wales, Australia.,Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
| | - Helen Badge
- Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia.,School of Allied Health, Faculty of Health Science, Australian Catholic University, Sydney, New South Wales, Australia
| | - Toby Fogg
- Emergency Department, Royal North Shore Hospital, Sydney, New South Wales, Australia.,CareFlight, Sydney, New South Wales, Australia
| | - Sally McCarthy
- Faculty of Medicine, The University of New South Wales, Sydney, New South Wales, Australia.,Emergency Care Institute, Agency for Clinical Innovation, Sydney, New South Wales, Australia.,Emergency Department, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - John Vassiliadis
- Emergency Department, Royal North Shore Hospital, Sydney, New South Wales, Australia.,Discipline of Emergency Medicine, Northern Clinical School, The University of Sydney Medical School, Sydney, New South Wales, Australia
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Alkhouri H, Vassiliadis J, Murray M, Mackenzie J, Tzannes A, McCarthy S, Fogg T. Emergency airway management in Australian and New Zealand emergency departments: A multicentre descriptive study of 3710 emergency intubations. Emerg Med Australas 2017; 29:499-508. [PMID: 28582801 DOI: 10.1111/1742-6723.12815] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Revised: 03/20/2017] [Accepted: 04/16/2017] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The aim of this study was to describe the practice of endotracheal intubation across a range of Australasian EDs. METHODS We established a multicentre airway registry (The Australian and New Zealand Emergency Department Airway Registry [ANZEDAR]) prospectively capturing intubations from 43 Australian and New Zealand EDs over 24 months using the ANZEDAR form. Information recorded included patient demographics, intubation indications, predicted difficulty, rapid sequence induction and endotracheal intubation preparation technique, induction drugs, airway adjuncts and complications. Factors associated with first attempt success were explored. RESULTS Of the 3710 intubations captured, 3533 were in adults (95.2%), 2835 (76.4%) for medical and 810 (21.8%) for trauma indications. Overall, 3127 (84.3%) patients were successfully intubated at the first attempt; the majority by ED doctors (2654 [72.1%]). A total of 10 surgical airways were performed, all of which were successful cricothyroidotomies. Propofol, thiopentone or ketamine were used with similar frequency for induction, and suxamethonium was the most often used muscle relaxant. Adverse events were reported in 964 (26%), the majority involving desaturation or hypotension. CONCLUSION Australasian ED doctors, predominantly specialist emergency physicians or trainees, perform the majority of ED intubations using rapid sequence induction as their preferred technique mainly for medical indications. First attempt success rate was not different between different types of EDs, and is comparable published international data. Complications are not infrequent, and are comparable to other published series. Monitoring and reporting of ED intubation practice will enable continued improvements in the safety of this high-risk procedure.
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Affiliation(s)
- Hatem Alkhouri
- Emergency Care Institute, Agency for Clinical Innovation, Sydney, New South Wales, Australia.,Faculty of Medicine, The University of New South Wales, Sydney, New South Wales, Australia
| | - John Vassiliadis
- Emergency Department, Royal North Shore Hospital, Sydney, New South Wales, Australia.,Discipline of Emergency Medicine, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia.,Sydney Clinical Skills and Simulation Centre, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Matthew Murray
- Emergency Care Institute, Agency for Clinical Innovation, Sydney, New South Wales, Australia
| | - John Mackenzie
- Emergency Care Institute, Agency for Clinical Innovation, Sydney, New South Wales, Australia
| | - Alex Tzannes
- Emergency Department, St George Hospital, Sydney, New South Wales, Australia.,Ambulance Service of New South Wales, Greater Sydney Area Helicopter Emergency Medical Service, Sydney, New South Wales, Australia
| | - Sally McCarthy
- Emergency Care Institute, Agency for Clinical Innovation, Sydney, New South Wales, Australia.,Faculty of Medicine, The University of New South Wales, Sydney, New South Wales, Australia
| | - Toby Fogg
- Emergency Department, Royal North Shore Hospital, Sydney, New South Wales, Australia.,Discipline of Emergency Medicine, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia.,CareFlight, Sydney, New South Wales, Australia
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