Hospitals and medical personnel performing high volumes of procedures demonstrate better patient outcomes and fewer adverse events. The relationship between rescuer experience and patient survival for out-of-hospital endotracheal intubation is unknown.
An American study analysing 3 statewide databases with 26,000 records aimed to determine the association between endotracheal intubation experience and patient survival.
In-the-field intubators were EMS paramedics, nurses, and physicians, although paramedics performed more than 94% of out-of-hospital tracheal intubations. Although all air medical rescuers may use neuromuscular- blockade-assisted (rapid sequence) tracheal intubation, select ground EMS units are allowed to use tracheal intubation facilitated by sedatives only; the rest are done ‘cold’.
Patients in cardiac arrest and medical nonarrest experienced increased odds of survival when intubated by rescuers with high procedural experience. In trauma patients, survival was not associated with rescuer experience.
The odds of survival for air medical trauma patients were almost twice that of other patients, which may be related to the use of neuromuscular- blocking agents by air medical crews, or due to more specialised critical care training. The authors suggest that rescuers should perform at least 4 to 12 annual tracheal intubations.
Out-of-Hospital Endotracheal Intubation Experience and Patient Outcomes
Ann Emerg Med. 2010 Jun;55(6):527-537
Tag Archives: airway
Early CPAP versus Surfactant in Extreme Prems
In a randomised, multicentre trial of 1316 infants born between 24 weeks 0 days and 27 weeks 6 days of gestation, infants were randomly assigned to intubation and surfactant treatment (within 1 hour after birth) or to CPAP treatment initiated in the delivery room, with subsequent use of a protocol-driven limited ventilation strategy. The primary outcome was death or bronchopulmonary dysplasia as defined by the requirement for supplemental oxygen at 36 weeks.
Infants who received CPAP treatment, as compared with infants who received surfactant treatment, less frequently required intubation or postnatal corticosteroids for bronchopulmonary dysplasia (P<0.001), required fewer days of mechanical ventilation (P=0.03), and were more likely to be alive and free from the need for mechanical ventilation by day 7 (P=0.01). However the rates of the primary outcome did not differ significantly between the CPAP group and the surfactant group (47.8% and 51.0%, respectively; relative risk with CPAP, 0.95; 95% confidence interval [CI], 0.85 to 1.05).
The infants randomised to CPAP could receive limited invasive ventilation if necessary; 83.1% of the infants in the CPAP group were intubated. They did not include infants who were born at a gestational age of less than 24 weeks, since the results of a pilot trial showed that 100% of such infants required intubation in the delivery room.
This study had a 2-by-2 factorial design in which infants were also randomly assigned to one of two target ranges of oxygen saturation.
Early CPAP versus Surfactant in Extremely Preterm Infants
N Engl J Med. 2010 May 16. [Epub ahead of print]
The myth of ketamine and head injury
A literature review addresses the myth that ketamine is contraindicated in head injured patients. They summarise articles from the 1970’s which identified an association between ketamine and increased ICP in patients with abnormal cerebrospinal fluid pathways (such as those caused by aqueductal stenosis, obstructive hydrocephalus and other mass effects). In more recent studies no statistically significant increase in ICP was observed following the administration of ketamine in patients with head injury; some of the studies showed a net increase in CPP following ketamine administration. They list ketamine’s stable haemodynamic profile and potential neuroprotective effects as further rationale for its use.
The authors boldly summarise:
‘Based on its pharmacological properties, ketamine appears to be the perfect agent for the induction of head-injured patients for intubation.’
Myth: ketamine should not be used as an induction agent for intubation in patients with head injury
CJEM. 2010 Mar;12(2):154-7
Protected: Positive capnography in cadavers
Current Controversy in RSI
A review article in Anesthesia and Analgesia provides a summary of the literature surrounding RSI controversies.
- Should a pre-determined dose of induction drug be given or should it be titrated to effect prior to giving suxamethonium?
- Should fast acting opioids be coadministered to blunt the pressor response?
- What is the optimal dose of suxamethonium?
- Should defasciculating doses of neuromuscular blocking drugs be given?
- What is the ‘priming’ technique with rocuronium and is it necessary?
- Is it really bad to bag-mask ventilate the patient after induction prior to intubation? Which patients might this benefit?
- Should patients with full stomachs be anaesthetised sitting up, supine, or head down?
- Is cricoid pressure a good or a bad thing?
Not surprisingly the jury is still out on these, which is of course why they remain ‘controversies’. The review article provides a readable, interesting, and up to date summary of the evidence to date.
Rapid Sequence Induction and Intubation: Current Controversy
Anesth Analg. 2010 May 110(5):1318-25
Inhaled NPA
A case is reported of a stroke patient who aspirated his nasopharyngeal airway, resulting in coughing and desaturation. After iv propofol and topical anaesthesia to the oropharynx and hypopharynx, it was seen on laryngoscopy to be within the trachea but could not be retrieved with Magill forceps. Instead, his doctors inserted a well lubricated 14 Fr foley catheter through the lumen of the tube, inflated the balloon, and pulled it out.
Retrieval of Aspirated Nasopharyngeal Airway Using Foley Catheter
Anesth Analg. 2010 Apr;110(4):1245-6
Single-use Metal Laryngoscope Blades
In a randomised study of more than 1072 patients for emergency intubation using rapid sequence induction, single-use metal blades were associated with fewer failed first attempts and fewer poor grade laryngeal views than reusable metal blades. Improved illumination may be a factor.
Comparison of Single-use and Reusable Metal Laryngoscope Blades for Orotracheal Intubation during Rapid Sequence Induction of Anesthesia
Anesthesiology. 2010 Feb;112(2):325-32
A human suction unit for choking
A case is described of a 12 month old who completely obstructed her airway from an inhaled plastic ketchup container. As she did not improve with backslaps or chest thrusts her father, a physician, suctioned her airway using his own mouth (intermittently spitting out secretions) until the obstruction was relieved and the object removed. Something to think about if you’re at the end of your own child’s choking algorithm and you have no airway equipment with you.
Maneuver for the recovery of a foreign body causing a complete airway obstruction: illustrative case.
Pediatr Emerg Care. 2010 Jan;26(1):39-40
Win with the chin
Medical students and junior doctors were successfully taught correct airway management positioning for intubation on a manikin when told to position the manikin in the best position to win a running race, where the chin wins the race. (The so-called ‘win with the chin’ position). This was superior to the traditional ‘sniff the morning air’ position.
Teaching airway management to novices: a simulator manikin study comparing the ‘sniffing position’ and ‘win with the chin’ analogies
Br J Anaesth. 2010 Apr;104(4):496-500
College of Paramedics stands its ground
Articles in this month’s EMJ demonstrate an interesting conflict within UK pre-hospital care. The Joint Royal Colleges Ambulance Liaison Committee Airway Working Group, heavily represented by anaesthetists, recommend the removal of tracheal intubation from UK paramedic practice. The College of Paramedics reject this recommendation, providing a robust critique of the paper and calling for better evidence before changing current practice. A fascinating read.
A critical reassessment of ambulance service airway management in prehospital care: Joint Royal Colleges Ambulance Liaison Committee Airway Working Group, June 2008
Emerg Med J 2010;27:226-233
Full Text
The College of Paramedics (British Paramedic Association) position paper regarding the Joint Royal Colleges Ambulance Liaison Committee recommendations on paramedic intubation
Emerg Med J 2010;27:167-170
Full Text