First pass success is important in prehospital tracheal intubation to minimise the risk of physiologic deterioration

Abstract

Pre-hospital tracheal intubation of the critically ill and injured can be challenging and patients are at risk of serious complications. The purpose of this study was to determine the association between the number of intubation attempts and the occurrence of physiologic deterioration. This institutional review board (IRB)-approved project was an observational study conducted in a large USA helicopter emergency medical service (HEMS) of patients undergoing rapid sequence intubation in the field by the flight crew (flight nurse/flight paramedic) over a 4 yr period from January 1, 2015 to December 31, 2018. Data were collected on patient, operator, and procedural characteristics, and included method of intubation, drugs and devices used, difficult airway characteristics, number of intubation attempts, outcome of each attempt, and complications associated with intubation. The predictor variable was first pass failure, which was defined as failure to achieve tracheal intubation on a single laryngoscope insertion. The outcome variable was physiologic deterioration, which was defined as the occurrence of any one of the following three physiologic complications: hypoxemia (SpO2 <90%), hypotension (systolic blood pressure <90 mm Hg) or cardiac arrest (loss of pulses requiring cardiopulmonary resuscitation). Patients were excluded if they were <18 or >89 yr of age, or if they were hypoxaemic, hypotensive, or in cardiac arrest before intubation was attempted. Multivariable logistic regression was performed to evaluate the relationship between first pass failure and the occurrence of physiologic deterioration. A total of 6247 patients were included in the analysis. Of these, 93.0% (n=5811) required one attempt, 5.7% (n=353) required two attempts, and 1.3% (n=83) required three or more attempts. Physiologic deterioration occurred in 5.2% of patients (n=300) who required one attempt, 26.9% of patients (n=95) who required two attempts, and 32.5% of patients (n=27) who required three or more attempts (Table 2). In the multivariable logistic regression analysis, first pass failure was associated with an increased risk of physiologic deterioration (adjusted odds ratio [aOR], 5.7; 95% confidence interval [CI], 4.4–7.4). In this study of prehospital intubations by an aeromedical service, first pass failure was associated with a marked increase in the risk of physiologic deterioration. To maximise patient safety during prehospital intubation, every effort should be made to optimise conditions for first pass success.Table 2Physiologic deterioration with first pass success vs first pass failure.Physiologic deteriorationFirst pass success% (n)First pass failure% (n)%Difference (95% CI)Hypoxaemia4.5 (262)27.1 (118)–22.6 (–26.8 to –18.4)Arterial hypotension0.7 (39)1.8 (8)–1.1 (–2.4 to 0.1)Cardiac arrest0.2 (9)1.4 (6)–1.2 (–2.3 to –0.1)Total patients*5.2 (300)28.0 (122)–22.8 (–27.1 to –18.6)*Patients may have more than one complication. Open table in a new tab *Patients may have more than one complication.