Early Endotracheal Intubation Research Articles

Early endotracheal intubation is not associated with the rate of return of spontaneous circulation following cardiac arrest at the emergency department: an exploratory analysis.

Early endotracheal intubation is not associated with the rate of return of spontaneous circulation following cardiac arrest at the emergency department: an exploratory analysis.

Volumetric capnography and return of spontaneous circulation in an experimental model of pediatric asphyxial cardiac arrest

A secondary analysis of a randomized study was performed to study the relationship between volumetric capnography (VCAP) and arterial CO2 partial pressure (PCO2) during cardiopulmonary resuscitation (CPR) and to analyze the ability of these parameters to predict the return of spontaneous circulation (ROSC) in a pediatric animal model of asphyxial cardiac arrest (CA). Asphyxial CA was induced by sedation, muscle relaxation and extubation. CPR was started 2 min after CA occurred. Airway management was performed with early endotracheal intubation or bag-mask ventilation, according to randomization group. CPR was continued until ROSC or 24 min of resuscitation. End-tidal carbondioxide (EtCO2), CO2 production (VCO2), and EtCO2/VCO2/kg ratio were continuously recorded.Seventy-nine piglets were included, 26 (32.9%) of whom achieved ROSC. EtCO2 was the best predictor of ROSC (AUC 0.72, p < 0.01 and optimal cutoff point of 21.6 mmHg). No statistical differences were obtained regarding VCO2, VCO2/kg and EtCO2/VCO2/kg ratios. VCO2 and VCO2/kg showed an inverse correlation with PCO2, with a higher correlation coefficient as resuscitation progressed. EtCO2 also had an inverse correlation with PCO2 from minute 18 to 24 of resuscitation. Our findings suggest that EtCO2 is the best VCAP-derived parameter for predicting ROSC. EtCO2 and VCO2 showed an inverse correlation with PCO2. Therefore, these parameters are not adequate to measure ventilation during CPR.

Analysis of relevant factors influencing the 30-day survival rate of patients with cardiac arrest and cardiopulmonary resuscitation: research based on 8-year data of a class III hospital

To investigate the survival of patients with cardiac arrest and cardiopulmonary resuscitation (CA-CPR), and to analyze the factors influencing survival at 30 days after restoration of spontaneous circulation (ROSC). A retrospective cohort study was conducted. Clinical data of 538 patients with CA-CPR admitted to the People's Hospital of Ningxia Hui Autonomous Region from January 2013 to September 2020 were enrolled. The gender, age, underlying disease, cause of CA, type of CA, initial rhythm, presence or absence of endotracheal intubation, defibrillation, use of epinephrine, and 30-day survival rate of patients were collected. The etiology of CA and 30-day survival rate among patients with different ages were compared, as well as the clinical data between patients who survived and died at 30 days after ROSC were also compared. Multivariate Logistic regression was used to analyze the relevant factors affecting the 30-day survival rate of patients. Among 538 patients with CA-CPR, 67 patients with incomplete information were excluded, and 471 patients were enrolled. Among 471 patients, 299 were males and 172 were females. Aged from 0 to 96 years old, 23 patients (4.9%) were < 18 years old, 205 patients (43.5%) were 18 to 64 years old, and 243 patients (51.6%) were ≥ 65 years old. 302 cases (64.1%) achieved ROSC, and 46 patients (9.8%) survived for more than 30 days. The 30-day survival rate of patients aged < 18 years old, 18-64 years old and ≥ 65 years old was 8.7% (2/23), 12.7% (26/205) and 7.4% (18/243), respectively. The main causes of CA in patients younger than 18 years were severe pneumonia (13.1%, 3/23), respiratory failure (13.1%, 3/23), and trauma (13.1%, 3/23). The main causes were acute myocardial infarction (AMI; 24.9%, 51/205), respiratory failure (9.8%, 20/205), and hypoxic brain injury (9.8%, 20/205) in patients aged 18-64 years old, and AMI (24.3%, 59/243) and respiratory failure (13.6%, 33/243) in patients aged ≥ 65 years old. Univariate analysis results revealed that the 30-day survival rate of patients with CA-CPR may be related to the the cause of CA was AMI, initial rhythm was ventricular tachycardia/ventricular fibrillation, endotracheal intubation and epinephrine. Multivariate Logistic regression analysis results showed that CA was caused by AMI [odds ratio (OR) = 0.395, 95% confidence interval (95%CI) was 0.194-0.808, P = 0.011] and endotracheal intubation (OR = 0.423, 95%CI was 0.204-0.877, P = 0.021) was a protective factor for 30 days of survival after ROSC in patients with CA-CPR. The 30-day survival rate of CA-CPR patients was 9.8%. The 30-day survival rate of CA-CPR patients with AMI after ROSC is higher than that of patients with other CA causes, and early endotracheal intubation can improve the prognosis of patients.

721: MULTICENTER VALIDATION AND REFINEMENT OF THE CRITICAL BRONCHIOLITIS SCORE

Introduction: We previously created the “Critical Bronchiolitis Score” (CBS) to predict outcomes for this very common, low-mortality Pediatric Intensive Care Unit (PICU) disease. We created 4 models to evaluate 2 outcomes, duration of ICU-level respiratory support (D-ICU-LRS) and PICU length of stay (LOS), in 2 groups: children requiring or not requiring early endotracheal intubation within first 12 hours of PICU stay. The original CBS performed better than mortality based PICU severity scores. However, relevant variables were unavailable in the original dataset. This study aims to improve CBS performance by adding variables in a second, large multi-center dataset. Methods: With IRB approval, we retrospectively studied children < 2 years of age admitted to 37 PICUs with bronchiolitis. We collected demographics, original CBS and several novel variables: age, specific co-morbidities, SpO2, encephalopathy, effort of breathing, and specific ICU-LRS settings (e.g., FiO2). As previously, missing variables were imputed with age-specific norms for the 12 centers with incomplete chart review. The newly assessed variables were tested for inclusion and retained if performance improved. CBS performance was assessed by root mean square error (RMSE) and mean absolute error (MAE). Data shown as median (IQR). Results: In 1163 subjects, median age was 5 (2-11) months, 60% had respiratory syncytial virus, 16% required early intubation. Median D-ICU-LRS was 2.3 (1.4-4.2) days and median PICU LOS was 2.8 (1.8-5.0) days. In all models, adding FiO2 improved performance. In the 2 models for children not requiring early intubation, adding minimum SpO2 in the first 12hrs improved performance for both D-ICU-LRS and PICU LOS. In early intubated patients, RMSE improved from the original CBS to the revised CBS by 6% for D-ICU-LRS and 18% for PICU LOS, and MAE improved by 2% and 16%. Among non-intubated patients, RMSE and MAE improved by 55% for both outcomes. Similar improvements were seen in centers with (n = 667) and without (n = 496) complete chart review. Conclusions: Compared to the original CBS, adding FiO2 and minimum SpO2 substantially improved performance and expanded its ability to aide providers in predicting clinically relevant outcomes in bronchiolitis.

Prevalence of significant traumatic brain injury among patients intubated in the field due to impaired level of consciousness.

Current guidelines advocate prehospital endotracheal intubation (ETI) in patients with suspected severe head injury and impaired level of consciousness. However, the ability to identify patients with traumatic brain injury (TBI) in the prehospital setting is limited and prehospital ETI carries a high complication rate. We investigated the prevalence of significant TBI among patients intubated in the field for that reason. Data were retrospectively collected from emergency medical services and hospital records of trauma patients for whom prehospital ETI was attempted and who were transferred to Rambam Health Care Campus, Israel. The indication for ETI was extracted. The primary outcome was significant TBI (clinical or radiographic) among patients intubated due to suspected severe head trauma. In 57.3% (379/662) of the trauma patients, ETI was attempted due to impaired consciousness. 349 patients were included in the final analysis: 82.8% were male, the median age was 34years (IQR 23.0-57.3), and 95.7% suffered blunt trauma. 253 patients (72.5%) had significant TBI. In a multivariable analysis, Glasgow Coma Scale>8 and alcohol intoxication were associated with a lower risk of TBI with OR of 0.26 (95% CI 0.13-0.51, p<0.001) and 0.16 (95% CI 0.06-0.46, p<0.001), respectively. Altered mental status in the setting of trauma is a major reason for prehospital ETI. Although most of these patients had TBI, one in four of them did not suffer a significant TBI. Patients with a higher field GCS and those suffering from intoxication have a higher risk of misdiagnosis. Future studies should explore better tools for prehospital assessment of TBI and ways to better define and characterize patients who may benefit from early ETI.

Cardiopulmonary Resuscitation in Obstetric Patient: Special Considerations.

The prevalence of cardiac arrest in pregnant women varies from 1/20,000 to 1/50,000 pregnancies and is associated with high fetomaternal mortality. The pregnant mother is more susceptible to cardiac arrest as hypoxia is poorly tolerated. Hemorrhage, eclampsia, sepsis, and embolism are common causes of arrest. Cardiac arrest is preventable if a predisposing clinical problem is detected in time by an early warning score and treated immediately. Resuscitation in obstetricpatient is challenging and special as it involves the lives of two patients, the mother and the fetus. Physiological and anatomical changes during pregnancy need special considerations during cardiopulmonary resuscitation. Chest compressions, defibrillation, and drug administration guidelines are similar to those in non-pregnant women. Early endotracheal intubation by an expert is desirable but bag-mask ventilation with oxygen supplementation should be initiated immediately by the first responder to prevent hypoxia. Hyperventilation should be avoided. An intravenous line should be established above the level of the diaphragm. Manual left lateral uterine displacement is necessary to relieve aortocaval compression when uterine height is more than 20weeks. Perimortem cesarean delivery at the site is a part of resuscitation if spontaneous circulation is not established within 4min, after detection of the arrest. Echocardiography and ultrasonography can help to find out the etiology of the arrest. Targeted temperature management and extracorporeal cardiopulmonary resuscitation should be considered as needed. The newborn will be taken care of by a neonatologist. Following emergency protocols, early warning scores, training and updating resuscitation guidelines, simulations, collecting a national database of pregnant mothers along with the teamwork of obstetrician, anesthesiologist, neonatologist, and emergency physician can reduce fetomaternal mortality.

Outcomes of Early versus Late Endotracheal Intubation in Patients with Initial Non-Shockable Rhythm Cardiopulmonary Arrest in the Emergency Department.

Background Sudden cardiac arrest is a critical condition in the emergency department (ED). Currently, there is no considerable evidence supporting the best time to complete advanced airway management (AAM) with endotracheal intubation in cardiac arrest patients presented with initial non-shockable cardiac rhythm. Objectives To compare survival to hospital discharge and discharge with favorable neurological outcome between the ED cardiac arrest patients who have received AAM with endotracheal intubation within 2 minutes (early AAM group) and those over 2 minutes (late AAM group) after the start of chest compression in ED. Methods We conducted a retrospective cohort study involving the ED cardiac arrest patients who presented with initial non-shockable rhythm in ED. Multivariable logistic regression analysis was used to evaluate the independent effect of early AAM on outcomes. The outcomes included the survival to hospital discharge and discharge with favorable neurological outcome. Results There were 416 eligible participants: 209 in the early AAM group and 207 participants in the late AAM group. The early AAM group showed higher survival to hospital discharge compared with the late AAM group, but no statistically significant difference (adjusted odds ratio (aOR): 1.28, 95% confidence interval (CI): 0.59 -2.76, p = 0.524). Discharge with favorable neurological outcome is also higher in the early AAM group (aOR: 1.68, 95% CI, 0.52 -5.45, p = 0.387). Conclusion This study did not demonstrate a significant improvement of survival to hospital discharge and discharge with favorable neurological outcome in the ED cardiac arrest patients with initial non-shockable cardiac arrest who underwent early AAM within two minutes. More research is needed on the timing of AAM and on airway management strategies to improve survival.

Effects of airway management and tidal volume feedback ventilation during pediatric resuscitation in piglets with asphyxial cardiac arrest

To compare the effect on the recovery of spontaneous circulation (ROSC) of early endotracheal intubation (ETI) versus bag-mask ventilation (BMV), and expiratory real-time tidal volume (VTe) feedback (TVF) ventilation versus without feedback or standard ventilation (SV) in a pediatric animal model of asphyxial cardiac arrest. Piglets were randomized into five groups: 1: ETI and TVF ventilation (10 ml/kg); 2: ETI and TVF (7 ml/kg); 3: ETI and SV; 4: BMV and TVF (10 ml/kg) and 5: BMV and SV. Thirty breaths-per-minute guided by metronome were given. ROSC, pCO2, pO2, EtCO2 and VTe were compared among groups. Seventy-nine piglets (11.3 ± 1.2 kg) were included. Twenty-six (32.9%) achieved ROSC. Survival was non-significantly higher in ETI (40.4%) than BMV groups (21.9%), p = 0.08. No differences in ROSC were found between TVF and SV groups (30.0% versus 34.7%, p = 0.67). ETI groups presented lower pCO2, and higher pO2, EtCO2 and VTe than BMV groups (p < 0.05). VTe was lower in TVF than in SV groups and in BMV than in ETI groups (p < 0.05). Groups 1 and 3 showed higher pO2 and lower pCO2 over time, although with hyperventilation values (pCO2 < 35 mmHg). ETI groups had non significantly higher survival rate than BMV groups. Compared to BMV groups, ETI groups achieved better oxygenation and ventilation parameters. VTe was lower in both TVF and BMV groups. Hyperventilation was observed in intubated animals with SV and with 10 ml/kg VTF.

Early endotracheal intubation improves neurological outcome following witnessed out-of-hospital cardiac arrest in Japan: a population-based observational study.

AimIt is unclear whether endotracheal intubation in the prehospital setting improves outcomes following out‐of‐hospital cardiac arrest. The purpose of this study was to evaluate the association between endotracheal intubation time (time from patient contact to endotracheal intubation) and favorable neurological outcomes on out‐of‐hospital cardiac arrest.MethodsWe extracted patients who underwent endotracheal intubation on the scene from a nationwide out‐of‐hospital cardiac arrest database registered between 2014 and 2017 in Japan. We included 14,969 witnessed and intubated adult out‐of‐hospital cardiac arrest cases. Patients were divided into Shockable (n = 1,102) and Non‐shockable (n = 13,867) cohorts. We first drew the logistic curve due to predicting the association between endotracheal intubation time and favorable neurological outcome defined as Cerebral Performance Category (CPC) 1 or 2. Secondary, multivariable logistic regressions were used to estimate the association between the endotracheal intubation time (1‐min unit increase), CPC 1 or 2.ResultsThe logistic curve for CPC 1 or 2 showed similar shapes and indicated a decreasing outcome over time. From the results of multivariable logistic regression, in the Shockable cohort, endotracheal intubation time delay was correlated with decreasing favorable outcomes: CPC 1 or 2 (adjusted odds ratio, 0.89; 95% confidence interval, 0.82–0.87). Results were the same for the Non‐shockable cohort: CPC 1 or 2 (adjusted odds ratio, 0.94; 95% confidence interval, 0.89–0.99).ConclusionEarly endotracheal intubation was correlated with favorable neurological outcome. Training for intubation skills and improving protocols are needed for carrying out early endotracheal intubation.

A fatal case of severe pufferfish poisoning

Abstract Introduction: Pufferfish poisoning is the main cause of death due to food poisoning in China. No effective treatment has been proposed so far. The artificial airway and early mechanical ventilation are crucial for the prognosis, but the optimal time for these interventions remains unclear. Here we present an unsuccessful use of mechanical respiratory support in a patient with pufferfish poisoning. Patient concerns: A 62-year-old male patient presented to the emergency department with complaints of numbness around the mouth. He gave a history of eating pufferfish 3 hours before the coming to the hospital. Diagnosis: He was diagnosed as pufferfish poisoning based on the history of consuming pufferfish and the symptom of numbness. Interventions: Gastric lavage was performed in time, but he did not receive protective endotracheal intubation. His condition worsened rapidly with respiratory failure and cardiac arrest. He received active treatment in the intensive care unit with mechanical ventilation. Outcomes: Spontaneous breathing was not restored during the intensive care unit stay. He underwent treatment with hyperbaric oxygen in another hospital and died of respiratory failure eventually. Conclusion: The establishment of artificial airway and early implementation of mechanical ventilation are crucial for good prognosis. Our case report provides a valuable experience for implementing early endotracheal intubation intervention in patients with pufferfish poisoning.

Meta-Analysis of Failure of Prehospital Endotracheal Intubation in Pediatric Patients.

Prehospital care is essential for airway preservation in pediatric patients who require early endotracheal intubation to improve oxygenation and prevent aspiration. However, high frequencies of failure of endotracheal intubation have been reported for this age group. We aimed to analyze the frequency of failure of endotracheal intubation in pediatric patients within a prehospital context and compare it with adult patients. Thus, a systematic revision of literature with a meta-analysis was performed using a study search and selection strategy ensuring extensiveness, sensitivity, and reproducibility. Meta-analyses were performed for odds ratio, DerSimonian and Laird's Q test was used to assess heterogeneity, and Egger and Begg's test was used to assess publication bias. Overall, 17 papers and 8772 patients were included, and the main cause of prehospital care was assessed to be trauma. Failed endotracheal intubation frequency was 0.4%–52.6% in pediatric patients. The most frequent complication was with esophageal intubation. Forest plot suggests that risk of failure during intubation of pediatric patients is 3.54 fold higher than that observed for adults. It was concluded that airway management in pediatric patients within a prehospital context is a challenge for prehospital care providers because it entails clear physiological and anatomical differences and a low frequency of exposure to this kind of events as opposed to adults. These differences support a widely higher risk of failure of intubation, suggesting the necessity of consistently trained prehospital care providers to ensure proficiency in technique as well as availability of the required equipment.

Timing of Endotracheal Intubation in Patients with Fulminant Enterovirus 71 Infection.

Background and objective: Enterovirus 71 (EV 71) infections may result in the rapid progression of cardiopulmonary failure. Early endotracheal intubation is considered to be of primary importance. However, the appropriate timing for this is still not known. The aim of this study is to investigate the timing of intubation of children with fulminant EV71 infection. Material and Methods: From March 1998 to May 2012, patients with severe EV71 infection who were admitted to the pediatric intensive care unit of the National Cheng Kung University Hospital were enrolled in this study. Medical records were retrospectively reviewed. The patients were classified into three groups in accordance with the outcome of intubation. We used rhombencephalitis grading to describe the neurological presentation of these patients. The study was approved by the institutional review board. Results: There were a total of 105 patients enrolled. Of these, 77 patients were in Grade I, and only three of them needed intubation, who were, however, soon extubated within 24 h. There were 10 patients in Grade II; nine of them needed intubation. In total, 18 patients belonged to Grade III, and all of them need to be intubated. We then compared the outcome of intubation of grades II and III. There was only one patient out of the nine patients in grade II who experienced failed extubation due to the progression of the disease. Among grade III patients, only four patients were successfully extubated. We also listed clinical parameters to determine which one could be a sign that indicated intubation. Comparing the favorable outcomes, cranial nerve involvement was a good indicator for the timing of intubation. Conclusions: This study showed that early intubation in Grade II provides favorable outcomes and improves morbidity and mortality. We also found that if cranial nerve involvement was present, then early intubation is indicated.

Airway management of coronavirus-infected patients

The coronavirus pandemic is a serious challenge for healthcare workers worldwide. The virus is spread through the air by droplets of moisture when people cough or sneeze and it has a very high virulence. Procedures generating airway aerosols are dangerous for every participant of patient care. The serious form of coronavirus infection can cause progressive respiratory failure. The best treatment is early endotracheal intubation and invasive mechanical ventilation. Intubation is an aerosol-generating process and thus carries the risk of contamination. Additionally the airway management of this patient population is usually difficult. The goal of this article is to give a practice-based overview of the peculiarities of airway management in coronavirus-infected patients with special regard to infection control and patient safety considerations. Orv Hetil. 2020; 161(17): 696–703.

Changing perspectives in the prehospital management of patients with severe burns

Treatment for burn injuries has typically involved the immediate cooling of the affected area with water to reduce pain and halt the progression of heat-induced tissue necrosis. For patients suspected to be at risk of airway compromise following inhalation burn injury, historical research has long advocated early prophylactic endotracheal intubation. In contrast, current literature is showing a change in the evidence base. To investigate this, a literature review was carried out and the evidence scrutinised in conjunction with local and national guidance. Controversy has more recently emerged over whether prophylactic endotracheal intubation is appropriate in the initial emergency management of suspected inhalation burn injury. Compounding this, it appears that no appropriate evidence-based guidelines have yet been made available. Traditional indications for prophylactic endotracheal intubation are sensitive but not specific. Research has subsequently demonstrated that large numbers of patients are being unnecessarily intubated and thus placed at risk of avoidable iatrogenic harm. A higher threshold for airway intervention is warranted. Additionally, a consensus remains over the use of prehospital cooling for burn injuries. This practice is, however, informed primarily by anecdotal and animal evidence. Patients with severe burns are at significant risk of hypothermia, which is associated with mortality. There is significantly more literature demonstrating the detrimental effects of hypothermia over the benefits of burn injury cooling in patients with severe burns. Treatment should therefore focus on the maintenance of normothermia as a priority. If cooling burned areas risks inducing hypothermia, it should be postponed.

Early endotracheal intubation improves neurological outcomes on witnessed OHCA

Early endotracheal intubation improves neurological outcomes on witnessed OHCA

Bispectral Index in Poisoning Cases with Multi-drug Ingestion: A Predictable Role for Early Endotracheal Intubation.

Objective:Bispectral index (BIS) is one of the several methods used to monitor the depth of anesthesia. Poisoning with ingestion of different drugs is one of the most common poisonings that have different clinical signs from drowsiness to coma. This study was performed to compare the BIS index number in poisoned patients with multi drugs ingestion with or without the need for endotracheal intubation.Methods:This cross-sectional study was performed on poisoned patients with ingestion of different drugs referring to Clinical Toxicology Department of Noor University Hospital, Isfahan, Iran. The clinical signs and symptoms and the vital signs at the admission time were measured, and the required therapies were given. The endotracheal intubation was done for patients who had the indication of intubation. BIS was monitored and compared for all patients with or without a need for intubation on the admission time and time of endotracheal intubation. Obtained data were analyzed by SPSS software.Findings:At the admission time, the mean (standard error [SE]) BIS index value for poisoned patients who needed endotracheal intubation was 66.47 ± 2.57 in comparison with 85.21 ± 1.47 for patients who did not need intubation (P < 0.001). The results of receiver operating characteristic curve (mean ± SE) showed the discrimination was excellent for BIS (0.899 ± 0.04; 95% confidence interval: 0.81–0.98) (P < 0.0001). BIS <79.5 had the sensitivity 88% and specificity 87% for endotracheal intubation.Conclusion:BIS is an appropriate index for prediction of the need to intubation in poisoned patients with ingestion of different drugs.

早期气管插管对心肺复苏抢救窒息病人的临床意义

目的：探讨早气管插管对提高急诊窒息病人心肺复苏(CPR)成功率的影响。方法：回顾性分析2008年2月到2015年2月两所医院急诊救治的86例因窒息导致心脏骤停患者。其中心脏骤停后胸外按压5分钟内给予气管插管术48例，超过5分钟以上时间给予气管插管术38例。所有病例均施与人工胸外心脏按压，肾上腺素静注，以及在适应症范围内电击复律等抢救措施。结果：因窒息导致的心脏骤停5分钟内给予气管插管术的48例中，32例复苏成功，成功率67%，有效43例(90%)；超过5分钟以上时间给予气管插管术的38例中,抢救成功3例(8%)，有效20例(53%)。结论：因窒息导致心脏骤停的病人早期进行气管插管术配合常规心肺复苏处理提高了心肺复苏的成功率。 Objective: To investigate the success rate of cardiopulmonary resuscitation by early endotracheal intubation for patients with asphyxia in emergency treatment. Methods: Retrospective analysis of clinical data from 86 cardiac arrest patients caused by asphyxia rescued in emergency room in two hospitals during the course from February 2008 to February 2015. Among these patients, 48 patients were treated with endotracheal intubation within 5 minutes of chest compression after heart arrest and 38 patients were given the same treatment after 5 minutes of chest compression. All patients were offered chest compressions, intravenous epinephrine, cardioversion and other life support treatments within indications. Results: 32 of 48 patients were successfully rescued with endotracheal intubation within 5 minutes (67% of successful rate) and 43 of 48 patients were responded by the same treatment (90% of response rate). In contrast, 3 of 38 patients were suc-cessfully rescued with endotracheal intubation after 5 minutes (8% of successful rate) and 20 of 38 patients were responded by the same treatment (53% of response rate). Conclusion: Early phase endotracheal intubation combined with regular cardiopulmonary resuscitation increased the success rate of cardiopulmonary resuscitation for cardiac arrest patients caused by asphyxia.

Resuscitator's perceptions and time for corrective ventilation steps during neonatal resuscitation

BackgroundThe 2010 neonatal resuscitation program (NRP) guidelines incorporate ventilation corrective steps (using the mnemonic – MRSOPA) into the resuscitation algorithm. The perception of neonatal providers, time taken to perform these maneuvers or the effectiveness of these additional steps has not been evaluated. MethodsUsing two simulated clinical scenarios of varying degrees of cardiovascular compromise – perinatal asphyxia with (i) bradycardia (heart rate – 40min–1) and (ii) cardiac arrest, 35 NRP certified providers were evaluated for preference to performing these corrective measures, the time taken for performing these steps and time to onset of chest compressions. ResultsThe average time taken to perform ventilation corrective steps (MRSOPA) was 48.9±21.4s. Providers were less likely to perform corrective steps and proceed directly to endotracheal intubation in the scenario of cardiac arrest as compared to a state of bradycardia. Cardiac compressions were initiated significantly sooner in the scenario of cardiac arrest 89±24s as compared to severe bradycardia 122±23s, p<0.0001. There were no differences in the time taken to initiation of chest compressions between physicians or mid-level care providers or with the level of experience of the provider. ConclusionsEffective ventilation of the lungs with corrective steps using a mask is important in most cases of neonatal resuscitation. Neonatal resuscitators prefer early endotracheal intubation and initiation of chest compressions in the presence of asystolic cardiac arrest. Corrective ventilation steps can potentially postpone initiation of chest compressions and may delay return of spontaneous circulation in the presence of severe cardiovascular compromise.

Pre-Hospital Intubation is Associated with Increased Mortality After Traumatic Brain Injury

Early endotracheal intubation in patients sustaining moderate to severe traumatic brain injury (TBI) is considered the standard of care. Yet the benefit of pre-hospital intubation (PHI) in patients with TBI is questionable. The purpose of this study was to investigate the relationship between pre-hospital endotracheal intubation and mortality in patients with isolated moderate to severe TBI. The Los Angeles County Trauma System Database was queried for all patients > 14 y of age with isolated moderate to severe TBI admitted between 2005 and 2009. The study population was then stratified into two groups: those patients requiring intubation in the field (PHI group) and those patients with delayed airway management (No-PHI group). Demographic characteristics and outcomes were compared between groups. Multivariate analysis was used to determine the relationship between pre-hospital endotracheal intubation and mortality. A total of 2549 patients were analyzed and then stratified into the two groups: PHI and No-PHI. There was a significant difference noted in overall mortality (90.2% versus 12.4%), with the PHI group being more likely to succumb to their injuries. After adjusting for possible confounding factors, multivariable logistic regression analysis demonstrated that PHI was independently associated with increased mortality (AOR 5, 95% CI: 1.7-13.7, P = 0.004). Pre-hospital endotracheal intubation in isolated, moderate to severe TBI patients is associated with a nearly 5-fold increase in mortality. Further prospective studies are required to establish guidelines for optimal pre-hospital management of this critically injured patient population.

Expositionen mit Ätzstoffen

Caustic injuries of the eye usually occur accidentally and can result in minor eye irritations to total loss of vision. All chemical exposures to the eye require immediate decontamination by copious irrigation with an aqueous solution for at least 15-30 minutes up to two hours in single cases of massive exposure. Tap water is readily available, safe, and effective and, thus, the preferred irrigation fluid. Warmed lactated Ringer's solution is theoretically preferable to normal saline as an ocular irrigant because it has a more physiologic pH and osmolarity. Immediate ophthalmologic referral is recommended for all but the most trivial chemical burns to the eye. Specific treatments for decontamination depend on the underlying agent. Chemical burns of the skin usually occur accidentally. Initial treatment consists of copious water lavage commencing at the scene and removal of particles. While most caustic injuries are treated symptomatically, exposures to hydrofluoric acid (HFA) frequently necessitate specific topic, subcutaneous, intralesional, intravenous or intraarterial injections of calcium gluconate to bind fluoride ions until analgesia. A burn from HFA that involves more than 5% of total body-surface area, or more than 1% of total body-surface area if the concentration of HFA is greater than 50%, requires admission to an ICU for electrocardiographic monitoring and serial measurements of calcium levels, since life-threatening arrhythmias and hypocalcemia can occur. Caustic injuries of the gastrointestinal tract can occur due to inadvertent ingestion of mislabelled fluids or as a suicidal attempt. Ingestion of alkalis is generally thought to result in more severe injuries than ingestion of acids. The oropharynx needs to be first examined by laryngoscopy. A supraglottic or epiglottic burn with erythema and edema formation may be a harbinger of airway obstruction and should be seen as an indication of early endotracheal intubation or tracheostomy. Endoscopy should be performed preferably within 12 hours and generally not later than 24 hours and can serve as a prognostic tool to manage patients appropriately. The risk of procedure related perforation is generally accepted to be negligible. Existing data fail to support the routine use of steroids and antibiotics to prevent esophageal stricture formation and may mask signs of peritonitis. Esophageal strictures, stenosis or gastric outlet obstruction are formidably long-term complications. There is a 1000- to 3000-fold increase in the incidence of esophageal carcinoma after lye-ingestion with a latent period between the time of ingestion and the development of carcinoma as long as 60 years. Endoscopic dilatation or insertion of intraluminal stents should not be performed within the first 6 weeks. Patients with grade 3b injuries may underwent prompt surgical resection in single cases, even if no perforation is confirmed. Perforation, evolution of a mediastinitis or peritonitis with multi-organ failure are devastating complications with extremely high mortality and warrants immediate surgical treatment.