Endotracheal Intubation In Emergency Department Research Articles

227 Impact of Active versus Passive Preoxygenation on Emergency Department Mortality in Kigali, Rwanda

Preoxygenation for endotracheal intubation (EI) is well studied in high-income countries (HIC). However, its effect on emergency department (ED) airway management in low- and middle-income countries (LMIC) is not well characterized. This study compared the impacts of active versus passive preoxygenation methods on ED mortality among patients presenting for emergency care and undergoing EI at the University Teaching Hospital-Kigali (UTH-K). A prospective cohort of patients requiring ED EI, accrued continuously over twelve months (January 1st, 2017 – December 31st, 2017) with documented preoxygenation methods, were evaluated. The exposure of interest was active preoxygenation (defined as bag-valve mask or positive pressure ventilation) versus passive preoxygenation (defined as non-rebreather mask or oxygen facemask). The primary outcome was ED mortality. Collected data included: duration of preoxygenation, EI indication, clinical characteristics, and pre-intubation vital signs. Magnitudes of effects were quantified using multivariable regression models to yield adjusted odds ratios (aOR) with 95% confidence intervals (CI). Of 194 patients undergoing EI, 163 met inclusion and were analyzed. Median age was 38.7 years (IQR 6-84), 72% were male, with 52% trauma patients. Within the cohort, 73.6% received passive preoxygenation while 26.4% were actively preoxygenated. The shock index (SI) was higher than 0.9 in 45% of those with passive preoxygenation and 58.6% of those who were actively preoxygenated. The majority of both passively (68.3%) and actively preoxygenated (53.9%) patients were preoxygenated for 3-5 minutes. Actively preoxygenated patients had higher ED mortality (81.4%) as compared to passively preoxygenated patients (45.8%) (p<0.001). This translated to significantly lower adjusted odds of ED mortality for those with passive preoxygenation in multivariable models controlling for EI indication, pre-intubation oxygen saturation, pre-intubation SI, and intubation method (aOR 0.30, 95% CI: 0.11, 0.82, p=0.02). In adjusted analyses, passively preoxygenated patients had much lower odds of ED mortality. This association could be due to the impacts of active preoxygenation methods or potentially unmeasured confounding factors. Further research is needed to better understand this clinical approach in LMICs where there exists limited data on preoxygenation methods in emergency care and where there are often barriers to oxygen availability.

The application of HC visual laryngoscope as a visualization teaching method for the standardized training of endotracheal intubation in emergency department

Objective To investigate the feasibility and effect of visualization teaching method using HC visual laryngoscope for the standardized training of endotracheal intubation in emergency department. Methods Forty standard-trainee doctors were divided into two groups randomly. 20 standard-trainee doctors in team N were taught using the conventional teaching method of emergency medicine for the standardized training of endotracheal intubation, and the other 20 standard-trainee doctors in team HC were taught by visualization teaching method using HC visual laryngoscope. After 1 month training, comparisons of the success rate of tracheal intubation in airway management simulator, the time consumed for intubation and the number of attempt on successful intubation cases, and the satisfaction score with the teaching mode scored by standard-trainee doctors between the two groups were done. Results The one-attempt success rate and the success rate of tracheal intubation in airway management simulator by the standard-trainee doctors in group HC were significantly higher than those in group N (40% vs. 10%, 85% vs. 55%), while the number of attempt and the time consumed for successful intubation were significantly less than those in group N[ (1.65±0.61) vs. (2.27±0.66), (79.00±8.35) s vs. (89.36±12.03) s). The satisfaction score with this teaching mode and teaching effect of standard-trainee doctors in group HC were significantly higher than those in group N (8.10±0.74 vs. 6.55±1.05, 8.15±0.80 vs. 6.85±0.91). Conclusions The visualization teaching method with application of HC visual laryngoscope for standardized training of endotracheal intubation in emergency department could improve the success rate and efficiency of tracheal intubation in airway management simulator for standard-trainee doctors, and this teaching method may be better than the conventional teaching method on teaching mode presenting some feasibility. Key words: HC visual laryngoscope; Visualization teaching; Endotracheal intubation; Emergency department; Standardized training; Teaching

Frequency and outcomes of endotracheal intubation in the pediatric emergency department.

Intubation is a core airway skill in Pediatric Emergency Medicine (PEM). The data on pediatric endotracheal intubation in the emergency department, especially in developing countries, is currently very limited. This study was designed to describe the frequency, clinical features and outcomes of pediatric intubation in a large children`s hospital. We performed a retrospective analysis of PEM medical records between January 2014 and December 2015 that involved any attempted intubations of children younger than 18 years. The medical records were reviewed to describe the intubation process, demographics, clinical features and outcomes. A total of 110,000 patients visited our emergency department during the study period. Ninety-one of them (1/1300) were intubated. The median age was 2 years, (F/M: 1) and 25 patients were younger than 12 months. Respiratory failure was the most common indication for intubation (42%), followed by status epilepticus (26%) and sepsis-shock (16%). Mortality was associated with prolonged chest compression (more than 10 minute). A poor outcome was associated with sepsis-shock and cardiac diseases; however, better outcomes were associated with status epilepticus (p < 0.001). The first attempt success (FAS) was achieved in 60/91 (66 %) patients and the FAS rate was also higher in younger patients (p=0.002). The discharge rate of all intubated patients in our study was sixty-four percent. Pediatric residents performed the majority of intubations. A higher FAS rate was associated with younger patients. Favorable outcomes were directly related to duration of cardiopulmonary resuscitation and main diagnosis.

What factors affect the success rate of the first attempt at endotracheal intubation in emergency departments?

Study objectiveThis study aimed to determine the factors associated with successful endotracheal intubation (ETI) on the first-attempt in an emergency department.MethodWe studied all of the ETI data at two urban...

Prevalence of Acute Lung Injury Among Medical Patients in the Emergency Department

Acute lung injury (ALI) affects an estimated 190,000 persons per year in U.S. intensive care units (ICUs), but little is known about its prevalence in the emergency department (ED). The objective was to describe the prevalence of ALI among mechanically ventilated adult nontrauma patients in the ED. The hypothesis was that the prevalence of ALI in adult ED patients would be low. This was a retrospective cohort study of admitted nontrauma patients presenting to an academic ED. Two trained investigators abstracted data from patient records using a standardized form. The use of mechanical ventilation in the ED was identified in two phases. First, all ED patients were screened for the current procedural terminology (CPT) code for endotracheal intubation (CPT 31500) from January 1, 2003, to December 31, 2006. Second, each patient record was reviewed to verify the use of mechanical ventilation. ALI was defined in accordance with a modified version of the American-European Consensus Conference criteria as: 1) hypoxemia defined as PaO(2) /FiO(2) ratio ≤300 mm Hg on all arterial blood gases (ABGs) in the ED and the first 24 hours of admission, 2) the presence of bilateral infiltrates on chest radiograph, and 3) the absence of left atrial hypertension. Data are presented in absolute numbers and percentages. Interobserver agreement was evaluated using the kappa statistic. Of the 552 patients who received mechanical ventilation in the ED and were subsequently admitted, a total of 134 (24.3%, 95% confidence interval [CI] = 20.8% to 28.0%) met hypoxemia criteria. Of these, 34 had evidence of left atrial hypertension, 52 did not have chest radiograph findings consistent with ALI, and two did not have a chest radiograph performed; the remaining 46 met ALI criteria. An additional two patients who died in the ED had clinical evidence of ALI. Thus, 48 of 552, or 8.7% (95% CI = 6.6% to 11.3%), met criteria for ALI. The kappa value for determination of ALI was 0.84 (95% CI = 0.54 to 1.0). The prevalence of ALI was nearly 9% in adult nontrauma patients receiving mechanical ventilation in the ED. Further study is required to determine which types of patients present to the ED with ALI, the extent to which lung protective ventilation is used, and the need for ED ventilator management algorithms.

Out-of-hospital endotracheal intubation and outcome after traumatic brain injury

Previous studies disagree about the effect of out-of-hospital endotracheal intubation on traumatic brain injury. This study compares the effects of out-of-hospital endotracheal intubation versus emergency department (ED) endotracheal intubation on mortality and neurologic and functional outcome after severe traumatic brain injury. From the 2000 to 2002 Pennsylvania Trauma Outcome Study (a registry of all patients treated at trauma centers in the Commonwealth of Pennsylvania), adult patients with head/neck Abbreviated Injury Scale score of 3 or greater and undergoing out-of-hospital endotracheal intubation or ED endotracheal intubation were included. Transferred patients were excluded. The primary outcome was death (on hospital discharge). The secondary outcomes were neurologic (good versus poor, inferred from discharge to home versus long-term care facility) and functional outcome (determined from a Functional Impairment Score). The key exposure was endotracheal intubation (out-of-hospital endotracheal intubation versus ED endotracheal intubation). Using multivariate logistic regression, odds estimates for out-of-hospital endotracheal intubation were adjusted using age, sex, head/neck Abbreviated Injury Scale score, Injury Severity Score, mechanism of injury (penetrating versus blunt), admission systolic blood pressure, mode of transport (ground only versus helicopter or helicopter + ground), and the use of out-of-hospital neuromuscular blocking agents. A propensity score adjustment accounted for the potential effects of preexisting conditions, inhospital complications, and social factors (drug and alcohol use, race, and insurance coverage). There were 4,098 patients with head/neck Abbreviated Injury Scale score of 3 or greater who received either out-of-hospital endotracheal intubation (n=1,797, 43.9%) or ED endotracheal intubation (n=2,301, 56.1%). Adjusted odds of death were higher for out-of-hospital endotracheal intubation than ED endotracheal intubation (odds ratio [OR] 3.99; 95% confidence interval [CI] 3.21 to 4.93). Out-of-hospital endotracheal intubation was associated with an increased adjusted odds of poor neurologic outcome (OR 1.61; 95% CI 1.15 to 2.26), moderate or severe functional impairment (Functional Impairment Score 6 to 15; OR 1.92; 95% CI 1.40 to 2.64), and severe functional impairment (Functional Impairment Score 11 to 15; OR 1.80; 95% CI 1.29 to 2.52). Out-of-hospital endotracheal intubation was associated with adverse outcomes after severe traumatic brain injury. The implications for current clinical care remain undefined.

Inadequate Oxygenation and Ventilation Using the Esophageal Gastric Tube Airway in the Prehospital Setting

In a prospective study to evaluate the respiratory effectiveness of the esophageal gastric tube airway (EGTA) in the prehospital setting, we analyzed arterial blood samples from 43 victims of out-of-hospital cardiopulmonary arrest managed with the EGTA. Five minutes after emergency department endotracheal intubation, arterial blood gas analysis was repeated for comparison. During EGTA ventilation, the mean arterial Po2measured 83.6 ±110.4 mm Hg; endotracheal intubation increased the mean Po2to 189 ±167.5 mm Hg. During EGTA ventilation, the mean arterial Pco2measured 77.1±34 mm Hg; endotracheal intubation decreased the mean Pco2to 57.8 ±34.4 mm Hg. We conclude that endotracheal intubation remains the procedure of choice for airway management in the victim of cardiopulmonary arrest. (JAMA1983;250:3067-3071)

Inadequate oxygenation and ventilation using the esophageal gastric tube airway in the prehospital setting

In a prospective study to evaluate the respiratory effectiveness of the esophageal gastric tube airway (EGTA) in the prehospital setting, we analyzed arterial blood samples from 43 victims of out-of-hospital cardiopulmonary arrest managed with the EGTA. Five minutes after emergency department endotracheal intubation, arterial blood gas analysis was repeated for comparison. During EGTA ventilation, the mean arterial Po₂measured 83.6 ±110.4 mm Hg; endotracheal intubation increased the mean Po₂to 189 ±167.5 mm Hg. During EGTA ventilation, the mean arterial Pco₂measured 77.1±34 mm Hg; endotracheal intubation decreased the mean Pco₂to 57.8 ±34.4 mm Hg. We conclude that endotracheal intubation remains the procedure of choice for airway management in the victim of cardiopulmonary arrest. (<i>JAMA</i>1983;250:3067-3071)

Inadequate Oxygenation and Ventilation Using the Esophageal Gastric Tube Airway in the Prehospital Setting

In a prospective study to evaluate the respiratory effectiveness of the esophageal gastric tube airway (EGTA) in the prehospital setting, we analyzed arterial blood samples from 43 victims of out-of-hospital cardiopulmonary arrest managed with the EGTA. Five minutes after emergency department endotracheal intubation, arterial blood gas analysis was repeated for comparison. During EGTA ventilation, the mean arterial PO2 measured 83.6 +/- 110.4 mm Hg; endotracheal intubation increased the mean PO2 to 189 +/- 167.5 mm Hg. During EGTA ventilation, the mean arterial PCO2 measured 77.1 +/- 34 mm Hg; endotracheal intubation decreased the mean PCO2 to 57.8 +/- 34.4 mm Hg. We conclude that endotracheal intubation remains the procedure of choice for airway management in the victim of cardiopulmonary arrest.