Prehospital Tracheal Intubation Research Articles

Prehospital and emergency department airway management of severe penetrating trauma in Sweden during the past decade

BackgroundPrehospital tracheal intubation (TI) is associated with increased mortality in patients with penetrating trauma, and the utility of prehospital advanced airway management is debated. The increased incidence of deadly violence in Sweden warrants a comprehensive evaluation of current airway management for patients with penetrating trauma in the Swedish prehospital environment and on arrival in the emergency department (ED).MethodsThis was an observational, multicenter study of all patients with penetrating trauma and injury severity scores (ISSs) ≥ 15 included in the Swedish national trauma register (SweTrau) between 2011 and 2019. We investigated the frequency and characteristics of prehospital and ED TI, including 30-day mortality and patient characteristics associated with TI.ResultOf 816 included patients, 118 (14.5%) were intubated prehospitally, and 248 (30.4%) were intubated in the ED. Patients who were intubated prehospitally had a higher ISS, 33 (interquartile range [IQR] 25, 75), than those intubated in the ED, 25 (IQR 18, 34). Prehospital TI was associated with a higher associated mortality, OR 4.26 (CI 2.57, 7.27, p < 0.001) than TI in the ED, even when adjusted for ISS (OR 2.88 [CI 1.64, 5.14, p < 0.001]). Hemodynamic collapse (≤ 40 mmHg) and low GCS score (≤ 8) were the characteristics most associated with prehospital TI. Traumatic cardiac arrests (TCAs) occurred in 154 (18.9%) patients, of whom 77 (50%) were intubated prehospitally and 56 (36.4%) were intubated in the ED. A subgroup analysis excluding TCA showed that patients with prehospital TI did not have a higher mortality rate than those with ED TI, OR 2.07 (CI 0.93, 4.51, p = 0.068), with OR 1.39 (0.56, 3.26, p = 0.5) when adjusted for ISS.ConclusionPrehospital TI was associated with a higher mortality rate than those with ED TI, which was specifically related to TCA; intubation did not affect mortality in patients without cardiac arrest. Mortality was high when airway management was needed, regardless of cardiac arrest, thereby emphasizing the challenges posed when anesthesia is needed. Several interventions, including whole blood transfusions, the implementation of second-tier EMS units and measures to shorten scene times, have been initiated in Sweden to counteract these challenges.

Association of prehospital tracheal intubation with outcomes comparing to supraglottic airway device during out-of-hospital cardiac arrest by drowning: nationwide cohort study in Japan

Abstract Background/Introduction Drowning is the third leading cause of unintentional injury death, which causes more than 500,000 deaths annually worldwide. Several studies have examined the impact of tracheal intubation for outcomes in out-of-hospital cardiac arrest (OHCA) patients, however few studies examined it in OHCA patients by drowning. Purpose To compare survival outcomes among adults OHCA patients by drowning between tracheal intubation and supraglottic airway device. Methods This study compared the outcome of OHCA patients by drowning according to the airway management using Japanese nationwide, population-based registry (All-Japan Utstein Registry). From 2014 to 2020, consecutive adult OHCA patients were included. Patients who received tracheal intubation during cardiopulmonary resuscitation (CPR) were matched with patients treated with supraglottic airway device on the basis propensity scores in a 1:1 ratio, with a 0.2 caliper width. Propensity score was calculated by logistic regression model using following variables; year, prefectural preference of ETI use, age, sex, witnessed status, those who witnessed (By family, citizen, EMS, others), AED use, bystander-initiated CPR, prehospital involvement of physician, defibrillation by EMS, administration of adrenaline, time from call to CPR, first rhythm documented by EMS. The outcome measures were return of spontaneous circulation, survival at one month, and favorable neurological outcome defined as cerebral performance status 1 or 2. Results Of the 11, 703 eligible patients, 4467 (38.2%) and 7236 (61.8%) received tracheal intubation and supraglottic airway device during CPR, respectively. After propensity score matching, 3566 patients in each cohort were matched. The return of spontaneous circulation was higher in those with tracheal intubation compared with those with supraglottic airway device: 207/3566 (5.8%) versus 167/3566 (4.7%) (odds ratio 1.25, 95% confidence interval[CI] 1.02 to 1.55). There was no difference between the groups in one-month survival and favorable neurological outcome: 32/3566 (0.90%) versus 34/3566 (0.95%) (odds ratio 0.94, 95% CI 0.58 to 1.53), and 9/3566 (0.25%) versus 8/3566 (0.22%) (odds ratio 1.13, 95% CI 0.43 to 2.92), respectively. Conclusions In the propensity score matched study for adult OHCA by drowning, tracheal intubation was associated with the return of spontaneous circulation, whereas it was not associated with survival and favorable neurological outcome at one month compared to those with supraglottic airway device. Further studies such as to investigate the heterogeneity of the effect of intubation during the resuscitation might be mandated for the improvement of the outcome among the OHCA patients by drowning.Out-of-hospital cardiac arrest outcomes

Prehospital tracheal intubations by anaesthetist-staffed critical care teams: a prospective observational multicentre study

BackgroundPrehospital tracheal intubation is a potentially lifesaving intervention, but is associated with prolonged time on-scene. Some services strongly advocate performing the procedure outside of the ambulance or aircraft, while others also perform the procedure inside the vehicle. This study was designed as a non-inferiority trial registering the rate of successful tracheal intubation and incidence of complications performed by a critical care team either inside or outside an ambulance or helicopter. MethodsThis observational multicentre study was performed between March 2020 and September 2021 and involved 12 anaesthetist-staffed critical care teams providing emergency medical services by helicopter in Denmark, Norway, and Sweden. The primary outcome was first-pass successful tracheal intubations. ResultsOf the 422 drug-assisted tracheal intubations examined, 240 (57%) took place in the cabin of the ambulance or helicopter. The rate of first-pass success was 89.2% for intubations in-cabin vs 86.3% outside. This difference of 2.9% (confidence interval −2.4% to 8.2%) (two sided 10%, including 0, but not the non-inferiority limit Δ=−4.5) fulfils our criteria for non-inferiority, but not significant superiority. These results withstand after performing a propensity score analysis. The mean on-scene time associated with the helicopter in-cabin procedures (27 min) was significantly shorter than for outside the cabin (32 min, P=0.004). ConclusionsBoth in-cabin and outside the cabin, prehospital tracheal intubation by anaesthetists was performed with a high success rate. The mean on-scene time was shorter in the in-cabin helicopter cohort. Clinical trial registrationNCT04206566.

Success of prehospital tracheal intubation during cardiac arrest varies based on race/ethnicity and sex

IntroductionTracheal intubation is a high-risk procedure often performed in the prehospital setting by emergency medical services (EMS) on patients experiencing cardiac arrest. Because of the high potential for adverse consequences resulting from unsuccessful intubation, intubation success rates are a topic of significant concern. There has been little research examining whether cardiac arrest intubation success rates vary based on patient race/ethnicity and patient sex. MethodsWe examined a national registry of EMS calls in the United States. Inclusion criteria were tracheal intubations (2017–2021) performed on adult cardiac arrest patients where EMS providers documented the patient's race/ethnicity and patient sex and whether the intubation was successful. A total of 210,992 cardiac arrests met inclusion criteria. When considering patient sex, intubation was more common in male patients than female patients, but intubation success rates were significantly higher in female patients (p < .01). When considering patient race/ethnicity, intubation success rates were highest in White patients and significantly lower in patients of all other races/ethnicities (p < .01). ConclusionsIntubation success rates were higher in female patients and White patients. Further studies need to examine disparities and identify strategies to improve intubation success for all patients with cardiac arrest. Possible explanations for the obtained results are differences in patient health, in provider familiarity with intubation, and in the availability of assistive technologies that facilitate intubation (e.g. video laryngoscopy).

クリニカルシナリオ1急性心不全におけるドクターカーによる病院前硝酸薬投与と救急外来での気管挿管の割合との関連(Association between prehospital nitrates administration and tracheal intubation at emergency department in patients with the Clinical Scenario 1 acute heart failure)

要旨【背景】Clinical Scenario（CS）1心不全は早急な血管拡張と呼吸管理による肺うっ血の解除が必要である。本研究の目的はドクターカーによる病院前硝酸薬投与と救急外来で気管挿管された割合を検討することである。【方法】2015年1月から2020年12月までの間，当救命救急センターへ搬送されたCS1心不全患者209例のうち，ドクターカーによる病院前に硝酸薬を投与された病院前投与群（29例）と管轄救急隊により搬送された病着後に硝酸薬を投与された病着後投与群（123例）の両群へ分け，病院前硝酸薬投与に対する傾向スコアを算出し，1対1傾向マッチングを行った。主要評価項目は救急外来で気管挿管された割合，副次評価項目は非侵襲的陽圧換気とした。病院前投与群の過度な血圧低下についても検討した。【結果】傾向スコアマッチング後の病院前投与群と病着後投与群はともに23例であり，救急外来での気管挿管された割合は両群に有意差を認めなかった（9% vs. 13%, p&gt;0.99）。非侵襲的陽圧換気は病院前投与群において有意に低値であった（48% vs. 83%, p=0.03）。病院前投与群では病院到着時に過度な血圧低下を認めなかった。【結語】本研究ではドクターカーによる病院前硝酸薬投与は救急外来での気管挿管された割合と有意な関連は認めなかったが，病着時の過度な降圧は認めなかった。

Perception and success rate of using advanced airway management by hospital-based paramedics in the Kingdom of Saudi Arabia.

The study aimed to measure the success rate of pre-hospital tracheal intubation (TI) and supraglottic airway devices (SADs) performed by paramedics for adult patients and to assess the perception of paramedics of advanced airway management. The study consisted of two phases: phase 1 was a retrospective analysis to assess the TI and SADs' success rates when applied by paramedics for adult patients aged >14 years from 2012 to 2017, and phase 2 was a distributed questionnaire to assess paramedics' perception of advanced airway management. In phase 1, 24 patients met our inclusion criteria. Sixteen (67%) patients had TI, of whom five had failed TI but then were successfully managed using SADs. The TI success rate was 69% from the first two attempts compared to SADs (100% from first attempt). In phase 2, 63/90 (70%) paramedics responded to the questionnaire, of whom 60 (95%) completed it. Forty-eight (80%) paramedics classified themselves to be moderately or very competent with advanced airway management. However, most of them (80%) performed only 1-5 TIs or SADs a year. Hospital-based paramedics (i.e. paramedics who are working at hospitals and not in the ambulance service, and who mostly respond to small restricted areas in Saudi Arabia) handled few patients requiring advanced airway management and had a higher competency level with SADs than with TI. The study findings could be impacted by the low sample size. Future research is needed on the success rate and impact on outcomes of using pre-hospital advanced airway management, and on the challenges of mechanical ventilation use during interfacility transfer.

Risk factors and outcomes of unrecognised endobronchial intubation in major trauma patients

BackgroundEmergency tracheal intubation during major trauma resuscitation may be associated with unrecognised endobronchial intubation. The risk factors and outcomes associated with this issue have not previously been fully defined.MethodsWe retrospectively...

Pediatric Prehospital Advanced Airway Management by Anesthesiologist and Nurse Anesthetist Staffed Critical Care Teams.

Prehospital pediatric tracheal intubation (TI) is a possible life-saving intervention that requires adequate experience to mitigate associated complications. The pediatric airway and respiratory physiology present challenges in addition to a relatively rare incidence of prehospital pediatric TI. The aim of this study was to describe characteristics and outcomes of prehospital TI in pediatric patients treated by critical care teams. This is a sub-group analysis of all pediatric (<16 years old) patients from a prospective, observational, multi-center study on prehospital advanced airway management in the Nordic countries from May 2015 through November 2016. The TIs were performed by anesthesiologists and nurse anesthetists staffing six helicopter and six Rapid Response Car (RRC) prehospital critical care teams. In the study, 74 children were tracheal intubated, which corresponds to 3.7% (74/2,027) of the total number of patients. The pediatric patients were intubated by very experienced providers, of which 80% had performed ≥2,500 TIs. The overall TI success rate, first pass success rate, and airway complication rate were in all children (<16 years) 98%, 82%, and 12%. The corresponding rates among infants (<2 years) were 94%, 67%, and 11%. The median time on scene was 30 minutes. This study observed a high overall prehospital TI success rate in children with relatively few associated complications and short time on scene, despite the challenges presented by the pediatric prehospital TI.

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

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.

Early airway management of patients with severe head injury: opportunities missed?

Early airway management of patients with severe head injury: opportunities missed?

Variation in the practice of tracheal intubation in Europe after traumatic brain injury: a prospective cohort study

SummaryTraumatic brain injury patients frequently undergo tracheal intubation. We aimed to assess current intubation practice in Europe and identify variation in practice. We analysed data from patients with traumatic brain injury included in the prospective cohort study collaborative European neurotrauma effectiveness research in traumatic brain injury (CENTER‐TBI) in 45 centres in 16 European countries. We included patients who were transported to hospital by emergency medical services. We used mixed‐effects multinomial regression to quantify the effects on pre‐hospital or in‐hospital tracheal intubation of the following: patient characteristics; injury characteristics; centre; and trauma system characteristics. A total of 3843 patients were included. Of these, 1322 (34%) had their tracheas intubated; 839 (22%) pre‐hospital and 483 (13%) in‐hospital. The fit of the model with only patient characteristics predicting intubation was good (Nagelkerke R2 64%). The probability of tracheal intubation increased with the following: younger age; lower pre‐hospital or emergency department GCS; higher abbreviated injury scale scores (head and neck, thorax and chest, face or abdomen abbreviated injury score); and one or more unreactive pupils. The adjusted median odds ratio for intubation between two randomly chosen centres was 3.1 (95%CI 2.1–4.3) for pre‐hospital intubation, and 2.7 (95%CI 1.9–3.5) for in‐hospital intubation. Furthermore, the presence of an anaesthetist was independently associated with more pre‐hospital intubation (OR 2.9, 95%CI 1.3–6.6), in contrast to the presence of ambulance personnel who are allowed to intubate (OR 0.5, 95%CI 0.3–0.8). In conclusion, patient and injury characteristics are key drivers of tracheal intubation. Between‐centre differences were also substantial. Further studies are needed to improve the evidence base supporting recommendations for tracheal intubation.

Impact of drug and equipment preparation on pre-hospital emergency Anaesthesia (PHEA) procedural time, error rate and cognitive load

BackgroundWe examined the effect of advanced preparation and organisation of equipment and drugs for Pre-hospital Emergency Anaesthesia (PHEA) and tracheal intubation on procedural time, error rates, and cognitive load.MethodsThis study was a randomised, controlled experiment with a crossover design. Clinical teams (physician and paramedic) from the Emergency Medical Retrieval Service and the Scottish Air Ambulance Division were randomised to perform a standardised pre-hospital clinical simulation using either unprepared (standard practice) or pre-prepared (experimental method) PHEA equipment and drugs. Following a two-week washout period, each team performed the corresponding simulation. The primary outcome was intervention time. Secondary outcomes were safety-related incidents and errors, and degree of cognitive load.ResultsIn total 23 experiments were completed, 12 using experimental method and 11 using standard practice. Time required to perform PHEA using the experimental method was significantly shorter than with standard practice (11,45 versus 20:59) minutes: seconds; p = < 0.001). The experimental method also significantly reduced procedural errors (0 versus 9, p = 0.007) and the cognitive load experienced by the intubator assistant (41.9 versus 68.7 mm, p = 0.006).ConclusionsPre-preparation of PHEA equipment and drugs resulted in safer performance of PHEA and has the potential to reduce on-scene time by up to a third.

Pre-hospital advanced airway management by anaesthetist and nurse anaesthetist critical care teams: a prospective observational study of 2028 pre-hospital tracheal intubations

BackgroundPre-hospital tracheal intubation success and complication rates vary considerably among provider categories. The purpose of this study was to estimate the success and complication rates of pre-hospital tracheal intubation performed by physician anaesthetist or nurse anaesthetist pre-hospital critical care teams. MethodsData were prospectively collected from critical care teams staffed with a physician anaesthetist or a nurse anaesthetist according to the Utstein template for pre-hospital advanced airway management. The patients served by six ambulance helicopters and six rapid response vehicles in Denmark, Finland, Norway, and Sweden from May 2015 to November 2016 were included. ResultsThe critical care teams attended to 32 007 patients; 2028 (6.3%) required pre-hospital tracheal intubation. The overall success rate of pre-hospital tracheal intubation was 98.7% with a median intubation time of 25 s and an on-scene time of 25 min. The majority (67.0%) of the patients' tracheas were intubated by providers who had performed >2500 tracheal intubations. The success rate of tracheal intubation on the first attempt was 84.5%, and 95.9% of intubations were completed after two attempts. Complications related to pre-hospital tracheal intubation were recorded in 10.9% of the patients. Intubations after rapid sequence induction had a higher success rate compared with intubations without rapid sequence induction (99.4% vs 98.1%; P=0.02). Physicians had a higher tracheal intubation success rate than nurses (99.0% vs 97.6%; P=0.03). ConclusionsWhen performed by experienced physician anaesthetists and nurse anaesthetists, pre-hospital tracheal intubation was completed rapidly with high success rates and a low incidence of complications. Clinical trial numberNCT 02450071.

Intubation Success in Critical Care Transport: A Multicenter Study

Introduction: Tracheal intubation (TI) is a lifesaving critical care skill. Failed TI attempts, however, can harm patients. Critical care transport (CCT) teams function as the first point of critical care contact for patients being transported to tertiary medical centers for specialized surgical, medical, and trauma care. The Ground and Air Medical qUality in Transport (GAMUT) Quality Improvement Collaborative uses a quality metric database to track CCT quality metric performance, including TI. We sought to describe TI among GAMUT participants with the hypothesis that CCT would perform better than other prehospital TI reports and similarly to hospital TI success. Methods: The GAMUT Database is a global, voluntary database for tracking consensus quality metric performance among CCT programs performing neonatal, pediatric, and adult transports. The TI-specific quality metrics are “first attempt TI success” and “definitive airway sans hypoxia/hypotension on first attempt (DASH-1A).” The 2015 GAMUT Database was queried and analysis included patient age, program type, and intubation success rate. Analysis included simple statistics and Pearson chi-square with Bonferroni-adjusted post hoc z tests (significance = p < 0.05 via two-sided testing). Results: Overall, 85,704 patient contacts (neonatal n [%] = 12,664 [14.8%], pediatric n [%] = 28,992 [33.8%], adult n [%] = 44,048 [51.4%]) were included, with 4,036 (4.7%) TI attempts. First attempt TI success was lowest in neonates (59.3%, 617 attempts), better in pediatrics (81.7%, 519 attempts), and best in adults (87%, 2900 attempts), p < 0.001. Adult-focused CCT teams had higher overall first attempt TI success versus pediatric- and neonatal-focused teams (86.9% vs. 63.5%, p < 0.001) and also in pediatric first attempt TI success (86.5% vs. 75.3%, p < 0.001). DASH-1A rates were lower across all patient types (neonatal = 51.9%, pediatric = 74.3%, adult = 79.8%). Conclusions: CCT TI is not uncommon, and rates of TI and DASH-1A success are higher in adult patients and adult-focused CCT teams. TI success rates are higher in CCT than other prehospital settings, but lower than in-hospital success TI rates. Identifying factors influencing TI success among high performers should influence best practice strategies for TI.

Prehospital Tracheal Intubation versus Emergency Department Intubation for Trauma Patients

Prehospital Tracheal Intubation versus Emergency Department Intubation for Trauma Patients

Comparison of Pentax-AWS®, Glidescope®, and King Vision® for difficult-airway intubation in manikins model by paramedics

Introduction: Prehospital tracheal intubation of a difficult airway is challenging for paramedics. Thus far, the potential role of video laryngoscopes for this purpose has not been confirmed. Therefore, this study aimed to determine the impact of different types of video laryngoscopes on the success rate and time to intubation by paramedics. Methods: This is a prospective, randomized, crossover manikin study involving 18 paramedics. Participants performed intubation on a difficult airway in a high-fidelity manikin using Pentax-AWS®, Glidescope®, and King Vision® (with two blade types). Time to intubation and success rate of intubation were determined. Participants also rated the best glottic view and reported their preferences of devices. Results: In a difficult-airway scenario, the median time to intubation with Pentax-AWS® was 22.9 s (interquartile range, 19.5–24.9 s), which was significantly shorter than using other devices. There were no significant differences in the time to maximal exposure of the vocal cords between four devices ( p = 0.156). The time to insert the endotracheal tube with Pentax-AWS® and King Vision® with a guide-channel blade was significantly shorter than that with the other two devices (all, p &lt; 0.05). Pentax-AWS® and King Vision® with a guide-channel blade showed higher success rates than the other two devices ( p = 0.04). With regard to device preference, 14 participants preferred Pentax-AWS® among all devices analyzed. Conclusion: Pentax-AWS® could be an appropriate device for paramedics in cases of difficult airways, with high success rate.

A systematic review and meta-analysis comparing mortality in pre-hospital tracheal intubation to emergency department intubation in trauma patients

BackgroundPre-hospital endotracheal intubation is frequently used for trauma patients in many emergency medical systems. Despite a wide range of publications in the field, it is debated whether the intervention is associated with a favourable outcome, when compared to more conservative airway measures.MethodsA systematic literature search was conducted to identify interventional and observational studies where the mortality rates of adult trauma patients undergoing pre-hospital endotracheal intubation were compared to those undergoing emergency department intubation.ResultsTwenty-one studies examining 35,838 patients were included. The median mortality rate in patients undergoing pre-hospital intubation was 48% (range 8–94%), compared to 29% (range 6–67%) in patients undergoing intubation in the emergency department. Odds ratios were in favour of emergency department intubation both in crude and adjusted mortality, with 2.56 (95% CI: 2.06, 3.18) and 2.59 (95% CI: 1.97, 3.39), respectively. The overall quality of evidence is very low. Twelve of the twenty-one studies found a significantly higher mortality rate after pre-hospital intubation, seven found no significant differences, one found a positive effect, and for one study an analysis of the mortality rate was beyond the scope of the article.ConclusionsThe rationale for wide and unspecific indications for pre-hospital intubation seems to lack support in the literature, despite several publications involving a relatively large number of patients. Pre-hospital intubation is a complex intervention where guidelines and research findings should be approached cautiously. The association between pre-hospital intubation and a higher mortality rate does not necessarily contradict the importance of the intervention, but it does call for a thorough investigation by clinicians and researchers into possible causes for this finding.

Hypoxia and hypotension in patients intubated by physician staffed helicopter emergency medical services - a prospective observational multi-centre study

BackgroundThe effective treatment of airway compromise in trauma and non-trauma patients is important. Hypoxia and hypotension are predictors of negative patient outcomes and increased mortality, and may be important quality indicators of care provided by emergency medical services. Excluding cardiac arrests, critical trauma and non-trauma patients remain the two major groups to which helicopter emergency medical services (HEMS) are dispatched. Several studies describe the impact of pre-hospital hypoxia or hypotension on trauma patients, but few studies compare this in trauma and non-trauma patients. The primary aim was to describe the incidence of pre-hospital hypoxia and hypotension in the two groups receiving pre-hospital tracheal intubation (TI) by physician-staffed HEMS.MethodsData were collected prospectively over a 12-month period, using a uniform Utstein-style airway template. Twenty-one physician-staffed HEMS in Europe and Australia participated. We compared peripheral oxygen saturation and systolic blood pressure before and after definitive airway management. Data were analysed using Cochran–Mantel–Haenszel methods and mixed-effects models.ResultsEight hundred forty three trauma patients and 422 non-trauma patients receiving pre-hospital TI were included. Non-trauma patients had significantly lower predicted mean pre-intervention SpO2 compared to trauma patients. Post-intervention and admission SpO2 for the two groups were comparable. However, 3% in both groups were still hypoxic at admission. For hypotension, the differences between the groups were less prominent. However, 9% of trauma and 10% of non-trauma patients were still hypotensive at admission. There was no difference in short-term survival between trauma (97%) and non-trauma patients (95%). Decreased level of consciousness was the most frequent indication for TI, and was associated with increased survival to hospital (cOR 2.8; 95% CI: 1.4–5.4).ConclusionsOur results showed that non-trauma patients had a higher incidence of hypoxia before TI than trauma patients, but few were hypoxic at admission. The difference for hypotension was less prominent, but one in ten patients were still hypotensive at admission. Further investigations are needed to identify reversible causes that may be corrected to improve haemodynamics in the pre-hospital setting. We found high survival rates to hospital in both groups, suggesting that physician-staffed HEMS provide high-quality emergency airway management in trauma and non-trauma patients.Trial registrationClinicaltrials.gov Identifier: NCT01502111. Registered 22 Desember 2011.

The success of pre-hospital tracheal intubation by different pre-hospital providers: a systematic literature review and meta-analysis

BackgroundPre-hospital basic airway interventions can be ineffective at providing adequate oxygenation and ventilation in some severely ill or injured patients, and advanced airway interventions are then required. Controversy exists regarding the level of provider required to perform successful pre-hospital intubation. A previous meta-analysis reported pre-hospital intubation success rates of 0.849 for non-physicians versus 0.991 for physicians. The evidence base on the topic has expanded significantly in the last 10 years. This study systematically reviewed recent literature and presents comprehensive data on intubation success rates.MethodsA systematic search of MEDLINE and EMBASE was performed using PRISMA methodology to identify articles on pre-hospital tracheal intubation published between 2006 and 2016. Overall success rates were estimated using random effects meta-analysis. The relationship between intubation success rate and provider type was assessed in weighted linear regression analysis.ResultsOf the 1838 identified studies, 38 met the study inclusion criteria. Intubation was performed by non-physicians in half of the studies and by physicians in the other half. The crude median (range) reported overall success rate was 0.969 (0.616–1.000). In random effects meta-analysis, the estimated overall intubation success rate was 0.953 (0.938–0.965). The crude median (range) reported intubation success rates for non-physicians were 0.917 (0.616–1.000) and, for physicians, were 0.988 (0.781–1.000) (p = 0.003).DiscussionThe reported overall success rate of pre-hospital intubation has improved, yet there is still a significant difference between non-physician and physician providers. The finding that less-experienced personnel perform less well is not unexpected, but since there is considerable evidence that poorly performed intubation carries a significant risk of morbidity and mortality careful consideration should be given to the training and experience required to deliver this intervention safely.

Effect of cricoid pressure on laryngeal view during prehospital tracheal intubation: a propensity-based analysis

BackgroundThe benefit of cricoid pressure during tracheal intubation is still debated and, due to its potential negative impact on laryngeal views, its routine use is questioned. The goal of this...