Prehospital Intubation Research Articles

Feasibility of Prehospital Rapid Sequence Intubation in the Cabin of an AW169 Helicopter

ObjectivePrehospital rapid sequence intubation (RSI) is an important aspect of prehospital care for helicopter emergency medical services (HEMS). This study examines the feasibility of in-aircraft (aircraft on the ground) RSI in different simulated settings. MethodsUsing an AW169 aircraft cabin simulator at Air Ambulance Kent Surrey Sussex, 3 clinical scenarios were devised. All required RSI in a “can intubate, can ventilate” (easy variant) and a “can't intubate, can't ventilate” scenario (difficult variant). Doctor-paramedic HEMS teams were video recorded, and elapsed times for prespecified end points were analyzed. ResultsEndotracheal intubation (ETI) was achieved fastest outside the simulator for the easy variant (median = 231 seconds, interquartile range = 28 seconds). Time to ETI was not significantly longer for in-aircraft RSI compared with RSI outside the aircraft, both in the easy (p = .14) and difficult variant (p = .50). Wearing helmets with noise distraction did not impact the time to intubation when compared with standard in-aircraft RSI, both in the easy (p = .28) and difficult variant (p = .24). ConclusionIn-aircraft, on-the-ground RSI had no significant impact on the time to successful completion of ETI. Future studies should prospectively examine in-cabin RSI and explore the possibilities of in-flight RSI in civilian HEMS services.

Hypoxemia Index Associated with Prehospital Intubation in COVID-19 Patients.

Background: There exists a need for prognostic tools for the early identification of COVID-19 patients requiring prehospital intubation. Here we investigated the association between a prehospital Hypoxemia Index (HI) and the need for intubation among COVID-19 patients in the prehospital setting. Methods: We retrospectively analyzed COVID-19 patients initially cared for by a Paris Fire Brigade advanced life support (ALS) team in the prehospital setting between 8th March and 18th April of 2020. We assessed the association between HI and prehospital intubation using receiver operating characteristic (ROC) curve analysis and logistic regression model analysis after propensity score matching. Results are expressed as odds ratio (OR) and 95% confidence interval (CI). Results: We analyzed 300 consecutive COVID-19 patients (166 males (55%); mean age, 64 ± 18 years). Among these patients, 45 (15%) were deceased on the scene, 34 (11%) had an active care restriction, and 18 (6%) were intubated in the prehospital setting. The mean HI value was 3.4 ± 1.9. HI was significantly associated with prehospital intubation (OR, 0.24; 95% CI: 0.12–0.41, p < 10−3) with a corresponding area under curve (AUC) of 0.91 (95% CI: 0.85–0.98). HI significantly differed between patients with and without prehospital intubation (1.0 ± 1.0 vs. 3.6 ± 1.8, respectively; p < 10−3). ROC curve analysis defined the optimal HI threshold as 1.3. Bivariate analysis revealed that HI <1.3 was significantly, positively associated with prehospital intubation (OR, 38.38; 95% CI: 11.57–146.54; p < 10−3). Multivariate logistic regression analysis demonstrated that prehospital intubation was significantly associated with HI (adjusted odds ratio (ORa), 0.20; 95% CI: 0.06–0.45; p < 10−3) and HI <3 (ORa, 51.08; 95% CI: 7.83–645.06; p < 10−3). After adjustment for confounders, the ORa between HI <1.3 and prehospital intubation was 3.6 (95% CI: 1.95–5.08; p < 10−3). Conclusion: An HI of <1.3 was associated with a 3-fold increase in prehospital intubation among COVID-19 patients. HI may be a useful tool to facilitate decision-making regarding prehospital intubation of COVID-19 patients initially cared for by a Paris Fire Brigade ALS team. Further prospective studies are needed to confirm these preliminary results.

Comparing performance of video and direct laryngoscopy for pre-hospital intubation

Comparing performance of video and direct laryngoscopy for pre-hospital intubation

Pediatric Prehospital Airway Management by U.S. Forces in Iraq and Afghanistan.

Airway obstruction is a treatable cause of potentially preventable death on the battlefield. Emergency cricothyrotomies are rarely performed in developed countries, but are a common prehospital procedure in recent conflicts in Iraq and Afghanistan. We describe prehospital airway interventions performed on pediatric casualties with a focus on cricothyrotomy during these recent conflicts. This is a secondary analysis of previously published dataset from the Department of Defense Trauma Registry for pediatric encounters from January 2007 to January 2017. Within our dataset we searched for all instances of airway interventions in the prehospital setting. During this time, there were 3,439 pediatric casualties in the registry with a total of 18 prehospital cricothyrotomies and 211 prehospital intubations. For cricothyrotomies, the median age was 10 years, most (72.2%) were male, median composite injury score was 25, most were injured by explosive (44.4%), more commonly located in Afghanistan (77.8%), and approximately half survived to hospital discharge (44.4%). The head was most frequently injured (44.4%). Of those undergoing endotracheal intubation, the median age was 10 years, most (75.8%) were male, median injury score was 17, most were injured by explosives (53.5%), most were in Afghanistan (85.7%), and most survived to hospital discharge (66.8%). The head/neck most frequently had a serious injury (56.8%). In this dataset, 6.8% of children underwent prehospital intubation and 0.5% underwent prehospital cricothyrotomy. Airway interventions were frequently associated with head injuries. This highlights the importance of training and equipping prehospital medical personnel for pediatric trauma care in accordance with military clinical practice guidelines.

Tracheal intubation in traumatic brain injury: a multicentre prospective observational study

BackgroundWe aimed to study the associations between pre- and in-hospital tracheal intubation and outcomes in traumatic brain injury (TBI), and whether the association varied according to injury severity. MethodsData from the international prospective pan-European cohort study, Collaborative European NeuroTrauma Effectiveness Research for TBI (CENTER-TBI), were used (n=4509). For prehospital intubation, we excluded self-presenters. For in-hospital intubation, patients whose tracheas were intubated on-scene were excluded. The association between intubation and outcome was analysed with ordinal regression with adjustment for the International Mission for Prognosis and Analysis of Clinical Trials in TBI variables and extracranial injury. We assessed whether the effect of intubation varied by injury severity by testing the added value of an interaction term with likelihood ratio tests. ResultsIn the prehospital analysis, 890/3736 (24%) patients had their tracheas intubated at scene. In the in-hospital analysis, 460/2930 (16%) patients had their tracheas intubated in the emergency department. There was no adjusted overall effect on functional outcome of prehospital intubation (odds ratio=1.01; 95% confidence interval, 0.79–1.28; P=0.96), and the adjusted overall effect of in-hospital intubation was not significant (odds ratio=0.86; 95% confidence interval, 0.65–1.13; P=0.28). However, prehospital intubation was associated with better functional outcome in patients with higher thorax and abdominal Abbreviated Injury Scale scores (P=0.009 and P=0.02, respectively), whereas in-hospital intubation was associated with better outcome in patients with lower Glasgow Coma Scale scores (P=0.01): in-hospital intubation was associated with better functional outcome in patients with Glasgow Coma Scale scores of 10 or lower. ConclusionThe benefits and harms of tracheal intubation should be carefully evaluated in patients with TBI to optimise benefit. This study suggests that extracranial injury should influence the decision in the prehospital setting, and level of consciousness in the in-hospital setting. Clinical trial registrationNCT02210221.

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.

Challenges in airway management of trauma patients: An update

Trauma has been a widely studied subject in western world in past decade. Many international organizations have formulated guidelines regarding the management of victims who have threatened airway due to any kind of trauma. Indian subcontinent is following the western world in such situations but incidence and nature of trauma is different, moreover the availability of resources varies. This review article will highlight the topics like need for pre-hospital intubations, status of rapid sequence intubation, cricoid pressure, adjuncts for intubation and airway management of victims with trauma of special nature.“My heart and soul were wrecked; I was not sure whether my windpipe is going to make it or not”- Joshua Graham

Why do some trauma patients die while others survive? A matched-pair analysis based on data from Trauma Register DGU®

PurposeThe mortality rate for severely injured patients with the injury severity score (ISS) ≥16 has decreased in Germany. There is robust evidence that mortality is influenced not only by the acute trauma itself but also by physical health, age and sex. The aim of this study was to identify other possible influences on the mortality of severely injured patients. MethodsIn a matched-pair analysis of data from Trauma Register DGU®, non-surviving patients from Germany between 2009 and 2014 with an ISS≥16 were compared with surviving matching partners. Matching was performed on the basis of age, sex, physical health, injury pattern, trauma mechanism, conscious state at the scene of the accident based on the Glasgow coma scale, and the presence of shock on arrival at the emergency room. ResultsWe matched two homogeneous groups, each of which consisted of 657 patients (535 male, average age 37 years). There was no significant difference in the vital parameters at the scene of the accident, the length of the pre-hospital phase, the type of transport (ground or air), pre-hospital fluid management and amounts, ISS, initial care level, the length of the emergency room stay, the care received at night or from on-call personnel during the weekend, the use of abdominal sonographic imaging, the type of X-ray imaging used, and the percentage of patients who developed sepsis. We found a significant difference in the new injury severity score, the frequency of multi-organ failure, hemoglobine at admission, base excess and international normalized ratio in the emergency room, the type of accident (fall or road traffic accident), the pre-hospital intubation rate, reanimation, in-hospital fluid management, the frequency of transfusion, tomography (whole-body computed tomography), and the necessity of emergency intervention. ConclusionPreviously postulated factors such as the level of care and the length of the emergency room stay did not appear to have a significant influence in this study. Further studies should be conducted to analyse the identified factors with a view to optimising the treatment of severely injured patients. Our study shows that there are significant factors that can predict or influence the mortality of severely injured patients.

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.

Success and complications by team composition for prehospital paediatric intubation: a systematic review and meta-analysis

BackgroundClinical team composition for prehospital paediatric intubation may affect success and complication rates. We performed a systematic review and meta-analysis to determine the success and complication rates by type of clinical team.MethodsWe searched MEDLINE, EMBASE, and CINAHL for interventional and observational studies describing prehospital intubation attempts in children with overall success, first-pass success, and complication rates. Eligible studies, data extraction, and assessment of risk of bias were assessed independently by two reviewers. We performed a random-effects meta-analysis of proportions.ResultsForty studies (1989 to 2019) described three types of clinical teams: non-physician teams with no relaxants (22 studies, n = 7602), non-physician teams with relaxants (12 studies, n = 2185), and physician teams with relaxants (12 studies, n = 1780). Twenty-two (n = 3747) and 18 (n = 7820) studies were at low and moderate risk of bias, respectively. Non-physician teams without relaxants had lower overall intubation success rate (72%, 95% CI 67–76%) than non-physician teams with relaxants (95%, 95% CI 93–98%) and physician teams (99%, 95% CI 97–100%). Physician teams had higher first-pass success rate (91%, 95% CI 86–95%) than non-physicians with (75%, 95% CI 69–81%) and without (55%, 95% CI 48–63%) relaxants. Overall airway complication rate was lower in physician teams (10%, 95% CI 3–22%) than non-physicians with (30%, 95% CI 23–38%) and without (39%, 95% CI 28–51%) relaxants.ConclusionPhysician teams had higher rates of intubation success and lower rates of overall airway complications than other team types. Physician prehospital teams should be utilised wherever practicable for critically ill children requiring prehospital intubation.

Association of Prehospital Intubation with Decreased Survival among Adult and Pediatric Casualties in recent conflicts

Association of Prehospital Intubation with Decreased Survival among Adult and Pediatric Casualties in recent conflicts

Pre-hospital trauma care in Switzerland and Germany: do they speak the same language?

PurposeSwiss and German (pre-)hospital systems, distribution and organization of trauma centres differ from each other. It is unclear if outcome in trauma patients differs as well. Therefore, this study aims to determine differences in characteristics, therapy and outcome of trauma patients between both German-speaking countries.MethodsThe TraumaRegister DGU® (TR-DGU) was used. Patients with Injury Severity Score ≥ 9 admitted to a level 1 trauma centre between 01/2009 and 12/2017 were included if they required ICU care or died. Trauma pattern, pre-hospital procedures and outcome were compared between Swiss (CH, n = 4768) and German (DE, n = 66,908) groups.ResultsSwiss patients were older than German patients (53 vs. 50 years). ISS did not differ between groups (CH 23.8 vs. DE 23.0 points). There were more low falls < 3 m (34% vs. 21%) at the expense of less traffic accidents (37% vs. 52%) in the Swiss population. In Switzerland 30% of allocations were done without physician involvement, whereas this occurred in 4% of German cases. Despite a comparable number of patients with a GCS ≤ 8 (CH 29.6%; DE 26.4%), differences in pre-hospital intubation rates occurred (CH 31% vs. DE 40%). Severe traumatic brain injuries were diagnosed most frequently in Switzerland (CH 62% vs. DE 49%). Admission vital signs were similar, and standardized mortality ratios were close to one in both countries.ConclusionThis study demonstrates that patients’ age, trauma patterns and pre-hospital care differ between Germany and Switzerland. However, adjusted mortality was almost similar. Further benchmarking studies are indicated to optimize trauma care in both German-speaking countries.

Success of Pediatric Intubations Performed by a Critical Care Transport Service

Background: Prehospital pediatric endotracheal intubation (ETI) is rarely performed. Previous research has suggested that pediatric prehospital ETI, when performed by ground advanced life support crews, is associated with poor outcomes. In this study, we aim to evaluate the first-attempt success rate, overall success rate and complications of pediatric prehospital ETI performed by critical care transport (CCT) personnel.Methods: We conducted a retrospective observational study in a multi-state CCT service performing rotor wing, ground, and fixed wing missions. We included pediatric patients (<18 years) for whom ETI was performed by CCT personnel (flight nurse or flight paramedic).Our primary outcome of interest was rate of first-attempt ETI. Secondary outcomes were overall rates of successful ETI, complications encountered, and outcomes of patients with unsuccessful intubation.Results: 993 patients were included (63.2% male, median age 12 years, IQR 4–16 years). 807/993 (81.3%) patients were intubated on the first attempt. Lower rates of successful first-attempt intubation were seen in younger ages (42.9% in infants ≤30 days of age). In multivariable logistic regression, lower odds (adjusted odds ratio, 95% confidence interval) of successful first-attempt ETI were associated with ages >30 days to <1 year (0.33, 0.18-0.61) and 2 to <6 years (0.60, 0.39–0.94) compared to patients 12 to <18 years. Patients given an induction agent and neuromuscular blockade (NMB) had a higher odds of first-attempt ETI success (1.53, 1.06–2.15). 13 (1.3%) had immediately recognized esophageal intubation and 33 (3.3%) had vomiting. No episodes of pneumothorax were reported. 962/993 (96.9%) patients were successfully intubated after all attempts. In patients without successful ETI (n = 31), supraglottic airways were used in 24, bag-valve mask ventilation in 5, and surgical cricothyroidotomy in 2, with an overall advanced airway success rate of 988/993 (99.5%).Conclusion: Critical care flight nurses and paramedics performed successful intubations in pediatric patients at a high rate of success. Younger age was associated with lower success rates. Improved ETI training for younger patients and use of an induction agent and NMB may improve airway management in critically ill children.

Abstract 386: Prehospital Capnography in Non-Intubated Traumatic Brain Injury Patients: Association Between End-Tidal CO2 and Level of Consciousness

Background: The EMS traumatic brain injury (TBI) guidelines encourage limiting prehospital intubation (ETI) to patients with profoundly depressed level of consciousness (LOC) and who cannot protect their airway or adequately ventilate without ETI. Thus, EMS providers may manage many TBI patients without intubating even when they have significant alterations in LOC. Monitoring End-Tidal CO2 by placing sensors in the nares (NC-CO2) of non-intubated patients may give providers valuable information about ventilatory status and trends. Study Objective: To evaluate the association between LOC and NC-CO2 in non-intubated TBI patients. Methods: Non-intubated cases from 6 EMS agencies reporting continuous monitor data (Philips MRx™) in the EPIC Study (NIH 1R01NS071049) were evaluated (4/13-3/17). Glasgow Coma Scale (GCS) was available from the EMS record in call cases. Comparisons in patient-level mean, median, lowest and highest NC-CO2 levels were made across GCS categories using clinically meaningful thresholds: &lt;15, &lt;12, &lt;9, and 3. Statistics: Wilcoxon rank-sum test. Results: Included were 106 cases [median age: 47 (range: 9-91), 66% male]. The Table shows the NC-CO2 patterns and comparisons across the GCS categories. In no case was there a significant difference in NC-CO2 between the better vs. worse mental status cohort. Conclusion: We believe this is the first evaluation of the association between NC-CO2 and mental status in TBI. Patients that had significant (and even profound) decreases in LOC, but whom paramedics chose not to intubate, had remarkably similar NC-CO2 patterns compared to those with normal or near-normal mental status. This may support the overall approach of limiting ETI to those with airway/ventilatory compromise or impending hypoxia as there was no evidence of increasing NC-CO2, indicative of hypercapnia, in the non-intubated patients even when they had very depressed LOC.

Impact of an Extraglottic Device on Pediatric Airway Management in an Urban Prehospital System.

IntroductionPrehospital pediatric endotracheal intubation has lower first-pass success rates compared to adult intubations and in general may not offer a survival benefit. Increasingly, emergency medical services (EMS) systems are deploying prehospital extraglottic airways (EGA) for primary pediatric airway management, yet little is known about their efficacy. We evaluated the impact of a pediatric prehospital airway management protocol change, inclusive of EGAs, on airway management and patient outcomes in children in cardiac arrest or respiratory failure.MethodsUsing data from a large, metropolitan, fire-based EMS service, we performed an observational study of pediatric patients with respiratory failure or cardiac arrest who were transported by EMS before and after implementation of an evidence-based airway management protocol inclusive of the addition of the EGA. The primary outcome was change in frequency of intubation attempts when paired with an initial EGA. Secondary outcomes included EGA and intubation success rates and patient survival to hospitalization and discharge.ResultsWe included 265 patients age <16 years old, with 142 pre- and 123 post-protocol change. Patient demographics and event characteristics were similar between groups. Intubation attempts declined from 79.6% pre- to 44.7% (p<0.01) post-protocol change. In patients with an intubation attempt, overall intubation success declined from 81.4% to 63.6% (p<0.01). Post-protocol change, an EGA was attempted in 52.8% of patients with 95.4% success.ConclusionImplementation of an evidenced-based airway management algorithm for pediatric patients, inclusive of an EGA device for all age groups, was associated with fewer prehospital intubations. Intubation success may be negatively impacted due to decreases in procedural frequency.

Predictors of Definitive Airway Sans Hypoxia/Hypotension on First Attempt (DASH-1A) Success in Traumatically Injured Patients Undergoing Prehospital Intubation

Background: Prehospital intubation success is routinely treated as a dichotomous outcome based on an endotracheal tube passing through vocal cords regardless of number of attempts or occurrence of hypoxia, or hypotension, which are associated with worse outcomes. We explore patient, provider, and procedure-related variables associated with successful definitive airway sans hypoxia/hypotension on first attempt (DASH-1A) in traumatically injured subjects undergoing endotracheal intubation at the scene of injury by a helicopter EMS system.Methods: This single-center retrospective chart review included patients with traumatic injuries and at least one attempted intubation by helicopter EMS at the scene of injury. Demographic and clinical variables were tested for association with DASH-1A and overall first-attempt success using univariate comparisons and multivariable logistic regression to produce adjusted odds ratios (aORs) and 95% confidence intervals (CIs). Purposeful backwards stepwise elimination was used to develop logistic regression models for outcomes. Initial inclusion of covariates in multivariable models was based on clinical judgement, known or suspected risk factors and confounders for intubation success, and univariate associations.Results: Of 419 subjects screened, 263 met inclusion criteria. Median age was 34 years and the majority of subjects were Caucasian (95%), male (76%), and suffered blunt trauma (90%). The endotracheal tube was successfully placed on the first attempt in 198 (75.3%) of patients, but only 142 (55.3%) had a successful DASH-1A, and overall, 246 (94%) had an endotracheal tube passed successfully before hospital arrival. Factors significantly associated with successful DASH-1A were no ground EMS intubation attempt prior to arrival [aOR 2.2 (CI 1.0–4.9)], lack of airway secretions/blood [1.9 (1.0–3.4)], Cormack-Lehane Score of I and II [12.3 (4.5–33.2) & 3.2 (1.2–9.1), respectively], and bougie use [5.4 (1.8–15.8)]. For endotracheal tube passing only, the following were significantly associated with first pass success: grade of view I and II [aORs 87.3 (CI 25.8–295.7) & 6.8 (2.3–19.5), respectively], lack of secretions/blood [4.9 (2.1–11.2), bougie use [7.8 (2.3–26.3)], direct laryngoscopy [5.1 (1.5–17.0)] and not using apneic oxygenation through a nasal cannula [2.5 (1.1–5.6)].Conclusion: In our helicopter EMS system, successful endotracheal intubation on the first attempt and without an episode of hypoxia was associated with no ground EMS intubation attempt prior to flight crew arrival, lack of airway secretions/blood, Cormack-Lehane Score, and bougie use.

Physician-staffed helicopter emergency medical services augment ground ambulance paediatric airway management in urban areas: a retrospective cohort study

ObjectivesPaediatric intubation is a high-risk procedure for ground emergency medical services (GEMS). Physician-staffed helicopter EMS (PS-HEMS) may bring additional skills, drugs and equipment to the scene including advanced airway management...

74 Pediatric Cardiac Arrest is Associated With Increased Number of Intubation Attempts in the Emergency Department

Advanced airway management is central to pediatric resuscitation, especially since respiratory failure is a leading cause of pediatric cardiac arrest. There is limited evidence regarding airway management for pediatric patients who arrive in the emergency department (ED) in cardiac arrest. The purpose of this study was to compare the number of intubations attempts in the emergency department (ED) for pediatric patients in cardiac arrest to those that were not in arrest. This was an analysis of pediatric intubations prospectively recorded into a Continuous Quality Improvement (CQI) database in an academic pediatric ED over a 10-year period. Between July 1, 2007 and June 30, 2017, emergency physicians recorded all consecutive intubations performed in the pediatric ED. The database included patient demographics and detailed information about each intubation such as age of the patient, reason for intubation, number of intubations attempts and outcome of each attempt. All patients <18 years of age that underwent intubation by an emergency and emergency-pediatric physicians were included in the study. The primary outcome was number of intubations attempts for pediatric patients in cardiac arrest compared to those not in cardiac arrest. The secondary outcomes were rates of failed prehospital intubation attempts and their effect on ED success. A total of 472 pediatric intubations were attempted during the study period. 88 pediatric patients arrived in the ED in cardiac arrest while 384 pediatric patients were intubated for reasons other than cardiac arrest. Pediatric cardiac arrest is associated with an increased number of failed first intubation attempts as well as a higher rate of multiple intubation attempts compared to non-arrested patients. This is likely multifactorial and is likely due to limited time for airway assessment and procedure preparation, increased difficulty in directing a tracheal tube during active compressions and limited time for each attempt. This high intubation failure rate suggests that airway management in this cohort should focus on effective face mask ventilation or supraglottic ventilation.Tabled 1Arrest (95% CI)Non-Arrest (95% CI)First Pass Success48.8% (38.2-59.1%)76.3% (71.2-80.3%)Second Pass Success35.2% (26.0-45.6%)14.6% (11.4-18.5%)Third Pass Success15.9% (9.6-25.1%)0.5% (0.02-2.0%)Failed Prehospital Intubations36.4% (27.1-46.8%)6.3% (4.2-9.2%)Failed Prehospital Intubations – First Pass Success in ED56.3% (39.3-71.8%)75% (54.8-88.3%)Failed Prehospital Intubations – Second Pass Success in ED28% (15.4-45.5%)12.5% (3.5-31.8%)Failed Prehospital Intubations – Third Pass Success in ED15.6% (6.4-32.2%)12.5% (3.5-31.8%) Open table in a new tab

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.