An educational resource for the emergency clinician.
I have put together a capnography tutorial for your education and enjoyment. The videos below are the capnography tutorial. There are 7 lessons, consisting of relatively short videos.
Enjoy.
Adam Thompson, EMT-P
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Also posted over at Rogue Medic (now at EMS Blogs).
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One of the reasons we use RSI (Rapid Sequence Induction/Intubation) is to protect the airway from aspiration of stomach contents, blood, debris, and other things that might make their way into the lungs and make the patient’s already very bad day, very much worse.
Does RSI protect against aspiration of stomach contents?
We are presented with a patient who appears to need airway management.
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You believe that tracheal intubation to isolate the respiratory from the gastrointestinal tract is considered to be the optimum method to prevent aspiration in at-risk patients. Limiting the time that the airway is unprotected during the induction of anesthesia is intuitively advisable and the practice of rapid sequence induction (RSI) with cricoid pressure is widely accepted as the standard of care in this setting.1 [1]
When the word intuitively is used in a medical journal, that is a bad sign. The concerns about protecting the airway for anesthesia are minor concerns compared to those faced by EMS in the much less controlled prehospital environment.
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As you contemplate the intervention, you wonder what evidence is available to measure the impact of RSI on the incidence of aspiration, how it should best be performed, and what is its risk-to-benefit profile.[1]
Certainly, we should have considered this before beginning RSI, but this is a way of involving us in the care of a patient. I imagine Theodoric of York pausing during an intubation to ponder this. Naaaah!
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Does this –
protect against this?
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A search of the available research (2007) was performed and –
It was readily apparent that any conclusions addressing the primary question would be inadequately supported due to the limited number of studies, most of which were retrospective in nature. As well, the working definition of RSI used by researchers was variable and many of its component parts were of unproven or questionable merits.[1]
This is not a review of whether EMS should use RSI, but of the evidence that RSI works in the ideal environment of the OR (Operating Room).
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For the purpose of our review and discussion, we defined RSI as it would be conventionally carried out by practicing anesthesiologists. The technique evaluated includes preoxygenation, rapid administration of predetermined doses of both induction and paralytic drugs, concurrent application of cricoid pressure, avoidance of bag and mask ventilation, and direct laryngoscopy followed by tracheal intubation.[1]
How many of us avoid the use of BVM (Bag Valve Mask) ventilation for preoxygenation?
If we have paralyzed the patient’s muscles to prevent stomach contents from being propelled out of the stomach, haven’t we also paralyzed the muscles that may prevent oxygen from entering the stomach?
If we are using BVM ventilation before giving paralytics, and some of that oxygen is forced into the stomach by BVM, aren’t we providing more pressure to propel stomach contents into the airway?
Can crichoid pressure decrease the amount of oxygen that enters the stomach by positive pressure ventilation?
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However, a number of factors make it difficult to employ aspiration as the outcome variable in studies assessing the impact of RSI. Aspiration is rare and very large numbers of patients would need to be studied to assess the impact of RSI on its occurrence.[1]
Is aspiration rare because RSI works to protect against aspiration?
Is aspiration rare regardless of RSI?
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For practical reasons, surrogate outcomes, such as ease or success of intubation with RSI, are the most commonly reported, with successful tracheal intubation being the single most common outcome reported in clinical evaluations of RSI protocols.[1]
Surrogate endpoints are great for the initial assessment of a treatment, but do not tell us what we need to know about whether what we are doing is actually helping patients, is of no benefit to patients, or is harmful to patients.
We need to do better than just following some old wives’ tales from a time when far less was known about patient care.
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Further, many of the reports assessing RSI outcomes are simulations of RSI conducted in healthy elective populations who may not be representative of the cohorts of patients typically subjected to RSI.[1]
In EMS, we should not be treating many healthy patients.
EMS is supposed to be providing not elective airway management, but necessary airway management.
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Following our analysis of the literature it was apparent that there was no evidence available that would allow the following question to be answered: “Does RSI reduce either the incidence or the adverse consequences of aspiration during emergency airway management?” In fact, there is no study, randomized, controlled, blinded, or otherwise, that measures the impact of any intervention on the incidence of aspiration, nor is there likely to be a statistically meaningful study conducted on this issue.[1]
This seems to prevent the study of RSI for aspiration prevention by anesthesiologists, but maybe it is still something that EMS can examine.
We are fortunate in that our patients tend to be much more nauseated by us. At least they tend to vomit on us, or around us, much more often than they do around others (maybe oncologists or gastroenterologists see more vomit than EMS).
Can we show that the attempts to prevent aspiration are more than just placebo?
How rare is aspiration in EMS?
How many patients might benefit from RSI to prevent aspiration?
Do we want to know if we are harming our patients?
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Footnotes:
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[1] No evidence for decreased incidence of aspiration after rapid sequence induction.
Neilipovitz DT, Crosby ET.
Can J Anaesth. 2007 Sep;54(9):748-64. Review.
PMID: 17766743 [PubMed - indexed for MEDLINE]
Link to Abstract and Free Full Text PDF Download from Can J Anaesth
Assuming that the incidence of aspiration during emergency surgery is 0.15%,13 a strategy that would simply reduce the incidence by 50% would require a study of approximately 50,000 patients to confirm that benefit (one-tailed hypothesis for improved outcome, α = 0.05, β = 0.20). Thus, the strength of any recommendation favouring the use of RSI for the prevention of aspiration would be Grade D.[1]
All we need to understand about the evidence grading system is that D is bad. The grades do not go any lower than D. D includes expert opinion, which is the least reliable evidence that should ever be considered. Expert opinion is what is behind one of the worst abuses of patients – the Standard Of Care – I’m doing it because everyone else is doing it, not because there is any good reason to believe it is good for the patient.
Science alone of all the subjects contains within itself the lesson of the danger of belief in the infallibility of the greatest teachers in the preceding generation … Learn from science that you must doubt the experts. As a matter of fact, I can also define science another way:
Science is the belief in the ignorance of experts. – Richard Feynman.
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Also posted over at Rogue Medic (now at EMS Blogs).
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One contributing site introduced propofol into its ED 22 months after it began entering patients into the registry. This timing permitted a natural experiment to examine the impact of the use of this drug on physician preferences and patient outcomes in patients undergoing procedural sedation at this site. After the introduction of propofol, all previously available procedural sedation agents remained in the ED formulary and no endorsement for use of propofol over existing medication options was presented to the EPs.[1]
You should already know the questions I am going to raise – The Michael Jackson Drug? Where did they put all of the dead bodies?
You should also know the response – What dead bodies?
Why do we allow one unusual, dramatically publicized case affect our expectations? Because we don’t stop and think for ourselves.
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Minor complications are probably what killed Michael Jackson. Minor complications that should easily have been treated by any First Responder, or any Patient Care Technician, or and Nurse’s Aide in a nursing home. Minor complications that would have resulted in a great big YAWN from anyone with any experience managing airways.
Airway obstruction: responds to repositioning
Anyone who has taken CPR and even vaguely remembers the “Head tilt, chin lift,” method of opening the airway could treat this. No big deal.
or
Hypoxia: responsive to oxygen
Anyone monitoring the patient’s pulse oximetry could have noticed this and delivered some oxygen to bring the patient’s oxygen saturation back up to the normal range.
This requires only three things –
1. Pulse oximetry measuring equipment.
2. Oxygen (with a means of delivering the oxygen to the patient).
3. A clue.
All of these are part of the minimum equipment that should be present for the use of propofol.
None of these appear to have been present.
Part of the problem with the safety of propofol is that it is deceptive. So many of the complications resolve on their own, that some people will become complacent and not be prepared to deal with the complications, not even the minor complications. Then these minor complications become major life threatening/life ending complications.
How many times did Dr. Conrad Murray administer propofol (and other sedatives) to Michael Jackson, but get away with it because the complications resolved on their own?
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Many hospitals only permit anesthesia to administer propofol. The other drugs on this list are much less commonly restricted to just anesthesia. Yet, this most restricted drug, too dangerous for anyone outside of anesthesia, appears to be the safest.
Minor complications dropped from 5.8% to 1.7% when propofol use went from zero percent of procedural sedations to 40% of procedural sedations.
Propofol went from being the least commonly used drug (never used) to the most commonly used drug and the minor complication rate decreased by almost a factor of 3 1/2.
During that period there was an even greater decrease in major complications – from 3.6% they decreased to only 1.0%. This is a decrease by greater than a factor of 3 1/2.
I understand the concern about the ability of people to underestimate the potential for complications, but that is true of all of the drugs that anesthesia does not make a big deal about. By limiting access to the safest drug for procedural sedation, the anesthesia departments are harming patients.
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Is propofol a hand grenade or a Holy Grail?
Neither, but it depends on the person using it, which is just a variation of what Paracelsus warned us about medication/poison –
All things are poison and nothing is without poison, only the dose permits something not to be poisonous. – Paracelsus.
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There are several possible Michael Jackson effects with propofol.
Patients are choosing more dangerous medications when they need strong sedation.
Doctors should be using propofol with more awareness of the potential complications.
The shortage of propofol seems to have ended, perhaps because propofol was being used less often after the death of Michael Jackson.
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Teva
Teva Pharmaceuticals has discontinued their propofol injection.Hospira – 1-877-946-7747
All presentations: ample levels of inventory to support market demand.
Please check with your wholesaler for available inventory.APP – 1-888-386-1300
ALL Diprivan and Propofol presentations are sufficiently stocked at wholesalers and distributors nationwide.
Diprivan 1% (20mL, 50mL, and 100mL)
Generic Propofol 1% (20mL, 50mL, and 100mL)
Novaplus Propofol 1% (20mL, 50mL, and 100mL)
Please check with your wholesalers and distribution centers for available inventory.[2]
If you have not been able to get propofol for your ED (Emergency Department) because of supply issues, that should not be a problem any more.
If you have not been able to get propofol for your ED because of inappropriate restrictions by anesthesia, this study should help to clearly demonstrate that emergency physicians working in community emergency departments are able to use propofol safely. Emergency physicians are safer using propofol than the more conventional medicines – etomidate, fentanyl, and midazolam.
The lesson most people seem to have learned is that propofol is dangerous.
The reality is that propofol may be the safest drug for procedural sedation.
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There is also a discussion about this problem of inappropriate restriction of propofol to only anesthesia at Emergency Physicians Monthly –
CMS and Deep Sedation: A Win for Emergency Medicine
by Kevin Klauer, DO, EJD on January 31, 2011
Article
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Footnotes:
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[1] Impact of addition of propofol to ED formulary.
Senula G, Sacchetti A, Moore S, Cortese T.
Am J Emerg Med. 2010 Oct;28(8):880-3. Epub 2010 Feb 25.
PMID: 20887909 [PubMed - indexed for MEDLINE]
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[2] Propofol Injection (updated 10/11/2011)
FDA
Current Drug Shortages
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Also posted over at Rogue Medic (now at EMS Blogs)s.
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Yesterday I wrote about the law being signed to allow teachers to give rectal diazepam (Valium) to student (for seizures, not to keep the class quiet).[1] Today I look at some of the reasons to question the use of RD (Rectal Diazepam) Diastat from Valeant Pharmaceuticals North America.
SEIZURES ARE THE MOST COMMON medical problem requiring emergency medical services (EMS) transport in pediatric patients, accounting for up to 25% of all pediatric EMS calls in the United States.1 [2]
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This is certainly not an unimportant topic. IV (IntraVenous) lines may not be easy in children and are even more difficult during active seizures, so what is the best alternative? IO (Intraosseous) during a seizure? PR (Per Rectum) during a seizure? IN during a seizure?
On the other hand . . .
Most seizures stop within 5 minutes and do not mandate immediate medical treatment.3[2]
Maybe a more conservative approach is indicated and treatment is only indicated for active seizures.[3]
However, avoiding treatment is not always the right thing to do and can result in crippling or deadly outcomes.
Seizures that last longer than 5 to 10 minutes, however, are unlikely to stop without treatment and become more difficult to control with time.3 Prolonged or recurrent seizure activity persisting for 30 minutes may result in significant morbidity and mortality that correlates directly with seizure duration.3 [2]
Therefore, some treatment option is essential. An IV is not always possible, or even practical. An IO is also not always possible or practical. Since the lack of treatment may result in permanent disability or death, what options are available and what works best?
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The cost of IN midazolam is $12 per dose.11 [2]
In the United States, the cost of RD (Diastat) is roughly $212 per dose.11 [2]
For parents, it is probably cheaper to call an ambulance than to buy the RD (Rectal Diazepam) Diastat. There is usually no charge for treatment without transport. The concern is about stopping seizures and/or preventing further seizures. EMS is great at that.
Just based on money and the less socially awkward method of administration, unless PR diazepam significantly improves outcomes, the choice is simple for anyone who has to pay for Diastat.
Don’t!
Why pay over 17 times as much for the same outcome?
The burden of proof is clearly on those who would claim that PR diazepam is in any way better.
Diazepam has been around since 1963, so there should be a cheap generic version available. For EMS, there is a cheap generic version. For parents, there is the very expensive Diastat.
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Image credit.[4]
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In EMS, we just take the 14 gauge catheter off of the needle and put it on a syringe that already has diazepam drawn up in it, lubricate the catheter liberally, insert it a couple of inches into the rectum, slowly pushing the plunger over a few seconds, waiting a few seconds, and removing the catheter while holding the buttocks together. Do not ever duct tape the patients buttocks together.
Complicated? Not really, especially after doing this once. More effective?
No.
One affordable alternative to this multi-hundred dollar drug administration is –
The Mucosal Atomization Device (Wolf Tory Medical Inc, Salt Lake City, Utah) is an applicator placed on the syringe hub that distributes liquid for nasal administration in a 30-μ particle size, coating the mucosa.33 It is relatively inexpensive at $4 per applicator.11 [2]
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Image credit.[5]
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In Part II I will look at the results of this study. Is IN midazolam as effective as rectal Diastat?
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Footnotes:
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[1] Teachers to Give Rectal Valium in California
Rogue Medic
Article
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[2] Intranasal midazolam vs rectal diazepam for the home treatment of acute seizures in pediatric patients with epilepsy.
Holsti M, Dudley N, Schunk J, Adelgais K, Greenberg R, Olsen C, Healy A, Firth S, Filloux F.
Arch Pediatr Adolesc Med. 2010 Aug;164(8):747-53.
PMID: 20679166 [PubMed - indexed for MEDLINE]
Free Full Text at Arch Pediatr Adolesc Med
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[3] Management of prehospital seizure patients by paramedics
Rogue Medic
Article
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[4] Dosing and Administration of DIASTAT® AcuDial™ (diazepam rectal gel)
Diastat.com
Valeant Pharmaceuticals North America
Information page with link to PDF download of administration instructions
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[5] Therapeutic Intranasal Drug Delivery
IntraNasal.net
Article
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Also posted at Rogue Medic, which is now at EMS Blogs.
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In response to my post If We Were Really Serious About Intubation Quality was a comment from drastic suggesting that I take a look at a couple of studies that demonstrate that Australian paramedics do not need to improve their intubation skills and that intubation improves outcomes.
One of the studies does show a lot of positives for intubation. The big problem is the lack of statistical significance. A larger study needs to be done to confirm the results, an LMA (Laryngeal Mask Airway) or other group should be added. Otherwise, this appears to be a great study.
Does EMS RSI (Rapid Sequence Induction/Intubation) lead to better outcomes than delaying intubation until arrival at the trauma center for patients with TBI (Traumatic Brain Injury)?
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The difference in outcomes would no longer be statistically significant whether one more patient had a positive outcome in the treatment group (P = 0.059) or one less in the control group (P = 0.061).[1]
That limitation is very important, since 13 patients were lost to follow-up (10 in the hospital intubation group and 3 in the EMS RSI group), because their families lost contact with them. This apparent independence suggests, but certainly does not prove, that these patients would not have fallen into the more severely impaired categories. Even if all of the EMS RSI patients did have severe disabilities, while all of the hospital intubation patients had good neurological outcomes, the hospital intubation group would only come up to 43% (66/152) with a good neurological outcome, which is still less than the possible 50% (80/160) for the EMS RSI group. Therefore, the results would not change to the point of demonstrating worse outcomes with EMS RSI, but the results would no longer be statistically significant.
More likely is that they all have good neurological outcomes and the results would change to 52% (83/163) vs. 43% (66/152). Both outcomes improve, but the results are still not statistically significant.
All EMS RSI patients had waveform capnography, which may explain why the results are so different from the results of the study by Davis on EMS RSI for TBI. This study raised a bunch of questions about those results, which showed worse outcomes for EMS RSI. One hypothesis was that the much higher incidence of hypocapnea contributed to the bad outcomes even though the EMS intubation success rates more than doubled for TBI patients.
Conclusion: Paramedic RSI protocols to facilitate intubation of head-injured patients were associated with an increase in mortality and decrease in good outcomes versus matched historical controls.[2]
airway management success rates for severely head-injured patients in our prehospital system increased from 39% in the pre-trial period to 86% during the trial.20,21[2]
In this study, the intubation success rate for TBI patients was 97%, which is dramatically higher than 86%. 1/7 lack of success vs. 1/33.
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Does this study demonstrate good outcomes with paramedic intubation for TBI?
Yes.
Does this study demonstrate excellent intubation success with RSI for TBI?
Yes.
There is a lot more to discuss about this study, but I will go into more depth later.
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Footnotes:
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[1] Prehospital rapid sequence intubation improves functional outcome for patients with severe traumatic brain injury: a randomized controlled trial.
Bernard SA, Nguyen V, Cameron P, Masci K, Fitzgerald M, Cooper DJ, Walker T, Std BP, Myles P, Murray L, David, Taylor, Smith K, Patrick I, Edington J, Bacon A, Rosenfeld JV, Judson R.
Ann Surg. 2010 Dec;252(6):959-65.
PMID: 21107105 [PubMed - indexed for MEDLINE]
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[2] The effect of paramedic rapid sequence intubation on outcome in patients with severe traumatic brain injury.
Davis DP, Hoyt DB, Ochs M, Fortlage D, Holbrook T, Marshall LK, Rosen P.
J Trauma. 2003 Mar;54(3):444-53.
PMID: 12634522 [PubMed - indexed for MEDLINE]
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There is nothing scarier than a sick kid. I am becoming more and more obsessed with educating myself on pediatric emergencies. This is because of that fear, and the fact that I find it is one of those areas that I am less versed in. This post is aimed at identifying and treating the child who presents with an upper respiratory infection (URI) like croup or epiglottitis. These kids sound sick, look sick, and may get even sicker.
As always, aggressive airway management may be indicated if the child appears to have impending respiratory failure. Signs of this include severe hypoxia, bradycardia, and decreasing respiratory effort.
If the patient doesn’t present with imminent signs like those mentioned above, it is pertinent to obtain a good medical history.
History:
Has the child ever had a URI in the past?
- If so, did he/she present like this?
Was the onset acute or gradual?
- Epiglottits generally presents with an acute onset.
Has the child been sick, and is he up to date with vaccinations?
- Most cases of epiglottitis are caused by haemophilus influenza or H.flu
Has the child ever been intubated?
- This helps identify whether you will need to be aggressive, and a recent intubation could be the cause of hoarseness.
Epiglittits is actually inflammation of the epiglottis–you know, that flap that covers the trachea during swallowing? If this becomes inflamed, it swells, and that swelling could cause a partial or even a complete occlusion of the trachea, thus compromising ventilation.
- Usually febrile, without cough
- Patient may be in tripod position
- Drooling present
Treatment
- Immediate intubation may be indicated (may be very difficult!)
- Epinephrine may be administered in extremis
Croup or laryngotracheobronchitis is also an upper respiratory infection that may be mild, moderate, or severe. It tends to be worse at night, and is most commonly identified by the classic “seal-bark cough”.
- Inspiratory stridor & “barking cough”
- Often preceded by flu
- More likely if they have had croup before
Treatment
- Oxygen therapy
- Nebulized Saline
- If severely hypoxic, racemic epinephrine may be indicated.
- It is often taught to take these children outside, into colder air
So who is in extremis?
- The severely hypoxic child: Cyanosis, bradycardia
- Intercostal retractions with decreasing stridor is an ominous sign of impending respiratory failure
- Decreasing mental status means decreasing respiratory drive. TREAT AGGRESSIVELY
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Check out Justin, The Happy Medic, Schorr’s last run-in with croup in THIS POST.
Check this out…
J Trauma. 2010 Aug;69(2):294-301. [Pubmed]
Prehospital airway and ventilation management: a trauma score and injury severity score-based analysis.
Davis DP, Peay J, Sise MJ, Kennedy F, Simon F, Tominaga G, Steele J, Coimbra R.
Abstract
BACKGROUND:: Emergent endotracheal intubation (ETI) is considered the standard of care for patients with severe traumatic brain injury (TBI). However, recent evidence suggests that the procedure may be associated with increased mortality, possibly reflecting inadequate training, suboptimal patient selection, or inappropriate ventilation. OBJECTIVE:: To explore prehospital ETI in patients with severe TBI using a novel application of Trauma Score and Injury Severity Score methodology. METHODS:: Patients with moderate-to-severe TBI (head Abbreviated Injury Scale score 3+) were identified from our county trauma registry. Demographic information, pre-resuscitation vital signs, and injury severity scores were used to calculate a probability of survival for each patient. The relationship between outcome and prehospital ETI, provider type (air vs. ground), and ventilation status were explored using observed survival-predicted survival and the ratio of unexpected survivors/deaths. RESULTS:: A total of 11,000 patients were identified with complete data for this analysis. Observed and predicted survivals were similar for both intubated and nonintubated patients. The ratio of unexpected survivors/deaths increased and observed survival exceeded predicted survival for intubated patients with lower predicted survival values. Both intubated and nonintubated patients transported by air medical crews had better outcomes than those transported by ground. Both hypo- and hypercapnia were associated with worse outcomes in intubated but not in nonintubated patients. CONCLUSIONS:: Prehospital intubation seems to improve outcomes in more critically injured TBI patients. Air medical outcomes are better than predicted for both intubated and nonintubated TBI patients. Iatrogenic hyper- and hypoventilations are associated with worse outcomes.
This publication is prestigious enough to trust the validity of the study. It looks as if enough patients were ruled-in to take consideration of the evidence. With the increase in ICP (intracranial pressure) that intubation causes, it has been theorized in the past, that intubating the TBI patient only made them worse. However, this study shines a different light. So what do you think? The discussion is open.
Check this out…
J Burn Care Res. 2010 Jul 14. [Epub ahead of print]
Pre-Burn Center Management of the Burned Airway: Do We Know Enough?
Eastman AL, Arnoldo BA, Hunt JL, Purdue GF.
Abstract
Despite the traditional teaching of early and aggressive airway management in thermally injured patients, paramedics and medical providers outside of burn centers receive little formal training in this difficult skill set. However, the initial airway management of these patients is often performed by these preburn center providers (PBCPs). The purpose of this study was to evaluate the authors’ experience with patients intubated by PBCPs and subsequently managed at the authors’ center. A retrospective review of a level I burn center database was undertaken. All records of patients arriving intubated were reviewed. From January 1982 to June 2005, 11,143 patients were admitted to the regional burn center; 11.4% (n = 1,272) were intubated before arrival. In this group, mean age was 37.1 years, mean burn size was 35.3% TBSA, and mean length of hospital stay was 27.0 days. Approximately 26.3% were suspected of having an inhalation injury, and this was confirmed by either bronchoscopy or clinical course in 88.6% of this subgroup. Mortality in patients arriving intubated was 30.8%, and these were excluded from the rest of the analysis. In the surviving 879 intubated patients, reasons reported by PBCPs for intubation included “airway swelling” in 34.1%, “prophylaxis” in 27.9%, and “ventilation or oxygenation needs” in 13.2%. Of these patients, 16.3% arrived directly from the scene, with the remainder arriving from another hospital facility. Of all survivors who arrived intubated, 11.9% were extubated on the day of admission, 21.3% were extubated on the first postburn day (PBD), and 8.2% were extubated on the second PBD. No patients who were extubated on PBD1 or PBD2 had to be reintubated. A significant number of burn patients have their initial airway management by PBCPs. Of these, a significant number are extubated soon after arrival at the burn center without adverse sequelae. Rationale for their initial intubation varies, but education is warranted in the prehospital community to reduce unnecessary intubation of the burn patient.
Any thoughts or input?
How can we better educate our selves and fellow prehospital providers on this topic?
In the popular and acclaimed JEMS article Experts Debate Paramedic Intubation, there were a few key points made that I would like to elaborate on, as well as provide some of my own insight from the research I have come across.
Key Point 1
Experience should be maintained in a number of manors:
Dr. Bledsoe: Do you feel there’s a role for RSI in the prehospital setting? Dr. Wayne, I know your program has decades of success with RSI. What do you think?
Dr. Wayne: Although there are no nationally defined indications for the use of RSI in the field, we at Whatcom Medic One believe that RSI is indicated for any patient in whom there’s a need to control an “uncontrolled” airway. This may include depressed GCS score, excess secretions, hypoxia that may be correctable, ventilatory fatigue or central nervous system depression with or without secondary respiratory depression.
Dr. Tan: I believe there is, but it must be in the right context with requisite oversight and extraordinary training. I oversee more than 100 paramedics in my system, yet only 10 of them have RSI privileges. They’re required to obtain critical care certification, attend ongoing training sessions with me every 12 weeks, attend annual specialized training courses and undergo 100% audits of their critical care trips. It’s a strenuous and time-consuming process but one that can’t be overemphasized given the complexity and danger inherent to RSI. I certainly don’t believe RSI should be a “routine” part of any standing orders, as there is nothing routine about it.
Dr. Wang: I think RSI should be restricted to the aeromedical setting for use by critical care flight nurses and/or flight medics for the reasons I’ve previously detailed. I really challenge those medical directors who currently allow RSI and promote its use in other systems. Although I applaud their efforts and attention to quality improvement and training, they still equate successful intubation with a positive outcome. As Dr. Eckstein said, in the absence of prospective RCTs, we can’t assume that prehospital RSI has actually improved outcomes for our patients.
Dr. Eckstein: RSI is potentially useful where paramedics have exceptional skill, training and medical oversight. Unfortunately, this is a tiny fraction of EMS agencies. If we replaced the “I” (intubation) with “A” (airway—Combitube, King, etc.), this might relieve much of the angst over prehospital RSI.
Dr. Bledsoe: Are the alternative airway devices (e.g., King LT, etc.) good enough for prehospital airway management?
Mr. Gandy: Yes. The studies have shown that excellent ventilation can be achieved with these devices.
Key Point 3
The #1 way to confirm proper placement of the endotracheal tube in the field is end-tidal CO2 (ETCO2). If you have ETCO2 available in the field, use it.
ETCO2 measures the amount of CO2 that is being exhaled by the patient. This lets us know that the O2 we are putting into the body is being used and exchanged for the CO2 that comes out via pulmonary perfusion. This exchange occurs in the lungs, which just so happens to be the place that we are attempting to ventilate.
Key Point 4
Anticipate the difficult airway.
Mr. Gandy: The biggest problem is inadequate training and practice in airway evaluation, such as using the Malampatti or Cormack-Lehane criteria; using aids to intubation, such as bougies; the BURP maneuver; alternative laryngoscope techniques, such as the “skyhook” technique; and a good assortment of alternative airway devices, including either GlideScope or AirTraq. Ventilation should be emphasized over intubation, and extensive practice with BVM ventilation should be required.
Malampatti scoring is done by having the patient stick out their tongue. The difficulty of the proceeding ETI attempt can be gauged by the visibility of the oropharynx.
Cormack-Lehane Citeria is utilized with direct laryngoscopy. This is done by visualizing the vocal cords and making note of how much of the opening is visible:
BURP Maneuver – Backward, Upward, Rightward, Pressure of the larynx.
Don’t worry if you don’t understand the picture above. It is just a step by step of the BURP maneuver. Basically you place your fingers on the palpable cricoid ring of the patient. Push towards their posterior, and slightly towards their right. This should bring the trachea and it’s structures to the best point of view during direct laryngoscopy.
“Skyhook” – I believe Gandy is referring to what my peers and I call the “fish hook” maneuver. This is reserved for the more hefty patients that may be hard to intubate.
This is a two person procedure. One person is dedicated to laryngocopy, and the other will direct person 1, visualize the vocal cords, and pass the ET tube.
Person 1 – With Laryngoscope and a Macintosh blade
- Straddle the supine patient
- Hook the blade into the mouth
- Pull back, keeping the blade off of the teeth
- Make adjustments based off person 2′s direction
Person 2 – With appropriately sized ET Tube
- Position yourself at patient’s head
- Direct person 2 until the vocal cords are visible
- Pass ET tube
I spoke about the Glidescope in my post Video Laryngocopy. Go check it out.
Key Point 5
In the article I was writing about[1] (Experts Debate Paramedic Intubation) in my post Experts Debate Paramedic Intubation – JEMS.com, there is a bit of defense of the status quo in intubation and intubation training.
We get hung up on many of the same problems. We think that there is one right way to do things, rather than accept that we are adapting what we do to the different circumstances we are faced with.
We act as if the OR (Operating Room) is the only place that we can obtain good practice. There is no evidence to support this.
There is nothing to show that OR training is superior to morgue training and mannequin training, but we act as if the decreased availability of OR time is the only reason medics can’t intubate competently.
We act as if the only problem with the way we are teaching paramedic school is that the students are not learning. As if this is not a reflection on the teaching.
Teaching means providing information to students in a way that helps the students to understand. If the students do not understand, the teacher did not teach.
Perhaps you do not believe that we do a poor job at intubation education.
ResultsNine hundred twenty-six patients had an attempted intubation. Methods of airway management were determined for 97.5% (825/846) of those transported to a hospital and 33.8% (27/80) of those who died in the field. For transported patients, 74.8% were successfully intubated, 20% had a failed intubation, 5.2% had a malpositioned tube on arrival to the ED, and 0.6% had another method of airway management used. Malpositioned tubes were significantly more common in pediatric patients (13.0%, compared with 4.0% for nonpediatric patients).
Conclusions
Overall intubation success was low, and consistent with previously published series. The frequency of malpositioned ETT was unacceptably high, and also consistent with prior studies. Our data support the need for ongoing monitoring of EMS providers’ practices of endotracheal intubation.[2]
Those numbers may be considered good in many areas – batting average, picking winning stocks, votes in an election. When it comes to airway management, we would be more appropriate if we described failure rates.
These failure rates are unacceptably high.
Overall intubation success was low, and consistent with previously published series.
In other words, the authors believe that this is the expected result of the way we train paramedics to intubate.
Can anyone show that this is not true?
The frequency of malpositioned ETT was unacceptably high, and also consistent with prior studies.
This is the expected result of the way we train paramedics to intubate.
Our data support the need for ongoing monitoring of EMS providers’ practices of endotracheal intubation.
5.2% had a malpositioned tube on arrival to the ED.
5.2% Unrecognized Esophageal Intubations!
Ongoing monitoring Watching is not enough.
We need to dramatically change the way we handle intubation education.
Footnotes:
[1] Experts Debate Paramedic Intubation – Should paramedics continue to intubate?
JEMS.com
Bryan E. Bledsoe, DO, FACEP, FAAEM | Darren Braude, MD, MPH, FACEP, EMT-P | David K. Tan, MD, FAAEM, EMT-T | Henry Wang, MD, MS | Marc Eckstein, MD, MPH, FACEP | Marvin Wayne, MD, FACEP, FAAEM | William E. Gandy, D, LP, NREMT-P
Thursday, July 1, 2010
Article
[2] A prospective multicenter evaluation of prehospital airway management performance in a large metropolitan region.
Denver Metro Airway Study Group.
Colwell CB, Cusick JM, Hawkes AP, Luyten DR, McVaney KE, Pineda GV, Riccio JC, Severyn FA, Vellman WP, Heller J, Ship J, Gunter J, Battan K, Kozlowski M, Kanowitz A.
Prehosp Emerg Care. 2009 Jul-Sep;13(3):304-10.
PMID: 19499465 [PubMed - in process]
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