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 and at Research Blogging.
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We don’t need to improve airway management. We were placing tubes correctly 30 years ago without waveform capnography, so we certainly don’t need any technology to substitute for a competent assessment.
Right?
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Placement of endotracheal tubes (ETTs) in the field by paramedics is a well-accepted out-of-hospital procedure used to obtain definitive airway control. Several studies have reported the incidence of unrecognized, misplaced endotracheal intubations in the field to be low, typically 1% to 5% 1-5 (Table 1). In the majority of these studies, verification of tube placement was performed in the field. It was our clinical impression before conducting our study that the incidence of patients with misplaced ETTs on arrival to our emergency department was substantially higher than that reported in the literature. To our knowledge, no study had investigated the actual incidence of misplaced ETTs on patient arrival to an ED.[1]
Here is a study that sets out to determine if one part of my statement is correct. Were we correctly placing endotracheal tubes before we even had the fancy technology of waveform capnography?
Click on images to make larger.
These results suggest that there is not a huge problem with the ability of paramedics to recognize the correct placement of endotracheal tubes. The rate of unrecognized esophageal intubation should be zero, but these are close and zero might be within reach even without waveform capnography.
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Trauma patients were significantly more likely to have misplaced ETTs than medical patients (37% versus 14%, P<.01). With one exception, all the patients found to have esophageal tube placement exhibited the absence of ETCO2 on patient arrival. In the exception, the patient was found to be breathing spontaneously despite a nasotracheal tube placed in the esophagus.[1]
We assume that what we are doing is helping patients.
We have a bias toward treating, rather than benign neglect.
We are repeatedly told that we need to do everything we can do.
In the exception, the patient was found to be breathing spontaneously despite a nasotracheal tube placed in the esophagus.
This patient did not survive to the hospital because of EMS.
This patient survived to the hospital in spite of EMS.
What more could EMS have done to this patient to find out how much it will take to kill the patient? We are only limited by our imagination.
What could EMS have done to minimize the harm to the 25% of patients with misplaced tubes?
One of the problems is too much treatment and not enough discretion.
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In the group of patients found to have tube placement in the hypopharynx, 44.4% (4/9) exhibited the absence of ETCO2 on patient arrival.[1]
These are the patients more likely to actually have the tube dislodged by movement. The tube is not that far from the right place. These patients may have oxygen delivered to the lungs, but the lack of ETCO2 suggests that the CO2 is not being removed by a tube just above the vocal cords.
How low were the patients’ pH levels due to the inability to remove CO2?
How many of these patients were not capable of producing CO2 at high enough levels to register ETCO2 levels?
How many of these patients would have survived if EMS had not done all it could?
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The incidence of unrecognized, misplaced endotracheal intubations in the present study is alarming, and substantially higher than in previously reported series. We believe there may be several explanations for this discrepancy. All of the previously published series1-5 were conducted in EMS systems directed by academic EMS directors with tightly controlled oversight of paramedic training and practice. Evaluation occurred in the field with researchers present during the procedures. Eligible patients included only selected subsets of the total intubated populations. In the previous studies, the status of tube position at EDD arrival was not reported.[1]
In the last sentence, EDD should probably be ED (Emergency Department).
My reading of this is –
Absentee medical directors kill.
I do not mean that the lack of involvement of medical directors is the sole cause of these iatrogenic deaths, but I do not see any way of expecting any good outcome from authorizing intubation by personnel with minimal training and continuing education that makes the initial minimal training seem exhaustive. This is not oversight.
At least there is interest in improving things in this system.
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But is waveform capnography needed?
Endotracheal intubation is a psychomotor skill. Even under ideal conditions with the procedure performed by qualified anesthesiologists, it may be difficult to recognize esophageal intubations.12 Adverse conditions in the field may make intubation even more difficult than in a hospital setting. Skill levels of various paramedic providers within a community may differ sharply.20 Assessing tube position after intubation in this setting requires rigorous training and adherence to protocol.11,16 Standard physical assessment techniques for verifying tube placement may be unreliable.12,14,17 Auscultation over the chest can fail to detect esophageal placement in 15% of patients, and fogging of the tube has been shown to be present in 85% of esophageal intubations.14[1]
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WWAD?
What Would Anesthesiologists Do?
After all, if we are going to claim that what we are doing is right, shouldn’t we look at what is done by those most experienced at intubation?
ETCO2 monitoring is routinely used by anesthesiologists to verify proper ETT position. Since 1990, the American Society of Anesthesiologists has considered this to be the standard of care in the operating room, and has now extended that standard to include all anesthetic practice irrespective of geographic location.10[1]
Irrespective of geographic location?
Not just in the OR (Operating Room).
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The rate of unrecognized, misplaced ETTs found in our community is alarmingly high. There are several factors that may have contributed to this problem. Despite written protocols requiring the out-of-hospital use of ETCO2 devices in our community, we anecdotally found their use to be sporadic. To avoid the Hawthorne effect, we chose not to query paramedics regarding verification techniques used in the field. Accordingly, we were unable to document the frequency of field ETCO2 device use during the study period.[1]
we anecdotally found their use to be sporadic.
In other words –
We don’t know how often ETCO2 is measured, but we do know that it is not enough.
Is it 90%?
Is it 50%?
Is it 10%?
The only thing we can tell from the term sporadic is that it is not 100% and it is not 0%.
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A significant limitation of the study was the lack of uniformity of direct laryngoscopy on all tube verifications. All but 4 of the tubes deemed to be misplaced were confirmed by laryngoscopy. In each of these 4 cases, there was vomitus in the ETT and absent breath sounds on examination. The attending physician in each case promptly removed the tube and replaced it. In each of these cases, tube placement was deemed esophageal.[1]
Unless there is a good reason to believe that the vomitus is coming from the lungs, removing the tube should be the highest priority.
On the other hand, I have seen a paramedic recognize an esophageal intubation, decide to leave the esophageal tube in place, and move the patient from the floor of a clean home to the ambulance before doing anything to correct the esophageal intubation. Getting the patient to the hospital was considered more important than providing a patent airway.
One shortcoming not mentioned is that the assessment of tube placement was probably done on the ED stretcher after movement. the proper place to assess the placement of the tube by EMS is on the EMS stretcher. I do not believe that tubes are dislodged frequently by this movement, but the number dislodged by moving the patient to the ED stretcher should not be assumed to be zero just because the movement happens in the hospital.
We should be reassessing the placement of the tube with every movement, so it should only be after EMS reassesses the tube placement that the emergency physician is allowed to assess the tube. Even so, unless they are lifting the patient by the tube, this should not produce a significant number of intubations. The problem is that this introduces an uncontrolled variable. This is an easily controlled variable, but it does not appear to have been controlled for.
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Our data may differ from data in the EMS literature because this is one of the few studies undertaken in an EMS system not organized and run by academic emergency physicians with strong out-of-hospital care training and interest. No one is comfortable in reporting difficulty and poor performance in patient care activities. These data may be reflective of an unspoken, pervasive national problem in serious need of attention. Accordingly, we urge our colleagues across the country to review their experience in their own communities.[1]
How many systems do not measure their intubation failure rate, or their unrecognized esophageal intubation rate?
If we do not know what the intubation failure rate is in our system, we cannot honestly claim that we are not killing patients.
If we do not know what the unrecognized esophageal intubation rate is in our system, we cannot honestly claim that we are not killing patients.
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Footnotes:
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[1] Misplaced endotracheal tubes by paramedics in an urban emergency medical services system.
Katz SH, Falk JL.
Ann Emerg Med. 2001 Jan;37(1):32-7.
PMID: 11145768 [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
There has been quite a bit of research done on post-intubation injuries caused by the pressure of the endotracheal tube cuff. This is something that has been addressed by a few EMS agencies. My agency implemented a protocol based on the research about two years ago:
Pubmed [1]
Abstract
BACKGROUND: Initiated by a clinical case of critical endotracheal tube (ETT) obstruction, we aimed to determine factors that potentially contribute to the development of endotracheal tube obstruction by its inflated cuff. Prehospital climate and storage conditions were simulated. METHODS: Five different disposable ETTs (6.0, 7.0, and 8.0 mm inner diameter) were exposed to ambient outside temperature for 13 months. In addition, every second of these tubes was mechanically stressed by clamping its cuffed end between the covers of a metal emergency case for 10 min. Then, all tubes were heated up to normal body temperature, placed within the cock of a syringe, followed by stepwise inflation of their cuffs to pressures of 3 kPa and > or =12 kPa, respectively. The inner lumen of the ETT was checked with the naked eye for any obstruction caused by the external cuff pressure. RESULTS: Neither in tubes that were exposed to ambient temperature (range: -12 degrees C to +44 degrees C) nor in those that were also clamped, visible obstruction by inflated cuffs was detected at any of the two cuff pressure levels. CONCLUSIONS: We could not demonstrate a critical obstruction of an ETT by its inflated cuff, neither when the cuff was over-inflated to a pressure of 12 kPa or higher, nor in ETTs that had been exposed to unfavorable storage conditions and significant mechanical stress.
Pubmed [2]
Abstract
STUDY OBJECTIVE: We evaluate changes in endotracheal tube intracuff pressures among intubated patients during aeromedical transport. We determine whether intracuff pressures exceed 30 cm H(2)O during aeromedical transport. METHODS: During a 12-month period, a helicopter-based rescue team prospectively recorded intracuff pressures of mechanically ventilated patients before takeoff and as soon as the maximum flight level was reached. With a commercially available pressure manometer, intracuff pressure was adjusted to /=30 cm H(2)O, 72% had intracuff pressures >/=50 cm H(2)O, and 20% even had intracuff pressures >/=80 cm H(2)O. CONCLUSION: Endotracheal cuff pressure during transport frequently exceeded 30 cm H(2)O during aeromedical transport. Hospital and out-of-hospital practitioners should measure and adjust endotracheal cuff pressures before and during flight. Copyright © 2010 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.
Pubmed [3]
Endotracheal tube cuff pressures in patients intubated before transport.
Abstract
INTRODUCTION: Prolonged endotracheal tube cuff pressures (ETTCPs) greater than 30 cm H(2)O cause complications ranging from sore throat to rare cases of tracheoesophageal fistula. In a series of patients, we sought to determine the proportion of patients with overinflated cuffs and to determine whether overinflation was associated with demographics, diagnostic category, or intubator credentials. METHODS: Between July 2007 and April 2008, we measured cuff pressures on a convenience sample of patients drawn from 2 groups. The “helicopter group” had pressure measured before transport by a single aeromedical transport service. The “hospital group” had pressure measured upon arrival to 1 of 2 emergency departments after being intubated before transport. RESULTS: Three hundred patients aged 4 to 92 years (median, 57) were studied: 59.7% were male; and diagnostic categories were neurologic (33.7%), trauma (32.7%), cardiac (12.7%), and general medical/surgical (21.0%). Intubation occurred 1 to 28 000 minutes before ETTCP assessment (median, 60). Endotracheal tube cuff pressure was greater than 30 cm H(2)O in 64.7% and ranged from 10 to 180 (median, 40). Forty-nine percent of patients had ETTCP greater than 40 cm H(2)O. There was no association between ETTCP and age group, sex, diagnostic category, ETT size, time between intubation and ETTCP assessment, or intubator credentials. CONCLUSIONS: The most compelling results of the study are the high rates of elevated ETTCPs. Furthermore, there were no clear risk factors for elevated ETTCP. Although the risk of elevated ETTCP in the prehospital to acute care time frame is unclear, it seems reasonable to measure ETTCP after intubation in all patients.
Pubmed [4]
Intubation-induced tracheal stenosis — the urgent need for permanent solution.
Abstract
The most common site for the occurrence of intubation-induced tracheal damage is at the area in contact with the inflatable cuff. After the change from high-pressure to low-pressure cuffs, major tracheal lesions still continue to occur. This is a case of tracheal stenosis that occurred after 7 days of intubation with standard cuffed tube whose cuff pressure was assessed by subjective means. Three weeks later, patient was in need of reintubation, the trachea was found to be stenotic at the site of the previous tube cuff. Emergency tracheostomy had to be performed and computed axial tomography (CT) confirmed the tracheal stenosis. A month later, the patient had another cardiac arrest from which he did not recover. Our message in this report is to throw light and alert clinicians involved in tracheal intubation, of the presence of the Lanz endotracheal tube whose pilot balloon is designed to automatically regulate the intra-cuff pressure and thus prevent the occurrence of tracheal stenosis due to high pressure. We strongly recommend the presence of Lanz tracheal tubes as standard emergency equipment in intensive care settings and in any situation in which cuff pressure is likely to increase.
EMSResponder.com – Link to related article.
Every once in a while I will head over to Pubmed.com and run a quick search on prehospital. It is a good way to stay current in this ever-changing field. It is also good practice to stay relevant when advocating evidence-based medicine. Here are some abstracts from my most recent query. All are open for discussion, so please leave your comments.
BACKGROUND: The ability to perform drug calculations accurately is imperative to patient safety. Research into paramedics’ drug calculation abilities was first published in 2000 and for nurses’ abilities the research dates back to the late 1930s. Yet, there have been no studies investigating an undergraduate paramedic student’s ability to perform drug or basic mathematical calculations. The objective of this study was to review the literature and determine the ability of undergraduate and qualified paramedics to perform drug calculations. METHODS: A search of the prehospital-related electronic databases was undertaken using the Ovid and EMBASE systems available through the Monash University Library. Databases searched included the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, CINAHL, JSTOR, EMBASE and Google Scholar, from their beginning until the end of August 2009. We reviewed references from articles retrieved. RESULTS: The electronic database search located 1,154 articles for review. Six additional articles were identified from reference lists of retrieved articles. Of these, 59 were considered relevant. After reviewing the 59 articles only three met the inclusion criteria. All articles noted some level of mathematical deficiencies amongst their subjects. CONCLUSIONS: This study identified only three articles. Results from these limited studies indicate a significant lack of mathematical proficiency amongst the paramedics sampled. A need exists to identify if undergraduate paramedic students are capable of performing the required drug calculations in a non-clinical setting.
PURPOSE OF REVIEW: The primary purpose of this article is to highlight the latest airway research in multitrauma. RECENT FINDINGS: Management of the airway in multitrauma patients is a critical resuscitation task. Prehospital airway management is difficult with a high risk of failure, complications, or both. In-hospital performed conventional oral intubation with manual in-line stabilization, cricoid pressure, and a backup plan for a surgical airway is still the most efficient and effective approach for early airway control in multitrauma patients. Selective utilization of airway maintenance, instead of ultimate airway control in the field, has been suggested as a primary prehospital strategy. Properties of videolaryngoscopes complement standard laryngoscopes. When compared with a Macintosh laryngoscope, the Airtraq and Airwayscope diminish cervical spine motion during elective orotracheal intubation. Penetrating neck injuries are the most frequent indication for awake intubation, whereas patients with maxillofacial injuries have the highest rate of initial surgical airway. SUMMARY: Risks and benefits of ultimate prehospital airway control is a controversial topic. Utilization of videolaryngoscopes in multitrauma remains open for research. Standardization of training requirements, equipment, and development of prehospital and in-hospital airway algorithms are needed to improve outcomes. Rational utilization of available airway devices, development of new devices, or both may help to promote this goal.
Pubmed [3]BACKGROUND: Delay from onset of acute coronary syndrome (ACS) symptoms to hospital admission continues to be prolonged. To date, community education campaigns on the topic have had disappointing results. Therefore, we conducted a clinical randomized trial to test whether an intervention tailored specifically for patients with ACS and delivered one-on-one would reduce prehospital delay time. METHODS AND RESULTS: Participants (n=3522) with documented coronary heart disease were randomized to experimental (n=1777) or control (n=1745) groups. Experimental patients received education and counseling about ACS symptoms and actions required. Patients had a mean age of 67+/-11 years, and 68% were male. Over the 2 years of follow-up, 565 patients (16.0%) were admitted to an emergency department with ACS symptoms a total of 842 times. Neither median prehospital delay time (experimental, 2.20 versus control, 2.25 hours) nor emergency medical system use (experimental, 63.6% versus control, 66.9%) was different between groups, although experimental patients were more likely than control to call the emergency medical system if the symptoms occurred within the first 6 months following the intervention (P=0.036). Experimental patients were significantly more likely to take aspirin after symptom onset than control patients (experimental, 22.3% versus control, 10.1%, P=0.02). The intervention did not result in an increase in emergency department use (experimental, 14.6% versus control, 17.5%). CONCLUSIONS: The education and counseling intervention did not lead to reduced prehospital delay or increased ambulance use. Reducing the time from onset of ACS symptoms to arrival at the hospital continues to be a significant public health challenge. CLINICAL TRIAL REGISTRATION: clinicaltrials.gov. Identifier NCT00734760.
Pubmed [4]
BACKGROUND: Despite the existence of national American Heart Association guidelines and 2 termination-of-resuscitation (TOR) rules for ceasing efforts in refractory out-of-hospital cardiac arrest, many emergency medical services agencies in the United States have adopted their own local protocols. Public policies and local perceptions may serve as barriers or facilitators to implementing national TOR guidelines at the local level. METHODS AND RESULTS: Three focus groups, lasting 90 to 120 minutes, were conducted at the National Association of Emergency Medical Services Physicians meeting in January 2008. Snowball sampling was used to recruit participants. Two reviewers analyzed the data in an iterative process to identify recurrent and unifying themes. We identified 3 distinct groups whose current policies or perceptions may impede efforts to adopt national TOR guidelines: payers who incentivize transport; legislators who create state mandates for transport and allow only narrow use of do-not-resuscitate orders; and communities where cultural norms are perceived to impede termination of resuscitation. Our participants suggested that national organizations, such as the American Heart Association and American College of Emergency Physicians, may serve as potential facilitators in addressing these barriers by taking the lead in asking payers to change reimbursement structures; encouraging legislators to revise laws to reflect the best available medical evidence; and educating the public that rapid transport to the hospital cannot substitute for optimal provision of prehospital care. CONCLUSIONS: We have identified 3 influential groups who will need to work with national organizations to overcome current policies or prevailing perceptions that may impede implementing national TOR guidelines.
BACKGROUND: American College of Cardiology/American Heart Association guidelines recommend greater than 75% of patients with an ST-elevation myocardial infarction receive primary percutaneous coronary interventions (PPCI) within 90 minutes. Despite these recommendations, this goal has been difficult to achieve. METHODS AND RESULTS: We conducted a prospective interventional study involving 349 patients undergoing PPCI at a single tertiary referral institution to determine the impact of prehospital 12-lead ECG triage and emergency department activation of the infarct team on door-to-balloon time (D2BT). The median D2BT of all patients (n=107) who underwent PPCI after field ECG and emergency department activation of the infarct team (MonashHEART Acute Myocardial Infarction [MonAMI] group) was 56 minutes (interquartile range, 36.5 to 70) compared with the median time of a contemporary group (n=122) undergoing PPCI during the same period but not receiving field triage (non-MonAMI group) of 98 minutes (73 to 126.45). The median D2BT time of 120 consecutive patients who underwent PPCI before initiation of the project (pre-MonAMI group) was 101.5 minutes (72.5 to 134; P less than 0.001). The proportion of patients who achieved a D2BT of less than or = 90 minutes increased from 39% in the pre-MonAMI group and 45% in the non-MonAMI group to 93% in the MonAMI group (P less than 0.001). CONCLUSIONS: The performance of prehospital 12-lead ECG triage and emergency department activation of the infarct team significantly improves D2BT and results in a greater proportion of patients achieving guideline recommendations.
OBJECTIVES: For some time, the inaccuracies of non-invasive blood pressure measurement in critically ill patients have been recognised. Measurement difficulties can occur even in optimal conditions, but in prehospital transportation vehicles, problems are exacerbated. Intra-arterial pressures must be used as the reference against which to compare the performance of non-invasive methods in the critically ill patient population. Intra-arterial manometer data observed from the patient monitor has frequently been used as the reference against which to assess the accuracy of noninvasive devices in the emergency setting. To test this method’s validity, this study aimed to determine whether numerical monitor pressures can be considered interchangeable with independently sampled intra-arterial pressures. METHODS: Intensive Care Unit nurses were asked to document arterial systolic, diastolic and mean pressures numerically displayed on the patient monitor. Observed pressures were compared to reference intra-arterial pressures independently recorded to a computer following analogue to digital conversion. Differences between observed and recorded pressures were evaluated using the Association for the Advancement of Medical Instrumentation (AAMI) protocol. Additionally, two-level linear mixed effects analyses and Bland-Altman comparisons were undertaken. RESULTS: Systolic, diastolic and integrated mean pressures observed during 60 data collection sessions (n = 600) fulfilled AAMI protocol criteria. Integrated mean pressures were the most robust. For these pressures, mean error (reference minus observed) was 0.5 mm Hg (SD 1.4 mm Hg); 95% CI (two-level linear mixed effects analysis) 0.4-0.6 mm Hg; P less than 0.001. Bland-Altman plots demonstrated tight 95% limits of agreement (-2.3 to 3.2 mm Hg), and uniform agreement across the range of mean blood pressures. CONCLUSIONS: Integrated mean arterial pressures observed from a well maintained patient monitor can be considered interchangeable with independently sampled intra-arterial pressures and may be confidently used as the reference against which to test the accuracy of non-invasive blood pressure measuring methods in the prehospital or emergency setting.
Pubmed [1]
BACKGROUND AND OBJECTIVE: We investigated whether the use of two different video laryngoscopes [direct-coupled interface (DCI) video laryngoscope and GlideScope] may improve laryngoscopic view and intubation success compared with the conventional direct Macintosh laryngoscope (direct laryngoscopy) in patients with a predicted difficult airway. METHODS: One hundred and twenty adult patients undergoing elective minor surgery requiring general anaesthesia and endotracheal intubation presenting with at least one predictor for a difficult airway were enrolled after Institutional Review Board approval and written informed consent was obtained. Repeated laryngoscopy was performed using direct laryngoscope, DCI laryngoscope and GlideScope in a randomized sequence before patients were intubated. RESULTS: Both video laryngoscopes showed significantly better laryngoscopic view (according to Cormack and Lehane classification as modified by Yentis and Lee = C&L) than direct laryngoscope. Laryngoscopic view C&L >or= III was measured in 30% of patients when using direct laryngoscopy, and in only 11% when using the DCI laryngoscope (P or= III: 1.6%) than both direct (P or= III) could be achieved significantly more often with the GlideScope (94.4%) than with the DCI laryngoscope (63.8%) Laryngoscopy time did not differ between instruments [median (range): direct laryngoscope, 13 (5-33) s; DCI laryngoscope, 14 (6-40) s; GlideScope, 13 (5-34) s]. In contrast, tracheal intubation needed significantly more time with both video laryngoscopes [DCI laryngoscope, 27 (17-94) s, and GlideScope, 33 (18-68) s, P less than 0.01] than with the direct laryngoscope [22.5 (12-49) s]. Intubation failed in four cases (10%) using the direct laryngoscope and in one case (2.5%) each using the DCI laryngoscope and the GlideScope. CONCLUSION: We conclude that the video laryngoscope and GlideScope in particular may be useful instruments in the management of the predicted difficult airway.
