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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Even though epinephrine (adrenaline) is used automatically in cardiac arrest, and there is evidence that epinephrine helps to produce a pulse (ROSC – Return Of Spontaneous Circulation), there is no evidence that epinephrine improves the only survival statistic that matters – discharge from the hospital with a brain that still works. There were so many deviations from assignment protocol in their 2009 study,[1] that the authors decided to examine the results based on what treatment patients actually received. They refer to epinephrine as adrenaline, which is the same drug. I will use adrenaline for consistency.
Our randomized study was analyzed on an intention-to-treat basis.4 As expected; some patients in the intravenous group had achieved ROSC before adrenaline could be given, while some in the no-intravenous group received adrenaline for different reasons. For example, it was permitted to place the IV line 5 min after ROSC. If re-arrest occurred, adrenaline could be administered if indicated by the CPR guidelines.7 [2]
In the no andrenaline group, 37 of the 433 patients did receive andrenaline.
In the adrenaline group, 85 of the 418 patients did not receive andrenaline.
For 3 patients, the authors were unable to tell whether andrenaline was given and these patients were excluded.
This changes the data to 367 patients in the adrenaline group and 481 patients in the no adrenaline group.
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Patients in the adrenaline group were more likely to be admitted to hospital and an intensive care unit compared to the no-adrenaline group (OR 2.5 CI 1.9, 3.4 and OR 1.4 CI 1.0, 1.9, respectively). [2]
This is nothing new. Patients receiving andrenaline are more likely to have ROSC. All that really matters is what happens after ROSC.
If the patient loses pulses after ROSC, giving more adrenaline may not produce the desired effect – another ROSC.
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First look at Table 1. The duration of CPR is much longer with the adrenaline group. Is this because of patients losing pulses?
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Click on images to make them larger.
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You can also see how few drugs were given to the no adrenaline group. They were not supposed to receive any drugs, but the use of adrenaline was the only criterion for reassigning patients in this reanalysis of the data. Atropine was given to 2% of the no adrenaline group and amiodarone was given to 2%. Was there overlap of these patients? We can’t tell.
The defibrillations were also significantly different. More patients were shocked in the adrenaline group, but more patients in the adrenaline group were in VF (Ventricular Fibrillation) initially. How many of the patients with PEA (Pulseless Electrical Activity) or Asystole developed VF after adrenaline? More shocks were also used for each patient. Was this due to rearrest?
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Now looking at Table 2
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Adrenaline starts out 2 1/2 times more likely to produce a pulse (ROSC), but a lot of those patients appear to have lost those pulses before admission to the hospital, since Table 2 shows that 69 of the 175 adrenaline patients admitted with CPR (CardioPulmonary Circulation) in progress. Adrenaline wears off in several minutes and produces a lot of undesirable side effects.
More is not better, especially since the doses of adrenaline being given are already many times larger than would be given to any living human.
Most important is the neurological function. I do not want to be resuscitated with only enough neurological function to spend the rest of my life watching reality TV in a long term care facility, or worse. That is not a successful resuscitation.
Adrenaline = 48% admitted to the hospital, but only 6% alive one year later.
No adrenaline = 27% admitted to the hospital, but 12% alive one year later.
Adrenaline (epinephrine) is not just changing the location of death, but is cutting overall survival in half.
Is getting pulses back a good enough reason to kill half of the patients who could survive?
Of the patients admitted to the hospital, 11% of the adrenaline group were discharged with good brain function.
Of the patients admitted to the hospital, 45% of the no adrenaline group were discharged with good brain function.
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Of the patients admitted to the hospital, 12% of the adrenaline group were alive one year later.
Of the patients admitted to the hospital, 44% of the no adrenaline group were alive one year later.
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The actual use of adrenaline may be a surrogate marker for patients with bad prognosis, but that has previously only been published from studies without a group randomized to not receiving drugs.21 [2]
There are many limitations of this study, but the authors do not pretend that this is the final answer on adrenaline (epinephrine) in cardiac arrest. They do point out that we are not providing good care by continuing to use adrenaline without studying the outcome that matters – survival with good neurological function.
5% of the no adrenaline group survivors had significant brain damage.
20% of the adrenaline group survivors had significant brain damage.
Maybe the good news is that adrenaline does not produce a lot of survivors.
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See also -
Cardiac Arrest Management is an EMT-Basic Skill
Cardiac Arrest Management is an EMT-Basic Skill – The BLS Evidence
Cardiac Arrest Management is an EMT-Basic Skill – The Hands Only Evidence
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Footnotes:
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[1] Intravenous drug administration during out-of-hospital cardiac arrest: a randomized trial.
Olasveengen TM, Sunde K, Brunborg C, Thowsen J, Steen PA, Wik L.
JAMA. 2009 Nov 25;302(20):2222-9.
PMID: 19934423 [PubMed - indexed for MEDLINE]
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[2] Outcome when adrenaline (epinephrine) was actually given vs. not given – post hoc analysis of a randomized clinical trial.
Olasveengen TM, Wik L, Sunde K, Steen PA.
Resuscitation. 2011 Nov 22. [Epub ahead of print]
PMID: 22115931 [PubMed - as supplied by publisher]
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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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This post can also be found at 510 Medic.
It’s no secret that I’m a fan of capnography. One of the reasons I started a blog was to pass on what I felt were the best practices in EMS. Really that’s a huge part of the EMS 2.0 movement. So let me just say again, for the record, that capnography absolutely qualifies as a “best practice” and may be one of the greatest tools added to our arsenal in my time in the field. Though not universal, many EMS systems are now utilizing waveform capnography for confirmation of advanced airway placement in cardiac arrest patients. But what else can capnography do? Really, the question should be, what can’t it do?
Most providers are aware that higher capnography readings during a resuscitation are associated with a pending return of spontaneous circulation[1]. But is this true for all patients? In a study published in Critical Care, researchers looked at initial and serial CO2 readings in full arrest patients with both cardiac and respiratory origins [2]. The findings were interesting:
So what does this mean for us? Picture the following scenario:
You arrive on scene of a cardiac arrest first. After assessing the patient and finding no pulse, your partner begins chest compressions and you do one of the following next:
The answer to that question ultimately depends on the cause of the arrest right? A patient in cardiac arrest from primarily cardiac causes is likely to be in VF/pulseless VT (depending, of course, on downtime, bystander CPR and the like) and will benefit from early defibrillation. If a patient is in cardiac arrest from primarily respiratory causes (for instance a choking), they are more likely to need oxygenation. Ultimately, the history of the patient and their current medical condition affects the order of your steps on a call.
Now skip ahead a bit in the call. The next due unit has arrived and you have all the manpower you could possibly need. The patient is intubated and on the ECG monitor (which is showing PEA). Your initial post-intubation EtCO2 reading was 30 mmHg, but it has dwindled over a period of minutes to 15 mmHg. One of the other responders mentions that this might indicate that the resuscitation will be terminated. Is this true? It all depends on the patient’s history. If this was a cardiac arrest of respiratory origin, this may be the expected dip in the EtCO2 before an anticipated rise and, ultimately, a return of spontaneous circulation. If this is a cardiac arrest of primarily cardiac origin, it may well mean that the patient will not regain pulses. The take home lesson in this study is that capnography is really just a tool and findings must be interpreted in conjunction with a thorough history.
STUDY LIMITATIONS
The authors cite several limitations to their study including the need for a larger cohort study and the fact the EtCO2 is only an approximation of cardiac output. I’d like to add another one for application of this study to EMS: time frame.
The study found that EtCO2 values in cardiac arrest from both primary cardiac and asphyxial causes reached a prognostic value for ROSC in five minutes. Even in an urban system (with lots of paramedics), I would guess that it is probably unlikely that intubation has been performed with regularity within five minutes of the start of a code, even less likely within the three minutes required to see the drop in EtCO2 for asphyxial arrest. There is a way around this, however. Our crews have had good luck placing the capnography fitting between the BVM and facemask when using a BLS airway. This could allow for collection of capnography readings immediately upon start to run the code. Does anyone else use capnography inline with the BVM and facemask? Any feedback or stories?
CITED ARTICLES
[1] - Weil MH: “Partial pressure of end-tidal carbon dioxide predicts successful cardiopulmonary resuscitation in the field”. Crit Care 2008, 2:90.
[2] – Lah, K; et. al: “The dynamic pattern of end-tidal carbon dioxide during cardiopulmonary resuscitation – difference between asphyxial cardiac arrest and ventricular fibrillation/pulseless ventricular tachycardia cardiac arrest”.Crit Care 2011, 15:R13.
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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