Study objective Although repeated intubation attempts are believed to contribute to patient morbidity, only limited data characterize the association between the number of emergency department (ED) ...laryngoscopic attempts and adverse events. We seek to determine whether multiple ED intubation attempts are associated with an increased risk of adverse events. Methods We conducted an analysis of a multicenter prospective registry of 11 Japanese EDs between April 2010 and September 2011. All patients undergoing emergency intubation with direct laryngoscopy as the initial device were included. The primary exposure was multiple intubation attempts, defined as intubation efforts requiring greater than or equal to 3 laryngoscopies. The primary outcome measure was the occurrence of intubation-related adverse events in the ED, including cardiac arrest, dysrhythmia, hypotension, hypoxemia, unrecognized esophageal intubation, regurgitation, airway trauma, dental or lip trauma, and mainstem bronchus intubation. Results Of 2,616 patients, 280 (11%) required greater than or equal to 3 intubation attempts. Compared with patients requiring 2 or fewer intubation attempts, patients undergoing multiple attempts exhibited a higher adverse event rate (35% versus 9%). After adjusting for age, sex, principal indication, method, medication, and operator characteristics, intubations requiring multiple attempts were associated with an increased odds of adverse events (odds ratio 4.5; 95% confidence interval 3.4 to 6.1). Conclusion In this large Japanese multicenter study of ED patients undergoing intubation, we found that multiple intubation attempts were independently associated with increased adverse events.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Study objective We describe the operators, techniques, success, and adverse event rates of adult emergency department (ED) intubation through multicenter prospective surveillance. Methods Eighteen ...EDs in the United States, Canada, and Australia recorded intubation data onto a Web-based data collection tool, with a greater than or equal to 90% reporting compliance requirement. We report proportions with binomial 95% confidence intervals (CIs) and regression, with year as the dependent variable, to model change over time. Results Of 18 participating centers, 5 were excluded for failing to meet compliance standards. From the remaining 13 centers, we report data on 17,583 emergency intubations of patients aged 15 years or older from 2002 to 2012. Indications were medical in 65% of patients and trauma in 31%. Rapid sequence intubation was the first method attempted in 85% of encounters. Emergency physicians managed 95% of intubations and most (79%) were physician trainees. Direct laryngoscopy was used in 84% of first attempts. Video laryngoscopy use increased from less than 1% in the first 3 years to 27% in the last 3 years (risk difference 27%; 95% CI 25% to 28%; mean odds ratio increase per year ie, slope 1.7; 95% CI 1.6 to 1.8). Etomidate was used in 91% and succinylcholine in 75% of rapid sequence intubations. Among rapid sequence intubations, rocuronium use increased from 8.2% in the first 3 years to 42% in the last 3 years (mean odds ratio increase per year 1.3; 95% CI 1.3 to 1.3). The first-attempt intubation success rate was 83% (95% CI 83% to 84%) and was higher in the last 3 years than in the first 3 (86% versus 80%; risk difference 6.2%; 95% CI 4.2% to 7.8%). The airway was successfully secured in 99.4% of encounters (95% CI 99.3% to 99.6%). Conclusion In the EDs we studied, emergency intubation has a high and increasing success rate. Both drug and device selection evolved significantly during the study period.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Study objective We describe emergency department (ED) intubation practices for children younger than 16 years through multicenter prospective surveillance. Methods Academic and community EDs in the ...United States, Canada, and Australia recorded data electronically, from 2002 to 2012, with verified greater than or equal to 90% reporting. Results Ten of 18 participating centers provided qualifying data, reporting 1,053 encounters. Emergency physicians initiated 85% of intubations. Trainees initiated 83% (95% confidence interval CI 81% to 85%). Premedication became uncommon, reaching less than 30% by the last year. Etomidate was used in 78% of rapid sequence intubations. Rocuronium use increased during the period of study, whereas succinylcholine use declined. Video laryngoscopy increased, whereas direct laryngoscopy declined. The first attempt was successful in 83% of patients (95% CI 81% to 85%) overall. The risk of first-attempt failure was highest for infants (relative risk versus all others 2.3; 95% CI 1.8 to 3.0). Odds of first-attempt success for girls relative to boys were 0.57. The odds were 3.4 times greater for rapid sequence intubation than sedation without paralysis. The ultimate success rate was 99.5%. Conclusion Because we sampled only 10 centers and most of the intubations were by trainees, our results may not be generalizable to the typical ED setting. We found that premedication is now uncommon, etomidate is the predominant induction agent, and rocuronium and video laryngoscopy are used increasingly. First-attempt failure is most common in infants.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Study objective Glottic visualization with video is superior to direct laryngoscopy in controlled operating room studies. However, glottic exposure with video laryngoscopy has not been evaluated in ...the emergency department (ED) setting, where blood, secretions, poor patient positioning, and physiologic derangement can complicate laryngoscopy. We measure the difference in glottic visualization with video versus direct laryngoscopy. Methods We prospectively studied a convenience sample of tracheal intubations at 2 academic EDs. We performed laryngoscopy with the Karl Storz Video Macintosh Laryngoscope, which can be used for conventional direct laryngoscopy, as well as video laryngoscopy. We rated glottic visualization with the Cormack-Lehane (C-L) Scale, defining “good” visualization as C-L I or II and “poor” visualization as C-L III or IV. We compared glottic exposure between direct and video laryngoscopy, determining the proportion of poor direct visualizations improved to good visualization with video laryngoscopy. We also determined the proportion of good direct visualizations worsened to poor visualization by video laryngoscopy. Results We report data on 198 patients, including 146 (74%) medical, 51 (26%) trauma, and 1 (0.51%) unknown indications. All were tracheally intubated by emergency physicians. Postgraduate year 3 or 4 residents performed 102 (52.3%) of the laryngoscopies, postgraduate year 2 residents performed 60 (30.8%), interns performed 20 (10.3%), attending physicians performed 9 (4.6%), and operator experience and specialty were not reported in 4. Overall, good visualization (C-L grade I or II) was attained in 158 direct (80%) versus 185 video laryngoscopies (93%; McNemar's P <.0001). Of the 40 patients with poor glottic exposure on direct laryngoscopy, video laryngoscopy improved the view in 31 (78%; 95% confidence interval 62% to 89%). Of the 158 patients with good glottic view on direct laryngoscopy, video laryngoscopy worsened the view in 4 (3%; 95% confidence interval 0.7% to 6%). Conclusion Video laryngoscopy affords more grade I and II views than direct laryngoscopy and improves glottic exposure in most patients with poor direct glottic visualization. In a small proportion of cases, glottic exposure is worse with video than direct laryngoscopy.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Abstract Objectives There is little information on geriatric emergency airway management. We sought to describe intubation practices and outcomes for emergency department (ED) geriatric and younger ...patients in Japan. Method We formed the Japanese Emergency Airway Network, a consortium of 11 medical centers, and prospectively collected data on ED intubations between 2010 and 2011. All patients 18 years or older who underwent emergent airway management were included in our study. Patients were divided to into 2 groups: 18 to 64-year olds and 65 years or older. We present descriptive data as proportions with 95% confidence intervals (CI). Results The database recorded 3277 patients (capture rate 96%), and 3178 met the inclusion criteria. Of 3178 patients, 1844 (58%) were 65 years or older, 1334 (42%) were 18 to 64 years old, 809 (25%) were 80 years or older, and 407 (50%) of them were in the state of cardiac arrest. The geriatric group, compared to the younger group, had a higher success rate on the initial attempt (71% vs 64%; difference 7%; 95% CI 4%-10%;) and in 2 attempts (90% vs 88%; difference 3%; 95% CI 1%-5%) or less. There was no significant difference in the adverse event rates by age group (difference 0%; 95% CI − 2% to 3%). Conclusion In our multicenter study involving a large geriatric population, we found that geriatric patients were intubated with a higher success rate, compared to younger patients. These data provide implications for the geriatric ED airway practice that may lead to better patient-centered emergency care.
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The objective of this study was to investigate the factors associated with first-pass success in pediatric intubation in the emergency department (ED).
We analyzed the data from two multicenter ...prospective studies of ED intubation in 17 EDs between April 2010 and September 2014. The studies prospectively measured patient's age, sex, principal indication for intubation, methods (e.g., rapid sequence intubation RSI), devices, and intubator's level of training and specialty. To evaluate independent predictors of first-pass success, we fit logistic regression model with generalized estimating equations. In the sensitivity analysis, we repeated the analysis in children <10 years.
A total of 293 children aged ≤18 years who underwent ED intubation were eligible for the analysis. The overall first-pass success rate was 60% (95%CI 54%-66%). In the multivariable model, age ≥10 years (adjusted odds ratio aOR, 2.45; 95% CI 1.23-4.87), use of RSI (aOR, 2.17; 95% CI 1.31-3.57), and intubation attempt by an emergency physician (aOR, 3.21; 95% CI 1.78-5.83) were significantly associated with a higher chance of first-pass success. Likewise, in the sensitivity analysis, the use of RSI (aOR, 3.05; 95% CI 1.63-5.70), and intubation attempt by an emergency physician (aOR, 4.08; 95% CI 1.92-8.63) were significantly associated with a higher chance of first-pass success.
Based on two large multicenter prospective studies of ED airway management, we found that older age, use of RSI, and intubation by emergency physicians were the independent predictors of a higher chance of first-pass success in children. Our findings should facilitate investigations to develop optimal airway management strategies in critically-ill children in the ED.
Abstract Objective Neuromuscular paralysis without sedation is an avoidable medical error with negative psychologic and potentially physiologic consequences. We determine the frequency of long-acting ...paralysis without concurrent sedation among patients intubated in our emergency department (ED) or before arrival. Methods We performed a retrospective cohort study from July 2007 to August 2009. We chose this time interval because in 2006, our institution developed a multidisciplinary plan designed to improve care of intubated patients. We identified all mechanically ventilated patients using billing codes. We reviewed all records to identify use of long-acting neuromuscular blocking agents. We captured data on patient characteristics and location of intubation, using a standardized data collection form. We report bivariate risk ratios to quantify associations with lack of concurrent sedation. A priori, we defined concurrent sedation as administration of any sedative during the 60 minutes preceding and the 15 minutes after administration of the long-acting paralytic. Results Over the 26-month period of study, 292 patients received a long-acting paralytic. Of the 212 available for analysis, 39 (18%) did not receive concurrent sedation. Every decade of age increased the risk of paralysis without concurrent sedation by 1.2 (95% confidence interval CI, 1.1-1.4). Paralysis for intubation (vs for transport or ventilation management) increased the odds of no sedation by 2.1 (95% CI, 1.2-3.7). No other covariates predicted nonsedation. Conclusion Absence of concurrent sedation was common among patients receiving long-acting neuromuscular paralysis before arrival or at our ED, despite implementation of a guideline to improve practice.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
10.
Trauma Airway Management Horton, Cheryl Lynn, MD; Brown, Calvin A., MD; Raja, Ali S., MD, MBA, MPH
The Journal of emergency medicine,
06/2014, Volume:
46, Issue:
6
Journal Article
Peer reviewed
Abstract Background Airway management in a trauma patient can be particularly challenging when both a difficult airway and the need for rapid action collide. The provider must evaluate the trauma ...patient for airway difficulty, develop an airway management plan, and be willing to act quickly with incomplete information. Discussion Thorough knowledge of airway management algorithms will assist the emergency physician in providing optimal care and offer a rapid and effective treatment plan. Conclusions Using a case-based approach, this article reviews initial trauma airway management strategies along with the rationale for evidence-based treatments.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
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