Study objective Pediatric intubation is a core paramedic skill in some emergency medical services (EMS) systems. The literature lacks a detailed examination of the challenges and subsequent ...adjustments made by paramedics when intubating children in the out-of-hospital setting. We undertake a descriptive evaluation of the process of out-of-hospital pediatric intubation, focusing on challenges, adjustments, and outcomes. Methods We performed a retrospective analysis of EMS responses between 2006 and 2012 that involved attempted intubation of children younger than 13 years by paramedics in a large, metropolitan EMS system. We calculated the incidence rate of attempted pediatric intubation with EMS and county census data. To summarize the intubation process, we linked a detailed out-of-hospital airway registry with clinical records from EMS, hospital, or autopsy encounters for each child. The main outcome measures were procedural challenges, procedural success, complications, and patient disposition. Results Paramedics attempted intubation in 299 cases during 6.3 years, with an incidence of 1 pediatric intubation per 2,198 EMS responses. Less than half of intubations (44%) were for patients in cardiac arrest. Two thirds of patients were intubated on the first attempt (66%), and overall success was 97%. The most prevalent challenge was body fluids obscuring the laryngeal view (33%). After a failed first intubation attempt, corrective actions taken by paramedics included changing equipment (33%), suctioning (32%), and repositioning the patient (27%). Six patients (2%) experienced peri-intubation cardiac arrest and 1 patient had an iatrogenic tracheal injury. No esophageal intubations were observed. Of patients transported to the hospital, 86% were admitted to intensive care and hospital mortality was 27%. Conclusion Pediatric intubation by paramedics was performed infrequently in this EMS system. Although overall intubation success was high, a detailed evaluation of the process of intubation revealed specific challenges and adjustments that can be anticipated by paramedics to improve first-pass success, potentially reduce complications, and ultimately improve clinical outcomes.
Timing and preparation for tracheal extubation are as critical as the initial intubation. There are limited data on specific strategies for a planned extubation. The extent to which the difficult ...airway at reintubation contributes to patient morbidity is unknown. The aim of the present study was to describe the occurrence and complications of failed extubation and associated risk factors, and to estimate the mortality and morbidity associated with reintubation attempts.
Cohort study of 2,007 critically ill adult patients admitted to the ICU with an ETT. Patients were classified in 2 groups, based on the requirement for reintubation: "never reintubated" versus "≥ 1 reintubations." Baseline characteristics, ICU and hospital stay, hospital mortality, and in-patient costs were compared between patients successfully extubated and those with reintubation outside the operating room, using regression techniques. Reasons, airway management techniques, and complications of intubation and reintubation were summarized descriptively.
376 patients (19%) required reintubation, and 230 (11%) were reintubated within 48 hours, primarily due to respiratory failure. Patients requiring reintubation were older, more likely to be male, and had higher admission severity score. Difficult intubation and complications were similar for initial and subsequent intubation. Reintubation was associated with a 5-fold increase in the relative odds of death (adjusted odds ratio 5.86, 95% CI 3.87-8.89, P < .01), and a 2-fold increase in median ICU and hospital stay, and institutional costs. Difficult airway at reintubation was associated with higher mortality (adjusted odds ratio 2.23, 95% CI 1.01-4.93, P = .05).
Nearly 20% of critically ill patients required out of operating room reintubation. Reintubation was associated with higher mortality, stay, and cost. Moreover, a difficult airway at reintubation was associated with higher mortality.
Regional Anesthesia in Trauma Medicine Wu, Janice J.; Lollo, Loreto; Grabinsky, Andreas
Anesthesiology Research and Practice,
01/2011, Volume:
2011
Journal Article
Peer reviewed
Open access
Regional anesthesia is an established method to provide analgesia for patients in the operating room and during the postoperative phase. While regional anesthesia offers unique advantages, as shown ...by the recent military experience, it is not commonly utilized in the prehospital or emergency department setting. Most often, regional anesthesia techniques for traumatized patients are first utilized in the operating room for procedural anesthesia or for postoperative pain control. While infiltration or single nerve block procedures are often used by surgeons or emergency medicine physicians in the preoperative phase, more advanced techniques such as plexus block procedures or regional catheter placements are more commonly performed by anesthesiologists for surgery or postoperative pain control. These regional techniques offer advantages over intravenous anesthesia, not just in the perioperative phase but also in the acute phase of traumatized patients and during the initial transport of injured patients. Anesthesiologists have extensive experience with regional techniques and are able to introduce regional anesthesia into settings outside the operating room and in the early treatment phases of trauma patients.
Endotracheal intubation success rates in the prehospital setting are variable. Our objective was to describe the challenges encountered and corrective actions taken during the process of endotracheal ...intubation by paramedics.
Analysis of prehospital airway management using a prospective registry that was linked to an emergency medical services administrative database.
Emergency medical services system serving King County, Washington, 2006-2011. Paramedics in this system have the capability to administer neuromuscular blocking agents to facilitate intubation (i.e., rapid sequence intubation).
A total of 7,523 patients more than 12 years old in whom paramedics attempted prehospital endotracheal intubation.
None.
An intubation attempt was defined as the introduction of the laryngoscope into the patient's mouth, and the attempt concluded when the laryngoscope was removed from the mouth. Endotracheal intubation was successful on the first attempt in 77% and ultimately successful in 99% of patients (7,433 of 7,523). Paramedics used a rapid sequence intubation strategy on 54% of first attempts. Among the subset with a failed first attempt (n = 1,715), bodily fluids obstructing the laryngeal view (50%), obesity (28%), patient positioning (17%), and facial or spinal trauma (6%) were identified as challenges to intubation. A variety of adjustments were made to achieve intubation success, including upper airway suctioning (used in 43% of attempts resulting in success), patient repositioning (38%), rescue bougie use (19%), operator change (16%), and rescue rapid sequence intubation (6%). Surgical cricothyrotomy (0.4%, n = 27) and bag-valve-mask ventilation (0.8%, n = 60) were rarely performed by paramedics as final rescue airway strategies.
Airway management in the prehospital setting has substantial challenges. Success can require a collection of adjustments that involve equipment, personnel, and medication often in a simultaneous fashion.
Abstract Objective Some observational studies indicate that endotracheal intubation is associated with a worse outcome compared to bag-mask ventilation after out-of-hospital cardiac arrest in ...emergency medical services (EMS) systems without rapid sequence intubation (RSI). We evaluated the role of RSI in airway management following cardiac arrest. Methods We conducted a cohort study of all non-traumatic arrest patients treated by a metropolitan EMS system from 2007 to 2011. Advanced airway management information was obtained from a prospective airway registry and linked to a cardiac arrest registry. We used multivariate logistic regression to estimate the association between attempted intubation status and survival to hospital discharge. Results Of 3133 patients, 82% underwent attempted intubation without RSI, 15% underwent attempted RSI, and 3% experienced no intubation attempt. Survival to hospital discharge differed by attempted intubation status: 11% ( n = 291/2576) for intubation without RSI, 48% ( n = 226/471) for RSI, and 71% ( n = 61/86) for “no intubation.” Compared to the intubation without RSI group, the adjusted odds ratios of survival were 5.6 (95% CI 4.3, 7.2) for the RSI group and 15 (95% CI 9, 27) for the “no intubation” group. Conclusion In this population-based cohort of out-of-hospital cardiac arrest, RSI was used in 15% of patients and associated with a better prognosis than intubation attempted without paralytics. Because this subset with a favorable prognosis may not be readily intubated in systems without paralytics, these findings could help to explain the adverse relationship between intubation and survival observed in prior studies.
Airway Management in Trauma: Defining Expertise Grabinsky, Andreas; Vinca, Nancy; Tobin, Joshua M.
Current anesthesiology reports (Philadelphia),
3/2016, Volume:
6, Issue:
1
Journal Article
Prompt attention to airway management is a fundamental component of the approach to trauma anesthesiology. While anesthesiologists manage the greatest number of airways in their training and ...practice, a variety of medical providers perform airway management in the trauma population (i.e., paramedics, emergency physicians, anesthesiologists, respiratory therapists). Rates of successful intubation can vary widely between groups; therefore, a definition of expertise is required to develop training plans, as well as standards for maintenance of proficiency. While competency is challenging to define in any field, the data suggest that individuals with the greatest experience achieve the highest level of success. Given that anesthesiologists manage several thousand airway encounters throughout their training and careers, their leadership as subject matter experts is essential to development of training curricula in airway management of all varieties. Consensus on training of less experienced providers, as well as tasking of the most difficult cases to the most experienced provider, is imperative for successful airway management in trauma.
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