The following study is just another example, supporting my opinion on the outcome of properly trained prehospital personnel. Rogue Medic has been screaming this stuff from the blogshere rooftop. It takes much more training than you would probably think to remain proficient at this dangerous airway skill.
[Pubmed 1]
Background. Emergency airway management is an important component of resuscitation of critically ill patients. Multiple studies demonstrate variable endotracheal intubation (ETI) success by prehospital providers. Data describing how many ETI training experiences are required to achieve high success rates are sparse. Objectives. To describe the relationship between the number of prehospital ETI experiences and the likelihood of success on subsequent ETI and to specifically look at uncomplicated first-pass ETI in a university-based training program with substantial resources. Methods. We conducted a secondary analysis of a prospectively collected cohort of paramedic student prehospital intubation attempts. Data collected on prehospital ETIs included indication, induction agents, number of direct laryngoscopy attempts, and advanced airway procedures performed. We used multivariable generalized estimating equations (GEE) analysis to determine the effect of cumulative ETI experience on first-pass and overall ETI success rates. Results. Over a period of three years, 56 paramedic students attempted 576 prehospital ETIs. The odds of overall ETI success were associated with cumulative ETI experience (odds ratio [OR] 1.097 per encounter, 95% confidence interval [CI] = 1.026-1.173, p = 0.006). The odds of first-pass ETI success were associated with cumulative ETI experience (OR 1.061 per encounter, 95% CI = 1.014-1.109, p = 0.009). Conclusion. In a training program with substantial clinical opportunities and resources, increased ETI success rates were associated with increasing clinical exposure. However, first-pass placement of the ETT with a high success rate requires high numbers of ETI training experiences that may exceed the number available in many training programs.
[Pubmed 2]
STUDY OBJECTIVE: This study compares adhesive tape, non-adhesive tape and a commercial endotracheal tube holder in terms of the force required to extubate endotracheal tubes from a cadaver. METHODS: A newly deceased, unembalmed cadaver was orotracheally intubated. Senior paramedic students secured the endotracheal tube using adhesive tape applied using the Lillehei method, non-adhesive tape and the Thomas Tube Holder in a random order. The time taken to secure the endotracheal tube and the force required to remove the distal tip of the endotracheal tube from the glottis were recorded. RESULTS: Use of adhesive tape using the Lillehei method resulted in greatest resistance to tube dislodgement, although it took significantly longer to apply than the other two methods. CONCLUSION: Although the Lillehei method provided the greatest resistance to tube dislodgement, it may not be ideal for the prehospital or emergency department context. The Thomas Tube Holder was quick and effective and may provide a good compromise in these environments, although once time is no longer important, clinicians may elect to revert to the Lillehei method which provides greater security.
Check out the ET securing methods below.
I had never heard of the Lillehei method by name until I read this. Is one of those images you listed there the Lillehei method? A cursory search on google came up with no images and I'd like to learn it. If it is what is best I'd like to use it!
ReplyDeleteMe too. I couldn't find it, so I supplied those images instead. Remember, that is a single study. A commercial tube holder works fine, just trying to provide some more knowledge on the subject.
ReplyDeleteI must admit I was NEVER successful with taping tubes. I used to steal tube holders from the hospitals before they were recomended and then required for EMS.
ReplyDeleteAt first glance this techiques looks complicated, but like anything else, with lots of practice can be mastered. Looking at the picture still has me straining my brain in how this is done. Perhaps writing to the authors of the study will help.
I'm not familiar with the method of securing the tube pictured, but it looks as if the 3 images are parts 1, 2, and 3 of the same method.
ReplyDeleteI always, up until the Tube Tamer, used tape, a lot of tape. The patient would need to visit the barber, if they survived, but the tube was secure. The Tube Tamer never even came close to being as secure, but it is fast. the important thing is continual assessment of the airway to look for early signs of potential; dislodgement.
One thing I always do is: After securing the tube with the commercial tube holder, I rip off a small piece of tape and place it where the top of the tube holder meets the tube. This doesn't protect from dislodgment, but it lets me know that the tube isn't being pulled up or pushed down by the bagger. Constant ETCO2 monitoring is by far the gold standard.
ReplyDeleteAdam,
ReplyDeleteOne thing I always do is: After securing the tube with the commercial tube holder, I rip off a small piece of tape and place it where the top of the tube holder meets the tube. This doesn't protect from dislodgment, but it lets me know that the tube isn't being pulled up or pushed down by the bagger.
That is an excellent idea.
Constant ETCO2 monitoring is by far the gold standard.
I don't like the idea of a gold standard, but waveform capnography is the closest we have to one.