I have moved Rogue Medic to EMS Blogs. Also posted over at Rogue Medic and at Research Blogging.

Go check out the rest of what is available at EMS Blogs and at Research Blogging.

MANAGEMENT OF APE
Fluid accumulation in the lungs associated with APE, until recently, was attributed to excess accumulation of total body fluid. Accordingly, treatment of APE was aimed at removing excess fluid from the lungs by promoting massive diuresis. However, this explanation for APE could not reconcile the fact that APE typically occurs during early morning hours when fluid intake is minimal. The current explanation is that APE results from fluid redistribution within the body whereby a part of the intravascular volume is redistributed to the lungs as a consequence of increased intravascular pressure as outlined above.¹³ Primary objectives for the treatment of acute CHF are to reduce pulmonary capillary pressure, to redistribute pulmonary fluid, and to improve forward flow.^12,13 These may be achieved by reducing LV preload and afterload, providing ventilatory and inotropic supports, and identifying and treating the underlying etiology of the syndrome (Table 3). It should be recognized that these treatment measures are intended for APE patients who are normotensive or hypertensive and not those who are hypotensive. The latter comprises cardiogenic shock secondary to severe LV systolic dysfunction; treatment of these critically ill patients is beyond the scope of this review.^[1]

Most patients who experience CPE, however, do not have ECG evidence of an acute dysrhythmia or AMI. Treatment should therefore be aimed at redistributing the excessive pulmonary interstitial fluid into the systemic circulation, which improves alveolar oxygen-carbon dioxide exchange and hypoxia; therefore, pharmacologic agents that provide preload reduction and afterload reduction should be administered. In some cases, inotropic support is required also.^[2]

Nitroglycerin
The most effective and rapidly-acting preload-reducing medication is nitroglycerin (NTG) ^[21–25]. Multiple studies have demonstrated the superiority of NTG over furosemide ^{[21,24,26–28]} and morphine sulfate ^[28–30] for preload reduction, symptomatic improvement, and safety. NTG can be administered in sublingual, IV, or transdermal form, although the transdermal absorption can be erratic in the patient in extremis. NTG also has the benefit of a short half-life; therefore, if the patient develops a precipitous fall in blood pressure (generally uncommon in CPE {Cardiogenic Pulmonary Edema} patients), the blood pressure should return to previous values within 5 to 10 minutes of discontinuation of administration.^[2]

In one study ^[26], 3 mg IV boluses of NTG were administered every 5 minutes to patients who had developed CPE, a dose equivalent to a 600 mg/min infusion. This protocol was found to be safe, well-tolerated, and effective for these patients and associated with reduced need for mechanical ventilation and more rapid resolution of symptoms. Standard anti-anginal dosages of sublingual NTG with which most physicians are comfortable (ie, 400 µg every 5 minutes), has the bioequivalence of an IV NTG infusion of 60 to 80 µg/min. Physicians should, therefore, be comfortable with the safety of even higher dosages of NTG for patients who experience CPE and usually present in a hyper-adrenergic state with moderately-to-severely elevated blood pressures.^[2]

I have moved Rogue Medic to EMS Blogs. Also posted over at Rogue Medic and at Research Blogging.

Go check out the rest of what is available at EMS Blogs and at Research Blogging.

There is no evidence that any antiarrhythmic drug given routinely during human cardiac arrest increases survival to hospital discharge. Amiodarone, however, has been shown to increase short-term survival to hospital admission when compared with placebo or lidocaine.^[1]

DC shock was used in 16 nonresponders (22.9%) to procainamide and 10 non-responders (50%) to lidocaine.^[3]

Insights from the Gathering of Eagles - 2010

Shattering the Myths

Once again, Dr. Paul Pepe and the team of illustrious medical directors from the 50 largest municipalities in the United States, Canada and the United Kingdom met in early February to share their insights with over 700 of their closest friends.

As has become tradition at the Eagles Conference, the crowd of mostly pre-hospital EMS professionals was intrigued and oft times confused by the paradigm shifts proffered as a result of the research findings presented during the two day event.

In addition to the startling discovery that most of us who thought we resided in the United Stated were informed that we actually live in "Southern Canada" (during the peak of the Winter Olympic Games in Vancouver), the most startling themes to much of the information presented were:

-ALS care does not really make a difference in patient outcomes in almost all life threatening patient conditions
-Response and transport times in pre-hospital medical emergencies really don't make a difference in patient outcomes
-Many of the things we thought helped people may not!

In his opening presentation, Dr. Corey Slovis from Nashville reviewed the most important research papers published in 2009. Dr. Slovis' opening comments brought a hush over the crowd and set the stage for many of the presentations to come...

In the early 1970's the nationwide survival to discharge rate for out of hospital cardiac arrest was about 5.5%...

Today, the survival to discharge rate for out of hospital cardiac arrest is about 5.5%.

Blasphemy you say? How can that be? We have spent billions of dollars in advanced emergency medical service systems - certainly we have had a HUGE impact in patient outcomes - right!(?)

Consider the following ACLS study findings presented by Dr. Slovis...

Passive Oxygen Insufflation Is Superior to Bag-Valve-Mask Ventilation for Witnessed Ventricular Fibrillation Out-of-Hospital Cardiac Arrest (AnnEmergMed 2009;54:656-662) . Bobrow, et. al. found that for adult, witnessed, ventricular fibrillation/ventricular tachycardia, out-of-hospital cardiac arrest (OHCA) resuscitated with minimally interrupted cardiac resuscitation, adjusted neurologically intact survival to hospital discharge was higher for individuals receiving initial passive ventilation than those receiving initial bag-valve mask ventilation.

Advanced Cardiac Life Support in Out-of-Hospital Cardiac Arrest ( N Engl J Med 2004;351:647-56) done by Steil, et. al. as part of the OPALS study conducted in 17 cities with 5,638 patients included found that the addition of advanced-life-support interventionsdid not improve the rate of survival after OHCA in a emergency-medical-servicessystem previously optimized with rapid defibrillation. BCLS patients had a 5.0% survival rate and ACLS patients had a 5.1% survival rate.

Intravenous drug administration during out-of-hospital cardiac arrest: a randomized trial ( JAMA 2009 Nov 25;302(20):2222-9), by Olasveengan, et. al. analyzed the admission and discharged alive rate for 851 cardiac arrest and found that there was no significant difference in survival to hospital discharge for the intravenous drug group vs. the no intravenous drug group.



Ok, Ok, we get it, but certainly modern EMS systems and protocols make a difference in trauma care and airway management! I mean, paramedics have been doing intubation for decades, and we have Level I and Level II Trauma Centers and numerous aeromedical systems. Certainly that matters, right?

Consider these findings regarding trauma and advanced airway care...
Emergency medical services intervals and survival in trauma: assessment of the "golden hour" in a North American prospective cohort (Ann Emerg. Med. 2010 Mar;55(3):235-246.e4. Epub 2009 Sep 23) by Newgard, et. al. analyzed trauma patients transported by 146 EMS agencies to 51 Level I and II trauma hospitals in 10 sites across North America from December 1, 2005, through March 31, 2007. Inclusion criteria were systolic blood pressure less than or equal to 90 mm Hg, respiratory rate less than 10 or greater than 29 breaths/min, Glasgow Coma Scale score less than or equal to 12, or advanced airway intervention. The outcome was in-hospital mortality. The study looked at call processing, activation, response, scene and overall task times for the response. The study found that there was no association between EMS intervals and mortality among injured patients with physiologic abnormality in the field.

A Prospective Multicenter Evaluation of Pre-hospital Airway Management Performance in a Large Metropolitan Region ( Prehosp Emerg Care 2009 ; 13:304-310). This is the latest in a series of studies evaluating the efficacy of paramedics doing endotracheal intubation. The study evaluated 1,200 paramedics in 34 EMS transporting agencies. 58% were fire-based, 30% private and 12% were single agency systems. The procedural success rate for the 825 attempted intubations was 74.8%. This is consistent with the findings by others such as Dr. Wang in Pittsburg. Most of the Eagles agreed that intubation, if performed at all, needs to be limited to a single attempt and many were mandating that King airways be used as the main advanced airway procedure.


That's all fine and dandy, but there must be some time-honored care traditions that DO help - for example, applying cervical collars for suspected spinal trauma, right? Wrong??

Dr. Persse from Houston presented his data from the soon to be published study: C-Collar or De-Collar: Are Cervical Devices Harmful? Dr. Persse demonstrated 3-D CT and MRI scan images of unstable c-spine cadavers after c-collars were applied. In application after application the findings showed that in many cases the patient suffered debilitating spine injuries. Although Dr. Persse indicated that more research is needed, this certainly begins to call into question one of the core processes that we as EMS professionals have performed since essentially the dawning of modern EMS.

So, was there any good news about EMS presented during the conference?? Yep...

There was a lot of discussion about a few emerging trends that most Eagles felt should be studied for presentation next year...

Field Termination of Cardiac Arrest Cases - most systems are aggressively pursuing field termination of CPR cases to prevent unnecessary transports. In one notable quote, transporting a patient who has been systolic for 20 - 30 minutes to the emergency department is simply " relocating a corpse".

Community Health and Advanced Practice Paramedics - preventing EMS calls through a targeted approach to frequent emergency service users that can benefit from home visits and dedicated medical homes when they are transported. Similarly, using APPs to do the high risk, low frequency procedures such as endotracheal intubation, hypothermia in ROSC cardiac arrest cases, and medical clearance of psych patients.

Transport CPR cases Non-light and siren - Speaking to the concept of "relocating corpses", anyone who has been in EMS more than a few minutes realizes that if you have worked a CPR case for 30 minutes in the field, there is little to nothing that the hospital can do for the patient than has not already been done. Further, the recent resuscitation studies prove that the most important procedure in CPR is adequate chest compressions. Why then do we risk out lives and livelihood (and that of the public) screaming across town, weaving in and out of traffic, throwing the rescuers around in the back of the ambulance and diminishing the quality of chest compressions all to save 2 - 3 minutes on the transport time?

Those 2 minutes on the tail end of the call makes virtually no difference in the patient's outcome. Besides, if you want to save those 2 minutes, make a more efficient process for moving the patient from the back of the ambulance to the Code Room at the emergency room. Instead of waiting until the ambulance is in "park" at the emergency room, preparing the patient to be taken from the ambulance right away. Change over to portable O2, move the IVs to the stretcher mounted pole(s), buckle the patient safety harnesses, move the monitor to the stretcher, etc. Having all that done IN ADVANCE will make the unloading process more efficient.

Many of the Eagles felt that the time has come to evaluate non-light and siren transports for CPR cases to see if it makes a difference in the patient's outcome. It would improve CPR effectiveness, reduce rescuer injury, reduce the incidence of emergency medical vehicle collisions (and "wake effect" collisions from cars moving out of the way), and overall makes sense.


In my 30ish year career in EMS, I've had the fortune to attend countless conferences. The Eagles conference continues to be one of the most informative, fast-paced and FUN conferences. If you have not had the chance to attend one yet, you should seriously plan on attending the program next year.

For more information visit http://gatheringofeagles.us/

About the columnist:
Matt Zavadsky is the Associate Director for Operations at MedStar EMS, the Ambulance Authority System serving Fort Worth and 14 suburban cities in North Central Texas. In this role, he is responsible for overall system operations covering the 850,000 people and nearly 100,000 EMS responses.
He holds a Masters Degree in Health Service Administration and has 30 years experience in EMS including volunteer, fire department, public and private sector EMS agencies. He is a former paramedic and has managed private sector ambulance services from 10,000 to more than 100,000 annual call volume in locations including Fairfield, Connecticut; Augusta, Georgia; La Crosse, Wisconsin and Orlando, Florida. He has also served as a regulator in Lincoln, Nebraska and Volusia County (Daytona Beach), Florida.

Matt is a frequent speaker at national conferences and has done consulting on numerous EMS issues, specializing in high performance EMS system operations, public/media relations, public policy, employee recruitment and retention, data analysis, costing strategies and EMS research.

He has served as the American Ambulance Association as Chair of the Industry Image Committee and membership on the Professional Standards, Strategic Development and Management Training Institute Committees.

Matt is an Adjunct Faculty for the University of Central Florida's College of Health and Public Affairs teaching courses in Healthcare Economics and Policy, Ethics, Managed Care and US Healthcare Systems.

Grrr. Really trying to make an inflammatory post, aren't we RM ?

Couldn't find a copy of the ACTUAL study, and I'm never a fan of quoting USA Today as a source of anything, other than maybe a horoscope.

Cardiac Arrest Survival Rates Depend on Paramedic Experience

Michael R Sayre, Al Hallstrom, Thomas D Rea, Lois Van Ottingham, Lynn J White, James Christenson, Vince N Mosesso, Andy R Anton, Michele Olsufka, Sarah Pennington, Stephen Yahn, James Husar, Leonard A Cobb.

The Ohio State University Medical Center, Columbus, OH,
University of Washington, Seattle, WA,
British Columbia Ambulance Service, Victoria, British Columbia, Canada,
University of Pittsburgh, Pittsburgh, PA,
Calgary Emergency Ambulance Service, Calgary, Alberta, Canada,
University of Washington, Seattle, WA,
St. Paul’s Hospital, Vancouver, British Columbia, Canada,
Calgary Emergency Medical Services, Calgary, Alberta, Canada

Objective

Out-of-hospital cardiac arrest (OOH-CA) survival varies widely among communities. We compared OOH-CA survival rates among 5 North American cities to identify factors that influenced survival.

Methods

The AutoPulse Assisted Prehospital International Resuscitation (ASPIRE) Trial was amulticenter randomized comparison of the effectiveness of manual chest compression versus AutoPulse during resuscitation of OOH-CA. Adults with OOH-CA were enrolled in five cities. Survival data collected in each city for patients in the manual arm of the trial were compared. Regression using generalized linear models was used to adjust for covariates.

Results

Younger women with witnessed ventricular fibrillation (VF) arrests in public locations who had short first response times had the best chance of survival. Victims receiving bystander cardiopulmonary resuscitation (CPR) had a trend to better survival. Time to advanced life support (ALS) vehicle arrival was not significant. The mean regression residual by site correlated with cases per paramedic per year (Pearson R = 0.97, p = 0.006).

Conclusions

Significant variation exists among the cities even after known predictors of survival are controlled. A positive correlation exists between more cases treated per paramedic and survival to discharge. Whether that relationship is causal or a marker for some other factor(s) cannot be determined.

Did, however find this nugget in 'Emergency Medicine News' from the MD that authored that study. Note his last comment in the excerpt.

Excerpt:

The study was presented at the annual meeting for the Society for Academic Emergency Medicine. Almost instantly, it was the darling of the media, hitting the pages of USA Today under the banner, “Cities that Deploy Fewer Paramedics Save More Lives.”

“It touches a nerve,” said Dr. Sayre in explaining why the findings of an academic presentation made such a splash.

For one thing, it’s a sound bite that sounds too odd to be true: The fewer the paramedics in the system, the more likely patients are to survive.

More Skilled?

He cautioned, however, that what remains unexplained is whether the data reflect a direct result, achieved because a relatively low number of paramedics who administer advanced life support are likely to become more skilled at it or whether the correlation is a sign that something else may be occurring, such as more intensive training among systems that have fewer teams or personnel. “It could be a marker; it could be a causal. We don’t know,” said Dr. Sayre, an associate professor of emergency medicine at Ohio State University Medical Center in Columbus.

Interruptions in Cardiopulmonary Resuscitation From Paramedic Endotracheal Intubation

Henry E. Wang, MD, MS
Scott J. Simeone, BS, NREMT-P
Matthew D. Weaver, BS, NREMT-P
Clifton W. Callaway, MD, PhD

Presented at the Society for Academic Emergency Medicine annual meeting, May 2008, Washington, DC.
Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA

Study objective

Emergency cardiac care guidelines emphasize treatment of cardiopulmonary arrest with continuous uninterrupted cardiopulmonary resuscitation (CPR) chest compressions. Paramedics in the United States perform endotracheal intubation on nearly all victims of out-of-hospital cardiopulmonary arrest. We quantified the frequency and duration of CPR chest compression interruptions associated with paramedic endotracheal intubation efforts during out-of-hospital cardiopulmonary arrest.

Methods

We studied adult out-of-hospital cardiopulmonary arrest treated by an urban and a rural emergency medical services agency from the Resuscitation Outcomes Consortium during November 2006 to June 2007. Cardiac monitors with compression sensors continuously recorded rescuer CPR chest compressions. A digital audio channel recorded all resuscitation events. We identified CPR interruptions related to endotracheal intubation efforts, including airway suctioning, laryngoscopy, endotracheal tube placement, confirmation and adjustment, securing the tube in place, bag-valve-mask ventilation between intubation attempts, and alternate airway insertion. We identified the number and duration of CPR interruptions associated with endotracheal intubation efforts.

Results

We included 100 of 182 out-of-hospital cardiopulmonary arrests in the analysis. The median number of endotracheal intubation–associated CPR interruption was 2 (interquartile range [IQR] 1 to 3; range 1 to 9). The median duration of the first endotracheal intubation–associated CPR interruption was 46.5 seconds (IQR 23.5 to 73 seconds; range 7 to 221 seconds); almost one third exceeded 1 minute. The median total duration of all endotracheal intubation–associated CPR interruptions was 109.5 seconds (IQR 54 to 198 seconds; range 13 to 446 seconds); one fourth exceeded 3 minutes. Endotracheal intubation–associated CPR pauses composed approximately 22.8% (IQR 12.6-36.5%; range 1.0% to 93.4%) of all CPR interruptions.

Conclusion

In this series, paramedic out-of-hospital endotracheal intubation efforts were associated with multiple and prolonged CPR interruptions.

[Ann Emerg Med. 2009;xx:xxx.]

Assuming the need to reduce endotracheal intubation–associated CPR interruptions, potential strategies include improving paramedic endotracheal intubation skill or altering out-of-hospital airway management techniques. Improving endotracheal intubation skill may prove difficult, given limits in the quantity of paramedic student training and clinical endotracheal intubation experience in the United States.^26-28 Although select paramedics attempt endotracheal intubation without stopping CPR chest compressions, the broader feasibility of this technique remains unclear. To minimize CPR interruptions, many EMS agencies have substituted endotracheal intubation with Combitube or King LT airway insertion.¹³ Select studies suggest the viability of CPR without ventilation, potentially obviating the need for airway management interventions.^29,30 The relative effectiveness of these techniques remains unknown.

Success Rates in Out-of-Hospital Intubation

Temin E, Harrington L, Mitchell P, Rebholz C, Dyer K, Doyle J, Hughes P, Moyer P/Massachusetts General Hospital, Boston, MA; Boston Medical Center, Boston, MA; Boston Emergency Medical Services, Boston, MA

Background

Previous literature has questioned whether out-of-hospital endotracheal intubation (ETI) success rates can be comparable to those performed in the emergency department (ED). Prior studies report ED success rates ranging from 80%–98% with success rates increasing with the experience of the provider. Large studies on ground out-of-hospital intubation report success rates ranging from 33%-100% and a 77% success rate for rapid sequence intubation (RSI), all after multiple attempts. Although Bulger et al 2002 has reported similar out-of-hospital ETI success rates to the ED, some question whether this success can be reproduced in other services. Boston Emergency Medical Services (BEMS) is a 2-tiered system with all advanced life support (ALS) trucks staffed by 2 paramedics. BEMS has a ratio of 0.5 paramedics to 10,000 population making it one of the lowest ratios in the country.

Study Objective

To assess the proportion of successful paramedic out-of-hospital ETI on adult and pediatric patients in a 2-tiered urban EMS system.

Methods

A retrospective chart review from 7/1/06 to 6/30/07 of ETI data from the Boston Airway Registry was conducted. The primary outcome was the success rate of ETI by number of attempts (blade passing through the lips) overall and for the following subgroups: Cardiac arrest prior to ETI, medically assisted intubation (MAI) (any medication), rapid sequence intubation (RSI) (paralytic and sedative), documented head trauma, and pediatric (age ≤ 12 years old) patients. We used descriptive statistics with 95% confidence intervals for analysis.

Results

ETI was attempted on 569 individuals by 61 paramedics. Two were excluded due to incomplete data. 361/567 (64%) of patients were male, mean age was 56 years. 455/567 (80%) had a cardiac arrest prior to ETI. 97/567 (17%) had ETI attempted with MAI. 77/567 (14%) had ETI attempted with RSI. 107/566 (19%) had documented traumatic injury, of those 73/104 (70%) had documented head trauma. Of the 10 pediatric ETI 4/10 were male, mean age was 2.6 years.


Conclusion

In this EMS system, paramedics achieved high success rates in all ETI, comparable to those reported in ED settings. Further research should determine provider and system factors that contribute to this success.

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]

Objectives

To determine 1) the success rate of prehospital endotracheal intubation; 2) the unrecognized tube malposition rate; and 3) predictors of tube malposition upon arrival to the emergency department (ED) in the setting of a large metropolitan area that includes 18 hospitals and 34 transporting emergency medical services (EMS) agencies.

Methods

Prospective data were collected on patients for whom prehospital intubation was attempted between September 1, 2004, and January 31, 2005. Endotracheal tube (ETT) position upon arrival to the ED was verified by emergency medicine attending physicians. Missing cases were identified by matching prospective data with lists of attempted intubations submitted by EMS agencies, and data were obtained for these cases by retrospective chart review. Successful intubation was defined as an "endotracheal tube balloon below the cords" on arrival to the ED. Patients were the unit of analysis; proportions with 95% confidence intervals were calculated.

Results

Nine 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.

Prehospital intubations and mortality: a level 1 trauma center perspective.

Cobas MA, De la Peña MA, Manning R, Candiotti K, Varon AJ.

Department of Anesthesiology, Miller School of Medicine, University of Miami, Miami, Florida 33136, USA. mcobas@med.miami.ed

Background

Ryder Trauma Center is a Level 1 trauma center with approximately 3800 emergency admissions per year. In this study, we sought to determine the incidence of failed prehospital intubations (PHI), its correlation with hospital mortality, and possible risk factors associated with PHI.

Methods

A prospective observational study was conducted evaluating trauma patients who had emergency prehospital airway management and were admitted during the period between August 2003 and June 2006. The PHI was considered a failure if the initial assessment determined improper placement of the endotracheal tube or if alternative airway management devices were used as a rescue measure after intubation was attempted.

Results

One-thousand-three-hundred-twenty patients had emergency airway interventions performed by an anesthesiologist upon arrival at the trauma center. Of those, 203 had been initially intubated in the field by emergency medical services personnel, with 74 of 203 (36%) surviving to discharge. When evaluating the success of the intubation, 63 of 203 (31%) met the criteria for failed PHI, all of them requiring intubation, with only 18 of 63 (29%) surviving to discharge. These patients had rescue airway management provided either via Combitube (n = 28), Laryngeal Mask Airway (n = 6), or a cricothyroidotomy (n = 4). An additional 25 of 63 patients (12%) had unrecognized esophageal intubations discovered upon the initial airway assessment performed on arrival. We found no difference in mortality between those patients who were properly intubated and those who were not. Several other variables, including age, gender, weight, mechanism of injury, presence of facial injuries, and emergency medical services were not correlated with an increased incidence of failed intubations.

Conclusions

This prospective study showed a 31% incidence of failed PHI in a large metropolitan trauma center. We found no difference in mortality between patients who were properly intubated and those who were not, supporting the use of bag-valve-mask as an adequate method of airway management for critically ill trauma patients in whom intubation cannot be achieved promptly in the prehospital setting.

The significant difference we found in the success of PHI performed in connection with air (67%) and ground transport (33%; P < 0.001) may reflect the deployment to aerial units of paramedics with more experience and skills, including intubation, because it is usually a promotion from the ground units. Although this study did not correlate intubation skills of individual paramedics, data from Germany, where air rescue crews perform ETI three times as frequently as ground crews,¹ support this. Therefore, clinical experience of those performing the intubation is invaluable and perhaps the most important piece of the PHI puzzle.

Of the 203 patients, 115 (57%) were transported by air, and within that group, 94 (82%) were properly intubated in the field, and 21(18%) were not. Of the 88 patients who were transported by ground, 46 (52%) were successfully intubated in the prehospital setting and 42 (48%) had a failed PHI (P < 0.001 compared with patients transported by air).

Therefore, clinical experience of those performing the intubation is invaluable and perhaps the most important piece of the PHI puzzle.

Prehospital use of succinylcholine: a 20-year review.

Wayne MA, Friedland E.

Prehosp Emerg Care. 1999 Apr-Jun;3(2):107-9.
PMID: 10225641 [PubMed - indexed for MEDLINE]


Emergency Medical Services, Bellingham/Whatcom County Washington, WA 98225, USA. mwayne@cob.org

Objective

To determine the safety and efficacy of succinylcholine, as an adjunct to endotracheal intubation, administered by paramedics trained in its use.

Methods

Retrospective review of 1,657 consecutive patients, aged 16 years or older, receiving prehospital succinylcholine administered by paramedics. In this community of 175,000 people, trained paramedics intubated both medical and trauma patients with the assistance of succinylcholine. Main outcomes measured were success of intubations, complications of the procedure and/or the drug, and use of alternative methods of airway management.

Results

Paramedics successfully intubated 95.5% (1,582) of all patients receiving succinylcholine, 94% (1,045) of trauma patients, and 98% (538) of medical patients. They were unable to intubate 4.5% (74) of the patients. All of these were successfully managed by alternative methods. Unrecognized esophageal intubation occurred in six (0.3%) patients. The addition of capnography and a tube aspiration device, in 1990, decreased the incidence of esophageal intubations.

Conclusion

Paramedics trained to use succinylcholine, to assist the process of endotracheal intubation, can safely intubate a high percentage of patients.

Following didactic training, each student must successfully complete a minimum of 20 intubations, in the operating room, under the supervision of a board-certified anesthesiologist. Additionally, paramedics are required to successfully intubate at least one patient monthly for three years, post certification, and one per quarter thereafter. At least one intubation, annually, must be performed under an anesthesiologist’s supervision.