Showing posts with label Intubation. Show all posts
Showing posts with label Intubation. Show all posts

Research: Management of the Airway in the Trauma Patient

Adam Thompson, EMT-P | 5:55 PM | , , , , , | 1 comments

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.

Research: Management of the Airway in the Burn Patient

Adam Thompson, EMT-P | 10:44 AM | , , , | 3 comments

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?

Advocating Airway Education

Adam Thompson, EMT-P | 7:13 PM | , , , | 9 comments

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

Endotracheal Intubation has been best performed by those who maintain experience and those whom utilize Rapid Sequence Induction/Intubation.

Experience should be maintained in a number of manors:
  • Operating room rotations
  • Mannequin scenarios (without the dummy supine on a table)
  • Cadavers if possible
Rapid Sequence Induction is when one of many combinations of sedatives and paralytics are used to facilitate endotracheal intubation.  This is a high risk procedure with many possible complications.  It requires more education, and practice.
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.


Key Point 2
Airway Management ≠ Endotracheal Intubation (ETI)

What I mean by that, is that just because a patient's airway requires management, it does not mean that ETI is the only option.

Questions to ask:
  • Is there a risk for aspiration?
  • Is the patient ventilating on their own?
  • Is the patient oxygenating on their own?
  • Is the patient conscious?
  • How difficult will this ETI attempt be?
  • What is my backup plan?
Other options:
  • Bag-valve mask (possibly with an OPA/NPA)
  • Combi-tube
  • King LT/LTD
  • Laryngeal Mask Airway
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.


Don't aim for jewelry!



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:

  • Grade 1, visualization of the entire laryngeal aperture; 
  • Grade 2, visualization of parts of the laryngeal aperture or the arytenoids; 
  • Grade 3, visualization of only the epiglottis; and 
  • Grade 4, visualization of only the soft palate.

Bougie - This is almost like a super long rigid stylet that is introduced through the vocal cords first.  You then thread the ET tube over it.   




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


It doesn't end after the intubation is accomplished.


Once you've got the tube, you should aim all of your efforts at keeping the tube and ventilating ACCURATELY.  Using a mechanical ventilator after the ET tube is placed provides the ability to set an accurate rate and tidal volume.  If one is not available, ETCO2, and O2 saturation should guide your ventilation rate and tidal volume.  

Place a cervical collar on the patient to limit their movement.  

Make note of the depth,

Monitor diligently. 

It isn't the end of the world if you lose the tube.  It may be the end of your career if you don't realize it.

Please see Post-Intubation Tracheal Stenosis for yet another consideration.



Intubation Education

Rogue Medic | 4:33 PM | , , | 3 comments





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.


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.[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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S.A.L.T. Device

Adam Thompson, EMT-P | 2:21 PM | , , , | 2 comments




Supraglottic Airway Laryngopharyngeal Tube



Link to product: S.A.L.T.


Some videos:







I have used the S.A.L.T. device once on a cardiac arrest patient. Initially it found it's way in the right mainstem bronchus; which we easily resolved. Others have told me that they have had problems with the securing device. Some have stated that they have had trouble avoiding esophageal placement. I am not certain if the S.A.L.T. device will replace the King LT as my choice for cardiac arrest victims, but it is an interesting product nonetheless. It may have it's place in primary respiratory arrest. I am still a fan of videolaryngoscopy at the moment, even if it is the most expensive option.



Post-Intubation Tracheal Stenosis

Adam Thompson, EMT-P | 8:34 PM | , , , , | 3 comments


Post-Intubation Tracheal Stenosis


There has been quite a bit of research done on post-intubation injuries caused by the pressure of the endotracheal tube cuff. This is something that has been addressed by a few EMS agencies. My agency implemented a protocol based on the research about two years ago:

Based on what size ET tube you use. If you use a 9.0 tube, inflate with 9cc of air, 8.0 tube with 8cc of air and so on and so forth. This is not full proof, but it does make you think about how much air you are inflating with instead of just pumping in the full 10cc every time.





Here is some of the research done recently:

Pubmed [1]
Cuff overinflation and endotracheal tube obstruction: case report and experimental study.
Abstract
BACKGROUND: Initiated by a clinical case of critical endotracheal tube (ETT) obstruction, we aimed to determine factors that potentially contribute to the development of endotracheal tube obstruction by its inflated cuff. Prehospital climate and storage conditions were simulated. METHODS: Five different disposable ETTs (6.0, 7.0, and 8.0 mm inner diameter) were exposed to ambient outside temperature for 13 months. In addition, every second of these tubes was mechanically stressed by clamping its cuffed end between the covers of a metal emergency case for 10 min. Then, all tubes were heated up to normal body temperature, placed within the cock of a syringe, followed by stepwise inflation of their cuffs to pressures of 3 kPa and > or =12 kPa, respectively. The inner lumen of the ETT was checked with the naked eye for any obstruction caused by the external cuff pressure. RESULTS: Neither in tubes that were exposed to ambient temperature (range: -12 degrees C to +44 degrees C) nor in those that were also clamped, visible obstruction by inflated cuffs was detected at any of the two cuff pressure levels. CONCLUSIONS: We could not demonstrate a critical obstruction of an ETT by its inflated cuff, neither when the cuff was over-inflated to a pressure of 12 kPa or higher, nor in ETTs that had been exposed to unfavorable storage conditions and significant mechanical stress.


Pubmed [2]
Endotracheal Tube Intracuff Pressure During Helicopter Transport.
Abstract
STUDY OBJECTIVE: We evaluate changes in endotracheal tube intracuff pressures among intubated patients during aeromedical transport. We determine whether intracuff pressures exceed 30 cm H(2)O during aeromedical transport. METHODS: During a 12-month period, a helicopter-based rescue team prospectively recorded intracuff pressures of mechanically ventilated patients before takeoff and as soon as the maximum flight level was reached. With a commercially available pressure manometer, intracuff pressure was adjusted to /=30 cm H(2)O, 72% had intracuff pressures >/=50 cm H(2)O, and 20% even had intracuff pressures >/=80 cm H(2)O. CONCLUSION: Endotracheal cuff pressure during transport frequently exceeded 30 cm H(2)O during aeromedical transport. Hospital and out-of-hospital practitioners should measure and adjust endotracheal cuff pressures before and during flight. Copyright © 2010 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.


Pubmed [3]
Endotracheal tube cuff pressures in patients intubated before transport.
Abstract
INTRODUCTION: Prolonged endotracheal tube cuff pressures (ETTCPs) greater than 30 cm H(2)O cause complications ranging from sore throat to rare cases of tracheoesophageal fistula. In a series of patients, we sought to determine the proportion of patients with overinflated cuffs and to determine whether overinflation was associated with demographics, diagnostic category, or intubator credentials. METHODS: Between July 2007 and April 2008, we measured cuff pressures on a convenience sample of patients drawn from 2 groups. The "helicopter group" had pressure measured before transport by a single aeromedical transport service. The "hospital group" had pressure measured upon arrival to 1 of 2 emergency departments after being intubated before transport. RESULTS: Three hundred patients aged 4 to 92 years (median, 57) were studied: 59.7% were male; and diagnostic categories were neurologic (33.7%), trauma (32.7%), cardiac (12.7%), and general medical/surgical (21.0%). Intubation occurred 1 to 28 000 minutes before ETTCP assessment (median, 60). Endotracheal tube cuff pressure was greater than 30 cm H(2)O in 64.7% and ranged from 10 to 180 (median, 40). Forty-nine percent of patients had ETTCP greater than 40 cm H(2)O. There was no association between ETTCP and age group, sex, diagnostic category, ETT size, time between intubation and ETTCP assessment, or intubator credentials. CONCLUSIONS: The most compelling results of the study are the high rates of elevated ETTCPs. Furthermore, there were no clear risk factors for elevated ETTCP. Although the risk of elevated ETTCP in the prehospital to acute care time frame is unclear, it seems reasonable to measure ETTCP after intubation in all patients.


Pubmed [4]
Intubation-induced tracheal stenosis -- the urgent need for permanent solution.
Abstract
The most common site for the occurrence of intubation-induced tracheal damage is at the area in contact with the inflatable cuff. After the change from high-pressure to low-pressure cuffs, major tracheal lesions still continue to occur. This is a case of tracheal stenosis that occurred after 7 days of intubation with standard cuffed tube whose cuff pressure was assessed by subjective means. Three weeks later, patient was in need of reintubation, the trachea was found to be stenotic at the site of the previous tube cuff. Emergency tracheostomy had to be performed and computed axial tomography (CT) confirmed the tracheal stenosis. A month later, the patient had another cardiac arrest from which he did not recover. Our message in this report is to throw light and alert clinicians involved in tracheal intubation, of the presence of the Lanz endotracheal tube whose pilot balloon is designed to automatically regulate the intra-cuff pressure and thus prevent the occurrence of tracheal stenosis due to high pressure. We strongly recommend the presence of Lanz tracheal tubes as standard emergency equipment in intensive care settings and in any situation in which cuff pressure is likely to increase.


EMSResponder.com - Link to related article.

Intubation as a Right - No Practice required

Rogue Medic | 2:40 PM | , , , , | 0 comments


I was responding to a comment at 9-ECHO-1, by 9-ECHO-1, when I realized I was beginning to combine my responses to How things get done... and Do we make a difference?

As if I don't already regularly get this little message from Blogger.

Your HTML cannot be accepted: Must be at most 4,096 characters


Your hints are wasted on me, Blogger!

9-ECHO-1 was writing about running a code and keeping it organized and low stress. Something about sitting back with his feet on an ottoman, a drink in his hand, receiving a massage, and . . . Well, he did say that he was sitting back with his feet up on an ottoman. And there is nothing wrong with that. An ottoman could easily be added to crash carts. :-)

9-ECHO-1's description of the role of the person in charge at a code is important. We may not want to put our feet up in front of family, but I don't believe 9-ECHO-1 would do that at a code where family is present. What is important is for the person in charge to communicate clearly to everyone that, This is not a high stress environment.

Stress is the enemy of organization. We have a lot to organize during codes. We have much more to organize, than we have good research to support including in a code, but that will change.

Either there will be some research that supports the Better Resuscitation Through Better Chemistry approach, or AHA/ILCOR will admit that pouring a bunch of cardiotoxic chemicals into a patient, then shaking - not stirring - the patient, is more appropriate for bartenders than for paramedics, nurses, PAs, NPs, doctors . . . .

Although many of us in EMS might appreciate the bump in pay to what a bartender makes.

I have been to some codes that have led me to believe that there is a role for benzodiazepines in the management of cardiac arrest. Not for the patient, but for the EMS personnel exhibiting signs of Tourette syndrome, who show up to treat the cardiac arrest patient. If not benzodiazepines, then this may be an indication for medical marijuana. There might be some problem with the rate and depth of compressions, but that might be less of a problem than the current model of Dr. Fine, Dr. Howard, and Dr. Fine run a code.



Isn't this supposed to be about intubation?

OK. Back on track, or as close as I an going to get.


9-ECHO-1 wrote -

Place the King airway. In our system EMT-Bs on the ambulance can do this. Attach the ETCO2 and verify the waveform. Me personally, I will admit, I prefer the ET tube. I know, I know, there is all sorts of evidence out there about paramedics and tubes. And they all point to two things- practice and experience. More on that later.



In the comments, I responded -

I agree with you about the intubation. I think that the biggest part of the problem is that the systems studied do not provide excellent oversight of the quality of intubation and BLS. Otherwise, are we supposed to believe that these problems suddenly appeared during the study? More likely that they were there, just unrecognized.

The word unrecognized does not belong in a sentence describing excellent oversight.



9-ECHO-1's response included -

I have read all of the studies about intubation and its 'failings'. What I have noticed is that we NEVER PRACTICE. I used to practice all of the time- get me some spare time and a manikin and I would go at it, even practicing with someone doing chest compressions. But we never do that any more. No damn wonder we can't hit the right hole, and then don't recognize when it comes out or we missed completely.



I completely agree about practice. I used to spend so much time with the mannequin, that if my classmates weren't starting rumors about me, they were missing a good opportunity.

I believe that simulations are a great way to avoid doing real harm to real patients. A lot of practice helps to keep the stress level down and the tunnel vision away.

My first live intubation was an asystolic little old lady. We were running lights and sirens to the hospital, because we didn't know any better. I was riding with a supervisor for orientation vs. see if the new guy can avoid screwing up. We made a rendez-vous with the ambulance, so that they could give the new guy a chance to demonstrate skills on a real live patient.

We still put too much emphasis on the wrong skills.

While the mannequin is not as realistic as we would like, the practice with the laryngoscope and the tube is invaluable, when it comes to manipulating the airway of a real patient. Very handy experience when bouncing down the road about to perform my first tube.

I think that some of my But we did that when we covered airway classmates may be over-represented in the intubation studies with poor success rates/high wrong hole rates.


If medical directors would take more of an interest in the airway management practices of those they authorize to use lethal airways, I might not feel the need to describe endotracheal tubes as lethal airways.

Yearly (even quarterly) observation of mannequin management is not at all oversight of airway management. This is just documentation of an excuse, so that when a medic does mangle airway management, the medical director has an alibi.

It used to be that some schools/employers required medic students/new medics to manage an OR patient's airway with a BVM before ever being allowed to touch an endotracheal tube. I do not believe in good old days. That is just selective memory. However, we have abandoned some useful practices.

Now it seems that being authorized to intubate means never having to touch a BVM again - even in some all medic systems.

That isn't airway management.

Also, less than 8 - intubate, is not a rule, just a handy way of teaching one small idea in the much larger concept of airway management. Critical judgment is much more important than cute little rhymes.

If we think that we should be permitted to intubate, we need to put in the effort to become competent at airway management. Then we need to put in the effort to maintain competence at airway management. And we need to put in the effort to demonstrate excellence at airway management. Intubation is a very small part of airway management.

This is not about any right of the paramedic to intubate. This is about not abusing our patients.


I didn't even get to comments on Do we make a difference? That will be another post.


The Airway Continuum is essential reading for anyone interested in intubation and airway management.

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Video Laryngoscopy

Adam Thompson, EMT-P | 9:10 PM | , , , | 4 comments



With the advanced airway debate comes a need for solutions. Obviously increased training and QI/QA are at the top of the list. Another option is the Glidescope. This device is just one of a few video laryngoscopy devices that has shown phenomenal results. They are an expensive option, but probably cheaper than malpractice payouts. There is a ton of research out there regarding these devices. I have seen them used in the ER with great success, and I believe our helicopter has acquired one. Check out the video at the bottom.

Keep in mind that I am not the biggest advocate of prehospital intubation. Not until we improve our success rates and recognition of dislodged tubes. I believe laryngeal tubes and BVMs are the safer alternative as of yet. With that in mind, endotracheal intubation is the best way to secure an airway when performed adequately.

Pubmed [1]
BACKGROUND AND OBJECTIVE: We investigated whether the use of two different video laryngoscopes [direct-coupled interface (DCI) video laryngoscope and GlideScope] may improve laryngoscopic view and intubation success compared with the conventional direct Macintosh laryngoscope (direct laryngoscopy) in patients with a predicted difficult airway. METHODS: One hundred and twenty adult patients undergoing elective minor surgery requiring general anaesthesia and endotracheal intubation presenting with at least one predictor for a difficult airway were enrolled after Institutional Review Board approval and written informed consent was obtained. Repeated laryngoscopy was performed using direct laryngoscope, DCI laryngoscope and GlideScope in a randomized sequence before patients were intubated. RESULTS: Both video laryngoscopes showed significantly better laryngoscopic view (according to Cormack and Lehane classification as modified by Yentis and Lee = C&L) than direct laryngoscope. Laryngoscopic view C&L >or= III was measured in 30% of patients when using direct laryngoscopy, and in only 11% when using the DCI laryngoscope (P <>or= III: 1.6%) than both direct (P <>or= III) could be achieved significantly more often with the GlideScope (94.4%) than with the DCI laryngoscope (63.8%) Laryngoscopy time did not differ between instruments [median (range): direct laryngoscope, 13 (5-33) s; DCI laryngoscope, 14 (6-40) s; GlideScope, 13 (5-34) s]. In contrast, tracheal intubation needed significantly more time with both video laryngoscopes [DCI laryngoscope, 27 (17-94) s, and GlideScope, 33 (18-68) s, P less than 0.01] than with the direct laryngoscope [22.5 (12-49) s]. Intubation failed in four cases (10%) using the direct laryngoscope and in one case (2.5%) each using the DCI laryngoscope and the GlideScope. CONCLUSION: We conclude that the video laryngoscope and GlideScope in particular may be useful instruments in the management of the predicted difficult airway.



Airway Research

Adam Thompson, EMT-P | 7:01 AM | , , , | 6 comments





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.

Below is just an interesting study I fell upon. It is important to consider this stuff, because if we don't, we will just continue doing the same old thing; whether it is better or not.

[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.

Prehospital Intubations and Mortality - comment from RevMedic

Rogue Medic | 8:15 PM | , , , | 4 comments





RevMedic is not a name that signifies driving very fast - revving the engine - but that is what pops into my head every time I see his name. I know. I am by-passing St. Peter. I am not collecting 72 virgins. I am going straight to the great big tanning bed. This is not news.

RevMedic does all sorts of photography in the Newberg, Oregon area. If you need a photographer with some common sense, he seems like the guy to call.

Anyway RevMedic knows his stuff. Here is his comment on the post Prehospital Intubations and Mortality - comment from Herbie.


"I would much rather see medics using a BVM during their OR time, than intubating. Good BVM use is far more important than intubation skill."

Absolutely. I can't tell you how many times I've seen ineffectual ventilations with a BVM. There sits the EMT (at any level), blissfully unaware of the air blasting out from underneath the mask and not paying attention to the lack of a seal.



How is it that we graduate EMTs and medics, who are not skilled at airway management?

How is it that we graduate EMTs and medics, who do not understand airway management?

It isn't as if the courses suggest that there is a skill that comes before airway.

Excellent BVM use is all about assessment.

BVM excellence is the cornerstone of airway management.

Without excellence in the use of the BVM, the rest of airway management does not matter.

I prefer to do some of the bagging with patients who need ventilation. It is a skill that needs to be used, to be maintained. This also sets a good example for everyone else. This demonstrates to everyone else that, at least as far as I am concerned, skill with a BVM is a priority.

We also will find that some of the patients do not need to be intubated. Intubation should not be for the benefit of the medics. Intubation should be for the benefit of the patients.


There was another event where I was bagging the patient in preparation for intubation. I was having trouble getting an adequate seal, and asked for another set of hands. We had 4 PARAMEDICS in the rig, and the other three were solely concerned with getting the intubation equipment set up, preparing the drugs, etc. I had to repeat myself several times and finally loudly call one by name and DEMAND his/her assistance, before we achieved adequate ventilations.



One of the best uses for a separate pulse oximeter is to throw the machine at someone, when you need there attention. It can be very effective. It also demonstrates how little importance should be attached to the machine. It is just a tool, a slow tool, that should not be warning you that something happened, but should confirm what you already know from your continuous assessments.

One of the problems with these studies of systems that have horrible intubation success rates, is that their BVM use is probably just as bad. How much of the bad outcome is due to BVM incompetence, rather than the inability to put a tube in the right hole?

If we make the patient hypoxic enough in our focus on the intubation, does it matter if we are successful with the intubation?

No, it does not.

If we allow the patient to vomit and aspirate in our focus on the intubation, does it matter if we are successful with the intubation?

No, it does not.

RevMedic finishes up with:


BVM is the lost art of airway control.



There is only one appropriate response to that:

Amen.

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Prehospital Intubations and Mortality - comment from 30 ff/pm

Rogue Medic | 12:54 PM | , , , | 1 comments





In the comments to Prehospital Intubations and Mortality: A Level 1 Trauma Center Perspective I, 30 ff/pm wrote:


Like most studies done by someone who wants their name in a publication, this one is throws out some numbers as if they mean something.

To compare 4 diff. types of airway management and give the impression that there is a "relation with mortality" without giving at least a head nod to the INJURY is asinine.



I do not know what the motivations of the researchers[1] was, but it is good that they are publishing the results of their study, even though it makes them look really bad.

I would rather have them publicly face their problem, than cover it up and ignore it.

The type of injury should not matter. With a large enough sample size, there should be a wide enough variation in injuries, that the result falls into the category of normal distribution. A few really tough tubes should not make a big difference in this sample size.

The question is, Do they recognize what the problem is?

Sadly, I think we agree that the medical directors probably do not recognize that this is a problem of oversight, not so much a problem of bad medics. The medics were probably just doing what they were trained to do.


If they did 2 successful crics, what did they use for a tube? A Bic pen? If they used an ETT that pt IS TUBED, just not orally. That is NOT a failed intubation.



I will agree that this is successful airway management, if the crichothyrotomy truly was necessary. 1% is on the high side for crichothyrotomy rate, but this is such a small sample size that the numbers are well within the expected normal distribution of crichothyrotomies.

The term should be not a successful orotracheal intubation. You are correct, but it is not an important problem in my opinion. Their lack of understanding of airway management is a much greater problem.


Where we part ways in thought is your hairspltting "control" issues.

We never have control of the airway. Even a properly placed endotracheal tube does not mean control. Control suggests that something does what you want it to do.

We manage airways, i.e., we control them.

The airway may not do exactly what I want it to do - that's why I have a laryngoscope in my hand in the 1st place - but with a tube in place it sure as hell is easier to manage than without it and that is control as far as airways go.



with a tube in place it sure as hell is easier to manage than without it and that is control as far as airways go.

For the 12% of these patients with unrecognized esophageal intubations, the airway was not managed.

How is that control?


Control suggests something that has been accomplished, something that can be considered completed, something that can be checked off. This subconscious, or even conscious, approach to airway management is part of the problem. If you are managing the airway you are constantly reassessing it and looking to maintain oxygenation and, much more importantly, ventilation. Airway management is never a task that has been completed. Airway management is a process that requires perpetual vigilance. Control suggests just the opposite.

This is like the approach to success. Success is a way of doing things, not an easily definable goal. The goal is continually changing as one is presented with different complications.

If we look at intubation as control, once the tube is in, if we saw what we think was the tube going through the cords, how aggressive are we in looking for evidence that we were wrong?

There is one thing that is pretty consistent with unrecognized esophageal intubations. The medic/nurse/doctor thought the tube was in the trachea. They thought the airway was controlled.

They had stopped looking for evidence that the tube was in the wrong place.

They had become complacent with their assumed control.


What I want to know is how the hell did 8 friggin' people live with a tubed gut??

Those had to be tubes that got dislodged at the ED door or bedside moving the pt.



How the hell did 8 friggin' people live with a tubed gut??

They were probably breathing adequately on their own around the misplaced tube. Where is the evidence that all of these patients needed to be intubated? That all of these patients needed to have their airways controlled?

Where is the evidence that the tube suddenly migrated to the esophagus at the ED?

I am under the impression that endotracheal tubes are not any more migratory than coconuts. Besides, good airway management (unlike airway control) involves continual assessment of tube placement. Unrecognized esophageal endotracheal tubes should not happen with good airway management.

These GI medics were only controlling access to the esophagus, and probably not even doing that well. It isn't as if they were aware of what was going on with the airway. Control implies that there is no longer a need to remain aware of what is going on.

They certainly were not demonstrating any awareness of what was going on with the airway.

No. I believe these are the same as other groups of patients, who survived in spite of being esophageally intubated. They were spontaneously breathing. They were breathing around the tube. It isn't as if the tube was blocking the trachea, since it was not in the trachea even a little bit. They were overcoming some of the medics' best efforts to kill them.

With this group of medics, there is no reason to give them the benefit of the doubt about tube placement. They should have had waveform capnography, but even without waveform capnography there should be a much lower unrecognized esophageal intubation rate


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.[2]



12% vs. 0.3%.


Six (0.36%) unrecognized esophageal intubations were discovered in the emergency department or at autopsy. Only one (0.06%) of these occurred since the addition of capnography and a tube aspiration device in 1990. In this patient, a zero reading on the capnograph was ignored and not verified by a tube aspiration device or by removing the tube and re-intubating the patient.



That is the kind of problem that continues to exist even in places that use waveform capnography - and there is no acceptable excuse for not using waveform capnography.

The problem is that the tube is in the mouth. The medic/nurse/doctor thinks the tube is in the right place, for whatever reason, then the medic/nurse/doctor ignores all evidence to the contrary.

Maybe the tube was in originally, but came out en route. We have no way of knowing because the medics have no way of showing evidence of where the tube was. If we have a series of printouts of a good waveforms, we know that the tube was either in the trachea or above the cords, but resting with the tip of the tube in the top of the trachea. Without waveform capnography, we have the medic's word vs. the word of the unrecognized esophageal tube.

Is the medic telling a lie, or is the tube telling a lie?

We are very good at deceiving ourselves about what we want to believe. That is why we need to continually be looking for evidence that the tube is in the wrong place. That is why we should avoid using words that lead to airway complacency. that is why we should avoid using the word control. We should also avoid this fixation with, I saw the tube go through the cords. that is more self-deception. The only justification for it is to satisfy people who are incompetent at teaching and incompetent at assessment.


Footnotes:


^ 1 Prehospital intubations and mortality: a level 1 trauma center perspective.
Cobas MA, De la Peña MA, Manning R, Candiotti K, Varon AJ.
Anesth Analg. 2009 Aug;109(2):489-93.
PMID: 19608824 [PubMed - indexed for MEDLINE]

PubMed states that the full text article is free at the journal site, but it is not. This seems to have been posted on all of the Anesthesia & Analgesia abstracts at PubMed.


^ 2 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]




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Prehospital Intubations and Mortality - A Level 1 Trauma Center Perspective II

Rogue Medic | 9:26 PM | , , , | 3 comments





A new study of EMS intubation appears to show that prehospital intubation is a bad thing.

I do not agree. I wrote about this earlier in Part I.

Let me point out some more of the ways that I think this study demonstrates that the problems, and there are big problems, are with the medical oversight, more than with the paramedics.


During the study period, trauma patients were initially treated in the prehospital setting by fire rescue personnel of various municipalities and with different experience levels; typically, the fire rescue personnel trained as paramedics perform an average of 1–3 tracheal intubations per year and must undergo periodic assessments of their training and ability in airway management and intubation skills.[1]



That's an average of 1 - 3 tubes per year.

Not per month.

Not per quarter.

Per year. An average of 1 - 3 tubes.

Does anybody want to guess what the reason is?

Miami is not a low population are. Miami, Florida is not the location of the Fountain of Youth, although Ponce de León did wander around Florida looking for it. There is no reason to believe that intubation happens at a different rate in Miami, as opposed to Boston, Massachusetts or Bellingham and Whatcom Counties, Washington. Let's compare the number of intubations from the much larger study I cited before.[2] Over 20 years they intubated 94% of 1,045 trauma patients. An excellent record of consistent quality. In Miami, they intubated 68% of 203 trauma patients over about 3 years.

Miami has 203 trauma patients with attempted intubation arriving at this one trauma center over just less than 3 years. 203/3 = 68 trauma intubation attempts per year.

In Washington, they had 1,045 trauma intubation attempts over 20 years. 1,045/20 = 52 trauma intubation attempts per year. In Miami, they are averaging 1 to 3 intubation attempts per medic per year. In Washington, they have requirements for far more intubations per medic.

In Miami, 12% unrecognized esophageal intubations. In Washington, only one unrecognized esophageal intubation from the time they started using waveform capnography to the end of the study. A much longer period than the entire Miami study period.


This training includes didactic education in endotracheal intubation, alternative airway techniques, and skill simulation. Extensive education is provided in the pharmacology, indications, contraindications, and complications of the paralytic agent used, succinylcholine. 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.[2]



In Washington, they have fewer intubation attempts. They should have less experience at intubation. However, in Washington, the number of intubation attempts is divided by a much smaller number of medics.

In Miami, they have the EMS equivalent of clown cars full of medics showing up for just one patient.

Why do they need so many medics?

They don't. This is just politics. They do not understand that beyond a certain point, more medics just results in a dilution of skill. This is the More is Better mantra.

In Miami, they seem to have gone way past that point.

And they kept on going. Look at the way they approach airway management, then compare it to what I quoted from the Washington study. The difference is dramatic.

For Miami medics, all they say is: and must undergo periodic assessments of their training and ability in airway management and intubation skills.

Hasn't that been a success beyond their wildest dreams.

Success?

It worked. The blame is falling on the medics, not on the medical directors who designed this abattoir. Not that the medics are blameless, but where is the medical direction?

What do they do to keep the tubes-per-medic-per-year so ridiculously low?

They keep the number of medics unreasonably high.


Emergency medicine residents, for example, are required to perform between 35–200 ETIs prior to graduation.

Research has demonstrated that paramedic students require at least 15–20 intubations to attain basic skills proficiency. The National Standard Curriculum for Emergency Medical Technician—Paramedic requires only five intubations prior to graduation.[3]


The American Heart Association recommends that ALS providers perform a minimum of six–12 intubations a year to remain credentialed in the procedure. EMS systems that have reported a high ETI success rate require a minimum of 15 ETIs per provider per year for credentialing. Only extremely busy EMS systems could ever achieve this level of practice.[3]



Miami is an extremely busy EMS system.

Why do they feel the need to minimize the experience level of the medics?

The medical directors in Miami don't seem to begin to understand what they are doing.

12% unrecognized esophageal intubations pretty much screams incompetence.


Six (0.36%) unrecognized esophageal intubations were discovered in the emergency department or a autopsy. Only one (0.06%) of these occurred since the addition of capnography and a tube aspiration device in 1990. In this patient, a zero reading on the capnograph was ignored and not verified by a tube aspiration device or by removing the tube and re-intubating the patient.[2]



This appears to be beyond their capabilities of Miami. They have been doing an excellent job in Washington, but Miami has been happy to ignore the problem. Maybe the results of this study will cause them to change, but how could they have been this blind until now?


Footnotes:


^ 1 Prehospital intubations and mortality: a level 1 trauma center perspective.
Cobas MA, De la Peña MA, Manning R, Candiotti K, Varon AJ.
Anesth Analg. 2009 Aug;109(2):489-93.
PMID: 19608824 [PubMed - indexed for MEDLINE]

PubMed states that the full text article is free at the journal site, but it is not.


^ 2 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]

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.



^ 3 The Disappearing Endotracheal Tube - Historic skill threatened by lack of pratice and new devices
by Bryan E. Bledsoe, DO, FACEP, EMT-P and William E. Gandy, JD, LP, NREMT-P
March 2009 JEMS Vol. 34 No. 3
Article


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