Andreas Grabinsky

The Process of Prehospital Airway Management: Challenges and Solutions During Paramedic Endotracheal Intubation

Objectives:Endotracheal intubation success rates in the prehospital setting are variable. Our objective was to describe the challenges encountered and corrective actions taken during the process of endotracheal intubation by paramedics. Design:Analysis of prehospital airway management using a prospective registry that was linked to an emergency medical services administrative database. Setting:Emergency medical services system serving King County, Washington, 2006–2011. Paramedics in this system have the capability to administer neuromuscular blocking agents to facilitate intubation (i.e., rapid sequence intubation). Patients:A total of 7,523 patients more than 12 years old in whom paramedics attempted prehospital endotracheal intubation. Interventions:None. Measurements and Main Results:An intubation attempt was defined as the introduction of the laryngoscope into the patient’s mouth, and the attempt concluded when the laryngoscope was removed from the mouth. Endotracheal intubation was successful on the first attempt in 77% and ultimately successful in 99% of patients (7,433 of 7,523). Paramedics used a rapid sequence intubation strategy on 54% of first attempts. Among the subset with a failed first attempt (n = 1,715), bodily fluids obstructing the laryngeal view (50%), obesity (28%), patient positioning (17%), and facial or spinal trauma (6%) were identified as challenges to intubation. A variety of adjustments were made to achieve intubation success, including upper airway suctioning (used in 43% of attempts resulting in success), patient repositioning (38%), rescue bougie use (19%), operator change (16%), and rescue rapid sequence intubation (6%). Surgical cricothyrotomy (0.4%, n = 27) and bag-valve-mask ventilation (0.8%, n = 60) were rarely performed by paramedics as final rescue airway strategies. Conclusions:Airway management in the prehospital setting has substantial challenges. Success can require a collection of adjustments that involve equipment, personnel, and medication often in a simultaneous fashion.

Occurrence and complications of tracheal reintubation in critically ill adults.

BACKGROUND: Timing and preparation for tracheal extubation are as critical as the initial intubation. There are limited data on specific strategies for a planned extubation. The extent to which the difficult airway at reintubation contributes to patient morbidity is unknown. The aim of the present study was to describe the occurrence and complications of failed extubation and associated risk factors, and to estimate the mortality and morbidity associated with reintubation attempts. METHODS: Cohort study of 2,007 critically ill adult patients admitted to the ICU with an ETT. Patients were classified in 2 groups, based on the requirement for reintubation: “never reintubated” versus “≥ 1 reintubations.” Baseline characteristics, ICU and hospital stay, hospital mortality, and in-patient costs were compared between patients successfully extubated and those with reintubation outside the operating room, using regression techniques. Reasons, airway management techniques, and complications of intubation and reintubation were summarized descriptively. RESULTS: 376 patients (19%) required reintubation, and 230 (11%) were reintubated within 48 hours, primarily due to respiratory failure. Patients requiring reintubation were older, more likely to be male, and had higher admission severity score. Difficult intubation and complications were similar for initial and subsequent intubation. Reintubation was associated with a 5-fold increase in the relative odds of death (adjusted odds ratio 5.86, 95% CI 3.87–8.89, P < .01), and a 2-fold increase in median ICU and hospital stay, and institutional costs. Difficult airway at reintubation was associated with higher mortality (adjusted odds ratio 2.23, 95% CI 1.01–4.93, P = .05). CONCLUSIONS: Nearly 20% of critically ill patients required out of operating room reintubation. Reintubation was associated with higher mortality, stay, and cost. Moreover, a difficult airway at reintubation was associated with higher mortality.

Regional Anesthesia in Trauma Medicine

Regional anesthesia is an established method to provide analgesia for patients in the operating room and during the postoperative phase. While regional anesthesia offers unique advantages, as shown by the recent military experience, it is not commonly utilized in the prehospital or emergency department setting. Most often, regional anesthesia techniques for traumatized patients are first utilized in the operating room for procedural anesthesia or for postoperative pain control. While infiltration or single nerve block procedures are often used by surgeons or emergency medicine physicians in the preoperative phase, more advanced techniques such as plexus block procedures or regional catheter placements are more commonly performed by anesthesiologists for surgery or postoperative pain control. These regional techniques offer advantages over intravenous anesthesia, not just in the perioperative phase but also in the acute phase of traumatized patients and during the initial transport of injured patients. Anesthesiologists have extensive experience with regional techniques and are able to introduce regional anesthesia into settings outside the operating room and in the early treatment phases of trauma patients.

Pediatric Intubation by Paramedics in a Large Emergency Medical Services System: Process, Challenges, and Outcomes

STUDY OBJECTIVE Pediatric intubation is a core paramedic skill in some emergency medical services (EMS) systems. The literature lacks a detailed examination of the challenges and subsequent adjustments made by paramedics when intubating children in the out-of-hospital setting. We undertake a descriptive evaluation of the process of out-of-hospital pediatric intubation, focusing on challenges, adjustments, and outcomes. METHODS We performed a retrospective analysis of EMS responses between 2006 and 2012 that involved attempted intubation of children younger than 13 years by paramedics in a large, metropolitan EMS system. We calculated the incidence rate of attempted pediatric intubation with EMS and county census data. To summarize the intubation process, we linked a detailed out-of-hospital airway registry with clinical records from EMS, hospital, or autopsy encounters for each child. The main outcome measures were procedural challenges, procedural success, complications, and patient disposition. RESULTS Paramedics attempted intubation in 299 cases during 6.3 years, with an incidence of 1 pediatric intubation per 2,198 EMS responses. Less than half of intubations (44%) were for patients in cardiac arrest. Two thirds of patients were intubated on the first attempt (66%), and overall success was 97%. The most prevalent challenge was body fluids obscuring the laryngeal view (33%). After a failed first intubation attempt, corrective actions taken by paramedics included changing equipment (33%), suctioning (32%), and repositioning the patient (27%). Six patients (2%) experienced peri-intubation cardiac arrest and 1 patient had an iatrogenic tracheal injury. No esophageal intubations were observed. Of patients transported to the hospital, 86% were admitted to intensive care and hospital mortality was 27%. CONCLUSION Pediatric intubation by paramedics was performed infrequently in this EMS system. Although overall intubation success was high, a detailed evaluation of the process of intubation revealed specific challenges and adjustments that can be anticipated by paramedics to improve first-pass success, potentially reduce complications, and ultimately improve clinical outcomes.

A National Survey of Airway Management Training in United States Internal Medicine-Based Critical Care Fellowship Programs

BACKGROUND: Intensivists may be primarily responsible for airway management in non-operating room locations. Little is known of airway management training provided during fellowship. Our primary aim was to describe the current state of airway education in internal medicine-based critical care fellowship programs. METHODS: Between February 1 and April 30, 2011, program directors of all 3-year combined pulmonary/critical care and 2-year multidisciplinary critical care medicine programs in the United States were invited to complete an online survey. Contact information was obtained via FRIEDA Online (https://freida.ama-assn.org). Non-responders were sent automated reminders, were contacted by e-mail, or by telephone. RESULTS: The overall response proportion was 66% (111/168 programs). Sixty-four (58%) programs reported a designated airway rotation, chiefly occurring for 1 month during the first year of training. Thirty-five programs (32%) reported having a director of airway education and 78 (70%) reported incorporating simulation-based airway education. Nearly all programs (95%) reported provision of supervised airway experience during fellowship. Commonly used airway management devices, including video laryngoscopes, intubating stylets, supraglottic airway devices, and fiberoptic bronchoscopes, were reportedly available to trainees. However, 73% reported ≤ 10 uses of a supraglottic airway device, 60% ≤ 25 uses of intubating stylets, 73% ≤ 30 uses of a video laryngoscope, and 65% reported ≤ 10 flexible fiberoptic intubations. Estimates of the required number of procedures to ensure competence varied widely. CONCLUSIONS: The majority of programs have a formal airway management program incorporating a variety of intubation techniques. Overall experience varies widely, however.

Clinical and functional outcomes of acute lower extremity compartment syndrome at a Major Trauma Hospital

Background: Acute lower extremity compartment syndrome (CS) is a condition that untreated causes irreversible nerve and muscle ischemia. Treatment by decompression fasciotomy without delay prevents permanent disability. The use of intracompartmental pressure (iCP) measurement in uncertain situations aids in diagnosis of severe leg pain. As an infrequent complication of lower extremity trauma, consequences of CS include chronic pain, nerve injury, and contractures. The purpose of this study was to observe the clinical and functional outcomes for patients with lower extremity CS after fasciotomy. Methods: Retrospective chart analysis for patients with a discharge diagnosis of CS was performed. Physical demographics, employment status, activity at time of injury, injury severity score, fracture types, pain scores, hours to fasciotomy, iCP, serum creatine kinase levels, wound treatment regimen, length of hospital stay, and discharge facility were collected. Lower extremity neurologic examination, pain scores, orthopedic complications, and employment status at 30 days and 12 months after discharge were noted. Results: One hundred twenty-four patients were enrolled in this study. One hundred and eight patients were assessed at 12 months. Eighty-one percent were male. Motorized vehicles caused 51% of injuries in males. Forty-one percent of injuries were tibia fractures. Acute kidney injury occurred in 2.4%. Mean peak serum creatine kinase levels were 58,600 units/ml. Gauze dressing was used in 78.9% of nonfracture patients and negative pressure wound vacuum therapy in 78.2% of fracture patients. About 21.6% of patients with CS had prior surgery. Nearly 12.9% of patients required leg amputation. Around 81.8% of amputees were male. Sixty-seven percent of amputees had associated vascular injuries. Foot numbness occurred in 20.5% of patients and drop foot palsy in 18.2%. Osteomyelitis developed in 10.2% of patients and fracture nonunion in 6.8%. About 14.7% of patients underwent further orthopedic surgery. At long-term follow-up, 10.2% of patients reported moderate lower extremity pain and 69.2% had returned to work. Conclusion: Escalation in leg pain and changes in sensation are the cardinal signs for CS rather than reliance on assessing for firm compartments and pressures. The severity of nerve injury worsens with the delay in performing fasciotomy. Standardized diagnostic protocols and wound treatment strategies will result in improved outcomes from this complication.

Trauma epidemiology, mechanisms of injury, and prehospital care

Trauma epidemiology Trauma is defined as physical damage to the body as a result of mechanical, chemical, thermal, electrical, or other energy that exceeds the tolerance of the body. Although trauma is often thought of as a series of unavoidable accidents, in reality it is a disease with known risk factors. Like other diseases such as cancer and heart disease, trauma risk factors are modifiable and injuries can be avoided before their occurrence. There are three phases of injury: 1. Pre-injury 2. Injury 3. Post-injury

Trauma care today, what's new?

Injury is the fourth leading cause of death in the US, and the leading cause of death in younger age. Trauma is primarily a disease of the young and accounts for more years of productive life lost than any other illness. Consequently, almost every health care provider encounters trauma patients from time to time. Many of these patients are critically ill and pose several challenges in the acute phase, including airway and ventilation, fluid management, intracranial pressure control, etc. In the last decade, several strategies and treatment options have been studied in trauma care along with improvement in technologies. In this review, we will discuss a few of the new developments and updates in trauma care.

Two Cases of Lower Extremity Compartment Syndrome after Posterior Urethroplasty

Lower extremity compartment syndrome (CS) is characterized by severe pain resulting from increased interstitial pressure within the closed compartments of the calf musculature that impairs local circulation and left untreated results in irreversible peripheral nerve and muscle ischemia [1]. CS can occur in other anatomic regions including the arm, hand, foot, and gluteal area. Although an infrequent complication of severe tissue trauma including fracture and crush injury, it has been associated with minor injuries, and uncommon iatrogenic causes have been identified [2]. Acute CS is a surgical emergency treated by decompressive fasciotomy (DF) without delay to prevent permanent disability, amputation and death [3]. The diagnosis of acute CS is based on careful clinical examination. Intra-compartmental pressure (iCP) measurement, and monitoring if indicated, is a recommended clinical practice in equivocal situations [4]. Values of iCP greater than 30 mm Hg above diastolic blood pressure are an absolute indication for emergent DF [4]. Lower leg CS following orthopedic and urologic operative procedures that place patients in the lithotomy position is an infrequent occurrence [5-7]. This report summarizes perioperative events and long term outcomes for acute CS following urethroplasty. A review of emerging diagnostic, interventional and prognostic strategies aimed at improving patient care following this complication is included.

Reply to Letter: Re: Use of rapid sequence intubation predicts improved survival among patients intubated after out-of-hospital cardiac arrest

We thank Drennan et al.1 for their interest. Regarding airway raining and experience in the EMS system under study, there ay be less variability between paramedics and agencies than rennan et al. assume. All paramedics complete advanced airway raining that includes didactics, high-fidelity simulation, intubating xperience in the operating room and substantial opportunity for ntubating critically ill patients in the prehospital setting.2,3 They omplete at least forty-five intubations during the initial training eriod, and, thereafter, paramedics perform an average of fifteen ntubations annually in the field. Paramedics also participate in ontinuous quality improvement activities, including recording all irway management attempts into an electronic database.4 We agree that observational studies of advanced airway mangement following cardiac arrest, including ours, are vulnerable to onfounding by indication. A primary reason is that neurological tatus at the time of EMS arrival is closely related to both advanced irway management, i.e., the decision to intubate, and prognois. This decision occurs differently in systems with and without apid sequence intubation capability and may explain the associaions between intubation status and survival observed in different tudies. In our study, patients who were intubated without paraytic medications had much worse survival that either those who equired rapid sequence intubation or who were not intubated at ll. We suspect that the poor prognosis of the first group (intubation ithout paralytics) was related to diminished brainstem function nd airway reflexes, secondary to more protracted and severe brain schemia, at the time of EMS arrival. In studies that occurred in EMS ystems without rapid sequence intubation capability, patients ho were intubated (again, without paralytics) might similarly