Christopher S. Russi

A Comparison of the King-LT to Endotracheal Intubation andCombitube in a Simulated Difficult Airway

Background. Prehospital endotracheal intubation (ETI) is a complex skill to maintain proficiency. Several airway adjuncts are available for prehospital providers. A recent alternative is the King Laryngeal Tube (LT) approved for use by the FDA in 2003. The aim of this study was to determine if the King-LT offers improved placement success andtimes over the Combitube (ETC) andendotracheal tube (ETT) in a simulated difficult airway. Methods. Sixty-nine prehospital providers (EMT-Bs andEMT-Ps) were timed in a series of trauma scenarios involving the placement of an ETT, ETC, andLT in a difficult airway simulator. Primary outcome measures were placement time (seconds) andsuccess for each device. Successful placement in the manikin was defined by adequate placement depth, inflation of device cuffs, the presence of breath sounds, andthe absence of epigastric sounds. Results. EMT-P mean placement times were 91.3 seconds (76.6–106.0) for ETT, 53.7 seconds (48.3–59.1) for ETC, and27.0 seconds (24.3–29.7) for LT. EMT-B mean placement times were 46.4 seconds (37.5–55.3) for ETC and22.5 seconds (19.0–26.0) for LT. Subgroup analysis was completed andcompared in groups that either checked or did not check device balloons prior to insertion. EMT-Ps successfully placed an ETT in 68.9% (31/45) of attempts. EMT-P success for ETC andLT scenarios were 82.2% (37/45) and100% (45/45). EMT-B success in the ETC was 87.5% (21/24) and100% (24/24) with the LT. Differences in successful placement between all devices were significant for paramedics only. A survey was provided following the scenarios to assess comfort andease of each device; 17/45 EMT-P participants noted the ETT to be “difficult” to place versus 38/45 reporting the King-LT to be “easy” or “very easy.” Conclusions. The King-LT is a relatively new airway device with time andsuccessful placement advantages over ETT andETC.

Comparison of prehospital insertion success rates and time to insertion between standard endotracheal intubation and a supraglottic airway

OBJECTIVE To compare paramedic insertion success rates and time to insertion between standard ETI and a supraglottc airway device (King LTS-D™) in patients needing advanced airway management. METHODS Between June 2008 and June 2009, consented paramedics from 4 EMS systems performed ETI or placed a King LTS-D according to a predetermined randomization calendar. Data collection occurred following each placement via telephone. Placement success (ability to ventilate to chest rise, absence of gastric sounds, presence of bilateral lung sounds, and when applicable, quantitative end-tidal CO(2) reading) was compared between treatment groups. Time to ventilation (time from airway device in hand ready to place to time of first successful ventilation) was also compared. RESULTS A total of 213 patients in need of advanced airway management were treated during the study period, with 9 patients excluded from the analysis. The remaining 204 placements by 110 of the 272 consented paramedics were analyzed (median placements per paramedic=1; range=1-7). The overall placement success rate was virtually equal across the two groups (ETI=80.2%, King LTS-D=80.5%; p=0.97). The median time to placement between ETI and the King LTS-D was also not significantly different (ETI=19.5s vs. King LTS-D=20.0s; z=-0.25; p=0.80). CONCLUSION In this study, no differences in placement success rate or time to insertion were detected between the King LTS-D and ETI.

Population-Based Study of Severe Hypoglycemia Requiring Emergency Medical Service Assistance Reveals Unique Findings

Objective: The objective is to report a contemporary population-based estimate of hypoglycemia requiring emergency medical services (EMS), its burden on medical resources, and its associated mortality in patients with or without diabetes mellitus (DM, non-DM), which will enable development of prospective strategies that will capture hypoglycemia promptly and provide an integrated approach for prevention of such episodes. Methods: We retrieved all ambulance calls activated for hypoglycemia in Olmsted County, Minnesota, between January 1, 2003 and December 31, 2009. Results: A total of 1473 calls were made by 914 people (DM 8%, non-DM 16%, unknown DM status 3%). Mean age was 60 ± 16 years with 49% being female. A higher percentage of calls were made by DM patients (87%) with proportionally fewer calls coming from non-DM patients (11%) (chi-square test, p < .001), and the remaining 2% calls by people with unknown DM status. Emergency room transportation and hospitalization were significantly higher in non-DM patients compared to DM patients (p < .001) and type 2 diabetes mellitus compared to type 1 diabetes mellitus (p < .001). Sulphonylureas alone or in combination with insulin varied during the study period (p = .01). The change in incidence of EMS for hypoglycemia was tracked during this period. However, causality has not been established. Death occurred in 240 people, 1.2 (interquartile range 0.2–2.7) years after their first event. After adjusting for age, mortality was higher in non-DM patients compared with DM patients (p < .001) but was not different between the two types of DM. Conclusions: The population burden of EMS requiring hypoglycemia is high in both DM and non-DM patients, and imposes significant burden on medical resources. It is associated with long-term mortality.

A pilot study of the King LT supralaryngeal airway use in a rural Iowa EMS system

IntroductionIn 2003, the King Laryngeal Tube (LT) received FDA approval for US sales. Prehospital systems in urban setting have begun evaluating and adopting the LT for clinical airway management. However, it is not routinely approved by State EMS Boards for use by all prehospital providers. Given the LT’s simple design there may be benefit to using this tool for airway management in all levels of prehospital providers. This pilot study reviews cases where the King LT was used in a rural Iowa county EMS system.MethodsIn 2006, the Iowa Department of Public Health / Bureau of EMS approved a 12 month pilot evaluating the King LT by all levels of EMS providers in a rural county EMS system. Following a didactic and competency training session on using the King LT, the providers were instructed to continue airway management per usual protocol but were allowed to use the King LT as a first line airway tool if they felt indicated. Successful placement of airway devices used were determined by colourimetric end-tidal CO2, chest auscultation and rise as well as vital sign and skin colour improvement. Review of the data was approved by the University of Iowa Institution Review Board (IRB).ResultsDuring the 12-month pilot period, the King LT was used in 13 patients with a mean age of 60.7 years (24–81). All patients had cardiopulmonary or traumatic arrest. The King LT was successfully placed on the first attempt in all but one case. The King LT was placed following endotracheal intubation failure in 6/13 (46.1%) cases and in 3/13 (23.1%) of cases of Combitube attempt / failure.ConclusionsThis small pilot project emphasizes the need for additional rapid airway management tools given the demonstrated ETI failures. The authors believe the King LT has significant potential to impact prehospital airway management as a primary airway device or backup to other failed strategies. Further study is necessary to evaluate the LT’s efficacy compared to current strategies.

Prehospital peripheral intravenous vascular access success rates in children.

Abstract Objective. Achieving successful peripheral intravenous (PIV) vascular access in children can be difficult. In the prehospital setting, opportunities are rare. Obtaining access becomes vital in emergent and life-threating conditions, such as seizures, hypoglycemia, and cardiac arrest. This study examines prehospital pediatric PIV attempts, success rates, and the impact of patient age. Methods. This was a retrospective chart review of patients aged 18 years or younger receiving prehospital PIV attempts from January 1, 2003, through May 31, 2011. Included cases were identified by querying electronic patient care reports for PIV attempts within the specified age range. The documentation of PIV attempts and successes was reported by emergency medical service providers. This study was approved by an institutional review board. Results. Throughout the 101-month study period, there were 261,008 ambulance responses. PIV attempts were made in 4188 patients aged 18 years or younger. PIV placement was successful in 3699 patients (88.3%) and failed in 489 (11.7%). Age was significantly associated with success. Each 1-year increase in age was associated with an 11% increase in odds of PIV success (odds ratio, 1.11; 95% CI, 1.09–1.12; p < 0.001). Success was lowest in patients younger than 2 years old, with an overall success rate of 64.1% (141/220). Accounting for multiple attempts, success was achieved in 53.0% of attempts (141/266). Conclusions. Prehospital PIV attempts are uncommon (2% of emergent responses). Success rates are significantly associated with patient age in the pediatric population and lowest in those aged 2 years or less. Consideration of alternative forms of vascular access in this population may be beneficial. Key words: ambulance; emergency medical services; intraosseous; intravenous; pediatric

Semiautomatic intraosseous devices in pediatric prehospital care.

Abstract Background. Intraosseous (IO) access is attempted when intravenous access cannot be established during an emergency. The U.S. Food and Drug Administration–cleared semiautomatic IO access device (EZ-IO; Vidacare Corp., Shavano Park, TX) has been shown to be safe and effective. Objective. To examine the characteristics of pediatric patients receiving IO infusions, primary clinical impressions of emergency medical services providers, success rates, and subsequent treatment after use of a manual IO device or the semiautomatic IO device. Methods. A midwestern, 12-site, statewide ambulance service began using the semiautomatic device instead of a manual IO device in 2007. Retrospective review included analysis of device placement rates and subsequent treatment of children (younger than 18 years) who underwent an IO access procedure with either the manual device (January 2003 through February 2007) or the semiautomatic device (March 2007 through May 2009). Results. First-attempt success was achieved in 80.6% of patients (25 of 31) in the manual device group and in 83.9% of patients (52 of 62) in the semiautomatic device group (p = 0.98). In the manual device group, there were 37 attempts for 25 successful device placements (67.6% success), and in the semiautomatic group, there were 72 attempts for 58 successful placements (80.6% success) (p = 0.52). Intravenous attempts were made before IO attempts in 35.5% of patients (11 of 31) in the manual group and in 1.7% of patients (1 of 60) in the semiautomatic group (p < 0.001). Treatment (medication use, excluding lidocaine for local anesthetic purposes and intravenous crystalloid) was administered IO in 84.0% of the patients (21 of 25) in the manual device group and in 73.2% of the patients (41 of 56) in the semiautomatic device group. Conclusions. For the pediatric cohort, use of a semiautomatic IO access device in place of a manual device offered no statistically significant difference in first-attempt success (3.3%) or in success per attempt (13.0%). However, the rate at which IO access was used by emergency medical services providers more than tripled with use of the semiautomatic device.

Effect of an onboard event recorder and a formal review process on ambulance driving behaviour

Background Onboard event recorders in vehicles record external and internal video before and after when preset g-force limits are exceeded. The use of these recorders in a fleet of ambulances, along with formal review, may decrease the number of unsafe driving events. The aim of this study was to evaluate the number of driving events since the inception of DriveCam technology in a fleet. Methods 54 vehicles were outfitted with DriveCam event recorders in 2003. Events were captured and assigned a categorical severity score of 1–4 (1 being the lowest severity) when the vehicle exceeded preset g-force limits. An event was assigned a score of ‘good’ if the review determined that the driver demonstrated good judgement. A review and feedback process was implemented in August 2006 and analysed through June 2008. Results During the study period, 2 979 891 miles were driven for 115 019 ambulance responses, with 6009 events captured. Events were categorised as follows: 2008 (33.4%) level 1; 3726 (62.0%) level 2; 175 (2.9%) level 3; 3 (0.05%) level 4; and 97 (1.6%) good events. The proportion of all events per mile and all events per response decreased over time with use of the recorder and review and feedback. Conclusions The institution of video event recorder technology along with formal review and feedback resulted in a change in driving behaviour. Given that call volumes increased and driving events decreased, these measures may serve as surrogates for improvements in safety and maintenance costs. Economic analysis is necessary for conclusions on fiscal impact.

The Airtraq Optical Laryngoscope in helicopter emergency medical services: a pilot trial.

OBJECTIVE To determine the degree of success helicopter emergency medical services personnel have in placing an endotracheal tube using a relatively new device for endotracheal intubation (ETI) known as the Airtraq (AT) Optical Laryngoscope (King Systems Corp, Noblesville, IN), and to determine the frequency with which flight crews had to resort to other means for advanced airway management. METHODS This prospective, observational pilot trial evaluated the critical care flight teams ability to perform ETI using the AT as a first-line device in the prehospital setting. Flight crews were instructed to use the AT for any patient needing ETI. Teams completed a 30-minute training session followed by mannequin practice. They documented situations and outcomes: reason for ETI, success in placing the AT, reason for unsuccessful placement, end-tidal carbon dioxide concentration in expired air (ETCO2), and where patients were when they underwent intubation (field, ambulance, aircraft, hospital). Data were abstracted and analyzed using JMP software version 7.0 (SAS Institute, Inc, Cary, NC). RESULTS Fifty cases involving use of the AT were analyzed. Median patient age was 51.5 years (range, 15-90; interquartile range, 36-64.5). Most patients were male (n = 37 [74%]). The primary reasons for intubation were unresponsiveness and altered loss of consciousness (n = 23 [46%]), respiratory distress or apnea (n = 8 [16%]), cardiac arrest (n = 10 [20%]), and combative behavior (n = 7 [14%]). AT was successful (n = 31[62%]) in 1 to 2 attempts. The primary reason for AT failure was blood or vomit in the airway (n = 8 [42.1%]); 48.1% (n = 25) of patients required a different management mode. CONCLUSIONS HEMS crews had difficulty placing successful ET tubes with this device after minimal education with a single regular-sized device. Difficulty was pronounced when blood or vomit was present and obstructing the optical view. Further study is needed to evaluate the implementation time, training time required, and possible design advantages of the AT compared with those of traditional emergent airway management techniques.

Hours and Miles: Patient and Health System Implications of Transfer for Psychiatric Bed Capacity

Introduction An increasing number of behavioral health (BH) patients are presenting to the emergency department (ED) while BH resources continue to decline. This situation-may lead to more external transfers to find care. Methods This is a retrospective cohort study of consecutive patients presenting to a tertiary care academic ED from February 1, 2013, through January 31, 2014. Patients were identified through electronic health record documentation of psychiatric consultation during ED evaluation. We reviewed electronic health records for demographic characteristics, diagnoses, payer source, ED length of stay, ED disposition, arrival method, and distance traveled to an external facility for inpatient admission. Univariable and multivariable associations with transfer to an external facility in comparison with patients admitted internally were evaluated with logistic regression models and summarized with odds ratios (OR). Results We identified 2,585 BH visits, of which 1,083 (41.9%) resulted in discharge. A total of 1,502 patient visits required inpatient psychiatric admission, and of these cases, 177 patients (11.8%; 95% CI = [10.2–13.5]) required transfer to an external facility. The median ED length of stay for transferred patients was 13.9 hours (interquartile range [IQR], 9.3–20.2 hours; range, 3.0–243.0 hours). The median distance for transport was 83 miles (IQR, 42–111 miles; range, 42–237 miles). In multivariable analysis, patients with suicidal or homicidal ideation had increased risk of transfer (odds ratio [OR] [95% CI], 1.93 [1.22–3.06]; P=0.005). Children younger than 18 years (OR [95% CI], 2.34 [1.60–3.40]; P<0.001) and adults older than 65 years (OR [95% CI], 3.46 [1.93–6.19]; P<0.001) were more likely to require transfer and travel farther to access care. Conclusion Patients requiring external transfer for inpatient psychiatric care were found to have prolonged ED lengths of stay. Patients with suicidal and homicidal ideation as well as children and adults older than 65 years are more likely to require transfer.

Determinants of Success and Failure in Prehospital Endotracheal Intubationa

Introduction This study aimed to identify factors associated with successful endotracheal intubation (ETI) by a multisite emergency medical services (EMS) agency. Methods We collected data from the electronic prehospital record for all ETI attempts made from January through May 2010 by paramedics and other EMS crew members at a single multistate agency. If documentation was incomplete, the study team contacted the paramedic. Paramedics use the current National Association of EMS Physicians definition of an ETI attempt (laryngoscope blade entering the mouth). We analyzed patient and EMS factors affecting ETI. Results During 12,527 emergent ambulance responses, 200 intubation attempts were made in 150 patients. Intubation was successful in 113 (75%). A crew with paramedics was more than three times as likely to achieve successful intubation as a paramedic/emergency medical technician-Basic crew (odds ratio [OR], 3.30; p=0.03). A small tube (≤7.0 inches) was associated with a more than 4-fold increased likelihood of successful ETI compared with a large tube (≥7.5 inches) (OR, 4.25; p=0.01). After adjustment for these features, compared with little or no view of the glottis, a partial or entire view of the glottis was associated with a nearly 13-fold (OR, 12.98; p=0.001) and a nearly 40-fold (OR, 39.78; p<0.001) increased likelihood of successful intubation, respectively. Conclusion Successful ETI was more likely to be accomplished when a paramedic was partnered with another paramedic, when some or all of the glottis was visible and when a smaller endotracheal tube was used.