Joshua B. Gaither

Tongue Engorgement Associated With Prolonged Use of the King-LT Laryngeal Tube Device

We report a case of massive tongue engorgement associated with the placement of a laryngeal tube device (King Airway-LTS-D EMS). Our patient developed isolated, massive lingual swelling approximately 3 hours after the out-of-hospital placement of a laryngeal tube. Swelling resolved 2 days later in the ICU after fiberoptic-guided exchange of the laryngeal tube for an endotracheal tube. It is most likely that the observed swelling was due to obstruction of venous drainage from the tongue by the oropharyngeal balloon. Other etiologies for lingual swelling such as angioedema cannot be definitively ruled out but are less likely to have caused the patients tongue engorgement.

The Effect of Combined Out-of-Hospital Hypotension and Hypoxia on Mortality in Major Traumatic Brain Injury

Study objective: Survival is significantly reduced by either hypotension or hypoxia during the out‐of‐hospital management of major traumatic brain injury. However, only a handful of small studies have investigated the influence of the combination of both hypotension and hypoxia occurring together. In patients with major traumatic brain injury, we evaluate the associations between mortality and out‐of‐hospital hypotension and hypoxia separately and in combination. Methods: All moderate or severe traumatic brain injury cases in the preimplementation cohort of the Excellence in Prehospital Injury Care study (a statewide, before/after, controlled study of the effect of implementing the out‐of‐hospital traumatic brain injury treatment guidelines) from January 1, 2007, to March 31, 2014, were evaluated (exclusions: <10 years, out‐of‐hospital oxygen saturation ≤10%, and out‐of‐hospital systolic blood pressure <40 or >200 mm Hg). The relationship between mortality and hypotension (systolic blood pressure <90 mm Hg) or hypoxia (saturation <90%) was assessed with multivariable logistic regression, controlling for Injury Severity Score, head region severity, injury type (blunt versus penetrating), age, sex, race, ethnicity, payer, interhospital transfer, and trauma center. Results: Among the 13,151 patients who met inclusion criteria (median age 45 years; 68.6% men), 11,545 (87.8%) had neither hypotension nor hypoxia, 604 (4.6%) had hypotension only, 790 (6.0%) had hypoxia only, and 212 (1.6%) had both hypotension and hypoxia. Mortality for the 4 study cohorts was 5.6%, 20.7%, 28.1%, and 43.9%, respectively. The crude and adjusted odds ratios for death within the cohorts, using the patients with neither hypotension nor hypoxia as the reference, were 4.4 and 2.5, 6.6 and 3.0, and 13.2 and 6.1, respectively. Evaluation for an interaction between hypotension and hypoxia revealed that the effects were additive on the log odds of death. Conclusion: In this statewide analysis of major traumatic brain injury, combined out‐of‐hospital hypotension and hypoxia were associated with significantly increased mortality. This effect on survival persisted even after controlling for multiple potential confounders. In fact, the adjusted odds of death for patients with both hypotension and hypoxia were more than 2 times greater than for those with either hypotension or hypoxia alone. These findings seem supportive of the emphasis on aggressive prevention and treatment of hypotension and hypoxia reflected in the current emergency medical services traumatic brain injury treatment guidelines but clearly reveal the need for further study to determine their influence on outcome.

Mortality and prehospital blood pressure in patients with major traumatic brain injury: Implications for the hypotension threshold

Importance Current prehospital traumatic brain injury guidelines use a systolic blood pressure threshold of less than 90 mm Hg for treating hypotension for individuals 10 years and older based on studies showing higher mortality when blood pressure drops below this level. However, the guidelines also acknowledge the weakness of the supporting evidence. Objective To evaluate whether any statistically supportable threshold between systolic pressure and mortality emerges from the data a priori, without assuming that a cut point exists. Design, Setting, and Participants Observational evaluation of a large prehospital database established as a part of the Excellence in Prehospital Injury Care Traumatic Brain Injury Study. Patients from the preimplementation cohort (January 2007 to March 2014) 10 years and older with moderate or severe traumatic brain injury (Barell Matrix Type 1 classification, International Classification of Diseases, Ninth Revision head region severity score of 3 or greater, and/or Abbreviated Injury Scale head-region severity score of 3 or greater) and a prehospital systolic pressure between 40 and 119 mm Hg were included. The generalized additive model and logistic regression were used to determine the association between systolic pressure and probability of death, adjusting for significant/important confounders. Main Outcomes and Measures The main outcome measure was in-hospital mortality. Results Among the 3844 included patients, 2565 (66.7%) were male, and the median (range) age was 35 (10-99) years. The model revealed a monotonically decreasing association between systolic pressure and adjusted probability of death across the entire range (ie, from 40 to 119 mm Hg). Each 10-point increase of systolic pressure was associated with a decrease in the adjusted odds of death of 18.8% (adjusted odds ratio, 0.812; 95% CI, 0.748-0.883). Thus, the adjusted odds of mortality increased as much for a drop from 110 to 100 mm Hg as for a drop from 90 to 80 mm Hg, and so on throughout the range. Conclusions and Relevance We found a linear association between lowest prehospital systolic blood pressure and severity-adjusted probability of mortality across an exceptionally wide range. There is no identifiable threshold or inflection point between 40 and 119 mm Hg. Thus, in patients with traumatic brain injury, the concept that 90 mm Hg represents a unique or important physiological cut point may be wrong. Furthermore, clinically meaningful hypotension may not be as low as current guidelines suggest. Randomized trials evaluating treatment levels significantly above 90 mm Hg are needed.

Balancing the potential risks and benefits of out-of-hospital intubation in traumatic brain injury: the intubation/hyperventilation effect.

INTRODUCTION The early management of patients with severe traumatic brain injury presents a challenge for both out-of-hospital and emergency department (ED) providers. Every year, more than 1.4 million patients are evaluated in US EDs for traumatic brain injury; 235,000 of these patients require hospitalization and 50,000 die. The lifetime cost of traumatic brain injury sustained in 2000 alone was estimated to be more than

Prevalence of Difficult Airway Predictors in Cases of Failed Prehospital Endotracheal Intubation

60 billion, with more than 2% of the US population requiring long-term assistance with activities of daily living as a result of traumatic brain injury. Although only a fraction of these patients require out-of-hospital intubation, the potential influence of this intervention remains high because the intubated subgroup is generally a severely injured cohort. However, controversy now surrounds this issue. Patient outcomes after traumatic brain injury may be affected by early care, likely because outcomes are not determined solely by the severity of the initial insult, or primary brain injury. Additional secondary injury to the central nervous system may occur and increase disability or result in death. This potentially preventable or reversible damage may become indelible despite subsequent optimal management. In early traumatic brain injury care, intubation may be associated with worsened secondary injury. Some reports have implicated out-of-hospital intubation as a factor associated with negative outcomes. Other investigations have demonstrated no difference or improved outcomes with field intubation. These conflicting observations are the source of debate, complicated by growing evidence that postintubation hyperventilation is common and a cause of secondary brain injury. Even short periods of hyperventilation may result in increased morbidity and mortality. d

National Prehospital Evidence-Based Guidelines Strategy: A Summary for EMS Stakeholders

BACKGROUND Difficult airway predictors (DAPs) are associated with failed endotracheal intubation (ETI) in the emergency department (ED). However, little is known about the relationship between DAPs and failed prehospital ETI. OBJECTIVE Our aim was to determine the prevalence of common DAPs among failed prehospital intubations. METHODS We reviewed a quality-improvement database, including all cases of ETI in a single ED, over 3 years. Failed prehospital (FP) ETI was defined as a case brought to the ED after attempted prehospital ETI, but bag-valve-mask ventilation, need for a rescue airway (supraglottic device, cricothyrotomy, etc.), or esophageal intubation was discovered at the ED. Physicians performing ETI evaluated each case for the presence of DAPs, including blood/emesis, facial/neck trauma, airway edema, spinal immobilization, short neck, and tongue enlargement. RESULTS There were a total of 1377 ED ETIs and 161 had an FP-ETI (11.8%). Prevalence of DAPs in cases with FP-ETI was obesity 13.0%, large tongue 18.0%, short neck 13%, small mandible 4.3%, cervical immobility 49.7%, blood in airway 57.8%, vomitus in airway 23.0%, airway edema 12.4%, and facial or neck trauma 32.9%. The number of cases with FP-ETI and 0, 1, 2, 3, or 4 or more DAPs per case was 22 (13.6%), 43 (26.7%), 23 (24.3%), 42 (26.1%), and 31 (19.3%), respectively. CONCLUSIONS DAPs are common in cases of FP-ETI. Some of these factors may be associated with FP-ETI. Additional study is needed to determine if DAPs can be used to identify patients that are difficult to intubate in the field.

Comparison of Droperidol and Haloperidol for Use by Paramedics: Assessment of Safety and Effectiveness

Abstract Multiple national organizations have recommended and supported a national investment to increase the scientific evidence available to guide patient care delivered by Emergency Medical Services (EMS) and incorporate that evidence directly into EMS systems. Ongoing efforts seek to develop, implement, and evaluate prehospital evidence-based guidelines (EBGs) using the National Model Process created by a multidisciplinary panel of experts convened by the Federal Interagency Committee on EMS (FICEMS) and the National EMS Advisory Council (NEMSAC). Yet, these and other EBG efforts have occurred in relative isolation, with limited direct collaboration between national projects, and have experienced challenges in implementation of individual guidelines. There is a need to develop sustainable relationships among stakeholders that facilitate a common vision that facilitates EBG efforts. Herein, we summarize a National Strategy on EBGs developed by the National Association of EMS Physicians (NAEMSP) with involvement of 57 stakeholder organizations, and with the financial support of the National Highway Traffic Safety Administration (NHTSA) and the EMS for Children program. The Strategy proposes seven action items that support collaborative efforts in advancing prehospital EBGs. The first proposed action is creation of a Prehospital Guidelines Consortium (PGC) representing national medical and EMS organizations that have an interest in prehospital EBGs and their benefits to patient outcomes. Other action items include promoting research that supports creation and evaluates the impact of EBGs, promoting the development of new EBGs through improved stakeholder collaboration, and improving education on evidence-based medicine for all prehospital providers. The Strategy intends to facilitate implementation of EBGs by improving guideline dissemination and incorporation into protocols, and seeks to establish standardized evaluation methods for prehospital EBGs. Finally, the Strategy proposes that key stakeholder organizations financially support the Prehospital Guidelines Consortium as a means of implementing the Strategy, while together promoting additional funding for continued EBG efforts.

Association Between Difficult Airway Predictors and Failed Prehosptial Endotracheal Intubation.

Abstract Background. Since the 2001 “black box” warning on droperidol, its use in the prehospital setting has decreased substantially in favor of haloperidol. There are no studies comparing the prehospital use of either drug. The goal of this study was to compare QTc prolongation, adverse events, and effectiveness of droperidol and haloperidol among a cohort of agitated patients in the prehospital setting. Methods. In this institutional review board-approved before and after study, we collected data on 532 patients receiving haloperidol (n = 314) or droperidol (n = 218) between 2007 and 2010. We reviewed emergency department (ED) electrocardiograms when available (haloperidol, n = 78, 25%; droperidol, n = 178, 76%) for QTc length (in milliseconds), medical records for clinically relevant adverse events (defined a priori as systolic blood pressure (SBP) <90 mmHg, seizure, administration of anti-dysrhythmic medications, cardioversion or defibrillation, bag–valve–mask ventilation, intubation, cardiopulmonary arrest, and prehospital or in-hospital death). We also compared effectiveness of the medications, using administration of additional sedating medications within 30 minutes of ED arrival as a proxy for effectiveness. Results. The mean haloperidol dose was 7.9 mg (median 10 mg, range 4–20 mg). The mean droperidol dose was 2.9 mg (median 2.5 mg, range 1.25–10 mg.) Haloperidol was given IM in 289 cases (92%), and droperidol was given IM in 132 cases (61%); in all other cases, the medication was given IV. There was no statistically significant difference in median QTc after medication administration (haloperidol 447 ms, 95% CI: 440–454 ms; droperidol 454 ms, 95% CI: 450–457). There were no statistically significant differences in adverse events in the droperidol group as compared to the haloperidol group. One patient in the droperidol group with a history of congenital heart disease suffered a cardiopulmonary arrest and was resuscitated with neurologically intact survival. There was no significant difference in the use of additional sedating medications within 30 minutes of ED arrival after receiving droperidol (2.9%, 95% CI: −2.5–8.4%). Conclusions. In this cohort of agitated patients treated with haloperidol or droperidol in the prehospital setting, there was no significant difference found in QTc prolongation, adverse events, or need for repeat sedation between haloperidol and droperidol.

Long-Acting Neuromuscular Blocker Use During Prehospital Transport of Trauma Patients

OBJECTIVE Difficult airway predictors (DAPs) are associated with failure of endotracheal intubation (ETI) in the emergency department (ED). The purpose of this study was to determine if DAPs are associated with failure of prehospital ETI. METHODS This retrospective study compared the prevalence of DAPs in cases of failed prehospital ETI successfully intubated in the ED (FPH/SED) with cases with no prehospital attempt that were successfully intubated in the ED on the first attempt by a physician using direct laryngoscopy (NPH/SED). All cases were transported by ground or air to an academic, level-1 trauma center. RESULTS A total of 1377 ED ETIs were performed; 161 FPH/SED and 530 NPH/SED were identified. The odds ratios with 95% confidence intervals (CIs) of finding DAPs in the FPH/SED group compared with the NPH/SED group was blood = 5.80 (95% CI, 3.89-8.63), vomit = 2.01 (95% CI, 1.25-3.21), short neck = 2.67 (95% CI, 1.39-5.03), neck immobility = 2.52 (95% CI, 1.72-3.67), airway edema = 10.52 (95% CI, 4.15-29.92), facial trauma = 4.64 (95% CI, 2.91-7.39), and large tongue = 3.08 (95% CI, 1.75-5.40). When grouped by the number of DAPs per case (0, 1, 2, 3, or ≥ 4), the odds of multiple DAPs in cases of FPH/SED compared with NPH/SED ranged from 2.89 (95% CI, 1.71-4.90) with 1 DAP to 24.55 (95% CI, 10.60-56.90) with ≥ 4 DAPs. CONCLUSION Cases of FPH/SED have more DAPs than NPH/SEDs.

Association of Out-of-Hospital Hypotension Depth and Duration With Traumatic Brain Injury Mortality

INTRODUCTION The purpose of this study was to determine the rate of long-acting neuromuscular blocker (LA-NMB) use and evaluate the concurrent use of sedatives during prehospital care. SETTING Prehospital patients who were brought to a single emergency department in the United States. METHODS This was a retrospective cohort study of trauma patients who were intubated in the prehospital setting. The primary outcome measure was to determine the rate of LA-NMB use. The use of postintubation sedatives and the time to the administration of sedative agents was compared between patients who received an LA-NMB and those who did not. RESULTS A total of 51 patients were included in the final analyses. Overall, 82% (n = 42) of patients received an LA-NMB during transport. There was no difference in the rate of postintubation sedative use during transport between the LA-NMB and no LA-NMB groups (79% vs. 67%, respectively, P = .42). The LA-NMB group received sedatives less promptly after intubation compared with those who did not receive LA-NMBs (16 vs. 7 minutes, respectively; P = .04). CONCLUSION The use of LA-NMB is common during the prehospital transport of trauma patients. Some of these patients may not be given sedatives or may have delays in receiving sedatives after intubation.