Mel Ochs

Paramedic-administered neuromuscular blockade improves prehospital intubation success in severely head-injured patients

BACKGROUND The purpose of this study was to evaluate the effect of paramedic-administered neuromuscular blocking agents as part of a rapid-sequence intubation (RSI) protocol on successful intubation of severely head-injured patients in a large, urban prehospital system. METHODS Adult head-injured patients were prospectively enrolled over 1 year using these inclusion criteria: Glasgow Coma Scale (GCS) score of 3 to 8, transport time > 10 minutes, and inability to intubate without RSI. Midazolam and succinylcholine were administered before laryngoscopy; rocuronium was given after tube placement was confirmed using capnometry, syringe aspiration, and pulse oximetry. The Combitube was used as a salvage airway device. All adult trauma victims with a GCS score of 3 to 8 were identified during the first 12 months of the study as the trial cohort and from the preceding 12 months as the control cohort. The trial and control cohorts were compared with regard to demographic data, mechanism of injury, initial vital signs, and GCS scores. The primary outcome measure was intubation success, defined as insertion of either an endotracheal tube or a Combitube, with patients stratified by GCS score. RESULTS The trial cohort (n = 249) and control cohort (n = 189) were similar with regard to demographic data, mechanism of injury, and initial vital signs and GCS scores. Intubation success rates increased significantly during the trial period for all patients and when stratified into GCS score of 3 and GCS score of 4 to 8. The percentage of patients intubated without neuromuscular blocking agents actually increased during the trial period. Although the number of intubations by helicopter flight crews decreased during the trial, the overall use of aeromedical resources did not change. CONCLUSION Paramedic-administered neuromuscular blockade as part of an RSI protocol improves intubation success in a large, urban prehospital system.

The Combitube as a salvage airway device for paramedic rapid sequence intubation

STUDY OBJECTIVE The safety of out-of-hospital rapid sequence intubation depends on a reliable strategy when orotracheal intubation is unsuccessful. Here we describe our experience with the Combitube (esophageal-tracheal twin-lumen airway device) as a salvage airway device for paramedic rapid sequence intubation. METHODS The San Diego Paramedic Rapid Sequence Intubation Trial was performed to assess the effect of paramedic rapid sequence intubation on outcome in severely head-injured patients. Adults with severe head trauma (Glasgow Coma Scale score 3 to 8) who were unable to be intubated without medications were enrolled. Midazolam and succinylcholine were administered, and paramedics were allowed a maximum of 3 attempts at orotracheal intubation. If the attempts were unsuccessful, Combitube insertion was mandated. After confirmation of tube position, rocuronium was given and standard ventilation protocols were used. The primary outcome measure for this analysis was the success rate for Combitube insertion after unsuccessful orotracheal intubation. In addition, Combitube insertion and orotracheal intubation patients were compared with regard to demographic, clinical, and outcome data. RESULTS A total of 426 patients were enrolled in the trial, with 420 meeting inclusion criteria for this analysis. Orotracheal intubation was successful in 355 (84.5%) of 420; Combitube insertion was successful in 58 (95.1%) of 61 attempts, with no reported complications. Patients undergoing Combitube insertion had higher Face Abbreviated Injury Scale scores and were more likely to have oropharyngeal blood or vomitus. Arrival Pco(2) values were higher, and arrival Po(2) values were lower but still supranormal in patients undergoing Combitube insertion. There were no mortality differences between patients undergoing Combitube insertion and those undergoing orotracheal intubation. CONCLUSION The Combitube can be an effective salvage airway device for paramedic rapid sequence intubation in an urban/suburban, high-volume emergency medical services system with paramedics who are experienced in Combitube placement and with stringent protocols for its use. The device should be tested in other sizes and types of systems and under less medical scrutiny than was used in this study.

Successful prehospital airway management by EMT-Ds using the combitube.

Objective. To evaluate the ability to train emergency medical technicians-defibrillation (EMT-Ds) to effectively use the Combitube for intubations in the prehospital environment. Methods. This was an 18-month prospective field study in which EMT-Ds were trained how and in what situations to use the Combitube. Data were then obtained for all patients in whom Combitube insertion was attempted. Indications for use of the Combitube included: unconsciousness without a purposeful response, absence of the gag reflex, apnea or respiratory rate less than 6 breaths/min, age more than 16 years, and height at least 5 feet tall. Contraindications were: obvious signs of death, intact gag reflex, inability to advance the device due to resistance, or known esophageal pathology. Data were entered prospectively from the San Diego County EMS QANet database for prehospital providers. Results. Twenty-two EMT-D provider agencies, involving approximately 500 EMT-Ds, were included as study participants. Combitube insertions were attempted in 195 prehospital patients in cardiorespiratory arrest, with appropriate indication for Combitube use. An overall successful intubation rate (defined as the ability to successfully ventilate) of 79% was observed. Identical success rates for medical and trauma patients were noted. The device was placed in the esophagus 91% of the time. Resistance during insertion was the major reason for unsuccessful Combitube intubations. An overall hospital admission rate of 19% was observed. No complications were reported. Conclusion. EMT-Ds can be trained to use the Combitube as a means of establishing an airway in the pre-hospital setting. Future studies will need to further evaluate its effect on patient outcome.

Ventilation patterns in patients with severe traumatic brain injury following paramedic rapid sequence intubation

Introduction: Inadvertent hyperventilation has been documented during aeromedical transports but has not been studied following paramedic rapid sequence intubation (RSI). The San Diego Paramedic RSI Trial was designed to study the impact of paramedic RSI on outcome in patients with severe head injury. This analysis explores ventilation patterns in a cohort of trial patients undergoing end-tidal CO2 (ETCO2) monitoring.Methods: Adult patients with severe head injury (Glasgow Coma Score: 3–8) unable to be intubated without RSI were prospectively enrolled in the trial. Midazolam and succinylcholine were used for RSI; rocuronium was administered following tube confirmation. Standardized ventilation protocols were used by most paramedics; however, one agency instituted ETCO2 monitoring during the second trial year, with paramedics instructed to target ETCO2 values of 30 to 35 mmHg. The incidence and duration of inadvertent hyperventilation (ETCO2:<30 mmHg) and severe hyperventilation (ETCO2:<25 mmHg) were explored for patients undergoing ETCO2 monitoring. The initial, final, minimum, and maximum values for ETCO2 and the maximum and minimum ventilatory rate values were also calculated using descriptive statistics (95% confidence interval). The pattern of ETCO2 values over time and distribution of recorded ventilatory rate values were explored graphically.Results: A total of 76 trial patients had adequate ETCO2 data for this analysis. The mean values for initial, final, maximum, and minimum ETCO2 were 40.8 (range: 37.5–44.2), 28.4 (range: 25.4–31.4), 45.1 (range: 41.4–48.8), and 23.5 mmHg (range: 21.4–25.5), respectively. The mean maximum and minimum ventilatory rate values were 36.0/minute (range: 33.5–38.5) and 12.8/minute (range: 11.9–13.7), respectively. ETCO2 values less than 30 and 25 mmHg were documented in 79% and 59% of patients, respectively, with mean durations of 485 (range: 378–592) and 390 seconds (range: 285–494).Conclusion: Inadvertent hyperventilation is common following paramedic RSI, despite ETCO2 monitoring and target parameters.