Tracheal injury as a sequence of multiple attempts of endotracheal intubation in the course of a preclinical cardiopulmonary resuscitation

Association between multiple intubation attempts and complications during emergency department airway management: A national emergency airway registry study

OBJECTIVE

Peri-intubation complications are important sequelae of airway management in the emergency department (ED). Our objective was to quantify the increased risk of complications with multiple attempts at emergency airway intubation in the ED.

METHODS

This is a secondary analysis of a prospectively collected multicenter registry (National Emergency Airway Registry) consisting of attempted ED intubations among subjects aged >14 years. The primary exposure variable was the number of intubation attempts. The primary outcome measure was the occurrence of peri-intubation major complications within 15 min of intubation including hypotension, hypoxemia, vomiting, dysrhythmias, cardiac arrest, esophageal intubation, and failed airway with cricothyrotomy. We constructed multivariable logistic regression models to determine the associations between complications and the number of intubation attempts while controlling for measured pre-exposure variables.

RESULTS

There were 19,071 intubations in the NEAR database, of which 15,079 met inclusion for this analysis. Of these, 13,459 were successfully intubated on the first attempt, 1,268 on the second attempt, 269 on the third attempt, 61 on the fourth attempt, and 22 on the fifth or more attempt. A complication occurred in 2,137 encounters (14 %). Major complications accompanied 1,968 encounters (13 %) whereas minor complications affected 315 encounters (2 %). The most common major complication was hypoxia. In our multivariable logistic regression model, odds ratios with 95 % confidence intervals for the occurrence of major complications for multiple attempts compared to first-pass success were 4.4 (3.6-5.3), 7.4 (5.0-10.7), 13.9 (5.6-34.3), and 9.3 (2.1-41.7) for attempts 2-5+ (reference attempt 1), respectively.

CONCLUSIONS

We found an independent association between the number of intubation attempts among ED patients undergoing emergency airway intubation and the risk of complications.

Association between repeated intubation attempts and adverse events in emergency departments: an analysis of a multicenter prospective observational study

STUDY OBJECTIVE

Although repeated intubation attempts are believed to contribute to patient morbidity, only limited data characterize the association between the number of emergency department (ED) laryngoscopic attempts and adverse events. We seek to determine whether multiple ED intubation attempts are associated with an increased risk of adverse events.

METHODS

We conducted an analysis of a multicenter prospective registry of 11 Japanese EDs between April 2010 and September 2011. All patients undergoing emergency intubation with direct laryngoscopy as the initial device were included. The primary exposure was multiple intubation attempts, defined as intubation efforts requiring greater than or equal to 3 laryngoscopies. The primary outcome measure was the occurrence of intubation-related adverse events in the ED, including cardiac arrest, dysrhythmia, hypotension, hypoxemia, unrecognized esophageal intubation, regurgitation, airway trauma, dental or lip trauma, and mainstem bronchus intubation.

RESULTS

Of 2,616 patients, 280 (11%) required greater than or equal to 3 intubation attempts. Compared with patients requiring 2 or fewer intubation attempts, patients undergoing multiple attempts exhibited a higher adverse event rate (35% versus 9%). After adjusting for age, sex, principal indication, method, medication, and operator characteristics, intubations requiring multiple attempts were associated with an increased odds of adverse events (odds ratio 4.5; 95% confidence interval 3.4 to 6.1).

CONCLUSION

In this large Japanese multicenter study of ED patients undergoing intubation, we found that multiple intubation attempts were independently associated with increased adverse events.

Airway management in cardiac arrest

Airway management has been emphasized as crucial to effective resuscitation of patients in cardiac arrest. However, recent research has shown that coronary and cerebral perfusion should be prioritized rather than airway management. Endotracheal intubation has been deemphasized. This article reviews the current state of the literature regarding airway management of the patient in cardiac arrest. Ventilatory management strategies are also discussed.

Clinically correlated anatomical basis of cricothyrotomy and tracheostomy

OBJECTIVE

Cricothyrotomy and tracheostomy are performed by physicians in various disciplines. It is important to know the comprehensive anatomy of the laryngotracheal region. Hemorrhage, esophageal injury, recurrent laryngeal nerve injury, pneumothorax, hemothorax, false passage of the tube and tracheal stenosis after decannulation are well known complications of the cricothyrotomy and tracheostomy. Cricothyrotomy and tracheostomy should be performed without complications and as quickly as possible with regards the patients' clinical condition.

METHODS

A total of 40 cadaver necks were dissected in this study. The trachea and larynx and the relationship between the trachea and larynx and the surrounding structures was investigated. The tracheal cartilages and annular ligaments were counted and the relationship between tracheal cartilages and the thyroid gland and vascular structures was investigated. We performed cricothyrotomy and tracheostomy in eleven cadavers while simulating intensive care unit conditions to determine the duration of those procedures.

RESULTS

There were 11 tracheal cartilages and 10 annular ligaments between the cricoid cartilage and sternal notch. The average length of trachea between the cricoid cartilage and the suprasternal notch was 6.9 to 8.2 cm. The cricothyroid muscle and cricothyroid ligament were observed and dissected and no vital anatomic structure detected. The average length and width of the cricothyroid ligament was 8 to 12 mm and 8 to 10 mm, respectively. There was a statistically significant difference between the surgical time required for cricothyrotomy and tracheostomy (p < 0.0001).

CONCLUSION

Tracheostomy and cricothyrotomy have a low complication rate if the person performing the procedure has thorough knowledge of the neck anatomy. The choice of tracheostomy or cricothyrotomy to establish an airway depends on the patients' clinical condition, for instance; cricothyrotomy should be preferred in patients with cervicothoracal injury or dislocation who suffer from respiratory dysfunction. Furthermore; if a patient is under risk of hypoxia or anoxia due to a difficult airway, cricothyrotomy should be preferred rather than tracheostomy.

A consensus-based template for uniform reporting of data from pre-hospital advanced airway management

Background

Advanced airway management is a critical intervention that can harm the patient if performed poorly. The available literature on this subject is rich, but it is difficult to interpret due to a huge variability and poor definitions. Several initiatives from large organisations concerned with airway management have recently propagated the need for guidelines and standards in pre-hospital airway management. Following the path of other initiatives to establish templates for uniform data reporting, like the many Utstein-style templates, we initiated and carried out a structured consensus process with international experts to establish a set of core data points to be documented and reported in cases of advanced pre-hospital airway management.

Methods

A four-step modified nominal group technique process was employed.

Results

The inclusion criterion for the template was defined as any patient for whom the insertion of an advanced airway device or ventilation was attempted. The data points were divided into three groups based on their relationship to the intervention, including system-, patient-, and post-intervention variables, and the expert group agreed on a total of 23 core data points. Additionally, the group defined 19 optional variables for which a consensus could not be achieved or the data were considered as valuable but not essential.

Conclusion

We successfully developed an Utstein-style template for documenting and reporting pre-hospital airway management. The core dataset for this template should be included in future studies on pre-hospital airway management to produce comparable data across systems and patient populations and will be implemented in systems that are influenced by the expert panel.

Frequent and rare complications of resuscitation attempts

INTRODUCTION

Resuscitation attempts require invasive iatrogenic manipulations on the patient. On the one hand, these measures are essential for survival, but on the other hand can damage the patient and thus contain a significant violation risk of both medical and forensic relevance for the patient and the physician. We differentiate between frequent and rare resuscitation-related injuries. Factors of influence are duration and intensity of the resuscitation attempts, sex and age of the patient as well as an anticoagulant medication.

MATERIALS AND METHODS

Review of current literature and report on autopsy cases from our institute (approximately 1,000 autopsies per year).

RESULTS

Frequent findings are lesions of tracheal structures and bony chest fractures. Rare injuries are lesions of pleura, pericardium, myocardium and other internal organs as well as vessels, intubation-related damages of neural and cartilaginous structures in the larynx and perforations of abdominal organs such as liver, stomach and spleen.

CONCLUSION

We differentiate between frequent and rare complications. The risk of iatrogenic CPR-related trauma is even present with adequate execution of CPR measures and should not question the employment of proven medical techniques.

How many attempts are required to accomplish out-of-hospital endotracheal intubation?

BACKGROUND

An important goal of emergency airway management is to complete endotracheal intubation (ETI) correctly, safely, and quickly, and repeated ETI attempts can increase patient morbidity and mortality. Clinical protocols limiting the number of ETI attempts may minimize harm, but this strategy also may reduce the frequency of successful ETI.

OBJECTIVES

To characterize the relationship between the number of out-of-hospital ETI attempts and ETI success.

METHODS

This study used prospective, multicenter data from 42 emergency medical services agencies from an 18-month period. Out-of-hospital rescuers (paramedics, out-of-hospital nurses, and physicians) completed structured, closed-response data forms describing clinical methods, course, and outcomes for all ETIs. An ETI attempt was defined as an insertion of the laryngoscope blade. Rescuers identified ETI outcome (success or failure) for each attempt. The authors defined overall success as ETI outcome (success or failure) on the last attempt, examining cardiac arrest, conventional nonarrest, sedation-facilitated, and rapid-sequence ETI separately. Univariate odds ratios (ORs) were used to identify the number of ETI attempts in which the cumulative ETI success rate approached the overall ETI success rate.

RESULTS

Complete data were available for 1,941 cases. More than 30% of patients received more than one ETI attempt. For 1,272 cardiac arrest ETIs, cumulative success for the first three attempts were 69.9%, 84.9%, and 89.9%; cumulative success approached overall success (91.8%) after three attempts (OR, 0.79; 95% confidence interval [CI] = 0.61 to 1.04). For 463 conventional non-arrest ETIs, cumulative success for the first three attempts were 57.6%, 69.2%, and 72.7%; cumulative success approached overall success (73.7%) after two attempts (OR, 0.95; 95% CI = 0.71 to 1.28). For 126 sedation-facilitated ETIs, cumulative success for the first three attempts were 44.4%, 62.7%, and 75.4%; cumulative success approached overall success (77.0%) after three attempts (OR, 0.92; 95% CI = 0.51 to 1.64). For 80 rapid-sequence ETI, cumulative ETI success for the first three attempts were 56.3%, 81.3%, and 91.3%; cumulative success approached overall success (96.3%) after three attempts (OR, 0.41; 95% CI = 0.10 to 1.65).

CONCLUSIONS

Out-of-hospital rescuers often require multiple attempts to accomplish ETI. A protocol limit of three attempts offers reasonable opportunity for accomplishing ETI within the constraints of the out-of-hospital environment.

Out-of-hospital endotracheal intubation: where are we?

While remaining prominent in paramedic care and beneficial to some patients, out-of-hospital endotracheal intubation has not clearly improved survival or reduced morbidity from critical illness or injury when studied more broadly. Recent studies identify equivocal or unfavorable clinical effects, adverse events and errors, interaction with other important resuscitation interventions, and challenges in providing and maintaining procedural skill. We provide an overview of current data evaluating the overall effectiveness, safety, and feasibility of paramedic out-of-hospital endotracheal intubation. These studies highlight our limited understanding of out-of-hospital endotracheal intubation and the need for new strategies to improve airway support in the out-of-hospital setting.

Procedural experience with out-of-hospital endotracheal intubation

OBJECTIVE

Out-of-hospital rescuers likely need regular clinical experience to perform endotracheal intubation (ETI) in a safe and effective manner. We sought to determine the frequency of ETI performed by individual out-of-hospital rescuers.

DESIGN

Analysis of an administrative database of all emergency medical services (EMS) patient care reports in Pennsylvania.

SETTING

Commonwealth of Pennsylvania from January 1 to December 31, 2003.

SUBJECTS

EMS advanced life support rescuers (paramedics, prehospital nurses, and EMS physicians) who reported at least one patient contact during the study period.

INTERVENTIONS

None.

MEASUREMENTS

We calculated individual rescuer ETI frequency and opportunity. We evaluated relationships between ETI frequency and the number of patient contacts. We also examined the relationship with practice setting (air medical vs. ground rescuers and urban vs. rural rescuers).

MAIN RESULTS

In 1,544,791 patient care reports, 11,484 ETIs were reported by 5,245 out-of-hospital rescuers. The median ETI frequency was one (interquartile range, 0-3; range, 0-23). Of 5,245 rescuers, >67% (3,551) performed two or fewer ETIs, and >39% (2,054) rescuers did not perform any ETIs. The median number of ETI opportunities was three (interquartile range, 0-6; range, 0-76). ETI frequency was associated with patient volume (Spearman's rho = 0.67) and was higher for air medical (p = .006) and urban (p < .0001) rescuers. ETI frequency was not associated with response (Spearman's rho = -0.01) or transport (Spearman's rho = -0.06) times.

CONCLUSIONS

Out-of-hospital ETI, an important and difficult resuscitation intervention, is an uncommon event for most rescuers.

Airway and ventilation management

Airway management is fundamental to ACLS. Success with any airway device relies as much on the operator's experience and skill as on the device itself. The purpose of using an airway device is to provide a patent route for ventilating the lungs and to protect against pulmonary aspiration. Training should emphasize the importance of confirming that the airway device is positioned correctly and that the lungs can be ventilated effectively. If airway intervention is to have a positive effect on outcome, the choice of airway device is less important than thorough training, ongoing experience and review, and close attention to complications. Regardless of whether a provider chooses to use the LMA, the combitube, or the tracheal tube, providers must be familiar with more than one method of airway management because of the possibility of failure to insert or ventilate with their primary airway device of choice.