Does the ambulance environment adversely affect the ability to perform oral endotracheal intubation?

Comparison of the airway access skills of prehospital staff in moving and stationary ambulance simulation: A randomized crossover study

OBJECTIVES

We aimed to compare the procedural success and intervention durations regarding various airway access skills in moving and stationary ambulance simulations.

MATERIAL AND METHODS

An ambulance simulator was used to simulate the moving ambulance environment, and a standard manikin was used for airway simulation. The study included 38 paramedics and paramedic students. In stationary and moving environments, a classical endotracheal intubation with a stylet, an intubation with a gum elastic bougie (GEB), a laryngeal mask airway (LMA), and a laryngeal tube (LT) were applied randomly. The cuff inflation duration, the duration until the first ventilation, and the intubation success were assessed.

RESULTS

There was no difference in terms of success and intubation durations of the four methods in moving and stationary environments. In both environments, the LT and LMA were inserted most rapidly (p < 0.001). There was no difference in the intubation duration and the success among the supraglottic methods. In moving and stationary environments, the intubation with a classic stylet was faster than the intubation with a GEB. The use of a GEB did not increase the intubation success.

CONCLUSIONS

In this simulation study, the moving environment did not affect the duration or success of the endotracheal intubation. Supraglottic methods were applied more quickly in both moving and stationary environments. A GEB was used successfully by practioners with no previous experience; however, the duration of the intubation was longer.

Mapping the use of simulation in prehospital care - a literature review

Background

High energy trauma is rare and, as a result, training of prehospital care providers often takes place during the real situation, with the patient as the object for the learning process. Such training could instead be carried out in the context of simulation, out of danger for both patients and personnel. The aim of this study was to provide an overview of the development and foci of research on simulation in prehospital care practice.

Methods

An integrative literature review were used. Articles based on quantitative as well as qualitative research methods were included, resulting in a comprehensive overview of existing published research. For published articles to be included in the review, the focus of the article had to be prehospital care providers, in prehospital settings. Furthermore, included articles must target interventions that were carried out in a simulation context.

Results

The volume of published research is distributed between 1984- 2012 and across the regions North America, Europe, Oceania, Asia and Middle East. The simulation methods used were manikins, films, images or paper, live actors, animals and virtual reality. The staff categories focused upon were paramedics, emergency medical technicians (EMTs), medical doctors (MDs), nurse and fire fighters. The main topics of published research on simulation with prehospital care providers included: Intubation, Trauma care, Cardiac Pulmonary Resuscitation (CPR), Ventilation and Triage.

Conclusion

Simulation were described as a positive training and education method for prehospital medical staff. It provides opportunities to train assessment, treatment and implementation of procedures and devices under realistic conditions. It is crucial that the staff are familiar with and trained on the identified topics, i.e., intubation, trauma care, CPR, ventilation and triage, which all, to a very large degree, constitute prehospital care. Simulation plays an integral role in this. The current state of prehospital care, which this review reveals, includes inadequate skills of prehospital staff regarding ventilation and CPR, on both children and adults, the lack of skills in paediatric resuscitation and the lack of knowledge in assessing and managing burns victims. These circumstances suggest critical areas for further training and research, at both local and global levels.

On-site hospital helipads: resource document for the NAEMSP position paper on on-site hospital helipads

The purpose of this article is to address the question of helipad location for hospitals using helicopter emergency medical services (HEMS). A helipad is defined as off-site, or remote, if a ground ambulance is required for patient transport between the helicopter and the hospital's patient care area. On-site helipads are those for which no ground ambulance transport is required between the hospital and the helicopter. The article describes the attributes of on-site helipads, which include elimination of the inherent risks of additional patient transfers, enhanced availability of emergency medical services (EMS) resources that would otherwise be used for extra transfer, and decreased time to arrival at the receiving treatment site. It is acknowledged that helipad placement decisions are informed by non-patient care issues and a paucity of research. Nevertheless, when the choice is viewed from a patient care perspective, there is a clear preference for on-site helipad location.

Comparison of the intubating laryngeal mask airway versus laryngoscopy in the Bell 206-L3 EMS helicopter

INTRODUCTION

The purpose of this study is to compare intubation success rate and time to intubation for the intubating laryngeal mask airway (I-LMA) versus direct laryngoscopy (DL) using a manikin model during a simulated in-flight scenario.

SETTING

The setting for the study was a University hospital-based air medical program.

METHODS

This was a prospective, randomized, crossover trial. Eight nurses and 7 paramedics were randomly assigned to perform 3 intubations with either the I-LMA or DL first and then 3 intubations using the alternate technique. Descriptive statistics, 95% confidence intervals (CIs) of means, and Fisher's Exact test were conducted for comparisons.

RESULTS

Fifteen set-ups and 45 intubations were performed with each technique. Previous experience was 74 mm (95% CI 64-84) with DL and 18 mm (95% CI 9-27) with the I-LMA. Set-up time was 33 seconds (95% CI 26-40) for DL and 40 seconds (95% CI 29-50) for I-LMA. Time to intubation was 12 seconds (95% CI 10-14) for DL and 39 seconds (95% CI 31-48) for I-LMA. Success rate was 100% for DL and I-LMA placement and 98% for intubation through the I-LMA. Crew rated difficulty of DL 13 mm (95% CI 6-20), placing the I-LMA 23 mm (95% CI 13-32), and intubating through the I-LMA 17 mm (95% CI 10-24).

CONCLUSION

Intubation success was very high for both DL and the I-LMA, despite less flight crew experience with the I-LMA. Total time to intubation was longer with the I-LMA but still less than 1 minute. The flight crews considered both techniques easy to perform. The I-LMA appears to be a useful adjunct for airway management in the Bell 206-L3 helicopter.

Paramedic-performed rapid sequence intubation of patients with severe head injuries

STUDY OBJECTIVE

We evaluate the ability of paramedic rapid sequence intubation (RSI) to facilitate intubation of patients with severe head injuries in an urban out-of-hospital system.

METHODS

Adult patients with head injuries were prospectively enrolled over a 1-year period by using the following inclusion criteria: Glasgow Coma Scale score of 3 to 8, transport time of greater than 10 minutes, and inability to intubate without RSI. Midazolam and succinylcholine were administered before laryngoscopy, and rocuronium was given after tube placement was confirmed by means of capnometry, syringe aspiration, and pulse oximetry. The Combitube was used as a salvage airway device. Outcome measures included intubation success rates, preintubation and postintubation oxygen saturation values, arrival arterial blood gas values, and total out-of-hospital times for patients intubated en route versus on scene.

RESULTS

Of 114 enrolled patients, 96 (84.2%) underwent successful endotracheal intubation, and 17 (14.9%) underwent Combitube intubation, with only 1 (0.9%) airway failure. There were no unrecognized esophageal intubations. On arrival at the trauma center, median oxygen saturation was 99%, mean arrival PO2 was 307 mm Hg, and mean arrival PCO2 was 35.8 mm Hg. Total out-of-hospital times were higher when RSI was performed on scene (26 versus 13 minutes).

CONCLUSION

Paramedics can use RSI protocols that include neuromuscular blocking and sedative agents to facilitate intubation of patients with head injuries.

Survey of out-of-hospital emergency intubations in the French prehospital medical system: a multicenter study

STUDY OBJECTIVE

To determine the clinical characteristics of endotracheal intubation in the French emergency prehospital medical system and compare these data with those of other systems.

METHODS

This study was performed in lle de France (Paris Region) in mobile ICUs staffed by physicians. This prospective, descriptive study involved completion of a questionnaire by the operator just after endotracheal intubation was performed.

RESULTS

Six hundred eighty-five (99.1%) of 691 consecutive prehospital intubations were performed successfully in the field. The orotracheal route was used in 96.0%, and no surgical approaches such as cricothyroidotomy were used. Mechanical complications occurred in 84 patients, at a rate of 15.9% for nonarrest patients and 8.1% for arrest patients. A wide variety of sedation protocols were used. Difficult intubations (10.8%) were comparable in incidence to the number seen in US emergency departments, not US prehospital systems. By the same token, intubation success rates (99.1%) were comparable to US EDs and much higher than US prehospital results.

CONCLUSION

The characteristics of French prehospital airway management differ significantly from those of other countries. These differences may be explained by differences in approach to prehospital management rather than differences of skill.