Prospective observational study of the practice of endotracheal intubation in the emergency department of a tertiary hospital in Sydney, Australia

A Prospective Observational Study of Endotracheal Intubation Practices in an Academic Emergency Department of a Tertiary Care Hospital in South India

INTRODUCTION

Airway management is the first critical step to be addressed in the airway, breathing, and circulation algorithm for stabilizing critically ill patients. Since the emergency department (ED) is the primary contact of these patients in health care, doctors in the ED should be trained to perform advanced airway management. In India, emergency medicine has been recognized as a new specialty by the Medical Council of India (now the National Medical Commission) since 2009. Data related to airway management in the ED in India is sparse.

METHODS

We conducted a one-year prospective observational study to establish descriptive data regarding endotracheal intubations performed in our ED. Descriptive data related to intubation was collected using a standardized proforma that was filled by the physician performing intubation.

RESULTS

A total of 780 patients were included, of which 58.8% were intubated in the first attempt. The majority (60.4%) of the intubations were performed in non-trauma patients and the remaining 39.6% in trauma patients. Oxygenation failure was the most common indication (40%) for intubation followed by a low Glasgow coma scale (GCS) score (35%). Rapid sequence intubation (RSI) was performed in 36.9% of patients, and intubation was done with sedation only in 36.9% of patients. Midazolam was the most commonly used drug - either alone or in combination with other drugs. We found a strong association of first-pass success (FPS) with the method of intubation, Cormack-Lehane grading, predicted difficulty in intubation, and experience of the physician performing the first attempt of intubation (P<0.05). Hypoxemia (34.6%) and airway trauma (15.6%) were the most commonly encountered complications.

CONCLUSION

Our study showed an FPS of 58.8%. Complications were seen in 49% of intubations. Our study highlights the areas for quality improvement in intubation practices in our ED, like the use of videolaryngoscopy, RSI, airway adjuncts like stylet and bougie, and intubation by more experienced physicians in patients with anticipated difficult intubation.

National Emergency Resuscitation Airway Audit (NERAA): a pilot multicentre analysis of emergency intubations in Irish emergency departments

BACKGROUND

There is paucity of literature on why and how patients are intubated, and by whom, in Irish Emergency Departments (EDs). The aim of this pilot study was to characterise emergency airway management (EAM) of critically unwell patients presenting to Irish EDs.

METHODS

A multisite prospective pilot study was undertaken from February 10 to May 10, 2020. This project was facilitated through the Irish Trainee Emergency Research Network (ITERN). All patients over 16 years of age requiring EAM were included. Eleven EDs participated in the project. Data recorded included patients' demographics, indication for intubation, technique of airway management, medications used to facilitate intubation, level of training and specialty of the intubating clinician, number of attempts, success/complications rates and variation across centres.

RESULTS

Over a 3-month period, 118 patients underwent 131 intubation attempts across 11 EDs. The median age was 57 years (IQR: 40-70). Medical indications were reported in 83% of patients compared to 17% for trauma. Of the 118 patients intubated, Emergency Medicine (EM) doctors performed 54% of initial intubations, while anaesthesiology/intensive care medicine (ICM) doctors performed 46%. The majority (90%) of intubating clinicians were at registrar level. Emergency intubation check lists, video laryngoscopy and bougie were used in 55, 53 and 64% of first attempts, respectively. The first pass success rate was 89%. Intubation complications occurred in 19% of patients. EM doctors undertook a greater proportion of intubations in EDs with > 50,000 attendance (65%) compared to EDs with < 50,000 attendances (16%) (p < 0.000).

CONCLUSION

This is the first study to describe EAM in Irish EDs, and demonstrates comparable first pass success and complication rates to international studies. This study highlights the need for continuous EAM surveillance and could provide a vector for developing national standards for EAM and EAM training in Irish EDs.

Video screen visualization patterns when using a video laryngoscope for tracheal intubation: A systematic review

OBJECTIVE

Published studies of video laryngoscopes are often limited by the lack of a clear definition of video laryngoscopy (VL). We performed a systematic review to determine how often published studies of VL report on video screen visualization.

METHODS

We searched PubMed, EMBASE and Scopus for interventional and observational studies in which a video laryngoscope equipped with a standard geometry blade was used for tracheal intubation. We excluded simulation based studies. Our primary outcome was data on video laryngoscope screen visualization. Secondary outcomes were explicit methodology for screen visualization.

RESULTS

We screened 4838 unique studies and included 207 (120 interventional and 87 observational). Only 21 studies (10% of 207) included any data on video screen visualization by the proceduralist, 19 in a yes/no fashion only (ie, screened viewed or not) and 2 with detail beyond whether the screen was viewed or not. In 11 more studies, visualization patterns could be inferred based on screen availability and in 16 more studies, the methods section stated how screen visualization was expected to be performed without reporting data collection on how the proceduralist interacted with the video screen. Risk of bias was high in the majority of included studies.

CONCLUSIONS

Published studies of VL, including many clinical trials, rarely include data on video screen visualization. Given the nuances of using a video laryngoscope, this is a critical deficiency, which largely prevents us from knowing the treatment effect of using a video laryngoscope in clinical practice. Future studies of VL must address this deficiency.

Emergency intubation practices in a tertiary teaching hospital in Jakarta, Indonesia: A prospective observational study

OBJECTIVE

Intubation is an important competency for emergency doctors. Emergency patients are often unstable, with undifferentiated conditions. There is little time to prepare these patients prior to intubation and so ED intubation may differ from intubation in intensive care units and operating theatres. The present study aims to describe the characteristics of emergency intubation after an administrative policy change within a tertiary teaching hospital in Jakarta, allowing non-anaesthetists to perform intubation in the ED.

METHODS

Prospective data were collected regarding patients of all age groups who were intubated at the ED of Cipto Mangunkusumo General Hospital, Jakarta, from February 2018 to January 2019. Patient characteristics, intubation attempts, medications used, complications, and disposition were recorded in a self-reported airway registry based on the Australian and New Zealand Emergency Department Airway Registry (ANZEDAR) form.

RESULTS

During the 12-month study period, 231 patients, or 41.5% of ED intubated patients were enrolled in the study, and there were 268 intubation attempts on these enrolled patients. The first-pass success rate was 207 out of 231 patients, or 89.6%, with anaesthetist (88.9%), better than emergency doctors (55.4%). Complications were reported in 51 patients, or 22.0%, with desaturation and hypotension being the most common. Thirty-three patients, or 14.3%, died in the ED before being transferred to another unit.

CONCLUSIONS

The first-pass success rate is comparable with international data. Non-anaesthetic physicians must improve their experience to achieve a favourable success rate. The data on complications highlight the need for improvement in Indonesian ED intubation practices.

Anaesthesia protocol evaluation of the videolaryngoscopy with the McGrath MAC and direct laryngoscopy for tracheal intubation in 1000 patients undergoing rapid sequence induction: the randomised multicentre LARA trial study protocol

INTRODUCTION

Rapid sequence induction of anaesthesia is indicated in patients with an increased risk of pulmonary aspiration. The main objective of the technique is to reduce the critical time period between loss of airway protective reflexes and rapid inflation of the cuff of the endotracheal tube to minimise the chance of aspiration of gastric contents. The COVID-19 pandemic has reinforced the importance of first-pass intubation success to ensure patient and healthcare worker safety. The aim of this study is to compare the first-pass intubation success rate (FPS) using the videolaryngoscopy compared with conventional direct laryngoscopy in surgical patients with a high risk of pulmonary aspiration.

METHODS AND ANALYSIS

The LARA trial is a multicentre, patient-blinded, randomised controlled trial. Consecutive patients requiring tracheal intubation are randomly allocated to either the McGrath MAC videolaryngoscope or direct laryngoscopy using the Macintosh laryngoscope. The expected rate of FPS is 92% in the McGrath group and 82% in the Macintosh group. Each group must include a total of 500 patients to achieve 90% power for detecting a difference at the 5% significance level. Successful intubation with the FPS is the primary endpoint. The secondary endpoints are the time to intubation, the number of intubation attempts, the necessity of airway management alternatives, the visualisation of the glottis using the Cormack and Lehane Score and the Percentage Of Glottic Opening Score and definite adverse events.

ETHICS AND DISSEMINATION

The project is approved by the local ethics committee of the Medical Association of the Rhineland Palatine state (registration number: 2020-15502) and medical ethics committee of the University of Freiburg (registration number: 21-1303). The results of this study will be made available in form of manuscripts for publication and presentations at national and international meetings.

TRIAL REGISTRATION

NCT04794764.

Improving first-pass success rates during emergency intubation at an academic emergency department: a quality improvement initiative

BACKGROUND

Airway management is a high-stakes procedure in emergency medicine. Continuously monitoring this procedure allows performance improvement while revealing safety issues. We instituted a quality improvement initiative in the emergency department to improve first-pass success rates in the emergency department.

METHODS

This was a quality improvement initiative at an academic emergency department from 2018 to 2020. We developed a rapid sequence intubation guideline for procedure standardization and introduced an intubation procedure note for performance monitoring. Data were entered directly by the primary physician and nurse during intubation. The quality improvement team thereafter collected the data retrospectively and entered into a local airway database. More importantly, we introduced a culture of quality improvement and safety in airway management via regular education and feedback.

RESULTS

We included a total of 146 intubations. The first-pass success rate started at 57.1% and increased to 80.0% during the study period (P < 0.01). Fifty-six percent were male, and the mean age (±SD) was 55.56 (±17.64). Video laryngoscopy was used in 101 (69.2%) patients, while direct laryngoscopy was used in only 44 (30.8%) patients. A logistic regression analysis was conducted to determine the independent factors associated with first-pass success. These factors included the use of video laryngoscopy (odds ratio (OR) 2.47 95% confidence interval (95% CI) [1.62-3.76]) (adjusted OR 3.87 [1.13-13.23]) and good Cormack-Lehane views (grades 1-2) (OR 2.71 95% CI [1.74-4.20]) (adjusted OR 7.88 [2.43-25.53]).

CONCLUSION

Our study shows that implementing and maintaining an airway quality improvement program improves first-pass intubation success. Moreover, the use of video laryngoscopy and obtaining good Cormack-Lehane views (grades 1-2) are independently associated with improved first-pass success.

Case series and review of emergency front-of-neck surgical airways from The Australian and New Zealand Emergency Department Airway Registry

BACKGROUND

An emergency front-of-neck access (eFONA), also called can't intubate, can't oxygenate (CICO) rescue, is a rare event. Little is known about the performance of surgical or percutaneous airways in EDs across Australia and New Zealand.

OBJECTIVE

To describe the management of cases resulting in an eFONA, and recorded in The Australian and New Zealand Emergency Department Airway Registry (ANZEDAR).

METHODS

A retrospective case series and review of ED patients undergoing surgical or percutaneous airways. Data were collected prospectively over 60 months between 2010 and 2015 from 44 participating EDs.

RESULTS

An eFONA/CICO rescue airway was performed on 15 adult patients: 14 cricothyroidotomies (0.3% of registry intubations) and one tracheostomy. The indication for intubation was 60% trauma and 40% medical aetiologies. The intubator specialty was emergency medicine in eight (53.3%) episodes. Thirteen (86.7%) cricothyroidotomies and the sole tracheostomy (6.7%) were performed at major referral hospitals with 12 (80%) surgical airways out of hours. In four (26.7%) cases, cricothyroidotomy was performed as the primary intubation method. Pre-oxygenation techniques were used in 14 (93.3%) episodes; apnoeic oxygenation in four (26.7%).

CONCLUSIONS

Most cases demonstrated deviations from standard difficult airway practice, which may have increased the likelihood of performance of a surgical airway, and its increased likelihood out of hours. Our findings may inform training strategies to improve care for ED patients requiring this critical intervention. We recommend further discussion of proposed standard terminology for emergency surgical or percutaneous airways, to facilitate clear crisis communication.

The Success Rate of Endotracheal Intubation in the Emergency Department of Tertiary Care Hospital in Ethiopia, One-Year Retrospective Study

Background

Emergency medical care starts with airway assessment and intervention management. Endotracheal intubation is the definitive airway management in the emergency department (ED) for patients requiring a definitive airway. Successful first pass is recommended as the main objective of emergency intubation. There exists no published research regarding the success rates or complications that occur within Ethiopian hospitals emergency department intubation practice.

Objective

This study aimed to assess the success rate of emergency intubations in a tertiary hospital, Addis Ababa, Ethiopia. Methodology. This was a single institute retrospective documentation review on intubated patients from November 2017 to November 2018 in the emergency department of Addis Ababa Burn Emergency and Trauma Hospital. All intubations during the study period were included. Data were collected by trained data collectors from an intubation documentation sheet.

Result

Of 15,933 patients seen in the department, 256 (1.6%) patients were intubated. Of these, 194 (74.9%) were male, 123 (47.5%) sustained trauma, 65 (25.1%) were medical cases, and 13(5%) had poisoning. The primary indications for intubation were for airway protection (160 (61.8%)), followed by respiratory failure (72(27.8%)). One hundred and twenty-nine (49.8%) had sedative-only intubation, 110 (42.5%) had rapid sequence intubation, and 16 (6.2%) had intubation without medication. The first-pass success rate in this sample was 70.3% (180/256), second-pass 21.4% (55/256), and third-pass 7.4% (19/256), while the overall success rate was 99.2% (254/256). Hypoxia was the most common complication.

Conclusion

The intubation first-pass success rate was lower than existing studies, but the overall intubation success rate was satisfactory.

Safety of rapid sequence intubation in an emergency training network

OBJECTIVE

Rapid sequence intubation (RSI) is a core critical care skill. Emergency medicine trainees are exposed to relatively low numbers of RSIs. We aimed to improve patient outcomes by implementing an RSI checklist, electronic learning and audit, in line with current best evidence.

METHODS

Prospective observational study of RSIs performed in the EDs of two Queensland hospitals between January 2014 and December 2016. Data collected included: first-pass success (FPS), predicted difficulty, indication for intubation, drugs used, positioning, number of attempts, checklist use and complications. Descriptive statistics and multivariable modelling were used to describe differences in FPS, and complications.

RESULTS

Six hundred and fifty-five patients underwent RSI with FPS of 86.6%. Complications were reported in 15.9%, mainly hypotension (10.9%) and desaturation (4.0%). FPS improved with bougie use (88.9% vs 73.0% without bougie, P < 0.001) and video-laryngoscopy (88.2% vs 72.9% using standard laryngoscopy, P < 0.001). New desaturation was reduced with apnoeic oxygenation (2.0% vs 22.2%, P < 0.001), bougie use (2.8% vs 8.9%, P < 0.001), checklist use (2.3% vs 22.7%, P < 0.001) and achieving FPS (2.1% vs 16.3%, P < 0.001). Complications were reduced with checklist use (13.3% vs 43.2%, P < 0.001) and apnoeic oxygenation use (3.9% vs 31.1%, P < 0.001). Logistic regression found checklist use was associated with reduced desaturation (OR 0.1, 95% CI 0.04-0.27) and the composite variable of any complication (OR 0.39, 95% CI 0.17-0.89).

CONCLUSIONS

Implementation of an evidence-based care bundle and audit of practice has created a safe environment for trainees to learn the core critical care skill of RSI. In our setting, checklist use was associated with fewer complications.

Current airway management practices after a failed intubation attempt in Australian and New Zealand emergency departments

OBJECTIVE

The aims of the present study were to describe current airway management practices after a failed intubation attempt in Australian and New Zealand EDs and to explore factors associated with second attempt success.

METHODS

Data were collected from a multicentre airway registry (The Australian and New Zealand Emergency Department Airway Registry). All intubation episodes that required a second attempt between March 2010 and November 2015 were analysed. Analysis for association with success at the second attempt was undertaken for patient factors including predicted difficulty of laryngoscopy, as well as for changes in laryngoscope type, adjunct devices, intubator and intubating manoeuvres.

RESULTS

Of the 762 patients with a failed first intubation attempt, 603 (79.1%) were intubated successfully at the second attempt. The majority of second attempts were undertaken by emergency consultants (36.8%) and emergency registrars (34.2%). A change in intubator occurred in 56.5% of intubation episodes and was associated with higher second attempt success (unadjusted odds ratio [OR] 1.85; 95% confidence interval [CI] 1.29-2.65). In 69.7% of second attempts at intubation, there was no change in laryngoscope type. Changes in laryngoscope type, adjunct devices and intubation manoeuvres were not significantly associated with success at the second attempt. In adjusted analyses, second attempt success was higher for a change from a non-consultant intubator to a consultant intubator from any specialty (adjusted OR 2.31; 95% CI 1.35-3.95) and where laryngoscopy was not predicted to be difficult (adjusted OR 2.58; 95% CI 1.58-4.21).

CONCLUSIONS

The majority of second intubation attempts were undertaken by emergency consultants and registrars. A change from a non-consultant intubator to a consultant intubator of any specialty for the second attempt and intubation episodes where laryngoscopy was predicted to be non-difficult were associated with a higher success rate at intubation. Participation in routine collection and monitoring of airway management practices via a Registry may enable the introduction of appropriate improvements in airway procedures and reduce complication rates.

The practice and safety profile of endotracheal intubation in an emergency department: A single-center study in Shenzhen, China

Objectives:

Endotracheal intubation is an essential skill of every emergency department clinician. The current practice of emergency intubation in the emergency departments in China and its safety is largely unknown. This study aimed at evaluating the practice and the safety profile of emergency intubation in an emergency department in Shenzhen.

Methods:

This study was of retrospective design. It was conducted in the emergency department of a university affiliated hospital. All patients requiring emergency intubation from 1 January 2017 to 30 June 2018 were recruited. Data on demographic and clinical characteristics of patients and characteristics of intubations were collected and analyzed.

Results:

A total of 128 patients were analyzed. Patients with spontaneous intracerebral hemorrhage were most common. Airway protection for patency was the most common indication of intubation. Most intubations were performed by emergency department staff with direct laryngoscopy. The first attempt success rate was 93.8%. Serious adverse events were rare.

Conclusion:

The practice of endotracheal intubation in the emergency department is in line with international ones. The safety profile is good. A national registry of emergency airway management is recommended.

Effect of the introduction of C-MAC videolaryngoscopy on first-pass intubation success rates for emergency medicine registrars

OBJECTIVES

The present study investigated the impact of introducing C-MAC videolaryngoscopy as the standard method of visualising glottic structures on first-pass intubation success of emergency medicine (EM) registrars in a large tertiary academic hospital in New Zealand.

METHODS

In this retrospective cohort study, all patients receiving attempted orotracheal intubation in Auckland City Hospital ED 1 year prior to and 1 year after the introduction of C-MAC videolaryngoscopy were compared. The primary outcome was first-pass intubation success rates by EM registrars. Secondary outcomes were first-pass success rates by all intubators, and incidence of any complication of intubation.

RESULTS

There were 163 intubations by EM registrars from June 2015 to August 2017. There was a clinically important and statistically significant improvement in first-pass success from 59.2% (95% confidence interval [CI] 44.1-68.8%) to 85.1% (95% CI 76.0-91.2%, P < 0.001) after the introduction of C-MAC. In multivariate analysis, the independent predictors of success were: Airway Not Predicted Difficult, odds ratio (OR) 2.49 (95% CI 1.06-5.85, P = 0.037); and use of videolaryngoscope, OR 4.49 (95% CI 1.85-10.91, P = 0.001). Overall, complications of intubation improved significantly after introduction of C-MAC (28.9%, 95% CI 19.9-40.0% prior to C-MAC introduction; 16.1%, 95% CI 9.7-25.3% after; P = 0.048).

CONCLUSION

This is the first published study specifically addressing EM registrar intubation success rates in New Zealand, adding to the existing body of data suggesting that videolaryngoscopy may improve success rates for novice intubators.

Does the addition of fentanyl to ketamine improve haemodynamics, intubating conditions or mortality in emergency department intubation: A systematic review

BACKGROUND

Ketamine is an induction agent frequently used for general anaesthesia in emergency medicine. Generally regarded as haemodynamically stable, it can cause hypertension and tachycardia and may cause or worsen shock. The effects of ketamine may be improved by the addition of fentanyl to the induction regime. We conducted a systematic review to identify evidence with regard to the effect of adding fentanyl to an induction regime of ketamine and a paralysing agent on post-induction haemodynamics, intubating conditions and mortality.

METHODS

We conducted a search of the Cochrane library, EMBASE, MEDLINE, PROQUEST, OpenGrey and clinical trial registries. Prominent authors were contacted in order to identify additional literature pertinent to the research question. Studies were included if they pertained to intubation of adult patients in the prehospital or emergency department environments and included an induction regime of ketamine and a paralysing agent, with at least one outcome measure of haemodynamics, intubating conditions or mortality. Search results were reviewed by two investigators independently, adjudicated by a third investigator where disagreement occurred.

RESULTS

One observational study was identified that partially answered the research question.

DISCUSSION

Only one observational study was identified that partially answered the research question. This paper demonstrated that the use of fentanyl as a pretreatment increases the incidence of post-induction hypotension, a phenomenon that was seen with propofol, midazolam and ketamine. The difference in hypotension between these agents was not statistically significant. The impact of this on patient-orientated outcomes is unclear.

FentAnyl or placebo with KeTamine for emergency department rapid sequence intubation: The FAKT study protocol

BACKGROUND

Some critically ill patients require rapid sequence intubation in the emergency department, and ketamine is one sedative agent employed, due to its relative haemodynamic stability. Tachycardia and hypertension are frequent side effects, and in less stable patients, shock can be unmasked or exacerbated. The use of fentanyl as a co-induction agent may lead to a smoother haemodynamic profile post-induction, which may lead to reduced mortality in this critically ill cohort. This randomised controlled trial aims to compare the effect of administering fentanyl vs placebo in a standardised induction regimen with ketamine and rocuronium on (a) the percentage of patients in each group with a systolic blood pressure outside the range of 100-150 mm Hg within 10 minutes of induction, (b) the laryngoscopic view, and (c) 30-day mortality.

METHODS/DESIGN

Three hundred patients requiring rapid sequence intubation in participating emergency departments will be randomised to receive either fentanyl or placebo (0.9% saline) in addition to ketamine and rocuronium according to a standardised, weight-based induction regimen. The primary outcome measure is the percentage of patients in each group with a systolic blood pressure outside the range of 100-150 mm Hg within 10 minutes of induction. Secondary outcome measures include the laryngoscopic view, percentage of first pass success, 30-day mortality and number of ventilator-free days at 30 days.

DISCUSSION

The effect of adding fentanyl to an induction regimen of ketamine and rocuronium will be evaluated, both in terms of post-intubation physiology, the effect on intubating conditions, and 30-day mortality.

Airway Management in the Emergency Department (The OcEAN-Study) - a prospective single centre observational cohort study

BACKGROUND

Emergency airway management (AM) is a major key for successful resuscitation of critically ill non-traumatic (CINT) patients. Details of the AM of these patients in German emergency departments (ED) are unknown. This observational study describes epidemiology, airway techniques, success rates and complications of AM in CINT ED patients in the resuscitation room (RR).

METHODS

Data was collected prospectively on adult CINT patients admitted to the RR of a single German university ED September 2014 to August 2015. Patient characteristics, out-of-hospital and in-hospital RR AM, complications and success rates were recorded using a self-developed airway registry form.

RESULTS

During the study period 34,303 patients were admitted to the ED, out of those 21,074 patients for non-trauma emergencies. Suffering from severe acute life-threatening problems, 532 CINT patients were admitted to the RR. 150 (28.2%) CINT patients had received out-of-hospital AM. In 16 of these cases (10.7%) the inserted airway needed to be changed after RR admission (unrecognized oesophageal intubation: n = 2, laryngeal tube exchange: n = 14). 136 (25.6%) CINT patients without out-of-hospital AM received RR AM immediately after admission. The first-pass and overall success rate in the RR were 71 and 100%, respectively, and multiple intubation attempts were necessary in 29%. A lower Cormack/Lehane (C/L) grade was associated with less intubation attempts (C/L1/2 vs. 3/4: 1.2 ± 0.5 vs. 1.8 ± 1.2, p = 0.0002). Complication rate was 43%.

CONCLUSIONS

OcEAN demonstrates the challenges of AM in CINT patients in a German ED RR. We propose a nation-wide ED airway registry to better track outcomes in the future.

Usefulness of C-MAC video laryngoscope in direct laryngoscopy training in the emergency department: A propensity score matching analysis

Objectives

We determined the usefulness of C-MAC video laryngoscope (C-MAC) as a safe training tool for the direct laryngoscopy technique in the emergency department.

Methods

We retrospectively analyzed an institutional airway registry of adult (≥18 years old) patients from April 2014 through October 2016. In this study, the operator used C-MAC as a direct laryngoscope (DL) with limited access to the screen, and the supervisor instructed the operator via verbal feedback while watching the screen. Patients were categorized into the DL group if a conventional DL was used and the C-DL group if a C-MAC used as a DL.

Results

Of 744 endotracheal intubations, 163 propensity score-matched pairs were generated (1-to-n matching: C-DL group, 163 vs. DL group, 428). For the propensity-matched groups, the overall first pass success rate was 69%, while those in the C-DL and DL groups were 79% and 65%, respectively. Overall, multiple attempts were required in 8% of patients, with 4% in the C-DL group and 9% in the DL group. The overall complication rate was 11%, with 4% in the C-DL group and 14% in the DL group. In multivariable analysis, the adjusted odds ratios of C-DL use for first pass success, multiple attempts, and complications were 2.05 (95% confidence interval [CI] 1.18–2.87, p < 0.01), 0.38 (95% CI 0.15–0.94; p < 0.01), and 0.28 (95% CI 0.12–0.63; p < 0.01), respectively.

Conclusions

Our study suggests that the C-MAC could be useful for training residents in the direct laryngoscopy while ensuring patient safety in the emergency department.

Impact of acutely behavioural disturbed patients in the emergency department: A prospective observational study

OBJECTIVE

The present study describes patients with acute behavioural disturbance presenting to the ED, the impact they have on the department and any complications that occur.

METHODS

We performed a prospective observational study of adult patients (>17 years old) requiring parenteral sedation for acute behavioural disturbance over a 13 month period. Demographic data, mode of arrival, indication, drug type and dosing used for sedation were collected. Departmental data were recorded including the staff type and numbers involved and the condition of the department. The main outcomes were complications from sedative medication and injury sustained to patients or staff.

RESULTS

Over the study period 173 patients met inclusion criteria, the majority (n = 104, 60%) were men with a mean age of 38.5 years (standard deviation 14.4); 51% of patients had more than one indication for sedation (n = 89), the commonest being mental health related plus drug intoxication (n = 30, 33.7%). Intoxication was frequently from either alcohol (n = 62, 47%) or methamphetamine (n = 41, 31%). The median number of staff involved was 10 (interquartile range 8-12). Staff members received an injury in 12% (n = 20) of sedations, with only 1% (n = 2) of patients receiving any physical injury; 12% (n = 20) had a minor complication from the sedation medication. No patient had any major complication (apnoea, intubation, arrhythmias or cardiac arrest).

CONCLUSION

Patients with acute behavioural disturbance often have a history of mental illnesses and are commonly intoxicated. These patients have impacts on healthcare resources and pose risks to staff safety, but significant complications to patients do not occur frequently.

[Systematic analysis of airway registries in emergency medicine]

BACKGROUND

A myriad of publications have contributed to an evidence-based approach to airway management in emergency services and admissions in recent years; however, it remains unclear which international registries on airway management in emergency medicine currently exist and how they are characterized concerning inclusion criteria, patient characteristics and definition of complications.

METHODS

A systematic literature research was carried out in PubMed with respect to publications from 2007-2017. All publications from airway registries collecting data on prehospital or emergency department (ED) airway management were included. Publications from pediatric intensive care units (PICU) were also included as long as they were the primary place of pediatric emergency care.

RESULTS

A total of eleven emergency airway registries (EAR) were identified that were primarily concerned with airway management. Furthermore, reported data on emergency airway management were extracted from different, national resuscitation registries. There was only one multinational EAR which exclusively collects data on pediatric emergency airway management (NEAR4KIDS, National Emergency Airway Registry for Kids). Additionally, all emergency department airway registries identified include data on pediatric emergency airway management to varying degrees (0.2-10.5%). Published observation periods were also highly variable with a minimum of 18 months and a maximum of 156 months. The ANZEDAR (Australia and New Zealand Emergency Airway Registry) is currently the largest EAR with data from 43 participating institutions in 2 different countries, while the NEAR III (National Emergency Airway Registry) includes data on 21,374 emergency intubations over a 10-year period and thus has the largest number of emergency interventions. Reported rapid sequence induction (RSI) rates in the registries are between 27.5% and 100%. First-pass success rates vary between 69% and 89%, while the reported use of video laryngoscopy is 0-73%.

CONCLUSION

This study identified eleven EARs that sometimes widely differed concerning inclusion periods, inclusion criteria, definition of complications and application of newer methods of emergency airway management. Thus, comparability of the reported results and first-pass success rates is only possible to a limited extent. The authors therefore advocate the initiation of an airway registry in emergency medicine in German-speaking countries.

Ketamine use for rapid sequence intubation in Australian and New Zealand emergency departments from 2010 to 2015: A registry study

OBJECTIVE

This study aimed to quantify the proportion of patients undergoing rapid sequence intubation using ketamine in Australian and New Zealand EDs between 2010 and 2015.

METHODS

The Australian and New Zealand Emergency Department Airway Registry is a multicentre airway registry prospectively capturing data from 43 sites. Data on demographics and physiology, the attending staff and indication for intubation were recorded. The primary outcome was the annual percentage of patients intubated with ketamine. A logistic regression analysis was conducted to evaluate the factors associated with ketamine use.

RESULTS

A total of 4658 patients met inclusion criteria. The annual incidence of ketamine use increased from 5% to 28% over the study period (P < 0.0001). In the logistic regression analysis, the presence of an emergency physician as a team leader was the strongest predictor of ketamine use (odds ratio [OR] 1.83, 95% confidence interval [CI] 1.44-2.34). The OR for an increase in one point on the Glasgow Coma Scale was 1.10 (95% CI 1.07-1.12), whereas an increase of 1 mmHg of systolic blood pressure had an OR of 0.98 (95% CI 0.98-0.99). Intubation occurring in a major referral hospital had an OR of 0.68 (95% CI 0.56-0.82), while trauma conferred an OR of 1.38 (95% CI 1.25-1.53).

CONCLUSIONS

Ketamine use increased between 2010 and 2015. Lower systolic blood pressure, the presence of an emergency medicine team leader, trauma and a higher Glasgow Coma Scale were associated with increased odds of ketamine use. Intubation occurring in a major referral centre was associated with lower odds of ketamine use.

The Bougie and First-Pass Success in the Emergency Department

STUDY OBJECTIVE

The bougie may improve first-pass intubation success in operating room patients. We seek to determine whether bougie use is associated with emergency department (ED) first-pass intubation success.

METHODS

We studied consecutive adult ED intubations at an urban, academic medical center during 2013. Intubation events were identified by motion-activated video recording. We determined the association between bougie use and first-pass intubation success, adjusting for neuromuscular blockade, video laryngoscopy, abnormal airway anatomy, and whether the patient was placed in the sniffing position or the head was lifted off the bed during intubation.

RESULTS

Intubation with a Macintosh blade was attempted in 543 cases; a bougie was used on the majority of initial attempts (80%; n=435). First-pass success was greater with than without bougie use (95% versus 86%; absolute difference 9% [95% confidence interval {CI} 2% to 16%]). The median first-attempt duration was higher with than without bougie (40 versus 27 seconds; difference 14 seconds [95% CI 11 to 16 seconds]). Bougie use was independently associated with greater first-pass success (adjusted odds ratio 2.83 [95% CI 1.35 to 5.92]).

CONCLUSION

Bougie was associated with increased first-pass intubation success. Bougie use may be helpful in ED intubation.

Emergency airway management in Australian and New Zealand emergency departments: A multicentre descriptive study of 3710 emergency intubations

OBJECTIVE

The aim of this study was to describe the practice of endotracheal intubation across a range of Australasian EDs.

METHODS

We established a multicentre airway registry (The Australian and New Zealand Emergency Department Airway Registry [ANZEDAR]) prospectively capturing intubations from 43 Australian and New Zealand EDs over 24 months using the ANZEDAR form. Information recorded included patient demographics, intubation indications, predicted difficulty, rapid sequence induction and endotracheal intubation preparation technique, induction drugs, airway adjuncts and complications. Factors associated with first attempt success were explored.

RESULTS

Of the 3710 intubations captured, 3533 were in adults (95.2%), 2835 (76.4%) for medical and 810 (21.8%) for trauma indications. Overall, 3127 (84.3%) patients were successfully intubated at the first attempt; the majority by ED doctors (2654 [72.1%]). A total of 10 surgical airways were performed, all of which were successful cricothyroidotomies. Propofol, thiopentone or ketamine were used with similar frequency for induction, and suxamethonium was the most often used muscle relaxant. Adverse events were reported in 964 (26%), the majority involving desaturation or hypotension.

CONCLUSION

Australasian ED doctors, predominantly specialist emergency physicians or trainees, perform the majority of ED intubations using rapid sequence induction as their preferred technique mainly for medical indications. First attempt success rate was not different between different types of EDs, and is comparable published international data. Complications are not infrequent, and are comparable to other published series. Monitoring and reporting of ED intubation practice will enable continued improvements in the safety of this high-risk procedure.

BET 2: Should real resuscitationists use airway checklists?

A short cut review was carried out to establish whether the use of preprocedural checklists prior to intubation of critically ill patients outside a theatre environment can reduce the incidence of adverse events. Four directly relevant papers were found using the reported search strategy and presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated. It is concluded that preprocedural checklists may reduce adverse events in these patients, but that the evidence level is low and further matched cohort studies are needed to prove effectiveness.

Difficult Intubation Factors in Prehospital Rapid Sequence Intubation by an Australian Helicopter Emergency Medical Service

OBJECTIVE

Prehospital rapid sequence intubation (RSI) of critically ill trauma patients is a high-risk procedure that may be associated with an increased rate of severe complications such as failed intubation, failure of oxygenation, hypoxia, hypotension, or need for surgical airway. The objective of this study was to describe the factors associated with difficult intubation in prehospital RSI as defined by more than a single look at laryngoscopy to achieve tracheal intubation.

METHODS

This is an observational study using prospectively collected data.

RESULTS

Four hundred forty-three RSIs were performed. Paramedics were the initial laryngoscopist in 290 (65.5%). First-look laryngoscopy resulted in successful tracheal intubation (TI) in 372 (84.0%) (95% confidence interval, 80.3%-87.1%). Intubation was achieved on second look at laryngoscopy in 58 (13.1%). "First-pass" TI was achieved in 394 (88.9%). Overall, successful TI was achieved in 438 (98.9%) (95% confidence interval, 97.4%-99.5%). Complications occurred in 116 (26.2%), with desaturation the commonest in 77 (17.4%).

CONCLUSION

Factors associated with more than 1 look at laryngoscopy before TI included paramedic laryngoscopist and the presence of at least 1 of the following indicators: blood/vomitus in the airway, limited mouth opening, and limited neck movement. Trauma to face/neck, obese body habitus, C-spine precautions, cricoid pressure, midline stabilization, and intubation on the ground did not influence the level of difficulty encountered.

Device and Medication Preferences of Canadian Physicians for Emergent Endotracheal Intubation in Critically Ill Patients

OBJECTIVES

Various medications and devices are available for facilitation of emergent endotracheal intubations (EETIs). The objective of this study was to survey which medications and devices are being utilized for intubation by Canadian physicians.

METHODS

A clinical scenario-based survey was developed to determine which medications physicians would administer to facilitate EETI, their first choice of intubation device, and backup strategy should their first choice fail. The survey was distributed to Canadian emergency medicine (EM) and intensive care unit (ICU) physicians using web-based and postal methods. Physicians were asked questions based on three scenarios (trauma; pneumonia; heart failure) and responded using a 5-point scale ranging from "always" to "never" to capture usual practice.

RESULTS

The survey response rate was 50.2% (882/1,758). Most physicians indicated a Macintosh blade with direct laryngoscopy would "always/often" be their first choice of intubation device in the three scenarios (mean 85% [79%-89%]) followed by video laryngoscopy (mean 37% [30%-49%]). The most common backup device chosen was an extraglottic device (mean 59% [56%-60%]). The medications most physicians would "always/often" administer were fentanyl (mean 45% [42%-51%]) and etomidate (mean 38% [25%-50%]). EM physicians were more likely than ICU physicians to paralyze patients for EETI (adjusted odds ratio 3.40; 95% CI 2.90-4.00).

CONCLUSIONS

Most EM and ICU physicians utilize direct laryngoscopy with a Macintosh blade as a primary device for EETI and an extraglottic device as a backup strategy. This survey highlights variation in Canadian practice patterns for some aspects of intubation in critically ill patients.

Resuscitation Prior to Emergency Endotracheal Intubation: Results of a National Survey

Introduction

Respiratory failure is a common problem in emergency medicine (EM) and critical care medicine (CCM). However, little is known about the resuscitation of critically ill patients prior to emergency endotracheal intubation (EETI). Our aim was to describe the resuscitation practices of EM and CCM physicians prior to EETI.

Methods

A cross-sectional survey was developed and tested for content validity and retest reliability by members of the Canadian Critical Care Trials Group. The questionnaire was distributed to all EM and CCM physician members of three national organizations. Using three clinical scenarios (trauma, pneumonia, congestive heart failure), we assessed physician preferences for use and types of fluid and vasopressor medication in pre-EETI resuscitation of critically ill patients.

Results

In total, 1,758 physicians were surveyed (response rate 50.2%, 882/1,758). Overall, physicians would perform pre-EETI resuscitation using either fluids or vasopressors in 54% (1,193/2,203) of cases. Most physicians would “always/often” administer intravenous fluid pre-EETI in the three clinical scenarios (81%, 1,484/1,830). Crystalloids were the most common fluid physicians would “always/often” administer in congestive heart failure (EM 43%; CCM 44%), pneumonia (EM 97%; CCM 95%) and trauma (EM 96%; CCM 96%). Pre-EETI resuscitation using vasopressors was uncommon (4.9%). Training in CCM was associated with performing pre-EETI resuscitation (odds ratio, 2.20; 95% CI, [1.44–3.36], p<0.001).

Conclusion

Pre-EETI resuscitation is common among Canadian EM and CCM physicians. Most physicians use crystalloids pre-EETI as a resuscitation fluid, while few would give vasopressors. Physicians with CCM training were more likely to perform pre-EETI resuscitation.

Ease and difficulty of pre-hospital airway management in 425 paediatric patients treated by a helicopter emergency medical service: a retrospective analysis

Background

Pre-hospital paediatric airway management is complex. A variety of pitfalls need prompt response to establish and maintain adequate ventilation and oxygenation. Anatomical disparity render laryngoscopy different compared to the adult. The correct choice of endotracheal tube size and depth of insertion is not trivial and often challenged due to the initially unknown age of child.

Methods

Data from 425 paediatric patients (<17 years of age) with any airway manipulation treated by a Swiss Air-Ambulance crew between June 2010 and December 2013 were retrospectively analysed. Endpoints were: 1) Endotracheal intubation success rate and incidence of difficult airway management in primary missions. 2) Correlation of endotracheal tube size and depth of insertion with patient’s age in all (primary and secondary) missions.

Results

In primary missions, the first laryngoscopy-guided endotracheal intubation attempt was successful in 95.3% of cases, with an overall success rate of 98.6%. Difficult airway management was reported in 10 (4.7%) patients. Endotracheal tube size was frequently chosen inadequately large (overall 50 of 343 patients: 14.6%), especially and statistically significant in the age group below 1 year (19 of 33 patients; p < 0.001). Tubes were frequently and distinctively more deeply inserted (38.9%) than recommended by current formulae.

Conclusion

Difficult airway management, including cannot intubate and cannot ventilate situations during pre-hospital paediatric emergency treatment was rare. In contrast, the success rate of endotracheal intubation at the first attempt was very high. High numbers of inadequate endotracheal tube size and deep placement according to patient age require further analysis. Practical algorithms need to be found to prevent potentially harmful treatment.

Evaluation of Karl Storz CMAC Tip™ device versus traditional airway suction in a cadaver model

Introduction

We compared the efficacy of Karl Storz CMAC Tip™ with inline suction to CMAC with traditional suction device in cadaveric models simulating difficult airways, using media mimicking pulmonary edema and vomit.

Methods

This was a prospective, cohort study in which we invited emergency medicine faculty and residents to participate. Each participant intubated 2 cadavers (one with simulated pulmonary edema and one with simulated vomit), using CMAC with inline suction and CMAC with traditional suction. Thirty emergency medicine providers performed 4 total intubations each in a crossover trial comparing the CMAC with inline suction and CMAC with traditional suction. Two intubations were performed with simulated vomit and two with simulated pulmonary edema. The primary outcome was time to successful intubation; and the secondary outcome was proportion of successful intubation.

Results

The median time to successful intubation using the CMAC with inline suction versus traditional suction in the pulmonary edema group was 29s and 30s respectively (p=0.54). In the vomit simulation, the median time to successful intubation was 40s using the CMAC with inline suction and 41s using the CMAC with traditional suction (p=0.70). There were no significant differences in time to successful intubation between the 2 devices. Similarly, the proportions of successful intubation were also not statistically significant between the 2 devices. The proportions of successful intubations using the inline suction were 96.7% and 73.3%, for the pulmonary edema and vomit groups, respectively. Additionally using the handheld suction device, the proportions for the pulmonary edema and vomit group were 100% and 66.7%, respectively.

Conclusion

CMAC with inline suction was no different than CMAC with traditional suction and was associated with no statistically significant differences in median time to intubation or proportion of successful intubations.

Prospective observational study of emergency airway management in the critical care environment of a tertiary hospital in Melbourne

The objective of this study is to describe the population of patients receiving emergency airway management outside operating theatres at our institution, a tertiary referral centre in Melbourne. A registry of all patients receiving emergency airway management in the emergency department, ICU and on the wards as part of Medical Emergency Response teams' care, was prospectively collected. There were 128 adults and one paediatric patient requiring emergency airway management recruited to the study. Data for analysis included patient demographics, pre-oxygenation and apnoeic oxygenation, staff, drugs, details of laryngoscopic attempts, adjuncts, airway manoeuvres, complications sustained and method of confirmation of endotracheal tube placement. Over a 12-month period, there were 139 intubations of 129 patients, requiring a total of 169 attempts. Respiratory failure was the most common indication for intubation. Intubation was successful on the first episode of laryngoscopy in 116 (83.5%) patients. Complications occurred in 48 patients. In the cohort of patients without respiratory failure, nasal cannulae apnoeic oxygenation significantly reduced the incidence of hypoxaemia (0 out of 31 [0.0%] versus 10 out of 60 [16.7%], P=0.016; absolute risk reduction 16.7%; number needed to treat: 6). Waveform capnography was used to confirm endotracheal tube placement in 133 patients and there were four episodes of oesophageal intubation, all of which were recognised immediately. In the critical care environment of our institution, emergency airway management is achieved with a first-attempt success rate that is comparable to overseas data. Nasal cannulae apnoeic oxygenation appears to significantly reduce the risk of hypoxaemia in patients without respiratory failure and the use of waveform capnography eliminates episodes of unrecognised oesophageal intubation.

Endotracheal intubation in the pediatric emergency department

BACKGROUND AND OBJECTIVES

Prospective safety data on emergency department (ED) intubation in children are limited. We aimed to describe the practice and adverse events associated with endotracheal intubation in a large urban pediatric ED.

METHODS

Prospective observational study at a tertiary pediatric ED with an annual census of 82,000. The primary outcome measure was the adverse event rate. Secondary outcome measures were incidence of difficult laryngoscopy and first pass success rate without desaturation or hypotension.

RESULTS

Over a 12-month period in 2013, there were 71 intubations in 66 patients (9/10,000 ED visits). Median age was 3 years, with 25% in infants <1 year of age. Indications were as follows: trauma (21%) and medical conditions (79%); most frequently status epileptics (31%). Forty-four percent had cardiovascular compromise, 87% had respiratory compromise, and 70% had a GCS <9 prior to intubation. Adverse events occurred in 39%, the most common being hypotension (21%) and desaturation (14%). One anticipated and one unanticipated difficult laryngoscopy were encountered (both Cormack and Lehane grade 3). Overall first pass success rate was 78%, although first pass success without desaturation or hypotension was only 49%. Seven percent required more than two attempts for successful intubation.

CONCLUSION

Intubation of children in the ED is a low-frequency, high-risk procedure. The incidence of adverse events, particularly desaturation and hypotension, is high. The incidence of difficult laryngoscopy is low. First pass success rate without desaturation or hypotension is low. Strategies to avoid desaturation and hypotension in the peri-intubation setting should be prioritized.

Prospective observational study of emergent endotracheal intubation practice in the intensive care unit and emergency department of an Australian regional tertiary hospital

OBJECTIVE

The present study aimed to describe the characteristics and outcomes of intubation occurring in the ICU and ED of an Australian tertiary teaching hospital.

METHODS

This was a prospective observational study of intubation practice across the Geelong Hospital over a 6 month period from 1 August 2012 to 31 January 2013. Data were entered by the intubating team through an online data collection form.

RESULTS

There were 119 patients intubated and 134 attempts at intubation in the ED and ICU over a 6 month period. The first-pass success rate was 104/119 (87.4%), and all but a single patient was intubated by the second attempt. Propofol, fentanyl, midazolam and suxamethonium were the most common drugs used in rapid sequence induction. AEs were reported in 44/134 (32.8%) of intubation attempts, with transient hypoxia and hypotension being the most common. A significant adverse outcome, namely aspiration pneumonitis, occurred in one patient. There were no peri-intubation deaths.

CONCLUSION

The majority of airways are managed by ICU and ED consultants and trainees, with success rates and AE rates comparable with other published studies.

Emergency airway management by resident physicians in Japan: an analysis of multicentre prospective observational study

Aim

To examine the success rates of emergency department airway management by resident physicians in Japan.

Methods

We conducted an analysis of a multicentre prospective registry (Japanese Emergency Airway Network Registry) of 13 academic and community emergency departments in Japan. We included all patients who underwent emergency intubation performed by postgraduate year 1 to 5 transitional or emergency medicine residents (resident physicians) between April 2010 and August 2012. Outcome measures were success rates by the first intubator, and by rescue intubator, according to the level of training.

Results

We recorded 4,094 intubations (capture rate, 96%); 2,800 attempts (2,800/4,094; 68%; 95% confidence interval (CI), 67%-70%) were initially performed by resident physicians. Overall success rate on the first attempt was 63% (1,767/2,789; 95%CI, 61%-64%); the rate improved over the first 3 years of training before reaching a plateau (P _trend < 0.001). Success rate by the first intubator was 78% (2,185/2,800; 95%CI, 76%-79%); the rate steadily improved as level of training increased (P _trend < 0.001). Of 597 failed intubation attempts by the first intubator, 41% (247/597; 95%CI, 37%-45%) of rescue attempts were performed by resident physicians. Success rate on the first rescue attempt was 76% (187/247; 95%CI, 70%-81%), and success rate by first rescue intubator was 89% (220/247; 95%CI, 85%-93%). These rates on rescue attempts steadily improved as level of training increased (both P _trend < 0.001). Intubations were ultimately successful in 2,778 encounters (99.6%).

Conclusion

In this multicentre study characterizing emergency airway management across Japan, we observed that emergency department intubations were primarily managed by resident physicians with acceptably high success rates overall.