Tracheal intubation in the emergency department: the Scottish district hospital perspective

Mortality Prediction of Biochemical Parameters in Patients Intubated in the Emergency Department

Introduction Tracheal intubation is a high-risk airway management protocol frequently applied in patients with critical illnesses. Numerous parameters have been suggested to predict mortality in these patients. Blood gas analysis, electrolyte levels, enzyme activities, and other biochemical measurements provide insights into a patient's metabolic status and organ functions. Accordingly, it is considered that these parameters have a significant potential for predicting the clinical outcomes of intubated patients. The study aimed to investigate the role of biochemical parameters in determining the 24-hour mortality risk of patients intubated in the emergency department and understand the potential significance of these parameters in predicting the clinical prognosis of these patients. Methods The present study was conducted on 1,236 patients who were intubated within a 1.5-year period at the Emergency Medicine Clinic of a tertiary Education and Research Hospital. Lactate, hemoglobin (Hgb), platelets (PLT), pH, HCO3, K, urea, creatinine, high-sensitivity troponin I (HS troponin I), and serum sodium levels were recorded for each patient in a data form. The 24-hour mortality rates were then analyzed based on these test results and comorbidities in the patients, and the data were recorded. Results The study included 702 patients after reviewing 1,236 cases. The median/mean values of HCO3, PLT, and pH were significantly higher in survivors compared to those who did not survive within 24 hours. Conversely, the median/mean values of lactate, creatinine, potassium, and HS troponin I were significantly higher in the patients who lost their lives within 24 hours than in the survivors. Epilepsy status, HCO3, lactate, potassium, and PLT values were statistically significant in the multivariate model in predicting 24-hour mortality. Conclusion The results of this study indicate that specific laboratory values, particularly blood gas analysis, play a significant role in predicting mortality among patients who present to the emergency department and undergo rapid sequence intubation. Patient prognosis can be predicted using these parameters, and treatment can be planned accordingly. Future multicenter prospective studies using standardized patient-specific intubation could provide further evidence for using the parameters in question in predicting mortality.

Point of care gastric ultrasound to predict aspiration in patients undergoing urgent endotracheal intubation in the emergency medicine department

BACKGROUND

One significant cause of morbidity and mortality in patients undergoing endotracheal intubation is the aspiration of gastric contents. Its prevalence is more in the emergency than in elective settings. Point-of-care gastric ultrasound (GUS) is a non-invasive bedside ultrasonogram that provides both qualitative and quantitative information about the stomach contents. The diagnostic accuracy of GUS in terms of gastric parameters (measured antral diameters, antral cross-sectional area, and calculated gastric volume) to predict aspiration is yet unknown. We aim to determine this in the patients undergoing urgent emergency intubation (UEI) in the emergency department.

METHODOLOGY

A prospective observational study was conducted at the emergency department of a tertiary healthcare center in India. Patients requiring UEI were identified and a bedside gastric ultrasound was done in the right lateral decubitus position using low frequency curved array probe. The qualitative data and the antral diameters (anteroposterior and craniocaudal) were assessed. The patient's clinical parameters and history regarding the last meal were noted. The cross-sectional area of gastric antrum was calculated using CSA = (AP × CC) π/4. The gastric volume is estimated using Perla's formula: GV = 27.0 + 14.6(RLD CSA) -1.28(age).

RESULTS

A hundred patients requiring urgent endotracheal intubation were enrolled in the study. Visible aspiration was more in participants with a distended gastric status (χ2 = 16.880, p =  < 0.001). The median gastric volume in the patients who aspirated was 146.37 mL, and it ranged from 111.59 mL-201.01 mL. Using ROC analysis, a cut-off of CC diameter ≥ 2.35 cm (sensitivity 88%, specificity 91%) and AP diameter ≥ 5.15 cm (sensitivity 88%, specificity 87%) predicts aspiration. A calculated USG CSA cut-off ≥ 9.27cm2 (sensitivity 100%, specificity 87%) and an USG gastric volume ≥ 111.594 mL (sensitivity 100%, a specificity 92%) predicts aspiration.

CONCLUSION

Point-of-care gastric ultrasound is an useful non-invasive bedside tool for risk stratification for aspiration in busy emergency rooms. We present threshold gastric antral parameters that can be used to predict aspiration along with its diagnostic accuracy. This can help the treating ED physician take adequate precautions, decide on intubation techniques and treatment modifications to aid in better patient management.

Airway registries in primarily adult, emergent endotracheal intubation: a scoping review

BACKGROUND

Emergency Department (ED) airway registries are formalized methods to collect and document airway practices and outcomes. Airway registries have become increasingly common in EDs globally; yet there is no consensus of airway registry methodology or intended utility. This review builds on previous literature and aims to provide a thorough description of international ED airway registries and discuss how airway registry data is utilized.

METHODS

A search of Medline, Embase, Scopus, Cochrane Libraries, Web of Science, and Google Scholar was performed with no date limitations applied. English language full-text publications and grey literature from centres implementing an ongoing airway registry to monitor intubations performed in mainly adult patients in an ED setting were included. Non-English publications and publications describing airway registries to monitor intubation practices in predominantly paediatric patients or settings outside of the ED were excluded. Study screening for eligibility was performed by two team members individually, with any disagreements resolved by a third team member. Data was charted using a standardized data charting tool created for this review.

RESULTS

Our review identified 124 eligible studies from 22 airway registries with a global distribution. We found that airway registry data is used for quality assurance, quality improvement, and clinical research regarding intubation practices and contextual factors. This review also demonstrates that there is a great deal of heterogeneity in definitions of first-pass success and adverse events in the peri-intubation period.

CONCLUSIONS

Airway registries are used as a crucial tool to monitor and improve intubation performance and patient care. ED airway registries inform and document the efficacy of quality improvement initiatives to improve intubation performance in EDs globally. Standardized definitions of first-pass success and peri-intubation adverse events, such as hypotension and hypoxia, may allow for airway management performance to be compared on a more equivalent basis and allow for the development of more reliable international benchmarks for first-pass success and rates of adverse events in the future.

Advanced airway management and drug-assisted intubation skills in an advanced critical care practitioner team

INTRODUCTION

Airway management, including endotracheal intubation, is one of the cornerstones of care of critically ill patients. Internationally, health professionals from varying backgrounds deliver endotracheal intubation as part of their critical care role. This article considers the development of airway management skills within a single advanced critical care practitioner (ACCP) team and uses case series data to analyse the safety profile in performing this aspect of critical care. Skills were acquired during and after the ACCP training pathway. A combination of theoretical teaching, theatre experience, simulation and work-based practice was used. Case series data of all critical care intubations by ACCPs were collected. Audit results: Data collection identified 675 intubations carried out by ACCPs, 589 of those being supervised, non-cardiac arrest intubations requiring drugs. First pass success was achieved in 89.6% of cases. A second intubator was required in 4.3% of cases. Some form of complication was experienced by 42.3% of patients; however, the threshold for complications was set at a low level.

CONCLUSIONS

This ACCP service developed a process to acquire advanced airway management skills including endotracheal intubation. Under medical supervision, ACCPs delivered advanced airway management achieving a first pass success rate of 89.6%, which compares favourably with both international and national success rates. Although complications were experienced in 48.3% of patients, when similar complication cut-offs are compared with published data, ACCPs also matched favourably.

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.

Aspiration during Rapid Sequence Induction: Prevalence and Risk Factors

Background

Securing definitive airway with minimal complications is a challenging task for high-volume emergency departments (ED) that deal with patients with compromised airway.

Materials and methods

We conducted a prospective observational study between September 2019 and March 2020. Cohort of adults presenting to the ED requiring rapid sequence induction (RSI) were recruited to determine the prevalence and risk factors for the development of aspiration pneumonia(AP) in patients intubated in the ED.

Results

During the study period, a total of 154 patients with a mean age of 44.5 years required RSI in the ED. Male (61%) predominance was noted among the study cohorts. We did not find any association between RSI performed in the ED and the risk of developing AP. The first attempt success rate of RSI was 76.7%, and 33(21.4%) patients had immediate adverse events following RSI. Rescue intubation was required for 11(7.1%) patients. The prevalence of AP following RSI in the ED was 13.4%. Endotracheal tube (ET) aspirate pepsin was positive in 45(29.2%) samples collected. The ET aspirate pepsin assay had low sensitivity (44.44%), specificity (73.53%), positive predictive value (18%), and negative predictive value (91%) in predicting the occurrence of AP. On multivariate logistic regression analysis, male gender (AOR: 7.29, 95%CI: 1.51-35.03, p = 0.013) and diabetes mellitus (AOR: 3.75, 95%CI: 1.23-11.51, p = 0.02) were found to be independent risk factors for developing AP.

Conclusion

We identified male gender and diabetes mellitus to be independent predictors of risk of developing AP after RSI in the ED. ET aspirate pepsin levels proved to be neither sensitive nor specific in the diagnosis of AP.

How to cite this article

Roshan R, Sudhakar GD, Vijay J, Mamta M, Amirtharaj J, Priya G, et al. Aspiration during Rapid Sequence Induction: Prevalence and Risk Factors. Indian J Crit Care Med 2021;25(2):140-145.

A novel scale for predicting delayed intubation in patients with inhalation injury

BACKGROUND

Strategies to predict delayed airway obstruction in patients with inhalation injury have not been extensively studied. This study aimed to develop a novel scale, predicting the need for Delayed Intubation after inhalation injury (PDI) score.

METHODS

We retrospectively identified patients with inhalation injury at four tertiary care centers in Japan between 2012 and 2018. We included patients aged 15 or older and excluded those intubated within 30 min after hospital arrival. Predictors for delayed intubation were identified with univariate analyses and scored on the basis of odds ratios. The PDI score was evaluated with the area under the receiver operating characteristic (AUROC) curve and compared with other scaling systems for burn injuries.

RESULTS

Data from 158 patients were analyzed; of these patients, 18 (11.4%) were intubated during the delayed phase. Signs of respiratory distress, facial burn, and pharyngolaryngeal swelling observed on laryngoscopy, were identified as predictors for delayed intubation. The discriminatory power of the PDI (AUROC curve = 0.90; 95% confidence interval, 0.83 to 0.97; p < 0.01) was higher than that of the other scaling systems.

CONCLUSIONS

We developed a novel scale for predicting delayed intubation in inhalation injury. The score should be further validated with other population.

The provision of central venous access, transfer of critically ill patients and advanced airway management.: Are advanced critical care practitioners safe and effective?

Advanced critical care practitioners are a new and growing component of the critical care multidisciplinary team in the United Kingdom. This audit considers the safety profile of advanced critical care practitioners in the provision of central venous catheterisation and transfer of ventilated critical care patients without direct supervision and supervised drug assisted intubation of critically ill patients. The audit showed that advanced critical care practitioners can perform central venous cannulation, transfer of critically ill ventilated patients and intubation with parity to published UK literature.

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.

A comparison between video laryngoscopy and direct laryngoscopy for endotracheal intubation in the emergency department: A meta-analysis of randomized controlled trials

STUDY OBJECTIVES

Direct laryngoscopy is the most commonly used modality for endotracheal intubation in the emergency department. Video laryngoscopy may improve glottic view during laryngoscopy and intubation success rate in such patients. This meta-analysis has been designed to compare clinical efficacy of video laryngoscopy with direct laryngoscopy for endotracheal intubation in the emergency department.

DESIGN

Meta-analysis of randomized controlled trial.

SETTING

Randomized controlled trials comparing video laryngoscopy and direct laryngoscopy for endotracheal intubation in adult patients in emergency department. PubMed (1946 to 20th October 2017) and The Cochrane Library databases (CENTRAL) were searched for potentially eligible trials on 20th October 2017.

PATIENTS

Adult patients presenting in the emergency department.

INTERVENTIONS

Video laryngoscopy & direct laryngoscopy for intubation in emergency department.

MEASUREMENT

Primary outcome was 'first intubation success rate' and secondary outcomes were overall intubation success rate, in-hospital mortality and oesophageal intubation rate.

MAIN RESULTS

Data of 1250 patients from 5 randomized controlled trials have been included in this study. Video laryngoscopy offers no advantage over direct laryngoscopy in terms of first intubation success rate (odds ratio 1.28, 95% CI 0.70, 2.36; p = 0.42), overall intubation success rate (OR 1.26, 95% CI 0.53, 3.01; p = 0.6) or in-hospital mortality (OR 1.25, 95% CI 0.8, 1.95; p = 0.32). However, oesophageal intubation rate is lower with the use of video laryngoscopy (OR 0.09, 95% CI 0.01, 0.7; p = 0.02).

CONCLUSION

Use of video laryngoscopy for emergency endotracheal intubation in adult patients is associated with reduced oesophageal intubation over direct laryngoscopy. However, no benefit was found in terms of overall intubation success.

A sequential case series of 23 intubations in a rural emergency department in New Zealand

OBJECTIVE

To describe the practice and procedure of emergency intubation in Whanganui Emergency Department, New Zealand and determine whether intubation can be carried out effectively in the rural setting.

METHOD

A prospective observational study using the Australia and New Zealand Airway Registry proforma to collect data on the indication, lead intubator, first-pass success rate and peri-procedural complications. Data were also collected on whether a formal airway assessment was carried out and whether a checklist was used.

RESULTS

Twenty-three patients were intubated in the emergency department over a 12-month period. Sixty-two percent (14/23 cases) were medical encounters and the remaining 38% of indications due to a trauma. Head injury was the most common indication (23%). Ninety-two percent of primary intubators were emergency department-based Fellowship of the Australasian College for Emergency Medicine or resident medical officers, while anaesthetic-trained operators accounted for just 8%. Our first-pass intubation success rate was 87% and 16% of cases had procedural complications. Sixty-five percent (15/23) carried out a formal airway assessment and a checklist was only used in 23% of cases.

CONCLUSION

This sequential case series is the first study looking at airway management in rural New Zealand emergency department airway practice. Overall intubation success rates were comparable to larger tertiary centres across Australasia. We have demonstrated that with adequate resources and adherence to interventions, a rural emergency department can provide effective airway management.

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.

Tips to Improve Success Rate of Intubation: A Standardized Rapid Sequence Intubation Protocol Attached to the Resuscitation Cart

OBJECTIVES

The purpose of this study was to determine whether the implementation of a standardized rapid sequence intubation (RSI) protocol easily accessed on the resuscitation cart increased the success rate of intubation and reduced intubation-related complications in the emergency department (ED).

METHODS

This work was a retrospective study of patients who were intubated in the ED between February 2006 and June 2007. The RSI protocol and a dosage cross-table were attached to the resuscitation cart beginning in January 2007. Intubated patients before and after application of the protocol were sorted into two groups: pre-intervention and post-intervention.

RESULTS

A total of 147 patients were enrolled in the study, including 72 patients in the pre-intervention group and 75 patients in the post-intervention group. After application of the standardized protocol prompted on the resuscitation cart. The adherence rates to pre-treatment agents (69% vs. 90%; p < 0.01) and neuromuscular blocking agents (NMBA) (72% vs. 90%; p < 0.01) significantly improved. The first-attempt success rate was 57 of 72 (79%) in the pre-intervention group versus 70 of 75 (93%) in the post-intervention group (p = 0.016). The time to intubation did not differ signifi cantly, but the preintervention group had a higher percentage of prolonged time to intubation (13% vs. 3%; p = 0.029). The implementation of a standardized RSI protocol did not induce signifi cant adverse effects.

CONCLUSIONS

Our study demonstrated implementation of a standardized RSI protocol, improved clinician adherence to the RSI, increased success of first-attempt ED intubation and led to a decline in the rate of prolonged time to intubation.

The Impact of a Soiled Airway on Intubation Success in the Emergency Department When Using the GlideScope or the Direct Laryngoscope

BACKGROUND

The objective was to determine the impact of a soiled airway on firstpass success when using the GlideScope video laryngoscope or the direct laryngoscope for intubation in the emergency department (ED).

METHODS

Data were prospectively collected on all patients intubated in an academic ED from July 1, 2007, to June 30, 2016. Patients ≥ 18 years of age, who underwent rapid sequence intubation by an emergency medicine resident with the GlideScope or the direct laryngoscope, were included in the analysis. Data were stratified by device used (GlideScope or direct laryngoscope). The primary outcome was firstpass success. Patients were categorized as those without blood or vomitus (CLEAN) and those with blood or vomitus (SOILED) in their airway. Multivariate regression models were developed to control for confounders.

RESULTS

When using the GlideScope, the firstpass success was lower in the SOILED group (249/306; 81.4%) than the in CLEAN group (586/644, 91.0%; difference = 9.6%; 95% confidence interval [CI] = 4.7%-14.5%). Similarly, when using the direct laryngoscope, the firstpass success was lower in the SOILED group (186/284, 65.5%) than in the CLEAN group (569/751, 75.8%; difference = 10.3%; 95% CI = 4.0%-16.6%). The SOILED airway was associated with a decreased firstpass success in both the GlideScope cohort (adjusted odds ratio [aOR] = 0.4; 95% CI = 0.3-0.7) and the direct laryngoscope cohort (aOR = 0.6; 95% CI = 0.5-0.8).

CONCLUSION

Soiling of the airway was associated with a reduced firstpass success during emergency intubation, and this reduction occurred to a similar degree whether using either the GlideScope or the direct laryngoscope.

The Demographics and Education of Emergency Medical Services (EMS) Professionals: A National Longitudinal Investigation

Objectives

The objectives of this study were to assess longitudinal and cross-sectional changes in Emergency Medical Technician (EMT)-Basics and Paramedics: (1) demographics, (2) employment characteristics, and (3) initial Emergency Medical Services (EMS) education.

Methods

These data were collected between 1999 and 2008 employing survey techniques aimed at collecting valid data. A random, stratified sample was utilized to allow results to be generalizable to the nationally certified EMS population. Survey weights that were adjusted for each stratum’s response were estimated. Weighted percentages, averages for continuous variables, and 95% confidence intervals (CIs) were calculated. Significant changes over time were noted when the CIs did not overlap.

Results

In all 10 years of data collection, the proportion of EMT-Paramedics who were male was greater than the proportion of EMT-Basics who were male. A substantial proportion of respondents performed EMS services for more than one agency: between 39.8% and 43.5% of EMT-Paramedics and 18.4% and 22.4% of EMT-Basic respondents reported this. The most common type of employer for both EMT-Basics and EMT-Paramedics was fire-based organizations. About one-third of EMT-Basics (32.3%-40.1%) and almost one-half of EMT-Paramedics (43.1%-45.3%) reported that these organizations were their main EMS employer. Rural areas (<25,000 residents) were the most common practice settings for EMT-Basics (52.1%-63.7%), while more EMT-Paramedics worked in urban settings (65.2%-77.7%).

Conclusions

This analysis serves as a useful baseline to measure future changes in the EMS profession. This study described the demographic and work-life characteristics of a cohort of nationally certified EMT-Basics and Paramedics over a 10-year period. This analysis also summarized initial EMS education changes over time.

BentleyMA, ShobenA, LevineR. The demographics and education of Emergency Medical Services (EMS) professionals: a national longitudinal investigation. Prehosp Disaster Med. 2016;31(Suppl. 1):s18–s29.

Tracheal intubation in an urban emergency department in Scotland: a prospective, observational study of 3738 intubations

AIM

The emergency department (ED) is an area where major airway difficulties can occur, often as complications of rapid sequence induction (RSI). We undertook a prospective, observational study of tracheal intubation performed in a large, urban UK ED to study this further.

METHODS

We reviewed data on every intubation attempt made in our ED between January 1999 and December 2011. We recorded techniques and drugs used, intubator details, success rate, and associated complications. Tracheal intubation in our ED is managed jointly by emergency physicians and anaesthetists; an anaesthetist is contacted to attend to support ED staff when RSI is being performed.

RESULTS

We included 3738 intubations in analysis. 2749 (74%) were RSIs, 361 (10%) were other drug combinations, and 628 (17%) received no drugs. Emergency physicians performed 78% and anaesthetists 22% of intubations. Tracheal intubation was successful in 3724 patients (99.6%). First time success rate was 85%; 98% of patients were successfully intubated with two or fewer attempts, and three patients (0.1%) had more than three attempts. Intubation failed in 14 patients; five (0.13%) had a surgical airway performed. Associated complications occurred in 286 (8%) patients. The incidence of complications was associated with the number of attempts made; 7% in one attempt, 15% in two attempts, and 32% in three attempts (p<0.001).

CONCLUSION

A collaborative approach between emergency physicians and anaesthetists contributed to a high rate of successful intubation and a low rate of complications. Close collaboration in training and delivery of service models is essential to maintain these high standards and achieve further improvement where possible.

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.

Airway management of adult patients without trauma in an ED led by internists

BACKGROUND

Airway management is a key competence in emergency medicine. Patients heavily differ from those in the operating room. They are acutely ill by definition and usually not fasting. Evaluation of risk factors is often impossible. Current literature primarily originates from countries where emergency medicine is an independent specialty. We evaluated intubations in a high-volume emergency department run by internists and comprising its own distinctive intensive care unit.

METHODS

In this prospective, noncontrolled, observational study, we continuously documented all intubations performed at the emergency department. We analyzed demographic, medical, and staff-related factors predicting difficulties during intubation using logistic regression models.

RESULTS

For 73 months, 660 cases were included, 69 (10.5%) of them were without any induction therapy. Two hundred fifty-two (38.2%) patients were female, and their mean age was 59 ± 17 years. Three hundred four (49.9%) had an initial Glasgow Coma Scale of 3. Leading indications were respiratory insufficiency (n = 246; 37.3%), resuscitation (n = 172; 26.1%), and intracranial hemorrhage (n = 75; 11.4%). First attempt was successful in 465 cases (75.1%); alternative airway devices were used in 22 cases (3.3%). Time from the first intubation attempt to a validated airway was 1 minute (interquartile range, 0-2 minutes). Physicians' experience and anatomical risk factors were associated with failure at the first attempt, prolonged intubation, and the need for alternative devices.

CONCLUSIONS

Airway management at the emergency department possesses a high potential of failure. Experience seems to be the key to success.

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

OBJECTIVE

To describe the practice of endotracheal intubation in the ED of a tertiary hospital in Australia, with particular emphasis on the indication, staff seniority, technique, number of attempts required and the rate of complications.

METHODS

A prospective observational study.

RESULTS

Two hundred and ninety-five intubations occurred in 18 months. Trauma was the indication for intubation in 30.5% (95% CI 25.3-36.0) and medical conditions in 69.5% (95% CI 64.0-74.5). Emergency physicians were team leaders in 69.5% (95% CI 64.0-74.5), whereas ED registrars or senior Resident Medical Officers made the first attempt at intubation in 88.1% (95% CI 83.9-91.3). Difficult laryngoscopy occurred in 24.0% (95% CI 19.5-29.3) of first attempts, whereas first pass success occurred in 83.4% (95% CI 78.7-87.2). A difficult intubation occurred in 3.4% (95% CI 1.9-6.1) and all patients were intubated orally in five or less attempts. A bougie was used in 30.9% (95% CI 25.8-36.5) of first attempts, whereas a stylet in 37.5% (95% CI 32.1-43.3). Complications occurred in 29.0% (95% CI 23.5-34.1) of the patients, with desaturation the commonest in 15.7% (95% CI 11.9-20.5). Cardiac arrest occurred in 2.2% (95% CI 0.9-4.4) after intubation. No surgical airways were undertaken.

CONCLUSION

Although the majority of results are comparable with overseas data, the rates of difficult laryngoscopy and desaturation are higher than previously reported. We feel that this data has highlighted the need for practice improvement within our department and we would encourage all those who undertake emergent airway management to audit their own practice of this high-risk procedure.

Pediatric endotracheal intubations for airway management in the emergency department

OBJECTIVE

The objective of this study was to determine indications, type of medications used, and immediate complications of pediatric endotracheal intubations in the emergency department.

METHODS

A retrospective chart review was done on all pediatric patients (0-14 years old) who required endotracheal (ET) intubation for airway management in the Department of Emergency Medicine at Aga Khan University Hospital from January to December 2009. Data were collected on a preformed questionnaire for age, sex, indications, drugs used, and complications of pediatric ET intubations done in the emergency department. Dead-on-arrival patients and those intubated elsewhere were excluded.

RESULTS

A total of 83 pediatric intubations were done during the study period. Indications for ET intubations were respiratory failure in 51 (61%), unresponsiveness in 18 (22%), cardiac arrest in 8 (10%), and trauma in 6 cases (7%). Comorbid conditions were present in 28 (34%). Of 83 ET intubations, drugs were used in 48 cases (58%). Both sedation and neuromuscular blockade were used in 42 cases (51%), 4 cases (5%) received sedation only, and 2 cases (2%) received relaxation without sedation, and in 35 cases (42%), intubation was done without drugs. Drugs used for sedation/induction were ketamine in 22 (26%), midazolam in 14 (17%), propofol in 7 (8%), and etomidate in 3 cases (4%). Neuromuscular blockades used were rocuronium in 27 cases (32%), succinylcholine in 11 cases (13.5%), and atracurium in 5 cases (6%). Complications were noted in 16 cases (19%).

CONCLUSIONS

Respiratory failure was found to be the main presenting complaint. Drugs for sedation and relaxation to facilitate ET intubation were underused.

Emergency tracheal intubation without drugs: outcome and one-year survival of medical patients not in cardiac arrest

Non-medicine-assisted tracheal intubation in prehospital trauma is associated with a dismal prognosis. We wished to study the outcome of medical patients who underwent non-medicine-assisted tracheal intubation. This retrospective study of patients attending our university hospital emergency department was conducted over seven years. The tracheal intubation database was analysed to identify medical patients not in cardiac arrest undergoing tracheal intubation without medicines. Intensive care unit, hospital, 12-month mortality and patients' residence at 12 months were recorded. Eighty patients were identified who met inclusion criteria. The most common reason for intubation was definite airway compromise due to decreased conscious level (62.5%), then respiratory failure (26.3%) and finally potentially compromised airway due to a decreased conscious level (11.2%). Eighty-eight percent of patients with a definitely compromised airway were successfully intubated at first attempt compared with 66.7% of patients with a potentially compromised airway or respiratory failure (P= 0.03). Of 75 patients with complete data, 30 (40%) were survivors at 12 months, with all but two (6.7%) living at home. Non-medicine-assisted laryngoscopy leads to an increased first time tracheal intubation failure rate in patients with intact airway reflexes and, therefore, cannot be recommended as best practice.

Rapid sequence induction of anaesthesia in elderly patients in the emergency department

AIM

Our primary objective was to evaluate the characteristics and outcomes of elderly (≥ 80 years) patients undergoing rapid sequence induction of anaesthesia and intubation (RSI) in our emergency department (ED).

METHODS

We retrospectively analysed data collected prospectively between January 1999 and December 2007. We retrieved age; gender; presenting diagnosis; indication and urgency for RSI; complications related to RSI; hospital destination; and outcome.

RESULTS

1686 patients underwent RSI in the ED during the study period; 107 (6%) were aged ≥ 80 years. The mean age (range) was 84 (80-91) years. 94 patients (88%) were living in a private residence before presentation to the ED. Intracerebral haemorrhage, ischaemic stroke and head injury were the commonest presenting diagnoses. Forty-one patients were admitted to intensive care, 55 were admitted to a ward (31 for palliative care) and 11 died in the ED. Seventy-two patients (67%) died; of the 35 survivors, 21 (60%) made a good recovery with no requirement for increased social care. Outcome was worse after neurological diagnoses, sepsis and trauma than after cardiac or respiratory failure, seizures or drug overdose. Presenting diagnosis predicted outcome on univariable analysis (p<0.001), but it was not possible to calculate risk for individual diagnoses. RSI-related complications, of which hypotension was commonest, occurred in 15% of patients.

CONCLUSION

A small number of patients who undergo RSI in our ED are aged ≥ 80 years. They generally have high mortality with only 20% surviving to hospital discharge with no increase in dependency; however 60% of survivors make a good recovery. In this highly selected elderly population age is not the main determinant of outcome which is influenced more by presenting diagnosis.

A prospective study of tracheal intubation in an academic emergency department in Malaysia

BACKGROUND

Airway management is an important part of the management of the critically ill and injured patients in the Emergency Department (ED). Numerous studies from developed countries have demonstrated the competency of emergency doctors in intubation. To date there have been no published data on intubations performed in EDs in Malaysia.

METHODS

Data on intubations from 7 August 2007 till 28 August 2008 were prospectively collected.

RESULTS

There were 228 intubations included in the study period. Cardiopulmonary arrest was the main indication for intubation (35.5%). The other indications were head injury (18.4%), respiratory failure (15.4%), polytrauma (9.6%) and cerebrovascular accident (7.0%). All of the 228 patients were successfully intubated. Rapid sequence intubation (RSI) was the most frequent method (49.6%) of intubation. A total of 223 (97.8%) intubations were done by ED personnel. In 79.8% of the cases, intubations were successfully performed on the first attempt. Midazolam was the most common induction agent used (97 patients), while suxamethonium was the muscle relaxant of choice (109 patients). There were 34 patients (14.9%) with 38 reported immediate complications. The most common complication was oesophageal intubation.

CONCLUSION

Emergency Department UKMMC personnel have a high competency level in intubation with an acceptable complication rate. RSI was the most common method for intubation.

Controlled organ donation after cardiac death: potential donors in the emergency department

BACKGROUND.: The continuing shortfall of organs for transplantation has increased the use of donation after cardiac death (DCD). We hypothesized that some patients who undergo tracheal intubation in the emergency department (ED) and who are assessed for, but not admitted to, critical care might have potential for controlled DCD. METHODS.: We identified all patients who underwent tracheal intubation in the ED between 2004 and 2008 and studied their records to identify those not admitted to an intensive care unit. We reviewed the notes of patients extubated in the ED to ascertain the diagnosis, management, outcome, and potential exclusion criteria for controlled DCD. RESULTS.: One thousand three hundred seventy-four patients had tracheal intubation performed in the ED; 1053 received anesthetic drugs to assist intubation. Three hundred seventy-five patients were not admitted to intensive care unit; 235 died during resuscitation in the ED. Of the 49 patients extubated in the ED to allow terminal care, 26 were older than 70 years and 18 had comorbidities precluding organ donation. Fourteen patients could have been considered for DCD, but in eight, the time from extubation to death exceeded 2 hr. Thus, six patients might have been missed as potential controlled DCD from the ED in this 5-year period. CONCLUSIONS.: Identification of potential donors after cardiac death in the ED with appropriate use of critical care for selected patients may contribute to reducing the shortfall of organs for transplantation, although numbers are likely to be small. This area remains controversial and requires further informed discussion between emergency and critical care doctors and transplant teams.

Cricoid pressure and laryngeal manipulation in 402 pre-hospital emergency anaesthetics: essential safety measure or a hindrance to rapid safe intubation?

OBJECTIVES

This is the first study to look at the effects of cricoid pressure/laryngeal manipulation on the laryngeal view and intubation success in the emergency or pre-hospital environment. Cricoid pressure is applied in the hope of reducing the incidence of aspiration. However the technique has never been evaluated in a randomized trial and may adversely affect laryngeal view. In order to improve intubating conditions cricoid pressure may be released and the larynx manipulated into a more favourable position.

METHODS

We carried out a prospective observational study to evaluate the effects of cricoid pressure and laryngeal manipulation on laryngeal view in our physician led pre-hospital trauma service.

RESULTS

402 patients were included over a 16-month period. We intubated 98.8% patients on the first or second attempt. In 61 intubations (in 55 patients, 13.6%) the larynx required manipulation to facilitate intubation. In 22 intubations cricoid pressure was removed with the laryngeal view improving in 50%. Bimanual laryngeal manipulation was used in 25 intubations and the larynx better visualised in 60% of these. Backwards upwards rightwards pressure was applied to the larynx in 14 intubations and the laryngeal view improved in 64%. Two patients regurgitated when cricoid pressure was released. Both had prolonged periods of bag valve mask ventilation and difficult intubations.

DISCUSSION

The results suggest that cricoid pressure should be removed if the laryngeal view obtained is not sufficient to allow immediate intubation. Further manipulation of the larynx is likely to improve the chances of successful tracheal tube placement.